What is the immediate treatment for a patient presenting with a cerebral vascular accident (CVA) infarct?

Immediate Treatment for Acute Ischemic Stroke (CVA Infarct)

Administer intravenous recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) if the patient presents within 3 hours of symptom onset and has no contraindications, followed by aspirin 160-325 mg within 24-48 hours after stroke onset (delayed to >24 hours if thrombolysis given). 1, 2

Prehospital and Emergency Department Priorities

Immediate Stabilization

• Ensure airway, breathing, and circulation are stable 3
• Provide supplemental oxygen only if oxygen saturation is <94% 3
• Check capillary blood glucose immediately and treat hypoglycemia with IV dextrose 3
• Avoid aggressive blood pressure lowering unless systolic BP >220 mmHg or diastolic >120 mmHg in non-thrombolysis candidates 1

Rapid Triage and Assessment

• Assign highest triage priority with goal of emergency department evaluation within <10 minutes 1
• Perform NIHSS assessment immediately to quantify stroke severity 1, 2
• Use validated stroke screening tools (FAST, Cincinnati Prehospital Stroke Scale) to confirm stroke diagnosis 1, 3

Critical Time-Dependent Imaging

Brain Imaging Requirements

• Complete non-contrast CT head within 25 minutes of emergency department arrival and interpret within 45 minutes 1
• CT is essential to differentiate ischemic stroke from hemorrhagic stroke and exclude stroke mimics 1, 2
• MRI with diffusion-weighted imaging is acceptable if available and does not delay treatment 1, 2
• Do not delay IV rtPA to obtain advanced imaging (CT angiography, CT perfusion, MRI sequences) 1

Thrombolytic Therapy Decision-Making

Inclusion Criteria for IV rtPA (Within 3 Hours)

• Diagnosis of acute ischemic stroke with measurable neurologic deficit 1
• Symptom onset clearly defined and <3 hours before treatment initiation 1
• Age ≥18 years 1
• No evidence of intracranial hemorrhage on CT 1

Critical Exclusion Criteria

• Blood pressure >185/110 mmHg systolic/diastolic (must be lowered before rtPA) 1
• Platelet count <100,000/mm³ 1
• INR >1.7 or PT >15 seconds 1
• Blood glucose <50 mg/dL 1
• Head trauma or prior stroke in previous 3 months 1
• CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere) 1

Extended Window (3-4.5 Hours)

• IV rtPA may be considered for carefully selected patients presenting 3-4.5 hours from onset 1, 4
• Additional exclusions for 3-4.5 hour window: age >80 years, NIHSS >25, taking oral anticoagulants regardless of INR, history of both diabetes and prior stroke 1

Blood Pressure Management Protocol

For Thrombolysis Candidates

• Blood pressure must be reduced to <185/110 mmHg before rtPA administration 1, 2
• Use labetalol 10 mg IV followed by continuous infusion 2-8 mg/min, OR nicardipine IV 5 mg/h titrated up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h) 1
• Maintain BP <180/105 mmHg for 24 hours after rtPA administration 1
• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1

For Non-Thrombolysis Candidates

• Consider lowering BP only if systolic >220 mmHg or diastolic >120 mmHg 1
• Reasonable target is 15-25% reduction within first 24 hours 1

Antiplatelet Therapy

Aspirin Administration

• Start aspirin 160-325 mg within 24-48 hours of stroke onset 1
• For patients receiving IV rtPA, delay aspirin until >24 hours after thrombolysis 1
• Aspirin should NOT be given before brain imaging rules out hemorrhagic stroke 3

Mechanical Thrombectomy Considerations

Endovascular Treatment Indications

• Proximal intracranial artery occlusion (ICA or MCA-M1 segment) 1
• NIHSS score ≥6 1
• Pre-stroke modified Rankin Scale (mRS) score 0-1 1
• ASPECTS ≥6 on imaging 1
• Treatment can be initiated (groin puncture) within 6 hours of symptom onset 1
• Stent retrievers are strongly preferred over older mechanical devices 1
• Do not wait to observe clinical response to IV rtPA before pursuing endovascular therapy 1

Acute In-Hospital Management

Stroke Unit Admission

• All patients should be admitted to a dedicated stroke unit or intensive care unit if critically ill 1, 2
• Stroke unit care significantly reduces death and disability 1

Monitoring Requirements

• Cardiac monitoring for at least 24 hours to screen for atrial fibrillation and arrhythmias 1, 2
• Monitor body temperature and treat fever >38°C 1
• Serial neurological examinations to identify worsening 1

VTE Prophylaxis

• Use prophylactic-dose subcutaneous heparin (LMWH preferred over UFH) or intermittent pneumatic compression devices for patients with restricted mobility 1
• Start prophylaxis early, ideally within first 24-48 hours 1

Common Pitfalls to Avoid

Time-Related Errors

• Do not delay transfer for extensive diagnostic workup in primary care or community settings 3
• Every 30-minute delay in recanalization decreases chance of good outcome by 8-14% 4
• Target door-to-needle time ≤60 minutes for IV rtPA 1, 5
• Target door-to-groin puncture time ≤110 minutes for mechanical thrombectomy 4

Clinical Decision Errors

• Do not withhold rtPA solely because symptoms appear "mild" or "improving" - 27% of such patients have poor outcomes including death or inability to discharge home 6, 7
• Patients with ≥4-point NIHSS improvement before treatment decision are at higher risk for subsequent neurological worsening (relative risk 4.1) 6
• Do not administer aspirin or antiplatelet agents before brain imaging excludes hemorrhage 3

Blood Pressure Management Errors

• Avoid aggressive BP lowering in acute ischemic stroke unless meeting specific thresholds 1, 3
• Permissive hypertension may maximize cerebral perfusion in acute phase 2
• For hemorrhagic stroke with hypertension, different BP targets apply 1

Anticoagulation in Hemorrhagic Stroke

• If intracerebral hemorrhage is identified, discontinue anticoagulation immediately 1
• For warfarin-associated ICH with INR ≥2.0, use 4-factor prothrombin complex concentrate over fresh frozen plasma 1
• For dabigatran-related ICH, use idarucizumab for reversal 1
• For factor Xa inhibitor-related ICH, use andexanet alfa or 4-factor PCC if andexanet unavailable 1

Regional Transfer Protocols

Hospital Selection

• Transport to closest certified primary stroke center or comprehensive stroke center 1
• Provide pre-arrival notification to receiving hospital's stroke team 3
• Communicate time of symptom onset/last known well, current medications, and anticoagulant use 3
• Consider telemedicine/telestroke consultation if available 3