What is the management plan for Cerebrovascular Accident (CVA)?

Management of Cerebrovascular Accident (CVA)

Immediately administer IV tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) if the patient presents within 3 hours of symptom onset with confirmed ischemic stroke on CT imaging and no contraindications, followed by admission to a specialized stroke unit. 1, 2

Immediate Emergency Assessment (First 15 Minutes)

Document the precise time of symptom onset—this is the single most critical piece of information that determines all treatment eligibility. 1, 2 If the patient awakens with symptoms, use the "last known normal" time. 1

• Perform immediate non-contrast CT imaging to differentiate ischemic from hemorrhagic stroke—do not delay imaging to obtain detailed history. 1, 3, 2
• Assess stroke severity using the NIH Stroke Scale to guide treatment decisions and prognosis. 2
• Stabilize airway, breathing, and circulation, particularly in seriously ill or comatose patients. 2
• Record specific neurological deficits: motor weakness, sensory loss, visual field defects, language impairment, gaze deviation, and level of consciousness. 1
• Note risk factors: hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation, and previous stroke/TIA history. 1

Clinical Features Suggesting Hemorrhagic vs Ischemic Stroke

While imaging is the gold standard, certain clinical features have higher prevalence in hemorrhagic stroke: 4

• Dilated pupils, agitation, acute onset severe headache, lower Glasgow Coma Scale score, seizures, and eye gaze impairment are significantly more common in hemorrhagic stroke. 4
• Gradual progressive headache is significantly more common in ischemic stroke. 4

Acute Management of Ischemic Stroke

Thrombolytic Therapy (Time-Critical)

Administer IV tPA 0.9 mg/kg (maximum 90 mg) with 10% as bolus over 1 minute and remainder over 60 minutes if all criteria are met: 1, 2

• Symptom onset within 3 hours (Class I recommendation with strongest evidence). 2
• CT confirms ischemic stroke with no hemorrhage. 2
• No contraindications exist (recent surgery, active bleeding, platelets <100,000, INR >1.7, glucose <50 or >400 mg/dL, recent stroke or head trauma within 3 months). 2

Consider IV thrombolysis in the 3-4.5 hour window for eligible patients without extended contraindications (age >80 years, oral anticoagulant use regardless of INR, baseline NIHSS >25, or history of both diabetes and prior stroke). 2

Mechanical Thrombectomy

Consider mechanical thrombectomy for large vessel occlusion within 6-24 hours in selected patients based on advanced imaging showing salvageable tissue. 1, 3, 2 This can extend beyond the thrombolysis window and should be performed at comprehensive stroke centers. 2

Blood Pressure Management

Critical distinction based on thrombolysis status: 1, 3, 2

If thrombolysis administered:

• Maintain blood pressure <180/105 mmHg for at least 24 hours to prevent hemorrhagic transformation. 1, 2
• Treat aggressively if BP exceeds this threshold using IV labetalol or nicardipine. 1, 2

If no thrombolysis:

• Avoid aggressive blood pressure reduction in the acute phase—permissive hypertension maintains cerebral perfusion. 2
• Only treat if systolic BP >220 mmHg or diastolic >120 mmHg, and lower cautiously. 2

Antiplatelet Therapy

• Administer aspirin 160-300 mg within 48 hours of stroke onset. 2
• Delay aspirin for 24 hours if thrombolysis was given to reduce bleeding risk. 2

Acute Management of Hemorrhagic Stroke

Control systemic hypertension with goal systolic BP 130-150 mmHg. 1, 3

• Immediately reverse anticoagulation with dedicated reversal agents (prothrombin complex concentrate for warfarin, idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors). 3
• Administer tranexamic acid to patients with active bleeding as soon as possible. 3
• Consider neurosurgical consultation for hematoma evacuation if: cerebellar hemorrhage >3 cm with neurological deterioration, lobar hemorrhage with significant mass effect, or intraventricular hemorrhage with hydrocephalus. 3

