What is the management and workup for a patient with ischemic cerebral vascular accident (CVA)?

Workup and Management of Ischemic Cerebrovascular Accident

Immediate Emergency Assessment and Stabilization

All patients with suspected ischemic stroke require immediate triage as the highest priority emergency with rapid assessment, neuroimaging within 30 minutes of arrival, and treatment decisions within 60 minutes to maximize outcomes. 1, 2, 3

Initial Evaluation (First 15 Minutes)

• Airway, breathing, and circulation assessment is critical, particularly for seriously ill or comatose patients who may require intubation 4, 1
• Document precise symptom onset time - this single factor determines eligibility for all reperfusion therapies 1, 2, 3
• Perform NIH Stroke Scale (NIHSS) immediately upon arrival to quantify severity and guide treatment decisions 1, 3
• Obtain 12-lead ECG without delaying stroke treatment, and initiate continuous cardiac monitoring for 24-72 hours to detect atrial fibrillation 3

Blood Pressure Management

• Do NOT lower blood pressure aggressively unless >220/120 mmHg - permissive hypertension maximizes cerebral perfusion in acute ischemic stroke 3
• If thrombolysis is planned, blood pressure must be reduced to <185/110 mmHg before administration, then maintained <180/105 mmHg for 24 hours post-treatment 4, 1, 3

Supplemental Oxygen

• Administer supplemental oxygen only if oxygen saturation <94% - routine oxygen supplementation is not recommended 4
• Monitor for hypoxia, which occurs in 63% of hemiparetic patients within 48 hours, especially those with cardiac or pulmonary disease 4

Neuroimaging Protocol

Non-contrast CT head must be completed within 30 minutes of hospital arrival to distinguish ischemic from hemorrhagic stroke and exclude contraindications to thrombolysis 4, 3

Imaging Interpretation

• Brain imaging should be interpreted within 45 minutes by a physician with expertise in reading CT and MRI 4
• Frank hypodensity involving >1/3 of MCA territory is a contraindication to intravenous rtPA due to increased hemorrhage risk 4
• MRI with diffusion-weighted imaging (DWI) is preferred if available and doesn't delay treatment - it's more sensitive for early ischemic changes 4, 3

Vascular Imaging

• Noninvasive intracranial vascular imaging (CTA or MRA) is strongly recommended during initial evaluation if intra-arterial therapy or mechanical thrombectomy is contemplated, but should not delay IV rtPA 4

Reperfusion Therapy

Intravenous Thrombolysis

For patients presenting within 3 hours of symptom onset with no contraindications, administer intravenous recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg), with 10% given as bolus and 90% as infusion over 60 minutes. 4, 1, 2, 3

• Intravenous fibrinolytic therapy is recommended even with early ischemic changes on CT (other than frank hypodensity), regardless of extent 4
• Door-to-needle time should be ≤30 minutes for optimal outcomes 1, 3

Mechanical Thrombectomy

• Consider mechanical thrombectomy for large vessel occlusion if within appropriate time window 2
• This requires noninvasive vascular imaging to identify the occlusion 4

Antiplatelet Therapy

Administer aspirin 160-300 mg within 48 hours of stroke onset, but delay for 24 hours if thrombolysis was given to reduce risk of hemorrhagic transformation 4, 1, 2, 3

• Aspirin reduces early stroke recurrence and improves outcomes 4
• Early aspirin use is associated with a small increase in hemorrhagic transformation risk, but benefits outweigh risks 4

Comprehensive Stroke Unit Care

All patients with ischemic stroke should be admitted to a comprehensive specialized stroke unit - this organized care significantly reduces morbidity and mortality 4, 1, 2, 3

Early Mobilization and Rehabilitation

• Begin early mobilization when medically stable to prevent complications and improve outcomes 4, 1, 2
• Initiate physical, occupational, and speech therapy assessments early to address motor, sensory, language, cognitive, and visual deficits 2

Swallowing Assessment

Perform swallowing assessment before allowing any oral intake to prevent aspiration pneumonia 4, 1

