In a case of stroke with complaints of weakness in the arm, leg, and face, where is the damage likely located?

Middle Cerebral Artery Damage in Stroke with Arm, Leg, and Face Weakness

In a stroke case presenting with weakness in the arm, leg, and face, the damage is most likely located in the middle cerebral artery (MCA) territory. 1

Anatomical Basis for MCA Stroke Presentation

• The middle cerebral artery supplies the lateral surface of the cerebral hemisphere, including the motor cortex regions controlling the face and upper limb, explaining the classic presentation of face and arm weakness 2
• MCA territory infarcts frequently present with unilateral weakness affecting face, arm, and leg, with face and arm typically more severely affected than the leg 3
• The superficial MCA territory includes the greater part of the lateral surface of the cerebral hemisphere, which controls motor function for the contralateral side of the body 2

Clinical Features of MCA Stroke

• Patients with MCA territory strokes typically present with contralateral hemiparesis affecting the face, arm, and leg, with face and arm weakness often more pronounced than leg weakness 3, 4
• This pattern differs from anterior cerebral artery (ACA) strokes, which primarily cause isolated or predominant leg weakness 5
• Mid basilar artery strokes typically present with bilateral symptoms, cranial nerve deficits, and brainstem signs rather than unilateral face, arm, and leg weakness 6

Pathophysiology and Mechanisms

• MCA strokes commonly result from:
  • Cardiogenic embolism (54% of large MCA infarcts) 3
  • Internal carotid artery occlusion (41% of large MCA infarcts) 3
  • Atherothrombotic disease 6
• The MCA is the most common site for embolic strokes, which explains the high frequency of this presentation 3, 2

Diagnostic Considerations

• Urgent brain imaging (CT or MRI) and noninvasive vascular imaging (CTA or MRA from aortic arch to vertex) should be completed as soon as possible within 24 hours to confirm MCA territory involvement 1
• The combination of hemiplegia, hemisensory loss in the face/arm/leg, hemianopia, and (if dominant hemisphere) global aphasia has a positive predictive value of 0.73 for large MCA territory infarction 3
• Patients with this presentation should be considered at highest risk for recurrent stroke, especially if symptoms are fluctuating or persistent 1

Clinical Implications and Management

• MCA territory strokes, particularly those involving multiple MCA subterritories, are associated with higher mortality (17%) and severe disability (50%) compared to other stroke types 3, 4
• Patients with large MCA infarctions may develop malignant cerebral edema requiring consideration for decompressive hemicraniectomy, especially in patients under 60 years 1
• Immediate transfer to an emergency department with advanced stroke care capabilities is essential for patients presenting with this pattern of weakness 1

Differential Considerations

• Anterior cerebral artery strokes typically present with predominant leg weakness rather than the combined face, arm, and leg pattern 5
• Mid basilar artery strokes usually present with brainstem signs including bilateral symptoms, cranial nerve palsies, vertigo, and ataxia rather than unilateral weakness 6
• Internal capsule lesions can also cause face, arm, and leg weakness but are typically classified as subcortical MCA territory strokes 5