What is the management plan for a patient with acute ischemic Cerebrovascular Accident (CVA)?

Management of Acute Ischemic Cerebrovascular Accident (CVA)

All patients with acute ischemic stroke should receive immediate stabilization, rapid neuroimaging within 30 minutes, intravenous alteplase (0.9 mg/kg, maximum 90 mg) if presenting within 3-4.5 hours and eligible, followed by admission to a comprehensive stroke unit for monitoring and early rehabilitation. 1, 2

Immediate Emergency Department Management

Triage and Initial Assessment

• Assign highest triage priority with immediate hospital notification to minimize door-to-needle time to ≤30 minutes. 2
• Stabilize airway, breathing, and circulation immediately, with oxygen supplementation to maintain saturation >94%. 1, 3
• Perform NIHSS assessment immediately upon arrival to quantify stroke severity—patients with NIHSS <15 are optimal candidates for intervention, while those with NIHSS >15 who are obtunded have poor outcomes with aggressive intervention. 2
• Document precise time of symptom onset, as this determines eligibility for reperfusion therapies. 1

Emergent Neuroimaging

• Complete non-contrast CT head within 30 minutes of hospital admission to distinguish ischemic from hemorrhagic stroke and exclude stroke mimics. 2
• MRI with diffusion-weighted imaging is acceptable if available and doesn't delay treatment—it's more sensitive than CT for ischemic changes. 2
• For suspected large-vessel occlusion, obtain vascular imaging to determine eligibility for endovascular therapy. 4

Blood Pressure Management

• Do NOT lower blood pressure unless systolic BP >220 mmHg or diastolic >120 mmHg—permissive hypertension maximizes cerebral blood flow. 2, 3
• Before administering thrombolysis, blood pressure must be <185/110 mmHg, then maintained <180/105 mmHg for 24 hours post-treatment. 1, 2
• Use short-acting agents with minimal cerebral vascular effects if treatment is required. 3

Laboratory Evaluation

• Obtain complete blood count, electrolytes, renal function, glucose, cardiac biomarkers, coagulation studies (PT/INR, aPTT), and troponin immediately without delaying treatment. 1, 3
• Perform 12-lead ECG immediately and initiate continuous cardiac monitoring for 24-72 hours to detect atrial fibrillation and arrhythmias. 2
• Correct hypoglycemia immediately as it can mimic stroke symptoms and cause brain injury; lower markedly elevated glucose to <300 mg/dL. 3

Reperfusion Therapy

Intravenous Thrombolysis

• Administer intravenous alteplase at 0.9 mg/kg (maximum 90 mg) for patients presenting within 3-4.5 hours of symptom onset if no contraindications exist. 1, 2, 3
• Give 10% as bolus over 1 minute, then remaining 90% as infusion over 60 minutes. 1
• This is the single most important intervention to reduce morbidity and mortality. 4

Endovascular Therapy

• For large-vessel occlusion, endovascular mechanical thrombectomy should be performed as rapidly as possible, ideally using combined stent-retriever and aspiration approach to achieve first-pass complete reperfusion. 4
• Every 30-minute delay in recanalization decreases the chance of good functional outcome by 8% to 14%. 4
• Treatment delays and patient overselection should be avoided given the highly time-dependent treatment effect and poor natural course. 4

Antiplatelet Therapy

• Administer aspirin 160-300 mg within 48 hours of stroke onset, but typically after 24 hours if thrombolysis was given. 1, 2

Hospital Admission and Acute Care

Stroke Unit Care

• Admit all patients to a geographically defined comprehensive stroke unit with interdisciplinary specialized staff—this organized care reduces morbidity and mortality comparably to the effects of intravenous rtPA. 4, 1, 2
• Approximately 25% of patients have neurological worsening during the first 24-48 hours, making specialized monitoring essential. 4, 3

Monitoring and Complication Prevention

• Perform frequent neurological assessments using standardized stroke severity scales (NIHSS) during the first 24-48 hours. 3
• Monitor for cerebral edema, which typically peaks 3-5 days after stroke but can occur earlier with large infarctions. 1
• Watch for seizures and hemorrhagic transformation as common neurological complications. 1
• Implement early swallowing assessment using validated tools before allowing any oral intake to prevent aspiration pneumonia. 1, 3
• For patients with impaired swallowing, consider nasogastric or nasoduodenal tube feeding to maintain nutrition. 1

Deep Vein Thrombosis Prophylaxis

• For immobilized patients, use subcutaneous anticoagulants, intermittent external compression stockings, or aspirin to prevent deep vein thrombosis. 1, 3

Infection Prevention

• Fever after stroke should prompt immediate search for pneumonia, which is a leading cause of post-stroke mortality. 3
• Administer appropriate antibiotics early when infection is identified. 3

Secondary Prevention

Statin Therapy

• Initiate statin therapy regardless of baseline cholesterol levels. 1, 2
• For patients already taking statins at stroke onset, continuation during the acute period is reasonable. 4

Blood Pressure Management (Post-Acute Phase)

• Start antihypertensive therapy after the acute phase, typically 24-48 hours post-stroke. 1, 2

Anticoagulation

• For patients with atrial fibrillation, consider anticoagulation after ruling out hemorrhagic transformation. 1, 2
• Perform thorough cardiac evaluation including ECG monitoring for at least 24 hours to detect atrial fibrillation, which is a major risk factor for ischemic stroke. 1

Rehabilitation and Recovery

Early Mobilization

• Begin early mobilization when the patient is medically stable. 1
• Initiate comprehensive rehabilitation addressing specific deficits: motor, sensory, language, and cognitive. 1

Subacute Complication Prevention

• Implement measures to prevent aspiration, malnutrition, deep vein thrombosis, pulmonary embolism, and pressure sores. 1

Surgical Considerations

Carotid Endarterectomy

• Emergency CEA is generally NOT performed in acute ischemic stroke with large deficits due to high risk of adverse events from acute restoration of flow to damaged tissue. 4
• The usefulness of emergent CEA when imaging suggests small infarct core with large penumbra compromised by critical carotid stenosis is not well established. 4
• In patients with unstable neurological status (stroke-in-evolution or crescendo TIA), efficacy of emergent CEA is not well established. 4
• For neurologically stable patients after nondisabling stroke or TIA, early surgery (within 2 weeks) may be performed without incremental risk compared to delayed surgery. 4

Other Surgical Procedures

• Extracranial-intracranial bypass for acute ischemic stroke has not been shown to be of benefit. 4
• Endovascular approaches provide a better alternative than surgical embolectomy in most situations. 4

Therapies NOT Recommended

• No pharmacological agents with putative neuroprotective actions have demonstrated efficacy in improving outcomes after ischemic stroke, and therefore neuroprotective agents are not recommended. 4
• Induced hypothermia for treatment of ischemic stroke is not well established. 4
• Transcranial near-infrared laser therapy is not well established for treatment of acute ischemic stroke. 4

Follow-up and Education

• Provide education on stroke warning signs and risk factor modification. 1
• Schedule regular follow-up to monitor neurological recovery and medication adherence. 1
• Assess need for rehabilitation facility versus home with services based on functional status. 1