What is the assessment and plan for a patient with an ischemic stroke found to have a left M1 (middle cerebral artery) occlusion status post (after) thrombectomy?

Assessment and Plan for Ischemic Stroke with Left M1 Occlusion Status Post Thrombectomy

Mechanical thrombectomy is the gold standard treatment for patients with acute ischemic stroke due to left M1 (middle cerebral artery) occlusion, and post-thrombectomy care should focus on blood pressure management, neurological monitoring, and early rehabilitation to optimize functional outcomes.

Immediate Post-Thrombectomy Management

Blood Pressure Control

• Maintain blood pressure ≤180/105 mmHg during and for 24 hours after the procedure 1
• For patients with successful reperfusion, consider maintaining blood pressure <180/105 mmHg 1
• In patients with basilar artery occlusions who have undergone thrombectomy, some evidence suggests maintaining systolic BP <140 mmHg in the first 24 hours after successful reperfusion 1

Neurological Monitoring

• Perform frequent neurological assessments using the National Institutes of Health Stroke Scale (NIHSS) 2
• An NIHSS score ≤10 at 24 hours post-thrombectomy is strongly associated with good functional outcome at 90 days (modified Rankin Scale 0-2) 2
• Monitor for signs of neurological deterioration which may indicate complications such as hemorrhagic transformation or re-occlusion 1

Imaging Follow-up

• Obtain follow-up brain imaging (CT or MRI) within 24 hours to assess for hemorrhagic transformation and final infarct extent 3
• Ischemic brain lesion extension on 24-hour imaging is significantly associated with 3-month clinical outcome 3

Medical Management

Antithrombotic Therapy

• Administration of aspirin is recommended within 24-48 hours after stroke onset 1
• For patients who received IV alteplase prior to thrombectomy, aspirin administration should generally be delayed until 24 hours after thrombolysis 1

Glycemic Control

• Aggressive management of hyperglycemia is critical as it is independently associated with poor outcomes at 90 days 3
• Hyperglycemia at admission is a significant predictor of poor outcome (OR 10.013; 95% CI 1.068-93.915) 3

Complication Prevention

• Monitor for and promptly address post-procedural complications including:
  • Embolic complications (reported rate approximately 10%) 3
  • Symptomatic intracranial hemorrhage (reported rate approximately 2%) 3
  • Blood-brain barrier disruption which is significantly associated with clinical outcomes 3

Rehabilitation and Recovery

Early Rehabilitation

• Initiate early rehabilitation assessments and interventions 1
• Baseline NIHSS score is independently associated with 3-month outcomes (OR 1.228; 95% CI 1.075-1.402) 3
• Delta NIHSS score ≥8 between baseline and 24 hours is associated with good functional outcome at 90 days 2

Long-term Outcomes

• Approximately 54% of patients achieve good functional outcomes (mRS 0-2) at 3 months after thrombectomy for MCA occlusions 3
• The technical goal of thrombectomy should be reperfusion to modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b/3 to maximize probability of good functional outcome 1

Secondary Prevention

Stroke Etiology Workup

• Complete a comprehensive evaluation to determine stroke etiology (e.g., atrial fibrillation, large vessel atherosclerosis) 4
• For patients with atrial fibrillation, anticoagulation should be considered for secondary prevention 4

Systems of Care

• Consider transfer to a comprehensive stroke center if the patient is not already at one 1
• Regional systems of stroke care should include healthcare facilities that provide initial emergency care and centers capable of performing endovascular stroke treatment 1

Common Pitfalls and Considerations

• Failure to monitor for hyperglycemia, which is independently associated with poor outcomes 3
• Inadequate blood pressure control post-thrombectomy 1
• Delayed initiation of rehabilitation services 1
• Not recognizing the importance of the 24-hour NIHSS score as a predictor of long-term outcomes 2
• Lack of appropriate follow-up imaging to assess for complications and infarct extension 3

Special Considerations for M1 Occlusions

• M1 MCA location is associated with better clinical outcomes compared to internal carotid artery or basilar artery occlusions 3
• Successful recanalization of lateral lenticulostriate arteries may be important for recovery in M1 occlusions 5
• For patients with bilateral M1 occlusions (rare), more aggressive management may be required 4