What is the comprehensive management approach for a patient presenting with a cerebral vascular accident (CVA) or stroke?

Comprehensive Management of Cerebrovascular Accident (CVA): Detailed Case Presentation Logic

Immediate Prehospital and Emergency Department Triage

Stroke patients must receive the highest triage priority with immediate notification of the receiving hospital, preferably one with organized stroke unit care, to facilitate rapid assessment and minimize door-to-needle time to ≤30 minutes. 1, 2

Critical Time Documentation

• Record the exact time of symptom onset or last known well - this single data point determines eligibility for all reperfusion therapies (thrombolysis within 3-4.5 hours, mechanical thrombectomy potentially up to 24 hours). 3, 4, 5
• Document whether symptoms began suddenly (typical) or evolved over minutes to hours. 1
• For wake-up strokes where onset time is unknown, specialized MRI imaging may extend treatment windows up to 9 hours. 6, 7

Initial Stabilization (ABCs)

• Assess airway, breathing, and circulation immediately - posterior circulation strokes can require aggressive airway management if consciousness is altered. 1, 3
• Apply cardiac monitoring to all suspected stroke patients to identify atrial fibrillation, acute myocardial infarction, or congestive heart failure, which may cause circulatory collapse (uncommon in isolated ischemic stroke). 1
• Maintain oxygen saturation ≥92-94% with supplemental oxygen 2-3 L/min via nasal cannula as needed, though routine supplemental oxygen for non-hypoxic patients shows no clear benefit. 1, 2

Rapid Neurological Assessment

NIH Stroke Scale (NIHSS)

• Perform NIHSS assessment immediately upon arrival to quantify stroke severity and guide treatment decisions. 3, 2
• Repeat NIHSS every 15 minutes for 2 hours during thrombolysis, then every 30 minutes for 6 hours, then hourly for 16 hours to detect clinical deterioration. 1, 2
• **Patients with NIHSS <15 (preferably <10) are optimal candidates for early intervention**; those with NIHSS >15 who are obtunded have poor outcomes with aggressive intervention. 8

Vital Signs Monitoring Protocol

• Measure vital signs including temperature every 15-30 minutes initially, then at least every 30 minutes while in the ED. 1
• Treat any fever >37.5°C (99.6°F) with acetaminophen - hyperthermia is associated with poor outcomes. 1, 2
• Temperature should be monitored every 4 hours for the first 48 hours. 2

Emergent Neuroimaging (Target: Within 25-30 Minutes)

Non-contrast CT head must be completed within 30 minutes of hospital admission to distinguish ischemic from hemorrhagic stroke and exclude stroke mimics. 2

Imaging Protocol Logic

• Never delay imaging for laboratory results (except coagulation studies if thrombolysis is being considered). 2
• Never use contrast-enhanced CT initially as it may obscure hemorrhage. 2
• If patient arrives within 6 hours and is potentially eligible for endovascular thrombectomy, add CT angiography (CTA) from arch-to-vertex without delay. 2
• MRI with diffusion-weighted imaging (DWI) is acceptable if available and doesn't delay treatment - it's more sensitive than CT for ischemic changes and has similar accuracy for acute hemorrhage. 1, 2

Imaging Interpretation Goals

• Differentiate ischemic infarction from intracerebral hemorrhage (ICH). 1
• Identify stroke mimics (seizures, migraine, hypoglycemia, nonvascular lesions). 1, 4
• Localize the lesion and determine vascular territory affected (anterior vs. posterior circulation). 1, 4
• Assess for large vessel occlusion requiring mechanical thrombectomy. 6, 7

Laboratory Evaluation (Concurrent with Imaging)

Draw complete blood count with platelets, comprehensive metabolic panel, coagulation studies (PT/INR, aPTT), and troponin immediately. 2

Additional Laboratory Studies

• Glucose level is mandatory to rule out hypoglycemia as a stroke mimic. 1, 6
• Hemoglobin A1C and fasting lipid panel for risk stratification. 2
• Full blood count, electrolytes, renal function, cholesterol levels, and electrocardiogram are routine despite lacking direct evidence for each. 1

Blood Pressure Management Strategy

For Thrombolysis Candidates

• Blood pressure must be <185/110 mmHg before administering thrombolysis, then maintained <180/105 mmHg for 24 hours post-treatment. 3, 2
• Check pulse and blood pressure at least every 15 minutes during the 60-minute rtPA infusion. 1

For Non-Thrombolysis Ischemic Stroke

• Avoid aggressive BP lowering unless >220/120 mmHg - permissive hypertension may maximize cerebral blood flow. 2
• Head-flat positioning may optimize cerebral perfusion if no contraindications exist. 2

For Hemorrhagic Stroke

• Control systemic hypertension with goal systolic BP 130-150 mmHg. 4
• Immediately discontinue anticoagulation and arrange reversal. 4, 2

Reperfusion Therapy Decision Algorithm

Intravenous Thrombolysis (rtPA)

For patients presenting within 3 hours of symptom onset, intravenous recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) is strongly recommended if no contraindications exist. 1, 3

