Initial Management of CVA Patient with Left-Sided Weakness
Immediately send the patient to an emergency department with advanced stroke care capabilities, including on-site brain imaging and access to acute stroke treatments. 1
Immediate Time-Critical Actions
Establish "Last Known Well" Time
- Assess the exact time the patient was last known to be neurologically normal immediately upon presentation to determine eligibility for thrombolytic therapy. 1
- This is the single most critical piece of information, as it determines whether the patient qualifies for IV thrombolysis (rtPA) within the 3-4.5 hour window. 1
Emergency Brain Imaging
- Obtain brain imaging within 24 hours, with MRI with diffusion-weighted imaging (DWI) preferred over head CT for detecting acute infarction. 1
- Head CT is acceptable if MRI is unavailable, but MRI is superior for identifying acute ischemic changes. 1
Thrombolytic Therapy Decision
- Administer intravenous thrombolysis (rtPA) if the patient presents within 3-4.5 hours of symptom onset and meets eligibility criteria. 1
- Maintain blood pressure <185/110 mmHg before treatment and for 24 hours after thrombolysis. 1
- If the patient is NOT receiving thrombolysis, only treat hypertension if diastolic BP >120 mmHg or systolic BP >220 mmHg. 1
Localization and Risk Assessment
Understanding the Lesion Location
- Left-sided weakness indicates a right hemisphere stroke, most commonly involving the right internal carotid artery or middle cerebral artery distribution. 2
- Associated symptoms to assess include: left-sided paresthesia or sensory loss, left-sided neglect, abnormal visual-spatial ability, monocular blindness affecting the right eye, and right homonymous hemianopsia. 2
Recurrence Risk Stratification
- Patients with prior CVA and current unilateral weakness are at very high risk for recurrent stroke: 1.5% at 2 days, 2.1% at 7 days, and 2.8% at 30 days even with optimal management. 1
- Historical rates without immediate intervention approach 10.3% at 90 days. 1
Comprehensive Diagnostic Workup
Vascular Imaging
- Perform noninvasive imaging of cervicocephalic vessels (CTA or MRA from aortic arch to vertex) within 24 hours. 1
- If CTA/MRA unavailable, obtain carotid ultrasound/transcranial Doppler. 1
Cardiac Evaluation
- Obtain electrocardiogram, prolonged cardiac monitoring, and echocardiography to identify cardioembolic sources such as atrial fibrillation. 1
- This determines whether anticoagulation versus antiplatelet therapy is appropriate for secondary prevention. 1
Critical Pitfalls to Avoid
Do Not Dismiss Subtle Presentations
- Do not rely solely on clinical examination to rule out stroke, as focal neurologic symptoms may be lacking in one-third to two-thirds of patients with posterior circulation infarcts. 1
- Dizziness should not be dismissed as benign vertigo in high-risk patients, as it may indicate a central process requiring urgent evaluation. 1
Avoid Premature Discharge
- Patients with apparently good ADL performance may still lack general function and meaningful activity engagement (72% in one study), requiring selective rehabilitation referral criteria. 3
Post-Acute Management Planning
Secondary Prevention
- Initiate antiplatelet therapy (aspirin, clopidogrel, or combination based on etiology) for secondary prevention. 1
- If cardioembolic source identified (e.g., atrial fibrillation), initiate anticoagulation instead of antiplatelet therapy. 1
Rehabilitation Initiation
- Begin early mobilization when medically stable, and implement comprehensive rehabilitation addressing motor, speech, cognitive deficits, and activities of daily living. 1
- For visual-spatial deficits after right CVA, implement specific visual-spatial rehabilitation training. 2, 4
- Cognitive retraining for attention deficits, memory impairments, and executive function problems should be initiated early. 4
Mood Screening
- Screen all patients for depression given the high incidence (25-75%) after stroke, as poststroke depression often manifests with subtle signs such as refusal to participate in therapy. 2