• Patients with brainstem infarctions, multiple strokes, large hemispheric lesions, or depressed consciousness are at highest risk 4
• For patients with impaired swallowing, insert nasogastric or nasoduodenal tube for feeding and medication administration 4, 1
• Consider percutaneous endoscopic gastrostomy (PEG) tube if prolonged feeding support is anticipated, though optimal timing is uncertain 4

Prevention of Acute Complications

Deep Vein Thrombosis Prophylaxis

For immobilized patients, administer subcutaneous anticoagulants (unfractionated heparin or low-molecular-weight heparin) to prevent deep vein thrombosis - this is a quality indicator for stroke centers 4, 1

• There is no significant difference in efficacy or safety between unfractionated and low-molecular-weight heparins 4
• For patients with contraindications to anticoagulants, use intermittent external compression devices 4
• Aspirin may be used as alternative prophylaxis but is less effective than anticoagulants 4

Infection Prevention and Treatment

• Monitor for pneumonia, which is a leading cause of death after stroke, especially in immobile patients or those unable to cough 4
• Treat urinary tract infections promptly - avoid indwelling bladder catheters when possible due to infection risk 4
• Administer antibiotics early when infectious complications are identified 4

Management of Neurological Complications

Cerebral Edema and Increased Intracranial Pressure

Monitor for cerebral edema, which typically peaks 3-5 days after stroke but can occur earlier with large infarctions 4, 1

• Corticosteroids are NOT recommended for cerebral edema management after ischemic stroke 4
• Osmotherapy and hyperventilation are recommended for patients deteriorating from increased intracranial pressure, including herniation syndromes 4
• Surgical decompression and evacuation of large cerebellar infarctions causing brainstem compression and hydrocephalus is recommended and can be life-saving 4

Seizure Management

• Seizures occur in 4-43% of patients, most commonly within 24 hours of stroke 4
• Treat recurrent seizures as with any acute neurological condition 4
• Prophylactic anticonvulsants are NOT recommended for patients who have not had seizures 4

Hemorrhagic Transformation

• Approximately 5% of infarctions spontaneously develop symptomatic hemorrhagic transformation 4
• Management depends on the amount of bleeding and associated symptoms 4
• Small asymptomatic petechiae are less concerning than hematomas causing neurological decline 4

Etiologic Workup

Cardiac Evaluation

Perform continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation, which is a major risk factor requiring anticoagulation 1

• Evaluate for other cardiac sources of embolism including valvular disease and left ventricular thrombus 4

Vascular Assessment

Noninvasive imaging of cervical vessels (carotid ultrasound, CTA, or MRA) should be performed routinely to identify carotid stenosis 4

• For symptomatic carotid stenosis >70%, consider carotid endarterectomy within 2 weeks of stroke to reduce recurrence risk 4, 2
• The benefit of surgery diminishes with time after the initial event 4

Laboratory Studies

• Lipid profile (total cholesterol, triglycerides, HDL, LDL) 4
• Hemoglobin A1c or fasting glucose to assess diabetes 4
• Coagulation studies if hemorrhagic transformation or hypercoagulable state suspected 4

Secondary Prevention

Lipid Management

Initiate high-dose statin therapy regardless of baseline cholesterol levels - this is a quality indicator for stroke care 4, 1, 2, 3

Blood Pressure Management

Start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke) to reduce long-term recurrence risk 1, 2, 3

• Long-term blood pressure control is critical for preventing recurrent stroke 4

Anticoagulation

For patients with atrial fibrillation, initiate anticoagulation after ruling out hemorrhagic transformation (typically after repeat imaging at 24-48 hours) 1, 2, 3

Lifestyle Modifications

• Smoking cessation is essential 4
• Dietary modifications to address hyperlipidemia and diabetes 4
• Activity modifications reflecting neurological impairments 4

Discharge Planning and Follow-up

• Assess need for inpatient rehabilitation facility versus home with services based on functional status and NIHSS score 2
• Provide education on stroke warning signs (FAST: Face drooping, Arm weakness, Speech difficulty, Time to call 911) and risk factor modification 1, 2
• Schedule regular follow-up to monitor neurological recovery, medication adherence, and risk factor control 1
• Screen for and treat post-stroke depression as needed 4