What is the optimal management strategy for a patient with acute cerebral vascular accident (CVA)?

Acute Ischemic Stroke Management

Immediate Emergency Department Actions

For acute ischemic stroke, immediately perform non-contrast CT within 45 minutes of arrival to exclude hemorrhage, then administer IV alteplase (0.9 mg/kg, max 90 mg) within 30 minutes of door arrival for patients presenting within 4.5 hours of symptom onset, followed by mechanical thrombectomy for large vessel occlusions. 1, 2

Time-Critical Triage and Assessment

• Assign highest triage priority with immediate hospital notification to achieve door-to-needle time ≤30 minutes 2
• Stabilize airway, breathing, and circulation immediately, supplementing oxygen to maintain saturation >94% 2
• Perform NIHSS assessment immediately upon arrival—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 all reperfusion therapies 2

Neuroimaging Protocol

• Complete non-contrast CT within 45 minutes of emergency department arrival 1
• Interpret brain imaging within 45 minutes by a physician with expertise in reading CT and MRI studies 1
• Acute hemorrhage appears as hyperdense foci on non-contrast CT; absence virtually excludes intracranial hemorrhage 1
• Obtain CT angiography (CTA) during initial evaluation to detect large vessel occlusion—this adds only 2-4 minutes but guides treatment decisions 3, 1
• Avoid time-consuming imaging methods because every 30-minute delay in recanalization decreases chance of good functional outcome by 8-14% 1

Reperfusion Therapy

Intravenous Thrombolysis

Administer IV alteplase at 0.9 mg/kg (maximum 90 mg) for patients presenting within 4.5 hours of symptom onset if no contraindications exist. 2

• Give alteplase even in the presence of early ischemic changes on CT, regardless of extent, unless frank hypodensity involves more than one-third of the middle cerebral artery territory 1
• The greatest risk is treatment-associated intracranial hemorrhage, which increases with duration of ischemia, extent of early ischemic changes, stroke severity, and pre-existing coagulopathies 3

Endovascular Mechanical Thrombectomy

• Perform mechanical thrombectomy as rapidly as possible for patients with proximal artery occlusions in the anterior circulation who can be treated within 24 hours of symptom onset 3, 2
• Use combined stent-retriever and aspiration approach to achieve first-pass complete reperfusion 2
• Large vessel occlusions are less likely to recanalize with alteplase alone and should be considered for endovascular therapy 1
• If IV thrombolysis is contraindicated (e.g., warfarin-treated patient with therapeutic anticoagulation), mechanical thrombectomy is recommended as first-line treatment 3

Hospital Admission and Acute 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 IV rtPA 2
• Approximately 25% of patients have neurological worsening during the first 24-48 hours, making specialized monitoring essential 2
• Every emergency department must be prepared to treat acute stroke or have a plan for rapid transfer to a tertiary care center with neurology, neuroradiology, neurosurgery, and critical care facilities 1

Blood Pressure Management

• In exceptional cases with systemic hypotension producing neurological sequelae, prescribe vasopressors to improve cerebral blood flow with close neurological and cardiac monitoring 3
• Drug-induced hypertension is not well established for acute ischemic stroke and should only be performed in clinical trial settings 3
• Start antihypertensive therapy after the acute phase, typically 24-48 hours post-stroke 2
• Norepinephrine is the most common drug used to increase arterial blood pressure when needed 4

Fluid Management

• Target fluid balance to neutral 4
• Normal saline is the most common fluid used 4
• Hemodilution by volume expansion is not recommended for treatment 3

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. 2

• High-dose albumin is not well established as treatment until further definitive evidence becomes available 3
• Induced hypothermia for treatment of ischemic stroke is not well established 2
• Transcranial near-infrared laser therapy is not well established 2
• Administration of vasodilatory agents such as pentoxifylline is not recommended 3
• Nimodipine showed negative or worse outcomes in primary ischemic stroke trials, presumably due to antihypertensive effects 3

Secondary Prevention

• Initiate statin therapy regardless of baseline cholesterol levels 2
• Begin early mobilization when the patient is medically stable 2
• Implement measures to prevent aspiration, malnutrition, deep vein thrombosis, pulmonary embolism, and pressure sores 2

Surgical Considerations

• Emergency carotid endarterectomy 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 2
• For neurologically stable patients after nondisabling stroke or TIA, early surgery (within 2 weeks) may be performed without incremental risk compared to delayed surgery 2

Critical Pitfalls to Avoid

• Do not rely on clinical characteristics alone to differentiate hemorrhagic from ischemic stroke, as symptoms such as vomiting and severe headache are not specific 1
• Do not refuse admission to neurosurgical units for patients requiring emergency surgery due to lack of critical care beds—surgery remains the priority 3
• Do not delay transfer for mechanical thrombectomy—treatment is time-critical and should occur as rapidly as possible 3

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