Management of Cerebrovascular Accident (CVA)

Initial Assessment and Stabilization

The American Heart Association recommends immediate neuroimaging with CT or MRI to confirm stroke type and identify underlying vascular abnormalities, with admission to a specialized stroke unit to reduce mortality and improve outcomes 1
Prehospital management should focus on ventilatory and cardiovascular support while transporting the patient to the closest facility prepared to care for acute stroke patients, with emergency medical services providing advance notice to the emergency department to initiate critical pathways and alert consulting services 2
Admission to a stroke unit with specialized care is associated with a 14% reduction in the odds of death at 1 year and improved functional outcomes 3

Blood pressure management is critical, with targets varying based on whether thrombolytic therapy is administered, according to the American College of Cardiology 1
For patients with large vessel occlusion, mechanical thrombectomy should be considered if within the appropriate time window, as recommended by the American Heart Association 4

In swollen supratentorial hemispheric ischemic stroke, decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically, according to the American Association of Neurological Surgeons 4
For swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically, as recommended by the American Heart Association 4

Control systemic hypertension with a goal of achieving systolic blood pressure of 130-150 mmHg, according to the American College of Cardiology 1
Immediate reversal of anticoagulant treatment with dedicated reversal agents is recommended for patients on anticoagulation therapy, as recommended by the American Heart Association 1
Tranexamic acid should be administered to patients with active bleeding as soon as possible, according to the American College of Emergency Physicians 1

MRI with T2*-weighted imaging plus MRV is the preferred diagnostic method, as recommended by the American Heart Association 5, 6
Initiate anticoagulation if no major contraindications exist, even in the presence of hemorrhagic transformation, according to the American College of Chest Physicians 5, 6, 7
Continue oral anticoagulation for 3-12 months or lifelong depending on the underlying etiology, as recommended by the American Heart Association 7, 3

For arteriovenous malformations (AVMs), a multimodality approach is often necessary, including surgical extirpation, combined embolization followed by surgery, or radiosurgery, according to the American Heart Association 8

After stabilization, a multidisciplinary approach to rehabilitation is essential to reduce disability, as recommended by the American College of Rehabilitation Medicine 1
Follow-up imaging at 3-6 months after diagnosis is reasonable to assess for recanalization in CVT patients, according to the American Heart Association 3