CVA Medical Management

• Settings: EMS > Emergency (CVA equipped) > ICU > Acute > Rehabilitative (ARU) / Long-term (SNF) > Home
• Acute management: airway protection, adequate circulation maintenance, treatment of secondary injuries and conditions, finding the cause of the stroke, prevention of further progression, and treating acute neurologic complications.¹ 
• Management Principles: stop stroke progression, reduce cerebral edema, decrease the risk of hydrocephalus, treat seizures, prevent complications, e.g., DVT/PE, aspiration
• Specific treatment based on the underlying cause of stroke.

Ischemic Stroke Management

• May involve reestablishing blood flow to improve cerebral perfusion.
• Monitoring brain mass shift caused by edema which can lead to hydrocephalus.
• Pharmacological treatments include antithrombotic (antiplatelet and anticoagulation), thrombolytic (clot-dissolving, e.g., t-PA),²  neuroprotective (e.g., calcium channel blockers), and antiedema therapies.
• Surgical procedures include endarterectomy (surgical removal of plaque), extracranial-intracranial bypass, and balloon angioplasty.

Hemorrhagic Stroke Management

• Prognosis depends on the size and location of the bleed.
• Edema control, ICP control, prevention of rebleeding, maintenance of cerebral perfusion, control of vasospasm

Complications

• Spasticity and contractures in immobilized joints
• Shoulder pain and contractures occur in 70-80% of CVA patients with a hemiplegic stroke.³ 
• Contracture pattern: flexion, adduction, internal rotation⁴ 
  • Muscles that span two joints are at higher risk.
• Osteoporosis
• Heterotopic Ossification
• Falls
• Seizures
• Hydrocephalus
• Deconditioning – musculoskeletal, cardiovascular, neurologic, genitourinary, endocrine, body composition, metabolism
• Psychosocial
  • Negative emotional reactions
  • Stages of bereavement⁵ 
  • Lability⁶  & Pseudobulbar affect
  • Anxiety⁷ 
  • Depression⁸ 
  • Urinary tract infection⁹ 
  • Skin breakdown
  • Decubitus ulcers¹⁰ 
  • Dysphagia¹¹ 
  • Aspiration & aspiration pneumonia¹² 
  • DVT/PE¹³ 

1. Langhorne P, Williams BO, Gilchrist W, et al: Do stroke units save lives? Lancet 342(8868):395–398, 1993.[↩]
2. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995 Dec 14;333(24):1581-7. PMID: 7477192. LINK (NIH/NINDS, contracts NS02382, NS02374, NS02377, NS02381, NS02379, NS02373, NS02378, NS02376, NS02380; Genentech, tPA) [↩]
3. Roth EJ, Harvey RL: Rehabilitation of stroke syndromes. In Braddom RL, editor: Physical medicine and rehabilitation, Philadelphia, 1996, Saunders.[↩]
4. Harburn KL, Potter PJ: Spasticity and contractures. Phys Med Rehabil State Art Rev 7(8):113, 1993.[↩]
5. Worden JW: Grief counseling and grief therapy, New York, 1982, Springer.[↩]
6. House A, Dennis M, Molyneux A, et al: Emotionalism after stroke. BMJ 298(6679):991–994, 1989.[↩]
7. Lezak MD: Neuropsychological assessment, ed 2, New York, 1983, Oxford University Press.[↩]
8. Swartzman L, Teasell RW: Psychological consequences of stroke. Phys Med Rehabil State Art Rev 7(1):179, 1993.[↩]
9. Brockhurst JC, Andrews K, Richards B, et al: Incidence and correlates of incontinence in stroke patients. J Am Geriatr Soc 33(8):540–542, 1985.[↩]
10. Salcido R, Hart D, Smith AM: The prevention and management of pressure ulcers. In Braddom RL, editor: Physical medicine and rehabilitation, Philadelphia, 1996, Saunders.[↩]
11. Gordon C, Hewer RL, Wade DT: Dysphagia in acute stroke. Br J Med 295(6595):411–414, 1987.[↩]
12. Levison ME: Pneumonia, including necrotizing pulmonary infections (lung abscesses). In Isselbacher KJ, Braunwald E,[↩]
13. Warlow C, Ogston D, Douglas AS: Deep venous thrombosis of the legs after strokes. I. Incidence and predisposing factors; II. Natural history. BMJ 1(6019):1178–1181, 1976.[↩]