What is the management for a patient presenting with ischemic stroke within 2 hours, with a CT scan showing left sided main carotid artery and middle cerebral artery (MCA) involvement?

Management of Left-Sided Main Carotid Artery and MCA Ischemic Stroke Presenting Within 2 Hours

Thrombolytic therapy with intravenous alteplase should be administered immediately as the first-line treatment for patients presenting with ischemic stroke within 2 hours of symptom onset, with a door-to-needle time goal of less than 60 minutes. 1

Immediate Management Steps

• Perform rapid clinical assessment including neurological examination and obtain CT scan to rule out hemorrhage before initiating thrombolysis 1

• Check blood glucose immediately (hypoglycemia below 60 mg/dL or 3.3 mmol/L should be treated with IV dextrose) 1

• Ensure blood pressure is below 185/110 mmHg before administering thrombolysis 1

• Administer IV alteplase at 0.9 mg/kg (maximum dose 90 mg) with 10% given as bolus over 1 minute and the remaining 90% infused over 60 minutes 1

• Do NOT wait to evaluate response to IV thrombolysis before proceeding with evaluation for mechanical thrombectomy 1

Concurrent Evaluation for Mechanical Thrombectomy

• Perform CT angiography (CTA) immediately to identify large vessel occlusion, particularly given the involvement of the left main carotid artery and MCA 1

• If large vessel occlusion is confirmed, proceed directly to mechanical thrombectomy with a stent retriever, which should be initiated (groin puncture) within 6 hours of symptom onset 1

• The technical goal of mechanical thrombectomy should be reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b/3 1

Important Considerations

• Time is critical - every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 2

• The primary goal should be achieving door-to-needle time within 60 minutes in ≥50% of patients, with a secondary goal of achieving door-to-needle time within 45 minutes 1

• Multicomponent quality improvement initiatives, including ED education and multidisciplinary teams with access to neurological expertise, are recommended to safely increase IV thrombolytic treatment 1

• For patients with stroke and acute hypertension who are otherwise eligible for IV thrombolysis, blood pressure should be lowered below 185/110 mmHg before initiating treatment 1

Why Thrombolysis is the Correct Choice

• High-quality evidence supports IV alteplase administration within 3 hours (and up to 4.5 hours) of stroke onset to improve functional outcomes 1, 3

• The patient's presentation at 2 hours places them well within the established treatment window for thrombolysis 1

• Neither heparin nor warfarin is recommended as first-line treatment for acute ischemic stroke 1, 4

• Early aspirin therapy is recommended only for patients with acute ischemic stroke who are not receiving thrombolysis 4

Pitfalls to Avoid

• Delaying treatment while waiting for additional tests beyond the essential CT scan and glucose check 1, 2

• Failing to control blood pressure adequately before thrombolysis, which increases hemorrhagic risk 2

• Observing for clinical response to IV alteplase before pursuing endovascular therapy evaluation is not recommended and may delay potentially beneficial mechanical thrombectomy 1

• Administering anticoagulants like heparin or warfarin as first-line treatment, which is not supported by evidence and may increase bleeding risk 1, 4