Cerebrovascular Accident
Diagnosis of Stroke
- Acute onset of motor or sensory deficit.
- Acute difficulty with language production or comprehension.
- Acute gait or coordination dysfunction.
- Acute visual loss or difficulty.
Acute CVA Diagnosis and Management
- Any patient with a new neurologic deficit concerning for stroke should be evaluated in the ER. Time is critical as certain stroke medications may be used only in the first three hours after a stroke.
- Acute stroke management should include a detailed neurologic history and physical, imaging with head CT with CT angiogram initially, and MRI +/- MRA, carotid & vertebral U/S, Echo and lab work up (CBC, Chem 10, Coagulation studies, and Lipids). Close vitals monitoring to avoid severe hyper/hypotension, EKG and possible cardiac monitoring may be required.
- If the patient had onset of symptoms > 5 days ago and is stable, the above workup may be performed as an outpatient. It should be expedited (in 1 week or less).
- If the patient has a history of stroke see chronic CVA management below.
Ongoing CVA Treatment
- Patients who are in a-fib should be put on coumadin with goal INR 2.5 – 3.0.
- Patients who have had a stroke while not on antiplatelet medications, they should be initiated on aspirin 50 – 325 mg.
- Patients who are on ASA with a stroke should be put on dipyridamole/ASA or dipyridamole/ASA + additional ASA for total ASA dose of 375 mg.
- Yearly evaluation of carotids with surgery if > 70% stenosis in asymptomatic individuals or > 60% stenosis in symptomatic individuals.
- Echo as needed (and for any change in cardiac status). Stroke in person <50 should get bubble study then if positive trans-esophageal echocardiogram (TEE).
- Glucose evaluation with tight control.
- Lipid evaluation with goal towards normalization.
- Smoking cessation.
- Weight evaluation with normalization of BMI.
- BP normalization – though elderly persons with intracranial atherosclerosis should have SBP > 120 & DBP > 60.
- Physical therapy, OT, speech evaluation and referral as needed.
Indications for Specialty Care Referral
New neurologic deficits.
Recurring symptoms on antiplatelet therapy.
Questions regarding diagnosis.
Criteria for Return to Primary Care
Most stroke patients can be followed long term by their primary care provider provided that the above recommendations are followed.
