Comprehensive Management of Cerebrovascular Accident (CVA)

Immediate Prehospital and Emergency Department Triage

• The American Heart Association recommends that stroke patients receive the highest triage priority with immediate notification of the receiving hospital, preferably one with organized stroke unit care, to facilitate rapid assessment and minimize door-to-needle time to ≤30 minutes 1, 2

Rapid Neurological Assessment

• The American Stroke Association recommends performing NIHSS assessment immediately upon arrival to quantify stroke severity and guide treatment decisions 3, 2
• Patients with NIHSS <15 are optimal candidates for early intervention; those with NIHSS >15 who are obtunded have poor outcomes with aggressive intervention 5, 2

Emergent Neuroimaging

• The American College of Radiology recommends non-contrast CT head must be completed within 30 minutes of hospital admission to distinguish ischemic from hemorrhagic stroke and exclude stroke mimics 2
• MRI with diffusion-weighted imaging (DWI) is acceptable if available and doesn't delay treatment - it's more sensitive than CT for ischemic changes and has similar accuracy for acute hemorrhage 1, 2

Blood Pressure Management

• The American Heart Association recommends blood pressure must be <185/110 mmHg before administering thrombolysis, then maintained <180/105 mmHg for 24 hours post-treatment 3, 2
• Avoid aggressive BP lowering unless >220/120 mmHg - permissive hypertension may maximize cerebral blood flow 2

Reperfusion Therapy

• The American Stroke Association recommends intravenous recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) for patients presenting within 3 hours of symptom onset, if no contraindications exist 1, 3
• Aspirin 160-300 mg should be commenced within 48 hours of ischemic stroke onset, but typically after 24 hours if thrombolysis was given 1, 3

Cardiac Evaluation

• The American College of Cardiology recommends performing 12-lead ECG immediately without delaying stroke treatment, and initiate continuous cardiac monitoring for 24-72 hours to detect atrial fibrillation and arrhythmias 2

Stroke Unit Care

• The American Stroke Association recommends comprehensive stroke unit care for all patients with ischemic stroke - this organized care reduces morbidity and mortality 1, 3

Secondary Prevention

• The American Heart Association recommends initiating statin therapy regardless of baseline cholesterol levels 3, 4
• Start antihypertensive therapy after the acute phase (typically 24-48 hours post-stroke) 3, 4
• For patients with atrial fibrillation, consider anticoagulation after ruling out hemorrhagic transformation 3, 4