What is the management approach for cerebral vascular accident (CVA)?

Management of Cerebrovascular Accident (CVA)

Immediate Emergency Assessment

For suspected stroke, immediately perform non-contrast CT imaging to differentiate ischemic from hemorrhagic stroke without delaying for detailed history, and document the precise time of symptom onset or "last known normal" time if the patient awakened with symptoms. 1, 2

• Transport patients directly to a specialized stroke unit, as this reduces mortality by 14% at 1 year compared to general medical wards 3
• Assess stroke severity using the NIH Stroke Scale to guide treatment intensity and prognosis 1
• Focus prehospital care on ventilatory and cardiovascular support while providing advance notice to the receiving facility to activate stroke protocols 3

Acute Management of Ischemic Stroke

Administer IV tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) with 10% given as bolus over 1 minute and the remainder over 60 minutes if the patient presents within 3 hours of symptom onset, CT confirms ischemic stroke, and no contraindications exist. 1, 2

• Consider IV thrombolysis in the 3-4.5 hour window for eligible patients without extended contraindications 1, 2
• Maintain blood pressure <180/105 mmHg if thrombolysis is administered 2, 3
• For large vessel occlusion, perform mechanical thrombectomy within 6-24 hours in selected patients based on advanced imaging showing salvageable tissue 1, 4

Common Pitfalls in Ischemic Stroke Management

• The time window for mechanical thrombectomy has expanded significantly—recent evidence supports intervention up to 24 hours in carefully selected patients with favorable imaging 4
• Do not withhold thrombolysis based solely on age; eligibility depends on time window and contraindications, not arbitrary age cutoffs 1

Acute Management of Hemorrhagic Stroke

Control systemic hypertension with a goal systolic blood pressure of 130-150 mmHg, immediately reverse anticoagulation with dedicated reversal agents, and administer tranexamic acid as soon as possible if active bleeding is present. 1, 2, 3

• For swollen supratentorial hemispheric ischemic stroke with neurological deterioration, consider decompressive craniectomy with dural expansion 3
• For swollen cerebellar stroke with neurological deterioration, perform suboccipital craniectomy with dural expansion 3

Secondary Prevention

Initiate high-intensity statin therapy regardless of baseline cholesterol levels, start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke) with target blood pressure <140/90 mmHg (<130/80 mmHg for diabetics), and begin antiplatelet therapy with aspirin 81 mg daily or clopidogrel 75 mg daily. 1, 2

• For atrial fibrillation, initiate anticoagulation after ruling out hemorrhagic transformation, as this reduces stroke risk by 61% compared to no anticoagulation 5, 6
• Atrial fibrillation is the major risk factor for recurrent stroke, with odds ratios of 1.96 in men and 3.54 in women 6
• For symptomatic carotid stenosis >70%, perform carotid endarterectomy within 2 weeks 2

Antiplatelet vs. Anticoagulation Considerations

• In the CURE trial, clopidogrel plus aspirin reduced the composite endpoint of cardiovascular death, MI, or stroke by 20% compared to aspirin alone (9.3% vs. 11.4%, p<0.001) 5
• CYP2C19 poor metabolizers (2-5% of Caucasians, 14% of Chinese) have reduced clopidogrel efficacy due to decreased active metabolite formation 5
• Discontinuation of antihypertensive therapy increases stroke risk, particularly in women (OR: 2.53) 6

Rehabilitation

Begin early mobilization as soon as the patient is medically stable, and initiate physical therapy for motor deficits, occupational therapy for activities of daily living, and speech therapy for language and swallowing deficits. 1, 2

• Assess for cognitive deficits including attention deficits, visual neglect, memory deficits, and executive function problems, and provide targeted cognitive retraining 7
• For visual neglect after right hemisphere stroke, implement visual-spatial rehabilitation based on Level I evidence from 6 RCTs 7
• Use training to develop compensatory strategies for memory deficits in patients with mild short-term memory impairments who are fairly independent, actively involved in identifying their problems, and motivated to incorporate strategies 7
• For executive function and problem-solving dysfunction, teach formal problem-solving strategies that can be applied to everyday situations and functional activities 7
• Use subcutaneous anticoagulants or intermittent external compression stockings to prevent deep vein thrombosis in immobilized patients 1

Cognitive Rehabilitation Nuances

• Attention training shows fairly small and task-specific improvements, with unclear generalizability to functional outcomes 7
• Multimodal interventions may benefit patients with multiple areas of cognitive impairment, though evidence is limited to Level III studies 7
• Screen all patients for poststroke depression, which often manifests subtly as refusal to participate in rehabilitation 7

Special Populations and Conditions

Cerebral Venous Thrombosis

• Diagnose with MRI plus MRV as the preferred method 3
• Initiate anticoagulation even in the presence of hemorrhagic transformation if no major contraindications exist 3
• Continue oral anticoagulation for 3-12 months or lifelong depending on underlying etiology 3

Stroke Mimics

• Common conditions mimicking stroke include vertigo (19%), electrolyte and metabolic disturbances (12%), seizures (11%), cardiovascular disorders (10%), blood hypertension (8%), and brain tumors (5%) 8
• The positive predictive value of prehospital stroke diagnosis is 70% for stroke but only 34% for TIA, indicating frequent overdiagnosis of TIA 8