• Post-Acute Care:

  • Neuroprotective Agents: Research is ongoing into neuroprotective drugs that might minimize ischemic injury, but no specific agents are universally endorsed at present.
  • Stroke Units: Specialized stroke units provide intensive monitoring and rehabilitation.
  • Rehabilitation: Early mobilization and speech, physical, and occupational therapy are crucial for improving outcomes.

Hemorrhagic Stroke:

• Acute Management:
  • Blood Pressure Control: Blood pressure management is critical in hemorrhagic strokes to prevent rebleeding or hematoma expansion. Agents such as labetalol, nicardipine, or hydralazine may be used.
  • Surgical Intervention: Surgical evacuation of the hematoma may be required in cases of large hemorrhage or neurological deterioration.
  • Endovascular Treatment: For some patients, coiling (in aneurysms) or embolization (in arteriovenous malformations) may be beneficial.
• Post-Acute Care:
  • Seizure Prophylaxis: Antiepileptic drugs may be used in the early stages after hemorrhagic stroke to prevent seizures.
  • Rehabilitation: Similar to ischemic stroke, rehabilitation is key, focusing on neurocognitive and functional recovery.

2) Medical Management

Medical management of stroke and CVA focuses on preventing recurrence, managing comorbidities, and optimizing recovery. The primary pillars of medical management include:

• Antithrombotic Therapy:

  • For ischemic strokes, antiplatelet agents (e.g., aspirin, clopidogrel) are typically used in the long term.
  • For patients with atrial fibrillation or cardioembolic strokes, anticoagulants like apixaban or rivaroxaban are preferred.

• Blood Pressure Control:

  • Hypertension is a major risk factor for stroke. Aggressive management of blood pressure (targeting <140/90 mmHg) is crucial.

• Hyperlipidemia Management:

  • Statins are recommended for secondary stroke prevention, aiming to reduce cholesterol levels and prevent further vascular injury.

• Glycemic Control:

  • Strict glucose control (HbA1c < 7%) in diabetic patients to reduce stroke risk and complications.

• Neuroprotective Agents:

  • While research is ongoing, some agents like magnesium, edaravone, and nimodipine have shown promise in experimental settings but are not widely approved for routine clinical use.

3) Endovascular Management

Endovascular procedures have become central in the treatment of acute ischemic stroke, especially for large vessel occlusions. The key interventions include:

• Mechanical Thrombectomy:

  • Indications: Large vessel occlusion (typically in the internal carotid artery, M1 or M2 segments of the middle cerebral artery, or basilar artery) with a favorable salvageable brain tissue window (typically within 6 hours of symptom onset, and in some cases up to 24 hours with advanced imaging).
  • Technique: A stent retriever is used to capture the clot, which is then withdrawn or aspirated via a catheter inserted into the femoral artery.

• Intra-arterial Thrombolysis:

  • In some cases, direct administration of thrombolytic agents (e.g., rtPA) into the clot via the catheter can be used in addition to mechanical thrombectomy.

• Endovascular Coiling and Embolization:

  • Aneurysms: Coiling is a minimally invasive technique used for intracranial aneurysms to prevent rupture.
  • Arteriovenous Malformations (AVMs): Embolization or coiling can reduce the risk of bleeding by occluding abnormal vascular channels in the brain.

• Post-Endovascular Care:

  • After endovascular procedures, patients are monitored closely for complications like reperfusion injury, hemorrhage, or infection at the catheter insertion site.

4) Surgical Management

Surgical management is indicated for certain stroke-related complications, or when endovascular interventions are not feasible or effective. Surgical approaches include:

• Hematoma Evacuation (Hemorrhagic Stroke):

  • In cases of large intracerebral hemorrhage, surgery may be necessary to evacuate the blood and reduce intracranial pressure. The goal is to relieve mass effect and prevent further brain injury.
  • Decompressive Craniectomy: In severe cases, part of the skull may be removed to allow the brain to expand and reduce intracranial pressure.

• Carotid Endarterectomy (CEA):

  • Indicated for patients with symptomatic carotid stenosis (typically >70%) to reduce the risk of recurrent stroke. The procedure involves surgical removal of the atherosclerotic plaque from the carotid artery.

• Carotid Artery Stenting (CAS):

  • An alternative to carotid endarterectomy, CAS involves placing a stent in the carotid artery to open up the narrowed section. This option is preferred in patients who are not candidates for open surgery.

• Bypass Surgery:

  • For patients with intracranial stenosis or insufficient blood flow due to large vessel occlusion, cerebral revascularization surgeries like superficial temporal artery to middle cerebral artery (STA-MCA) bypass may be considered.

• Aneurysm Clipping:

  • For ruptured intracranial aneurysms, surgical clipping is often performed to prevent further bleeding. This involves placing a clip at the base of the aneurysm to occlude the blood flow.

In summary, advanced stroke and CVA management requires a comprehensive, personalized approach, integrating medical, endovascular, and surgical interventions as necessary to improve outcomes. Each patient’s condition, including the type, location, and timing of the stroke, guides the treatment strategy.