What is the appropriate management protocol for a patient presenting with a cerebrovascular accident (CVA)?

CVA Protocol Management

All patients with suspected stroke require immediate neuroimaging with CT or MRI to distinguish ischemic from hemorrhagic stroke, followed by rapid assessment for thrombolytic therapy eligibility within the 3-4.5 hour window for ischemic stroke, or immediate blood pressure control to systolic <140 mmHg for intracerebral hemorrhage. 1, 2

Immediate Assessment and Stabilization

Initial Evaluation (Within Minutes)

• Perform baseline stroke severity scoring using a standardized scale (e.g., NIH Stroke Scale) as part of initial evaluation 1, 2
• Document precise time of symptom onset or last known normal time, as this determines treatment eligibility 2, 3
• Obtain rapid neuroimaging with CT or MRI within 24 hours (ideally immediately) to distinguish ischemic from hemorrhagic stroke 1, 2
• Maintain oxygen saturation ≥94% with supplemental oxygen if hypoxic 2
• Assess airway, breathing, and circulation, particularly in seriously ill or comatose patients 4

Critical History Elements

• Record specific neurological deficits reported by patient or witnesses 3
• Document risk factors: hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation 3
• Note previous stroke or TIA history 3
• Identify any anticoagulant or antiplatelet use 1

Initial Monitoring Location

• Admit to intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1
• This represents Class I, Level B evidence and is critical for optimal outcomes 1

Acute Ischemic Stroke Management

Intravenous Thrombolysis (rtPA)

For patients presenting within 3 hours of symptom onset without contraindications, administer intravenous rtPA 0.9 mg/kg (maximum 90 mg) with 10% as initial bolus over 1 minute and remainder infused over 1 hour. 2

• Extended window of 3-4.5 hours is acceptable for selected patients 2
• Treatment benefit decreases with time: odds ratio 2.81 within 1.5 hours, 1.55 for 1.5-3 hours, and 1.40 for 3-4.5 hours 2
• Before thrombolysis, blood pressure must be <185/110 mmHg 2
• After thrombolysis, maintain blood pressure <180/105 mmHg for at least 24 hours 2, 4

Mechanical Thrombectomy

• Perform for large vessel occlusions within 6 hours of symptom onset 2
• Can be combined with intravenous rtPA 2
• Monitor vital signs every 5 minutes during the procedure 1

Antiplatelet Therapy

• Initiate aspirin 160-300 mg within 48 hours of ischemic stroke onset after hemorrhage is excluded by imaging 1, 2
• If thrombolysis was administered, typically wait 24 hours before starting aspirin 4

Blood Pressure Management in Ischemic Stroke

• Do not lower blood pressure unless systolic BP >220 mmHg or diastolic >120 mmHg 2
• Exception: if patient is candidate for thrombolysis, treat if systolic BP >185 mmHg or diastolic >110 mmHg 2
• Avoid aggressive blood pressure lowering to maintain cerebral perfusion to ischemic penumbra 1

Intracerebral Hemorrhage Management

Blood Pressure Control

For ICH patients with systolic BP 150-220 mmHg presenting within 6 hours, acutely lower systolic BP to 140 mmHg. 1, 2

• This is safe (Class I, Level A evidence) and effective for improving functional outcome (Class IIa, Level B evidence) 1
• For patients with history of hypertension, keep mean arterial pressure <130 mmHg 1

Coagulopathy Reversal

• Patients with elevated INR from vitamin K antagonists should have VKA withheld, receive therapy to replace vitamin K-dependent factors, correct the INR, and receive intravenous vitamin K 1
• Patients with severe coagulation factor deficiency should receive appropriate factor replacement therapy 1
• Patients with severe thrombocytopenia should receive platelets 1

Surgical Intervention

Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction require surgical removal of the hemorrhage as soon as possible. 1

Monitoring and Complication Prevention

Vital Signs Monitoring Frequency

• Before mechanical thrombectomy: every 30 minutes 1
• During procedure: every 5 minutes 1
• After thrombectomy: every 15 minutes for 2 hours, every 30 minutes for 6 hours, every 1 hour for 16 hours 1

Glucose Management

• Monitor glucose levels continuously 1
• Avoid both hyperglycemia and hypoglycemia 1

Seizure Management

• Treat clinical seizures with antiseizure drugs 1
• Treat electrographic seizures on EEG in patients with altered mental status 1

Dysphagia Screening

Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk. 1, 4

DVT Prophylaxis

Initiate intermittent pneumatic compression for venous thromboembolism prevention beginning the day of hospital admission. 1

Secondary Prevention

Immediate Measures

• Control blood pressure in all ICH patients beginning immediately after onset 1
• Initiate statin therapy regardless of baseline cholesterol levels 3, 4
• Start antihypertensive therapy after acute phase (typically 24-48 hours post-stroke) 3, 4

Cardiac Evaluation

• Perform ECG monitoring for at least 24 hours to detect atrial fibrillation 4
• For atrial fibrillation, consider anticoagulation after ruling out hemorrhagic transformation 3, 4

Carotid Disease Management

• Obtain urgent carotid duplex ultrasound for carotid territory symptoms in patients who are potential revascularization candidates 1
• For symptomatic carotid stenosis >70%, consider carotid endarterectomy within 2 weeks 3

Rehabilitation

Early Mobilization

• Begin early mobilization when medically stable 3, 4
• All patients with ICH should have access to multidisciplinary rehabilitation (Class I, Level A evidence) 1

Comprehensive Assessment

• Initiate physical, occupational, and speech therapy assessments early 4
• Address specific deficits: motor, sensory, language, cognitive, visual 3, 4

Discharge Planning

• Assess need for rehabilitation facility versus home with services based on functional status 3, 4
• Provide education on stroke warning signs and risk factor modification 3, 4

Critical Pitfalls to Avoid

• Never delay imaging: CT or MRI must be obtained immediately to guide treatment decisions 1
• Do not miss the thrombolysis window: Document time of onset immediately and move rapidly through evaluation 2
• Avoid aggressive blood pressure lowering in acute ischemic stroke: This can worsen outcomes by reducing perfusion to penumbra 2
• Do not start oral intake without dysphagia screening: This significantly increases aspiration pneumonia risk 1
• Never give aspirin before excluding hemorrhage on imaging: This could worsen hemorrhagic stroke 1, 2