What are the management options and doses for cerebrovascular accident (CVA) or stroke?

Management of Cerebrovascular Accident (CVA)

Immediate Stabilization and Assessment

For acute ischemic stroke, intravenous recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) administered within 3 hours of symptom onset is the cornerstone of treatment, with 10% given as bolus and 90% infused over 1 hour. 1

Airway, Breathing, and Circulation

• Secure airway and provide supplemental oxygen to maintain oxygen saturation ≥94% in patients with hypoxia 2
• Correct hypotension and hypovolemia to maintain adequate cerebral perfusion 2
• Check capillary blood glucose immediately and treat hypoglycemia with IV dextrose 2
• Avoid aggressive blood pressure lowering unless systolic BP >220 mmHg or diastolic >120 mmHg in thrombolysis candidates 1, 2

Urgent Diagnostic Evaluation

• Perform immediate non-contrast CT or MRI to differentiate hemorrhagic from ischemic stroke (within 24 hours, but ideally within minutes for thrombolysis candidates) 1
• Obtain CT angiography or MR angiography to identify large vessel occlusions requiring endovascular therapy 1
• Complete basic laboratory tests: complete blood count, electrolytes, renal function, coagulation studies (PT/INR, aPTT), glucose, and ECG 1, 2

Acute Ischemic Stroke Treatment

Intravenous Thrombolysis

Administer rtPA 0.9 mg/kg (maximum 90 mg) with 10% as initial bolus and remainder over 1 hour for patients presenting within 3 hours of symptom onset. 1

• Extended window (3-4.5 hours): rtPA can be administered with additional exclusions: age >80 years, NIHSS >25, oral anticoagulant use regardless of INR, or combination of prior stroke and diabetes 1
• The benefit decreases with time: OR 2.81 for treatment within 1.5 hours, 1.55 for 1.5-3 hours, 1.40 for 3-4.5 hours 1

Key contraindications for rtPA:

• Intracranial hemorrhage on imaging 1
• Recent major surgery or trauma 1
• Active bleeding or coagulopathy 1
• Systolic BP >185 mmHg or diastolic >110 mmHg (unless controlled) 1

Endovascular Therapy

• Mechanical thrombectomy is indicated for large vessel occlusions (internal carotid artery, M1 segment of middle cerebral artery) within 6 hours of symptom onset 1, 3
• Recent evidence suggests extending the window to 24 hours in selected patients based on advanced imaging showing salvageable tissue 1, 3
• Can be combined with intravenous rtPA 1

Antiplatelet Therapy

Aspirin 160-300 mg should be initiated within 48 hours of ischemic stroke onset (after hemorrhage is excluded by imaging). 1

• Do not administer aspirin within 24 hours of rtPA treatment 1
• Provides modest benefit with reasonable safety profile 1

Anticoagulation

• Urgent anticoagulation (unfractionated heparin, low molecular weight heparin) is not recommended for routine acute ischemic stroke due to increased hemorrhage risk without proven benefit 1
• May be considered for specific indications like cerebral venous thrombosis 1

Hemorrhagic Stroke Management

Intracerebral Hemorrhage

Target systolic blood pressure to 140 mmHg in patients with intracerebral hemorrhage presenting within 6 hours if initial systolic BP is 150-220 mmHg. 2

• Immediately discontinue anticoagulation and reverse coagulopathy 2
• For warfarin: administer vitamin K and prothrombin complex concentrate or fresh frozen plasma 1
• Monitor for neurological deterioration and increased intracranial pressure 1

Surgical Interventions

• Cerebellar hemorrhage/infarction: Surgical decompression and evacuation is recommended for large lesions causing brainstem compression and hydrocephalus 1
• Large hemispheric infarction: Decompressive hemicraniectomy can be life-saving but survivors have severe residual impairments 1
• Hydrocephalus: Ventricular drainage for increased intracranial pressure secondary to hydrocephalus 1

Blood Pressure Management

Ischemic Stroke

• Do not lower blood pressure unless: 1, 2
  • Systolic BP >220 mmHg or diastolic >120 mmHg (not receiving thrombolysis)
  • Systolic BP >185 mmHg or diastolic >110 mmHg (candidate for thrombolysis)
  • Concomitant acute myocardial infarction, aortic dissection, or hypertensive encephalopathy
• Permissive hypertension supports collateral flow to ischemic penumbra 1

Hemorrhagic Stroke

• Target systolic BP <140 mmHg in patients with history of hypertension and mean arterial pressure <130 mmHg 1, 2

Management of Complications

Increased Intracranial Pressure

• Elevate head of bed to 30 degrees 1
• Osmotic therapy (mannitol or hypertonic saline) for patients deteriorating from increased intracranial pressure or herniation 1
• Avoid hypotonic fluids 1

Seizures

• Treat recurrent seizures with anticonvulsants as with any acute neurological condition 1
• Prophylactic anticonvulsants are not recommended for stroke patients without seizures 1

Temperature and Glucose Control

• Treat fever aggressively; hyperthermia worsens outcomes 4
• Maintain blood glucose <8 mmol/L (144 mg/dL); hyperglycemia predicts poor prognosis 4
• Avoid hypoglycemia 4

Stroke Unit Care

All stroke patients should receive organized stroke unit care, which significantly improves outcomes compared to general medical ward care. 1

• Multidisciplinary team including neurology, nursing, physical therapy, occupational therapy, speech therapy 1
• Early mobilization and rehabilitation 1
• Prevention of complications: deep venous thrombosis prophylaxis (subcutaneous heparin or compression devices), aspiration pneumonia prevention, pressure ulcer prevention 1

Common Pitfalls to Avoid

• Do not delay transfer for extensive diagnostic workup in primary care or non-stroke centers 2
• Do not administer aspirin before brain imaging excludes hemorrhage 2
• Do not use hemodilution or vasodilatory agents (pentoxifylline) for acute stroke treatment 1
• Do not use neuroprotective agents outside clinical trials; none have proven efficacy 1
• Do not aggressively lower blood pressure in acute ischemic stroke unless specific indications exist 1, 2