What is the management of acute ischemic stroke due to right Middle Cerebral Artery (MCA) occlusion?

From the Guidelines

Immediate treatment for acute ischemic right MCA (middle cerebral artery) stroke occlusion should focus on rapid reperfusion therapy, with intravenous alteplase (tPA) administered within 4.5 hours of symptom onset and mechanical thrombectomy performed as soon as possible for patients with large vessel occlusion confirmed by imaging within 24 hours of symptom onset. The management of acute ischemic stroke due to right Middle Cerebral Artery (MCA) occlusion involves a multidisciplinary approach to minimize morbidity, mortality, and improve quality of life. According to the most recent guidelines, if the patient presents within 4.5 hours of symptom onset and has no contraindications, administer intravenous alteplase (tPA) at 0.9 mg/kg (maximum dose 90 mg), with 10% given as an initial bolus and the remainder infused over 60 minutes 1.

Key Considerations

• Mechanical thrombectomy is recommended in addition to i.v. thrombolysis to treat patients with demonstrable proximal artery occlusions in the anterior circulation who can be treated within 24 h of symptom onset 1.
• If i.v. thrombolysis is contra-indicated, mechanical thrombectomy is recommended as the first line of treatment 1.
• Adjunctive therapy includes aspirin 325 mg initially, followed by 81 mg daily, and blood pressure management targeting <185/110 mmHg before thrombolysis and <180/105 mmHg after.
• Patients should be monitored in a stroke unit with frequent neurological assessments using the NIH Stroke Scale.
• Right MCA strokes typically present with left-sided weakness, sensory deficits, left visual field cut, and possibly aphasia if the dominant hemisphere is affected.
• Early rehabilitation should begin within 24-48 hours of admission.

Timing and Treatment

The timing of treatment is critical, as each minute of arterial occlusion results in the loss of approximately 1.9 million neurons, making time-to-treatment the most critical factor in stroke outcomes. The 2020 guidelines from the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society emphasize the importance of rapid reperfusion therapy in improving outcomes for acute stroke patients 1. While the 2018 guidelines from the American Heart Association/American Stroke Association provide additional context for the use of mechanical thrombectomy, the most recent and highest quality study supports the use of intravenous alteplase (tPA) and mechanical thrombectomy as the primary treatment options for acute ischemic stroke due to right MCA occlusion 1.

From the Research

Management of Acute Ischemic Stroke due to Right Middle Cerebral Artery (MCA) Occlusion

The management of acute ischemic stroke due to right Middle Cerebral Artery (MCA) occlusion involves several approaches, including:

• Reperfusion therapy with intravenous tissue plasminogen activator (tPA) and/or endovascular thrombectomy, which is a mainstay of acute stroke management 2
• Mechanical thrombectomy, which has demonstrated benefit for patients with acute ischemic stroke from proximal large vessel occlusion, including M2 segment occlusions of the MCA 3
• Intra-arterial alteplase thrombolysis after successful thrombectomy, which may improve neurological outcomes in patients with acute ischemic stroke due to large-vessel occlusion (AIS-LVO) in the anterior circulation 4
• Trans-anterior communicating artery approach, which can be used for mechanical thrombectomy of acute MCA occlusion in patients without a direct access route to the occluded intracranial vessel 5

Treatment Options

Treatment options for acute ischemic stroke due to right MCA occlusion include:

• Intravenous thrombolysis with alteplase, which remains the mainstay of treatment 6
• Tenecteplase, which has been evaluated as an alternative thrombolytic drug and may be as effective as alteplase 6
• Endovascular therapy with mechanical thrombectomy, which has been shown to be beneficial up to 24 hours after stroke onset in carefully selected patients with proximal, large vessel occlusions 6
• Cytop─ protection, which is another potential acute stroke therapy that has not demonstrated efficacy in prior clinical trials, but may be reconsidered as an adjunct to reperfusion 6

Key Considerations

Key considerations in the management of acute ischemic stroke due to right MCA occlusion include:

• Timely recanalization of the occluded artery, which plays a critical role in the prognosis of patients with acute ischemic stroke 5
• Selection of patients for treatment, which should be based on advanced imaging techniques and careful evaluation of the patient's condition 6
• Monitoring for complications, such as hemorrhagic transformation and brain edema, which can occur after reperfusion therapy 2