What are the management strategies for Cerebrovascular Accident (CVA)?

CVA Management

Immediate Emergency Assessment and Treatment

Administer IV tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) immediately if the patient presents within 3 hours of symptom onset with CT-confirmed ischemic stroke and no contraindications—this is the single most critical intervention that reduces mortality and morbidity. 1, 2

Time-Critical Initial Steps

• Perform immediate non-contrast CT imaging to differentiate ischemic from hemorrhagic stroke before any treatment begins 1, 2, 3
• Document the precise time of symptom onset; if the patient awakened with symptoms, use the "last known normal" time as this determines eligibility for thrombolysis 1, 2, 3
• Transport directly to a specialized stroke unit, which reduces mortality by 14% at one year compared to general medical wards 2, 3
• Assess stroke severity using the NIH Stroke Scale to guide treatment intensity and establish baseline for monitoring 1, 2, 3

Acute Management: Ischemic Stroke

Thrombolytic Therapy

• Give IV tPA 0.9 mg/kg (maximum 90 mg) with 10% as bolus over 1 minute and remainder over 60 minutes if all criteria are met within 3 hours 1, 2, 3
• Extend the window to 3-4.5 hours for eligible patients without extended contraindications (age >80 years, prior stroke plus diabetes, anticoagulant use, or NIHSS >25) 1, 2, 3
• Maintain blood pressure <180/105 mmHg for at least 24 hours after thrombolysis to reduce bleeding risk 2, 3

Mechanical Intervention

• Perform mechanical thrombectomy for large vessel occlusion within 6-24 hours in selected patients based on advanced imaging (CT perfusion or MRI) showing salvageable tissue 1, 2, 3

Acute Management: Hemorrhagic Stroke

Control systolic blood pressure to 130-150 mmHg immediately, as uncontrolled hypertension drives hematoma expansion and worsens outcomes. 1, 2, 3

• Reverse anticoagulation immediately with dedicated reversal agents (prothrombin complex concentrate for warfarin, idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 1, 2, 3
• Administer tranexamic acid as soon as possible if active bleeding is present 1, 2, 3

Surgical Decompression

• Consider decompressive craniectomy with dural expansion for swollen supratentorial hemispheric ischemic stroke in patients who continue to deteriorate neurologically despite medical management 4, 2, 3
• Perform suboccipital craniectomy with dural expansion for swollen cerebellar stroke with neurological deterioration, as this prevents brainstem compression and death 2, 3

Note: Decompressive craniectomy reduces mortality by reducing progression to brain death, though morbidity can be substantial in one-third of patients while the remaining two-thirds have good potential for recovery after rehabilitation 4

Specialized Stroke Unit Care

• Admit all CVA patients to a geographically defined stroke unit with skilled multidisciplinary professionals (physicians, nurses, rehabilitation personnel) and coordinated care protocols 2
• Monitor neurological status and vital signs frequently during the first 24-48 hours, as approximately 25% of patients experience neurological worsening during this period 2
• Begin early mobilization as soon as the patient is medically stable to lessen complications and improve outcomes 1, 2, 3
• Maintain adequate hydration and nutrition, as dehydration slows recovery and increases deep vein thrombosis risk 2

Secondary Prevention

Pharmacologic Interventions

• Initiate high-intensity statin therapy (atorvastatin 80 mg or rosuvastatin 40 mg daily) regardless of baseline cholesterol levels 1, 2, 3
• Start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke) with target blood pressure <140/90 mmHg, or <130/80 mmHg for diabetics 1, 2, 3
• Administer aspirin 160-300 mg within 48 hours of stroke onset, but typically after 24 hours if thrombolysis was given 2
• Continue long-term antiplatelet therapy with aspirin 81 mg daily or clopidogrel 75 mg daily 1, 2, 3
• Consider anticoagulation for atrial fibrillation after ruling out hemorrhagic transformation (typically wait 1-2 weeks for small infarcts, 2-4 weeks for large infarcts) 1, 2

Surgical Prevention

• Perform carotid endarterectomy within 2 weeks for symptomatic carotid stenosis >70% 3

Rehabilitation: Early and Comprehensive

Begin rehabilitation interventions as soon as the patient is medically stable, as early initiation significantly improves functional outcomes. 2, 3

Physical and Functional Recovery

• Initiate physical therapy for motor deficits to restore movement and prevent contractures 1, 2, 3
• Provide occupational therapy for activities of daily living to maximize independence 2, 3
• Implement speech therapy for language and swallowing deficits 1, 2, 3

Cognitive Rehabilitation

• Assess for cognitive deficits including attention deficits, visual neglect, memory deficits, and executive function problems 3
• Implement visual-spatial rehabilitation for visual neglect after right hemisphere stroke (Level I evidence from 6 RCTs) 3
• Use training to develop compensatory strategies for memory deficits in patients with mild short-term memory impairments who are fairly independent and motivated 3
• Teach formal problem-solving strategies that can be applied to everyday situations for executive function and problem-solving dysfunction 3

Complication Prevention

• Use subcutaneous anticoagulants (enoxaparin 40 mg daily or heparin 5,000 units twice daily) or intermittent external compression stockings to prevent deep vein thrombosis in immobilized patients 1, 3
• Screen all patients for poststroke depression given its high incidence 2

Discharge Planning

• Provide education on stroke warning signs (sudden numbness, confusion, vision changes, difficulty walking, severe headache) and risk factor modification 2
• Schedule regular follow-up to monitor neurological recovery and medication adherence 2
• Assess the need for inpatient rehabilitation facility versus home with services based on functional status and caregiver support 2