What are the key components of case management for a patient with a cerebral vascular accident (CVA)?

CVA Case Management

Patients with cerebrovascular accident (CVA) should be immediately admitted to a specialized stroke unit with comprehensive multidisciplinary care, as this approach reduces mortality by 14% at one year and significantly improves functional outcomes compared to general medical ward care. 1, 2

Immediate Assessment and Stabilization

• Document the precise time of symptom onset (or "last known normal" time if patient awakens with symptoms), as this determines eligibility for time-sensitive reperfusion therapies 2, 3
• Perform immediate non-contrast CT imaging to differentiate ischemic from hemorrhagic stroke before initiating any treatment—do not delay imaging to obtain detailed history 2, 3
• Assess stroke severity using the NIH Stroke Scale to guide treatment decisions and establish baseline for monitoring 2, 3
• Monitor neurological status and vital signs frequently during the first 24-48 hours, as approximately 25% of patients experience neurological worsening during this period 1

Acute Management: Ischemic Stroke

• Administer IV tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) if patient presents within 3 hours of symptom onset with confirmed ischemic stroke on CT and no contraindications—give 10% as bolus over 1 minute, remainder over 60 minutes 2, 3
• Consider IV thrombolysis in the 3-4.5 hour window for eligible patients without extended contraindications 2
• For patients receiving thrombolysis, maintain blood pressure below 180/105 mmHg for at least 24 hours to reduce bleeding risk 3
• Consider mechanical thrombectomy for large vessel occlusion within 6-24 hours in selected patients based on advanced imaging showing salvageable tissue 2, 4

Acute Management: Hemorrhagic Stroke

• Control systemic hypertension with goal systolic BP 130-150 mmHg 2, 4
• Immediately reverse anticoagulation with dedicated reversal agents for patients on anticoagulant therapy 2, 4
• Administer tranexamic acid to patients with active bleeding as soon as possible 2, 4

Specialized Stroke Unit Care Components

The stroke unit should provide geographically defined care with skilled professionals including physicians, nurses, and rehabilitation personnel, with regular communications and coordinated care as key aspects 1

General Medical Management

• Begin early mobilization as soon as the patient's condition is stable, but observe closely during transition to upright posture as some patients experience neurological worsening 1, 2
• Implement frequent turning and alternating pressure mattresses with close skin surveillance to prevent pressure sores 1
• Apply measures to avoid falls during mobilization 1
• Maintain adequate hydration and nutrition as dehydration may slow recovery and increase deep vein thrombosis risk 1

Swallowing Assessment and Nutrition

• Perform early swallowing assessment before allowing oral intake to prevent aspiration pneumonia, as impairments in swallowing are associated with high pneumonia risk and increased mortality 1, 3
• Patients with brain stem infarctions, multiple strokes, major hemispheric lesions, or depressed consciousness are at greatest risk for aspiration 1
• Consider nasogastric or nasoduodenal tube feeding for patients with impaired swallowing to maintain nutrition 3

Prevention of Subacute Complications

• Use subcutaneous anticoagulants or intermittent external compression stockings to prevent deep vein thrombosis in immobilized patients 2, 3
• Monitor aggressively for and treat pneumonia, urinary tract infections, and deep vein thrombosis 3
• Watch for cerebral edema (typically peaks 3-5 days after stroke but can occur earlier with large infarctions), seizures, and hemorrhagic transformation 3

Rehabilitation: Early and Comprehensive

Begin rehabilitation interventions as soon as the patient is medically stable, as early mobilization lessens the likelihood of complications and improves outcomes 1, 2

Motor and Functional Rehabilitation

• Initiate physical therapy for motor deficits to restore movement and prevent contractures 2
• Provide occupational therapy for activities of daily living to maximize independence 2
• Implement speech therapy for language and swallowing deficits 2

Cognitive Rehabilitation

Patients should be assessed for cognitive deficits and receive cognitive retraining for the following conditions 1:

• Attention deficits: Use training to improve attention in post-acute stroke patients, as multiple RCTs demonstrate benefit though improvements may be task-specific 1
• Visual neglect: Implement visual-spatial rehabilitation for neglect after right CVA, supported by 6 Level I studies and 8 Level II studies 1
• Memory deficits: Use training to develop compensatory strategies for patients with mild short-term memory deficits who are fairly independent, actively involved in identifying problems, and motivated to incorporate strategies 1
• Executive function and problem-solving difficulties: Apply formal problem-solving strategies that can be applied to everyday situations and functional activities 1

Patients with multiple areas of cognitive impairment may benefit from multimodal cognitive retraining approaches involving multiple disciplines 1

Secondary Prevention

• Initiate high-intensity statin therapy regardless of baseline cholesterol levels 2, 3
• Start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke) with target BP <140/90 mmHg (or <130/80 mmHg for diabetics) 2, 3
• Administer aspirin (160-300 mg) within 48 hours of stroke onset, but typically after 24 hours if thrombolysis was given 3
• For long-term antiplatelet therapy, use aspirin 81 mg daily or clopidogrel 75 mg daily 2
• For patients with atrial fibrillation, consider anticoagulation after ruling out hemorrhagic transformation 2, 3

Monitoring for Neurological Complications

• Observe for neurological worsening during the first 24-48 hours, which occurs in approximately 25% of patients 1
• Monitor for cerebral edema, particularly in patients with large hemispheric or cerebellar infarctions 3, 4
• For swollen supratentorial hemispheric ischemic stroke, consider decompressive craniectomy with dural expansion in patients who continue to deteriorate neurologically 4
• For swollen cerebellar stroke, perform suboccipital craniectomy with dural expansion in patients who deteriorate neurologically 4

Mood and Emotional Disorders

• Screen all patients for emotional disorders given the high incidence of poststroke depression, which often manifests with subtle signs such as refusal to participate in rehabilitation 1

Discharge Planning and Follow-up

• Provide education on stroke warning signs and risk factor modification 3
• Schedule regular follow-up to monitor neurological recovery and medication adherence 3
• Assess need for rehabilitation facility versus home with services based on functional status 3