What are the current treatment modalities for a chronic Cerebrovascular Accident (CVA) patient experiencing a second ischemic stroke?

Treatment of Recurrent Ischemic Stroke in Chronic CVA Patients

Acute Reperfusion Therapy: The Foundation of Modern Treatment

For a chronic CVA patient experiencing a second ischemic stroke, immediate intravenous rtPA (0.9 mg/kg) should be administered within 3 hours of symptom onset if eligible, followed by mechanical thrombectomy with stent retrievers for large vessel occlusions—this combined approach represents the most significant advancement in acute stroke treatment. 1, 2

Intravenous Thrombolysis

• Administer IV rtPA within 3 hours of clearly defined symptom onset (Class I, Level A evidence), with the treatment window potentially extending to 4.5 hours in carefully selected patients 1, 3
• The presence of prior stroke is not an absolute contraindication to rtPA unless it occurred within the previous 3 months 1
• Time is critical: every 30-minute delay in recanalization decreases the chance of good outcome by 8-14% 2
• Target door-to-needle time of <60 minutes to maximize functional outcomes 2, 4

Mechanical Thrombectomy: The Game-Changer

Stent retrievers (Solitaire FR and Trevo) are strongly preferred over older coil retrievers like Merci (Class I, Level A evidence) and should be deployed for proximal large vessel occlusions 1, 2

• Proceed directly to endovascular thrombectomy without waiting to assess clinical response to IV rtPA—this is a critical change from older practice patterns (Class III recommendation against waiting) 1, 2
• Indicated for patients with:
  • Proximal MCA (M1) or ICA occlusions 2, 4
  • NIHSS ≥6 2
  • ASPECTS ≥6 on imaging 2
  • Prestroke mRS 0-1 2
• Target door-to-groin puncture time of <110 minutes 2, 4
• Combined approach using stent retrievers and aspiration techniques achieves faster and more complete reperfusion (TICI 2b/3 in 59-87.8% of cases) 1, 2, 4

Intra-arterial Thrombolysis

• Remains an option for carefully selected patients with major stroke of <6 hours duration caused by MCA occlusions who are not candidates for IV rtPA 1
• However, mechanical thrombectomy with stent retrievers has largely superseded intra-arterial thrombolysis alone due to superior recanalization rates 1, 2
• Requires immediate access to cerebral angiography and experienced interventionalists 1

Secondary Prevention: Preventing the Third Stroke

Antiplatelet Therapy

Aspirin should be administered within 24-48 hours after stroke onset, but must be delayed for 24 hours in patients who received thrombolytic therapy 2, 3

For long-term secondary prevention in noncardioembolic stroke:

• The combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily is preferred over aspirin alone (Grade 1A recommendation) 3
• Clopidogrel 75 mg daily is suggested over aspirin alone (Grade 2B recommendation) 3
• Avoid long-term combination of aspirin and clopidogrel (Grade 1B recommendation against) 3

Anticoagulation for Cardioembolic Stroke

For patients with atrial fibrillation and recurrent stroke, long-term oral anticoagulation with target INR 2.5 (range 2.0-3.0) is strongly recommended (Grade 1A) 3

• Rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily reduces the composite risk of stroke, MI, and cardiovascular death (HR 0.74,95% CI 0.65-0.86) in patients with coronary artery disease or peripheral artery disease 5
• This combination is particularly relevant for patients with both cerebrovascular and coronary disease 5

Blood Pressure Management: A Critical Balance

Maintain blood pressure ≤180/105 mmHg during and for 24 hours after mechanical thrombectomy or thrombolytic therapy 1, 2, 4

• Avoid aggressive blood pressure lowering in acute ischemic stroke unless BP exceeds 220/120 mmHg in patients not receiving thrombolysis 1, 6
• For patients eligible for thrombolysis, BP must be reduced to <185/110 mmHg before treatment 1
• Use labetalol 10-20 mg IV over 1-2 minutes or nicardipine infusion for BP control 1

Advanced Imaging: Selecting the Right Patients

CT angiography with source images (CTA-SI) should be performed along with vascular imaging and perfusion studies, particularly if mechanical thrombectomy is contemplated (Class I, Level A) 1

• The presence of cerebral microbleeds on MRI is not an absolute contraindication to IV tPA if there are only a small number (<5 microbleeds) (Class IIa, Level B) 1
• The risk with multiple microbleeds (>5) is uncertain and requires careful consideration 1

Common Pitfalls and Critical Caveats

Time-Related Errors

• Never delay transfer to an endovascular-capable center for extensive diagnostic workup—establish rapid transfer protocols 2, 6
• Do not wait to assess clinical response to IV rtPA before pursuing endovascular therapy—this outdated practice worsens outcomes 1, 2

Hemorrhagic Risk Management

• Symptomatic hemorrhage risk increases 8-fold with early edema or mass effect on CT after rtPA 4
• Monitor closely for hemorrhagic transformation, especially in patients requiring anticoagulation for atrial fibrillation 2

Reocclusion Risk

• Approximately one-third of patients develop reocclusion after IV thrombolysis, particularly those with partial recanalization 1
• This necessitates intensive monitoring in specialized stroke units with capabilities for managing post-thrombectomy patients 1, 2

Special Considerations for Recurrent Stroke

• Prior stroke is not a contraindication to acute reperfusion therapy unless it occurred within 3 months 1
• Patients with recurrent stroke often have multiple vascular risk factors requiring aggressive secondary prevention 7
• Dyslipidemia, atrial fibrillation, and obesity are significantly associated with recurrent CVA in elderly patients and require targeted management 7

Post-Procedure Monitoring

Intensive monitoring protocols must be implemented with vital signs and neurological checks every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours after thrombectomy 1

• Monitor arteriotomy site and distal pulses every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then hourly for 4 hours 1
• Early rehabilitation assessment should begin immediately to optimize functional recovery 2