• Aspirin 160-300 mg should be commenced within 48 hours of ischemic stroke onset, but typically after 24 hours if thrombolysis was given. 1, 3
• Never give aspirin or antithrombotics before brain imaging rules out hemorrhage. 2
• If thrombolysis is administered: NO heparin, warfarin, aspirin, clopidogrel, or dipyridamole for 24 hours. 2

Mechanical Thrombectomy

• Consider mechanical thrombectomy for large vessel occlusion - this is now the gold standard for large vessel occlusions in the anterior circulation. 4, 7
• Therapeutic windows extend to 6 hours, with recent data suggesting potential benefit up to 24 hours in selected patients. 5, 6
• Up to one-third of large-core patients can be functionally independent at 90 days with expanded thrombectomy indications. 7

Positioning and Aspiration Prevention

Head of Bed Positioning

• Elevate head of bed 25-30° if increased intracranial pressure is suspected (large lobar infarction, space-occupying lesions). 1, 2
• Elevate ≥30° if aspiration risk is present. 2
• Head-flat position may maximize cerebral blood flow if no contraindications. 2

Swallowing Assessment

• Keep patient NPO (including oral medications) until swallowing assessment is completed to prevent aspiration pneumonia. 3, 2
• Implement early swallowing assessment before allowing any oral intake. 3
• For patients with impaired swallowing, consider nasogastric or nasoduodenal tube feeding. 3

Cardiac Evaluation Protocol

Perform 12-lead ECG immediately without delaying stroke treatment, and initiate continuous cardiac monitoring for 24-72 hours to detect atrial fibrillation and arrhythmias. 2

• Cardiac monitoring for at least 24 hours helps identify atrial fibrillation, a major risk factor for ischemic stroke. 3
• Echocardiography (at least transthoracic) within 24 hours if no cardiac source is identified. 2

Vascular Imaging for Secondary Prevention

Perform Doppler ultrasound of carotid/vertebral arteries within 24 hours. 2

• CTA or MRA of cervical vessels for patients with suspected large vessel disease. 2
• For symptomatic carotid stenosis >70%, consider carotid endarterectomy within 2 weeks in patients with stable mild-to-moderate stroke (NIHSS <15). 4, 8
• Early carotid intervention prevents the 20% risk of secondary events that occur while waiting the traditional 4-6 weeks. 8

Stroke Unit Care and Monitoring

Comprehensive stroke unit care is recommended for all patients with ischemic stroke - this organized care reduces morbidity and mortality. 1, 3

High-Risk TIA Management

• Patients with ABCD2 score ≥4 should be admitted to a stroke unit to facilitate rapid assessment and treatment within 24-48 hours. 1
• Those with ABCD2 score <4 may be managed in the community but should have CT brain and carotid ultrasound within 48-72 hours. 1

Complication Prevention and Management

Venous Thromboembolism Prophylaxis

• Start intermittent pneumatic compression (IPC) devices bilaterally within 24 hours, continuing until independently mobile, discharge, or 30 days. 2
• Low-molecular-weight heparin (enoxaparin) for high VTE risk patients; unfractionated heparin if renal failure. 2

Neurological Complications Monitoring

• Monitor for cerebral edema, which typically peaks 3-5 days after stroke but can occur earlier with large infarctions. 3
• Watch for seizures and hemorrhagic transformation. 3
• Treat acute seizures with short-acting medications (lorazepam IV) if not self-limiting, but do NOT start prophylactic anticonvulsants. 2
• Single self-limiting seizure at onset does not require long-term anticonvulsants. 2

Infection Prevention

• Monitor for and aggressively treat pneumonia, urinary tract infections, and deep vein thrombosis. 3

Fluid Management

Administer normal saline at 75-100 mL/hour to maintain adequate hydration. 2

Early Rehabilitation

Begin early mobilization when the patient is medically stable. 3, 4

• Initiate physical, occupational, and speech therapy assessments. 4
• Address specific deficits: motor, sensory, language, cognitive, and visual impairments. 3, 4

Secondary Prevention Initiation

Antiplatelet Therapy

• If no thrombolysis: start aspirin 160-325 mg within the first 24 hours of admission. 2

Statin Therapy

• Initiate statin therapy regardless of baseline cholesterol levels. 3, 4

Antihypertensive Therapy

• Start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke). 3, 4

Anticoagulation

• For patients with atrial fibrillation, consider anticoagulation after ruling out hemorrhagic transformation. 3, 4

Special Considerations for Multifocal Ischemic Stroke

• Perform thorough cardiac evaluation to detect atrial fibrillation, which is a major source of emboli. 3
• Consider advanced vascular imaging to identify potential embolic sources. 3

Critical Pitfalls to Avoid

• Never delay door-to-needle time beyond 60 minutes (target ≤30 minutes). 2
• Never give aspirin before imaging rules out hemorrhage. 2
• Avoid overly aggressive intervention in patients with NIHSS >15 who are obtunded or have no "brain at risk" to salvage. 8
• For arterial dissections that are not flow-limiting, avoid aggressive stenting requiring dual antiplatelet therapy due to increased bleeding risk. 7

Discharge Planning

• Assess need for rehabilitation facility versus home with services based on functional status. 4
• Provide education on stroke warning signs and risk factor modification. 4
• Schedule regular follow-up to monitor neurological recovery and medication adherence. 4