What is the recommended treatment for a young female with a Middle Cerebral Artery (MCA) infarct?

Management of Middle Cerebral Artery (MCA) Infarct in Young Female Patients

For young female patients with MCA infarct, the recommended treatment is intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset, followed by endovascular therapy with stent retrievers within 6 hours if there is proximal MCA occlusion. 1

Initial Assessment and Management

• Rapid clinical assessment using the National Institutes of Health Stroke Scale (NIHSS) should be performed to determine stroke severity and guide treatment decisions 1
• Non-contrast CT scan should be performed immediately to rule out hemorrhage and assess early ischemic changes using ASPECTS (Alberta Stroke Program Early CT Score) 1, 2
• CT angiography should be obtained to confirm MCA occlusion and assess collateral circulation 2
• Diffusion-weighted MRI, when available, provides the most sensitive assessment of ischemic core 1, 2

Acute Reperfusion Therapy

• Intravenous tPA (0.9 mg/kg, maximum 90 mg, with 10% given as bolus and remainder over 60 minutes) should be administered within 4.5 hours of symptom onset if no contraindications exist 1

• Patients eligible for intravenous tPA should receive it even if endovascular treatments are being considered 1

• Endovascular therapy with stent retrievers is strongly recommended if all the following criteria are met 1:

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

• Observing patients after intravenous tPA to assess for clinical response before pursuing endovascular therapy is not recommended and may delay beneficial treatment 1

• Stent retrievers are preferred over other mechanical thrombectomy devices 1

Special Considerations for Young Female Patients

• Young female patients with MCA occlusion have been shown to have better recanalization rates with intravenous tPA compared to those with internal carotid artery occlusions (88% vs. 31%) 3
• For patients not responding to intravenous tPA, rescue intra-arterial thrombolysis may be considered, which has shown improvement in NIHSS scores from a median of 18 to 6 in selected patients 4
• Young patients (<60 years) with malignant MCA infarction should be considered for early decompressive hemicraniectomy if there are signs of significant edema or mass effect 1

Management of Cerebral Edema

• Early signs of malignant MCA infarction include severe neurological deficits, large hypodensity on CT (>50% of MCA territory), and early midline shift 5

• Initial medical management includes 2:

  • Elevating head of bed to 30 degrees
  • Restricting free water
  • Avoiding hypotonic fluids
  • Osmotic therapy with mannitol or hypertonic saline for patients with clinical deterioration

• Decompressive hemicraniectomy should be performed within 48 hours of stroke onset in young patients with malignant MCA infarction to reduce mortality by approximately 50% 1, 2

Post-Acute Management

• Antiplatelet therapy with aspirin (160-300 mg) should be initiated within 24-48 hours after stroke onset 2
• Blood pressure should be maintained at ≤180/105 mmHg during and for 24 hours after reperfusion therapy 2
• Prophylactic anticonvulsant treatment is not recommended but should be initiated if seizures occur 1

Common Pitfalls and Caveats

• Delaying endovascular therapy while waiting for clinical response to intravenous tPA can reduce the chances of good outcomes; these treatments should be pursued in parallel when indicated 1
• Young female patients may have non-atherosclerotic causes of stroke such as arterial dissection, vasculitis, or cerebral venous thrombosis that require specific diagnostic workup 2
• The risk of hemorrhagic transformation increases with large infarct size, use of thrombolytics, and reperfusion of severely damaged tissue, requiring careful patient selection and monitoring 2, 6
• Despite higher recanalization rates in MCA occlusions compared to ICA occlusions, functional outcomes at 3 months may not differ significantly, highlighting the importance of comprehensive post-stroke care 3