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

Management of Cerebrovascular Accident (CVA)

All patients with suspected stroke must be treated as a medical emergency with immediate triage to a specialized stroke unit, rapid neuroimaging within 30 minutes of arrival, and consideration for IV thrombolysis within 4.5 hours or mechanical thrombectomy up to 24 hours for selected patients, followed by comprehensive interdisciplinary stroke unit care. 1, 2

Immediate Emergency Response and Triage

• Transfer immediately to a stroke unit or intensive care unit with neuromonitoring capabilities and skilled physicians (neurointensivists, vascular neurologists, neurosurgeons) for all patients with suspected stroke 3, 1, 2
• Document the precise time of symptom onset or last known normal as this determines eligibility for reperfusion therapies 1, 2
• Perform rapid neurological assessment using the NIH Stroke Scale (NIHSS) immediately upon arrival to quantify deficit severity and guide treatment decisions 1, 2
• Stabilize airway, breathing, and circulation particularly in patients with depressed consciousness or large strokes 3, 1
• Provide supplemental oxygen only if needed to maintain oxygen saturation >94% 4

Emergent Neuroimaging (Within 30 Minutes)

• Non-contrast CT scan must be completed within 30 minutes of hospital admission as the first-line diagnostic test to differentiate ischemic from hemorrhagic stroke and rule out hemorrhage before any treatment 3, 1, 2
• CT findings predicting cerebral edema and poor prognosis include frank hypodensity within 6 hours, involvement of ≥1/3 of MCA territory, and early midline shift 3, 1
• MRI with diffusion-weighted imaging (DWI) is more sensitive for early ischemia, with volumes ≥80 mL predicting rapid fulminant course with malignant edema 3, 1, 2
• Serial CT imaging in the first 2 days is useful to identify patients at high risk for developing symptomatic swelling 3

Acute Reperfusion Therapy for Ischemic Stroke

IV Thrombolysis

• Administer IV alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) immediately for patients presenting within 4.5 hours of symptom onset who meet eligibility criteria and have no contraindications 1, 2, 5
• Blood pressure must be <185/110 mmHg before administering thrombolysis, then maintained <180/105 mmHg strictly for 24 hours after rtPA administration to prevent hemorrhagic transformation 1, 2
• Patients receiving thrombolytic therapy require close monitoring for bleeding complications 4

Mechanical Thrombectomy

• Consider mechanical thrombectomy for patients with large vessel occlusion within 6-24 hours according to specific imaging criteria 2, 4, 6
• Combined endovascular therapy using stent-retrievers and aspiration is most effective for achieving fast first-pass complete reperfusion 4

Blood Pressure Management

• For patients NOT receiving thrombolysis: Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg in the acute phase (permissive hypertension maximizes cerebral blood flow) 1, 2, 4
• For patients receiving thrombolysis: Blood pressure must be maintained <180/105 mmHg strictly for at least 24 hours after rtPA administration 1, 2

Antiplatelet Therapy

• Aspirin 160-300 mg should be administered within 48 hours of ischemic stroke onset 1, 2, 4
• Delay aspirin until 24 hours after thrombolysis if rtPA was given 1, 2
• Anticoagulation is not recommended as standard acute treatment due to increased bleeding risk 1, 4

Airway and Mechanical Ventilation

• Indications for endotracheal intubation include persistent hypoxemia, obstructed airway with pooling secretions, apneic episodes, hypercarbic/hypoxemic respiratory failure, generalized seizures, or recent aspiration 3, 1
• Use rapid sequence intubation with no evidence that depolarizing agents or propofol/fentanyl/lidocaine are harmful 3
• Maintain normocapnia with no benefit from prophylactic hyperventilation and potential harm 3

Swallowing Assessment and Nutrition

• Perform swallowing screening within 24 hours using a validated tool before allowing any oral intake (food, fluids, or medications) 1, 4
• Patients with impaired swallowing should use nasogastric or nasoduodenal tube feeding to maintain nutrition and prevent dehydration 1, 4
• Sustaining nutrition is important as dehydration or malnutrition may slow recovery and increase risk of deep vein thrombosis 4

