What is the management of a patient presenting with a CVA (Cerebrovascular Accident) or stroke?

Management of Cerebrovascular Accident (CVA)

All patients presenting with suspected stroke require immediate stabilization, rapid neuroimaging within minutes, and urgent consideration for reperfusion therapy (IV thrombolysis within 3-4.5 hours or mechanical thrombectomy for large vessel occlusion), followed by admission to a specialized stroke unit for comprehensive care and secondary prevention. 1, 2

Prehospital and Emergency Department Priorities

Immediate Recognition and Transport

• Activate emergency medical services (EMS) immediately upon recognition of stroke symptoms—EMS transport with prehospital hospital notification reduces time to brain imaging by 3-fold compared to private transport 3
• EMS should provide advance notification to the receiving hospital, which significantly shortens time to CT scanning and increases likelihood of receiving thrombolytic therapy 1
• Transport directly to a stroke-capable center with neurology, neurosurgery, neuroradiology, and critical care capabilities available 24/7 1, 4

Critical Initial Assessment (First 10-15 Minutes)

• Airway, breathing, and circulation (ABCs) must be assessed and stabilized immediately, particularly in comatose or seriously ill patients 1
• Document the exact time of symptom onset (or last known normal time)—this single piece of information determines eligibility for all time-sensitive reperfusion therapies 1, 2
• Perform rapid neurological examination using a standardized stroke scale (NIHSS or Canadian Neurological Scale) to quantify stroke severity 1
• Assess heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1

Urgent Neuroimaging (Target: Within 25 Minutes of Arrival)

• Non-contrast CT scan of the brain is mandatory and should be completed within 25 minutes of hospital arrival to differentiate ischemic from hemorrhagic stroke 1
• CT is the gold standard for detecting acute hemorrhage; MRI with gradient echo sequences is equally sensitive but often impractical in the hyperacute setting 1
• For patients with suspected large vessel occlusion and potential thrombectomy candidacy, obtain CT angiography (CTA) immediately—do not delay for renal function results in most cases ("neurons over nephrons") 1

Essential Laboratory Studies

• Draw blood immediately for: glucose, complete blood count, electrolytes, creatinine/eGFR, coagulation studies (INR, aPTT), and troponin 1
• Critical caveat: Do not wait for laboratory results before initiating imaging or treatment decisions unless there is specific clinical indication (e.g., known warfarin use requiring INR) 1
• Check fingerstick glucose immediately—hypoglycemia (<60 mg/dL) can mimic stroke and requires immediate IV glucose administration 1

ECG and Chest X-Ray Timing

• Obtain 12-lead ECG to screen for atrial fibrillation and acute cardiac conditions 1, 2
• Unless the patient is hemodynamically unstable, defer ECG and chest X-ray until after thrombolysis decisions are made—these should not delay acute stroke treatment 1

Acute Reperfusion Therapy

Intravenous Thrombolysis (tPA/Alteplase)

• For patients presenting within 3 hours of symptom onset with ischemic stroke and no contraindications, administer IV alteplase 0.9 mg/kg (maximum 90 mg) immediately 1, 2
• Selected patients may benefit from treatment up to 4.5 hours from onset 5
• Blood pressure must be reduced to <185/110 mmHg before administering thrombolysis to avoid hemorrhagic complications 1
• After thrombolysis, maintain blood pressure <180/105 mmHg for at least 24 hours 1, 5, 4

Mechanical Thrombectomy

• Consider endovascular thrombectomy for patients with large vessel occlusion presenting within the appropriate time window (typically up to 24 hours in selected cases) 2, 5
• CTA should be obtained urgently to identify large vessel occlusion candidates 1

Blood Pressure Management

For Ischemic Stroke (NOT Receiving Thrombolysis)

• Do not aggressively lower blood pressure unless systolic BP >220 mmHg or diastolic BP >120 mmHg—rapid reduction may worsen ischemia by decreasing cerebral perfusion pressure 1
• This remains controversial, but consensus supports permissive hypertension in the acute phase to maintain penumbral perfusion 1

For Hemorrhagic Stroke

• For spontaneous intracerebral hemorrhage presenting within 6 hours, reduce systolic BP acutely to target of 140 mmHg (strictly avoid SBP <110 mmHg) 4
• Control systemic hypertension with goal systolic BP 130-150 mmHg for hemorrhagic stroke 5

For Hypotension

• If systolic BP <120 mmHg or significantly below premorbid baseline, place patient flat and administer isotonic saline to improve cerebral perfusion 1

Antiplatelet Therapy

• Administer aspirin 160-300 mg within 24-48 hours of ischemic stroke onset 1, 5, 4
• For patients who received thrombolysis, delay aspirin administration until >24 hours post-tPA to reduce hemorrhagic risk 1, 4
• Patients with aspirin allergy should receive an alternative antiplatelet agent 1

