What is the management plan for a 40-year-old woman with a left Middle Cerebral Artery (MCA) stroke?

SOAP Note for 40-Year-Old Woman with Left MCA Stroke

Subjective

• 40-year-old female with acute left middle cerebral artery (MCA) stroke
• History to be obtained: onset time of symptoms, risk factors (hypertension, diabetes, smoking, hyperlipidemia, prior stroke/TIA, family history)
• Review for aphasia, right-sided weakness, sensory changes, visual disturbances

Objective

• Vital signs: Focus on blood pressure (maintain ≤180/105 mmHg) 1
• Neurological examination:
  • Language assessment (high likelihood of aphasia with left MCA stroke) 2
  • Motor/sensory examination (right-sided weakness/numbness)
  • Assess for buccofacial apraxia (strong predictor of dysphagia in left MCA stroke) 2
  • NIHSS score documentation
• Imaging:
  • CT/MRI brain: Assess infarct size, location, and presence of hemorrhage
  • CT/MR angiography: Evaluate for occlusion of left MCA
  • Perfusion imaging if available: Assess for penumbra (salvageable tissue) 3

Assessment

• Left MCA stroke with right-sided hemiparesis and likely aphasia
• Evaluate stroke etiology: cardioembolic, large vessel atherosclerosis, small vessel disease
• Assess for complications:
  • Cerebral edema risk (especially days 3-5 post-stroke) 1
  • Dysphagia risk (high with left MCA stroke due to aphasia and buccofacial apraxia) 2
  • Risk of recurrent stroke

Plan

Immediate Management

The patient should be admitted to a specialized stroke unit with comprehensive care capabilities and early neurosurgical consultation for potential decompressive hemicraniectomy if cerebral edema develops. 1

1. Airway/Breathing:

   • Assess swallowing before oral intake; perform bedside swallow evaluation 1
   • Consider nasogastric tube for medication administration and nutrition if dysphagia present

2. Circulation:

   • Maintain BP ≤180/105 mmHg during and for 24 hours after any endovascular procedure 1
   • Continue pre-existing antihypertensive medications if no symptomatic hypotension 1

3. Antithrombotic Therapy:

   • Initiate aspirin 160-300 mg within 24-48 hours of stroke onset 1
   • If patient is high-risk for recurrent stroke, consider dual antiplatelet therapy with:
     • Loading dose: Clopidogrel 300-600 mg + ASA 160 mg 1
     • Maintenance: Clopidogrel 75 mg daily + ASA 81 mg daily for 21-30 days 1
     • After 21-30 days: Switch to single antiplatelet therapy indefinitely 1

4. Neurological Monitoring:

   • Monitor for signs of increased intracranial pressure (declining consciousness, pupillary changes)
   • Serial neurological assessments
   • Consider repeat imaging if clinical deterioration

5. Prevention of Complications:

   • DVT prophylaxis: Subcutaneous anticoagulants or intermittent pneumatic compression 1
   • Early mobilization if stable
   • Bladder management: Avoid indwelling catheters if possible 1
   • Monitor for and treat infections promptly 1

6. Surgical Considerations:

   • Neurosurgical consultation for potential decompressive hemicraniectomy, especially if patient is under 60 years old 1
   • Monitor for cerebral edema, particularly during days 3-5 post-stroke 1

Discharge Planning

1. Secondary stroke prevention:

   • Long-term antiplatelet therapy
   • Risk factor modification (hypertension, diabetes, hyperlipidemia)
   • Lifestyle modifications (smoking cessation, diet, exercise)

2. Rehabilitation:

   • Speech therapy for aphasia
   • Physical therapy for right-sided weakness
   • Occupational therapy for activities of daily living

3. Follow-up:

   • Neurology appointment within 2-4 weeks
   • Carotid imaging if not done during hospitalization
   • Cardiac monitoring if etiology unclear

Key Considerations and Pitfalls

• Dysphagia assessment is critical in left MCA stroke; aphasia may mask swallowing difficulties 2
• Cerebral edema typically peaks 3-5 days after stroke; maintain vigilance even if initial stability 1
• Avoid overaggressive blood pressure lowering which may compromise penumbral tissue
• Consider patient's age for surgical intervention decisions; decompressive hemicraniectomy shows better outcomes in patients under 60 years 1