Treatment of Progressive Cerebrovascular Accident (CVA)

Initial Management

For patients with progressive CVA, immediate assessment for cerebrovascular disease should be conducted, including MRI/MRA brain or spine to exclude structural causes and determine the type of stroke (ischemic vs. hemorrhagic) 2
In cases of ischemic stroke, withhold any immune checkpoint inhibitors if the patient is on cancer therapy, as these can exacerbate neurological symptoms 2
Comprehensive neurological examination should be performed to assess the severity and progression of symptoms 2

For ischemic progressive CVA, DOACs (rivaroxaban/dabigatran) are suggested over standard-of-care anticoagulants (LMWH, UFH, VKAs, fondaparinux) 1
Rivaroxaban shows better outcomes with reduced thrombus recurrence and improved thrombus resolution compared to standard anticoagulants 1
Between rivaroxaban and dabigatran, either can be used, though individual factors and jurisdictional availability may influence the choice 1
Gastrointestinal side effects are more common with dabigatran and should be considered when selecting therapy 1

Patients with progressive CVA should be assessed for cognitive deficits and provided with appropriate cognitive retraining for attention deficits, visual neglect, memory deficits, and executive function and problem-solving difficulties 3
Training to develop compensatory strategies for memory deficits is beneficial for patients with mild short-term memory impairments 3
Multiple cognitive retraining approaches involving various disciplines may benefit patients with multiple areas of cognitive impairment 3

Screen for and aggressively manage vascular risk factors that can worsen stroke progression, including hypertension 4, diabetes mellitus 5, and hypercholesterolemia 5
Regular assessment of fasting glucose is recommended for all stroke survivors, with screening for altered glucose metabolism beginning as part of survivorship care and repeated every 3 years 5, 6

Cancer patients receiving certain therapies (bevacizumab, sorafenib, carfilzomib) have higher risk of arterial thrombotic events including CVA 7
In cancer patients with progressive CVA, the incidence of cerebrovascular events ranges from 2-5.9% depending on the therapy 7
Consider withholding cancer therapies known to increase thrombotic risk during acute stroke management 7
For patients showing progression despite antiplatelet therapy, consider testing for aspirin or clopidogrel resistance 8
Approximately 25-30% of patients may show aspirin resistance, which is associated with higher risk of recurrent vascular events 8

Daily neurological assessment for patients with severe symptoms 2
Pulmonary function assessment for patients with progressive symptoms affecting respiratory function 2
Consider involving physiotherapy, occupational therapy, and speech therapy as appropriate based on deficit areas 2
For patients with visual-spatial deficits after right CVA, specific visual-spatial rehabilitation should be implemented 3