Stroke Unit Care and Monitoring

Admission and Monitoring

• All stroke patients should be admitted to a specialized stroke unit—this is associated with reduced mortality and improved functional outcomes 1, 2, 5
• Critically ill patients require intensive care unit admission 1
• Cardiac monitoring for at least 24 hours to detect atrial fibrillation and serious arrhythmias 1, 2, 4

Seizure Management

• Treat acute seizures at stroke onset with short-acting medications (e.g., lorazepam IV) only if not self-limited 1
• Do not start long-term anticonvulsant therapy for a single self-limited seizure occurring within 24 hours of stroke onset 1
• Antiseizure medications are indicated only for documented recurrent secondary seizures 1, 4

Temperature and Fever Control

• Monitor body temperature continuously 1, 4
• Treat fever (temperature >38°C) aggressively—investigate and treat sources of infection 1, 4

Oxygen and Respiratory Support

• Administer supplemental oxygen to maintain oxygen saturation >94% 1
• Most ischemic stroke patients do not require emergency airway management unless there is respiratory insufficiency 1

Management of Complications

Cerebral Edema and Malignant Stroke

• Monitor for cerebral edema, which typically peaks 3-5 days after stroke but can occur earlier with large infarctions 2
• Patients with massive cerebral or cerebellar infarction at risk of malignant swelling should be rapidly transferred to a neurosurgical center 1
• Decompressive hemicraniectomy within 48 hours is indicated for massive hemispheric infarction with worsening neurological condition (greatest functional benefit in patients <60 years) 1
• For cerebellar infarction with brainstem compression or hydrocephalus, perform ventriculostomy and/or decompressive suboccipital craniectomy 1

Hemorrhagic Transformation

• Monitor for hemorrhagic transformation, particularly in patients who received thrombolysis 2
• Serial neurological examinations and repeat head CT when clinically indicated 1

Aspiration Prevention

• Perform swallowing assessment before allowing any oral intake—aspiration pneumonia is a leading cause of morbidity and mortality 2
• For patients with impaired swallowing, initiate nasogastric or nasoduodenal tube feeding 2

Venous Thromboembolism Prevention

• For patients with limited mobility, use thigh-high intermittent pneumatic compression devices (IPC) 1
• Consider subcutaneous anticoagulants for immobilized patients to prevent deep vein thrombosis 2

Early Mobilization and Rehabilitation

• Begin gradual early mobilization as soon as the patient is medically stable 1, 2, 5
• Initiate comprehensive rehabilitation addressing motor, sensory, language, and cognitive deficits 2, 5
• Physical, occupational, and speech therapy assessments should begin in the acute phase 5

Secondary Prevention

Statin Therapy

• Initiate statin therapy regardless of baseline cholesterol levels 2, 5
• For patients already on statins at stroke onset, continue during the acute period 1

Antihypertensive Therapy

• Start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke) 2, 5

Anticoagulation for Atrial Fibrillation

• For patients with atrial fibrillation, consider anticoagulation after ruling out hemorrhagic transformation 2, 5
• Timing depends on stroke size and hemorrhagic risk 5

Carotid Revascularization

• For symptomatic carotid stenosis >70%, consider carotid endarterectomy within 2 weeks in neurologically stable patients 5
• Emergency carotid endarterectomy is generally not recommended for acute stroke with large deficits due to high risk of hemorrhagic transformation 1

Special Considerations for Hemorrhagic Stroke

Anticoagulation Reversal

• For hemorrhagic stroke associated with anticoagulants, immediately discontinue anticoagulation and reverse as quickly as possible 4
• Use prothrombin complex concentrate (PCC) for warfarin reversal rather than fresh frozen plasma 1

Hydrocephalus Management

• Patients with spontaneous ICH and symptomatic hydrocephalus should receive ventricular drainage 1, 4
• For cerebellar ICH with neurological deterioration, brainstem compression, or hydrocephalus, perform decompressive suboccipital craniectomy with or without ventricular drainage 1

Discharge Planning and Follow-Up

• Assess need for inpatient rehabilitation facility versus home with services based on functional status 2, 5
• Provide education on stroke warning signs and risk factor modification 2, 5
• Schedule regular follow-up to monitor neurological recovery and medication adherence 2

Common Pitfalls to Avoid

• Do not delay imaging or treatment for laboratory results, ECG, or chest X-ray unless clinically indicated 1
• Do not aggressively lower blood pressure in acute ischemic stroke unless meeting specific thresholds or preparing for thrombolysis 1
• Do not start oral intake before swallowing assessment—aspiration is preventable 2
• Do not discharge TIA patients from the emergency department without complete evaluation and secondary prevention initiation 1
• Do not assume stroke mimics without proper imaging—hypoglycemia, seizures, and migraines can present similarly but require different management 1, 5