Stroke Unit Care (First 48-72 Hours)

Transfer all patients to a comprehensive stroke unit regardless of stroke severity—this intervention alone reduces mortality by 14% at 1 year and improves functional outcomes. 3, 2

Monitoring and Complication Prevention

• Perform swallowing assessment before allowing any oral intake to prevent aspiration pneumonia—this is non-negotiable. 2
• Use nasogastric or nasoduodenal tube feeding for patients with impaired swallowing. 2
• Monitor for cerebral edema (peaks at 3-5 days but can occur earlier with large infarctions). 2
• Watch for hemorrhagic transformation, seizures, pneumonia, urinary tract infections, and deep vein thrombosis. 2

Metabolic Management

• Treat hyperglycemia >155 mg/dL with insulin. 5
• Treat body temperature >37.5°C with antipyretic drugs. 5
• Maintain euvolemia and avoid hypotonic fluids. 5

Cerebral Edema Management

For swollen supratentorial hemispheric ischemic stroke: 3

• Consider decompressive craniectomy with dural expansion in patients who continue to deteriorate neurologically despite medical management. 3

For swollen cerebellar stroke: 3

• Perform suboccipital craniectomy with dural expansion in patients who deteriorate neurologically. 3

Special Stroke Subtypes

Cerebral Venous Thrombosis (CVT)

Initiate anticoagulation with IV heparin or subcutaneous LMWH even if intracranial hemorrhage is present—hemorrhage from CVT is NOT a contraindication to anticoagulation. 3, 2 This is a common and dangerous misconception. 2

• Diagnose with MRI plus MR venography (preferred over CT). 3
• Continue oral anticoagulation for 3-12 months depending on underlying etiology (provoked vs unprovoked). 3, 2
• Follow-up imaging at 3-6 months to assess for recanalization. 3

Carotid Artery Stenosis

For symptomatic carotid stenosis >70%, perform carotid endarterectomy within 2 weeks of the index event—benefit diminishes with time. 6, 1, 2

• The 2-year ipsilateral stroke risk is 9% with CEA versus 26% with medical therapy alone for 70-99% stenosis. 6
• Perioperative stroke/death risk should be <3% for asymptomatic patients and <6% for symptomatic patients. 6

Secondary Prevention (Initiated After Acute Phase)

Start these interventions 24-48 hours post-stroke: 1, 2

• Initiate high-intensity statin therapy regardless of baseline cholesterol levels (Class I recommendation). 1, 2
• Start antihypertensive therapy with target BP <140/90 mmHg (or <130/80 mmHg for diabetics). 1, 2
• Consider anticoagulation for atrial fibrillation after ruling out hemorrhagic transformation (typically wait 1-2 weeks for large infarcts). 1, 2
• Continue antiplatelet therapy (aspirin 81 mg daily or clopidogrel 75 mg daily). 6

Rehabilitation (Begin Immediately When Stable)

Begin early mobilization as soon as the patient is medically stable—do not wait for complete neurological recovery. 1, 2

• Initiate physical therapy for motor deficits, occupational therapy for activities of daily living, and speech therapy for language/swallowing deficits. 1, 2
• Implement cognitive retraining for attention deficits, visual neglect, memory deficits, and executive function problems. 2
• Use subcutaneous anticoagulants or intermittent external compression stockings to prevent deep vein thrombosis in immobilized patients. 2
• Assess need for inpatient rehabilitation facility versus home with outpatient services based on functional status and social support. 1

Critical Pitfalls to Avoid

• Never delay imaging to obtain detailed history—time is brain. 2
• Never withhold anticoagulation in cerebral venous thrombosis even if hemorrhage is present. 2
• Never aggressively lower blood pressure in acute ischemic stroke unless thrombolysis is given. 2
• Never allow oral intake before swallowing assessment. 2
• Never assume older patients should not receive acute stroke treatment—age alone is not a contraindication to thrombolysis. 2