Prevention of Venous Thromboembolism

• Apply intermittent pneumatic compression devices immediately for all immobilized patients to prevent deep vein thrombosis 1
• Use subcutaneous anticoagulants (low molecular weight heparin or unfractionated heparin) for immobilized patients 1
• Early mobilization when medically stable lessens complications including pneumonia, DVT, pulmonary embolism, and pressure sores 1, 4

Management of Cerebral Edema and Increased Intracranial Pressure

• Corticosteroids are NOT recommended for cerebral edema after stroke 3, 1, 4
• Osmotic therapy (mannitol or hypertonic saline) and hyperventilation are recommended for patients who deteriorate from malignant edema 3, 1, 4
• Decompressive craniectomy with dural expansion should be considered for patients with large hemispheric infarcts who continue to deteriorate neurologically despite medical management 3, 1
• Neurosurgical consultation should be sought early to facilitate planning of decompressive surgery or ventriculostomy if the patient deteriorates 3

Specialized Stroke Unit Care

• All stroke patients must be admitted to a geographically defined stroke unit with dedicated interdisciplinary staff trained in stroke management 1, 2, 4
• Stroke unit care reduces mortality and morbidity with benefits comparable to IV thrombolysis and persisting for years 1, 4
• Neurological status and vital signs should be assessed frequently during the first 24 hours after admission 4

Early Rehabilitation

• Rehabilitation assessment should begin within 48 hours of admission by specialized therapists (physical, occupational, speech) 1, 4
• Rehabilitation therapy should begin as soon as possible once the patient is medically stable 4
• If ongoing inpatient rehabilitation is needed, care should be provided in either a stroke rehabilitation unit or a general rehabilitation unit 4

Cardiac Evaluation

• Perform 12-lead ECG immediately without delaying stroke treatment 2
• Initiate continuous cardiac monitoring for 24-72 hours to detect atrial fibrillation and arrhythmias 1, 2
• Consider echocardiography (transthoracic or transesophageal) to evaluate for cardioembolic source 1

Secondary Prevention Workup

• Vascular imaging with carotid duplex ultrasound for carotid territory symptoms if the patient is a surgical candidate 1
• Carotid endarterectomy is recommended for 70-99% ipsilateral stenosis within 6 months of non-disabling stroke, ideally within 2 weeks 1, 4
• Consider carotid endarterectomy for 50-69% stenosis in select patients 1, 4

Long-term Secondary Prevention

• Initiate high-intensity statin therapy regardless of baseline cholesterol levels 1, 2
• Start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke) 2
• For patients with atrial fibrillation, consider anticoagulation after ruling out hemorrhagic transformation 2

Management of Intracerebral Hemorrhage (ICH)

• Blood pressure should be controlled in all ICH patients with measures beginning immediately after ICH onset 3
• Rapid admission to a stroke unit or neuroscience intensive care unit is essential 3
• Urgent treatment of time-sensitive issues including BP lowering and reversal of coagulopathy should be initiated in the ED rather than waiting for transfer 3
• All patients with ICH should have access to multidisciplinary rehabilitation 3

Discharge Planning and Follow-up

• Early assessment and planning of discharge needs with family education about management, rehabilitation, causes, secondary prevention, and community resources 1
• Education on stroke warning signs (FAST mnemonic) and risk factor modification 1, 4
• Regular follow-up to monitor neurological recovery and medication adherence 1

Common Pitfalls to Avoid

• Do not delay imaging or treatment while waiting for transfer to a higher level facility - initiate time-sensitive interventions immediately 3
• Do not aggressively lower blood pressure in acute ischemic stroke unless >220/120 mmHg (except when giving thrombolysis) as this may worsen cerebral perfusion 1, 2
• Do not give aspirin before 24 hours if thrombolysis was administered due to increased bleeding risk 1, 2
• Do not allow oral intake before swallowing screening is completed to prevent aspiration 1, 4
• Do not use corticosteroids for cerebral edema as they are ineffective and potentially harmful 3, 1, 4