What is the management plan for a patient presenting with symptoms of a left Middle Cerebral Artery (MCA) stroke?

Management of Left Middle Cerebral Artery (MCA) Stroke

Patients with left MCA stroke require immediate evaluation and treatment with intravenous thrombolysis within 4.5 hours of symptom onset, followed by consideration for endovascular therapy with stent retriever if there is proximal vessel occlusion, to significantly reduce mortality and improve functional outcomes. 1

Initial Assessment and Stabilization

• Rapid neuroimaging: CT or MRI must be performed immediately to distinguish ischemic from hemorrhagic stroke 1
• Baseline severity assessment: Use National Institutes of Health Stroke Scale (NIHSS) to quantify deficit severity 1
• Airway management and cardiovascular support: Ensure adequate oxygenation and circulation 1
• Symptom recognition: Left MCA strokes typically present with:
  • Right-sided weakness (face, arm, leg)
  • Right-sided sensory loss
  • Aphasia (language disturbance)
  • Right visual field defects 1

Hyperacute Management (0-6 hours)

Thrombolytic Therapy

• IV recombinant tissue plasminogen activator (rtPA):
  • Administer 0.9 mg/kg (maximum 90 mg) if patient presents within 4.5 hours of symptom onset
  • 10% as bolus, remainder over 60 minutes 1
  • Contraindications include recent surgery, active bleeding, uncontrolled hypertension

Endovascular Treatment

• Mechanical thrombectomy with stent retriever if patient meets ALL criteria:

  • Prestroke modified Rankin Scale (mRS) score 0-1
  • Causative occlusion of internal carotid artery (ICA) or proximal MCA (M1)
  • Age ≥18 years
  • NIHSS score ≥6
  • Alberta Stroke Program Early CT Score (ASPECTS) ≥6
  • Treatment can be initiated (groin puncture) within 6 hours of symptom onset 1

• Do not delay endovascular therapy to observe response to IV rtPA 1

Acute Management (First 24-48 Hours)

Blood Pressure Management

• For patients receiving thrombolysis:
  • Maintain BP <180/105 mmHg
• For patients not receiving thrombolysis:
  • Allow permissive hypertension in first 24 hours unless BP >220/120 mmHg 1

Monitoring for Malignant Edema

• Left MCA strokes may develop malignant cerebral edema within 2-5 days
• Risk factors include:
  • Young age
  • Large infarct volume (>50% of MCA territory)
  • Early CT hypodensity
  • Involvement of additional vascular territories
  • Hyperdense MCA sign 1, 2
• Monitor for:
  • Declining level of consciousness
  • New or worsening neurological deficits
  • Midline shift on imaging 2

Management of Malignant Edema

• Decompressive hemicraniectomy should be considered:

  • For patients <60 years: Strong evidence for reduced mortality (Class I, Level A)
  • For patients 60-80 years: Moderate evidence (Class I, Level B) 1
  • Optimal timing: within 48 hours of symptom onset 1
  • Discuss with neurosurgery early if patient has large MCA infarct

• Medical management of edema:

  • Elevate head of bed 20-30°
  • Avoid hypotonic fluids
  • Correct factors that exacerbate swelling (hypoxemia, hypercarbia, hyperthermia)
  • Consider osmotic therapy (mannitol 0.25-0.5 g/kg IV every 6 hours) as a temporizing measure 1

Secondary Prevention

Antiplatelet Therapy

• Aspirin: Initiate within 24-48 hours after stroke onset (after excluding hemorrhage)
• For high-risk TIA or minor stroke: Consider dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days 1

Carotid Evaluation and Intervention

• Evaluate for carotid stenosis if stroke mechanism suggests large artery atherosclerosis
• For symptomatic high-grade carotid stenosis:
  • Consider carotid endarterectomy or stenting
  • Benefit is greatest when performed within 2 weeks of symptom onset 1

Common Pitfalls to Avoid

1. Delayed recognition: Left MCA stroke symptoms (especially aphasia) may be mistaken for confusion or other non-stroke conditions
2. Missing the time window: Failure to determine last known well time accurately may exclude patients from time-sensitive therapies
3. Inadequate monitoring: Failure to monitor for neurological deterioration due to edema, especially in the first 2-5 days
4. Late surgical intervention: Delaying hemicraniectomy beyond 48 hours significantly reduces its benefit
5. Inappropriate blood pressure management: Overly aggressive BP lowering in acute phase may worsen ischemia

Rehabilitation Considerations

• Early mobilization (within 24 hours if stable)
• Speech and language therapy for aphasia
• Physical and occupational therapy for right-sided weakness
• Comprehensive stroke unit care improves outcomes 1

By following this structured approach to left MCA stroke management with emphasis on rapid assessment, timely reperfusion therapies, vigilant monitoring for complications, and early rehabilitation, patient outcomes can be significantly improved.