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

Initial Management of Cerebrovascular Accident (CVA)

Patients presenting with suspected CVA require immediate emergency evaluation with a goal of completing assessment and deciding treatment within 60 minutes of emergency department arrival, using an organized protocol involving physicians, nurses, and laboratory/radiology personnel. 1

Immediate Assessment and Stabilization

• Rapidly evaluate airway, breathing, and circulation (ABCs) upon patient arrival, ensuring adequate oxygenation and hemodynamic stability 2
• Assess stroke severity using the National Institutes of Health Stroke Scale (NIHSS), which is the recommended validated tool for quantifying neurological deficits 1, 2
• Document the exact time of symptom onset or when the patient was last known to be at their previous baseline—this is the single most critical piece of information for determining treatment eligibility 3, 2
• Obtain vital signs including blood pressure, heart rate and rhythm, temperature, and oxygen saturation to guide acute management decisions 2

Emergency Diagnostic Workup

Brain Imaging (Highest Priority)

• Perform non-contrast CT or MRI immediately to distinguish ischemic stroke from intracerebral hemorrhage—this is the most critical diagnostic step and should not be delayed 1, 4
• Complete CT imaging within 25 minutes of ED arrival, with interpretation within an additional 20 minutes (door-to-interpretation time of 45 minutes) for patients who are potential thrombolysis candidates 1
• Consider CT angiography (CTA) from aortic arch to vertex at the time of initial brain CT when endovascular therapy is being considered, to assess both extracranial and intracranial circulation 2, 4

Laboratory Studies

• Obtain essential blood work including:
  • Complete blood count (CBC) 4
  • Electrolytes and glucose 4
  • Coagulation studies (INR and aPTT) 4
  • Renal function (creatinine and eGFR) 4
  • Troponin 4
• These tests should not delay imaging or treatment decisions but are necessary for determining thrombolytic therapy eligibility 1, 4

Cardiac Evaluation

• Obtain 12-lead ECG due to the high incidence of cardiac disease in stroke patients and to identify atrial fibrillation, acute coronary syndrome, or other cardiac abnormalities 1, 4
• Chest x-ray is NOT routinely recommended for most stroke patients unless there is clinical evidence of acute cardiac or pulmonary disease 1

Acute Treatment Decisions

For Ischemic Stroke

• Administer intravenous tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) to eligible patients within 3-4.5 hours of symptom onset 3, 2
• Blood pressure must be below 185/110 mmHg before administering thrombolytic therapy 2
• Consider mechanical thrombectomy for large vessel occlusion if within the appropriate time window, with the technical goal of achieving TICI grade 2b/3 angiographic result 1, 3
• Patients should be transported rapidly to the closest certified primary stroke center or comprehensive stroke center for endovascular treatment capability 1

For Hemorrhagic Stroke

• Control systolic blood pressure to 130-150 mmHg for patients with intracerebral hemorrhage 3
• For patients with elevated INR due to vitamin K antagonists: withhold the anticoagulant, administer therapy to replace vitamin K-dependent factors and correct the INR, and give intravenous vitamin K 1
• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 1
• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible 1

Initial Monitoring and Care Setting

• Admit patients to an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise for initial monitoring and management 1
• Perform swallowing screening within 24 hours using a validated tool by a trained practitioner to prevent aspiration pneumonia 1, 2
• Monitor temperature every 4 hours for the first 48 hours, initiating temperature-reducing measures if temperature exceeds 37.5°C 2
• Initiate intermittent pneumatic compression for venous thromboembolism prevention beginning the day of hospital admission 1

Critical Pitfalls to Avoid

• Do NOT delay brain imaging for laboratory results—imaging is the priority and determines the entire treatment pathway 1, 4
• Do NOT obtain lumbar puncture routinely—the yield of brain imaging is very high for detecting intracranial hemorrhage, and CSF examination is rarely indicated 1
• Do NOT lower blood pressure in patients not receiving thrombolytic therapy unless systolic pressure exceeds 220 mmHg or diastolic exceeds 120 mmHg 2
• Do NOT use anti-embolism stockings alone for venous thromboembolism prophylaxis—they are ineffective and other methods such as intermittent pneumatic compression or pharmacological prophylaxis should be used 2

Secondary Prevention Initiation

• Begin planning for secondary prevention immediately, including assessment for atrial fibrillation (extended cardiac monitoring >24 hours), carotid stenosis evaluation, and initiation of statin therapy 3, 4
• For symptomatic carotid stenosis >70%, consider carotid endarterectomy within 2 weeks 3
• Start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke) 3