What are the typical physical exam findings and management for a patient with a right Middle Cerebral Artery (MCA) cerebrovascular accident (CVA)?

Right MCA Stroke Physical Examination Findings

A right middle cerebral artery stroke produces left-sided motor and sensory deficits, left-sided neglect, abnormal visual-spatial ability, right monocular blindness, and right homonymous hemianopsia. 1

Core Neurological Deficits

Motor and Sensory Findings

• Left-sided hemiplegia or hemiparesis is the hallmark finding, affecting the face, arm, and leg contralaterally to the lesion 1
• Left-sided paresthesia or sensory loss involving the entire left hemibody 1
• The motor deficit is typically severe from onset in space-occupying MCA infarctions 1

Visual Deficits

• Right homonymous hemianopsia (visual field loss affecting the right visual field in both eyes) 1
• Right eye monocular blindness may occur if the internal carotid artery is also involved 1
• Hemianopia is a predictor of severe disability and death when present 2

Spatial and Cognitive Findings

• Left-sided neglect is characteristic of right hemisphere strokes and represents inattention to the left side of space 1
• Abnormal visual-spatial ability distinguishes right from left MCA strokes 1
• Visual-spatial rehabilitation is supported by evidence from multiple studies for neglect after right CVA 1

Eye Movement Abnormalities

• Conjugate eye deviation toward the right (away from the paralyzed side) 1
• Unilateral or bilateral abducens nerve palsy may develop as the stroke evolves 1

Signs of Clinical Deterioration

Early Warning Signs (12-72 hours)

• Progressive headaches indicate developing cerebral edema 1
• Nausea and vomiting are both initial symptoms and predictors of malignant edema 1
• Impairment of consciousness progressing from alert to obtunded to comatose 1
• Ipsilateral pyramidal signs (right-sided weakness) suggest transtentorial herniation 1

Critical Herniation Signs

• Pupillary dilation (typically ipsilateral, then bilateral) 1
• Coma on day of admission strongly predicts death from brain edema 2
• Reduced consciousness attributed to brain swelling is a trigger for decompressive craniectomy 3, 4

Predictors of Malignant Course

Clinical Predictors

• NIHSS ≥15 for right MCA strokes (compared to ≥20 for left MCA) 1
• The lower threshold for right-sided strokes reflects the difficulty detecting neglect and spatial deficits with standard scales 1
• Combination of severe deficits: hemiplegia, hemisensory loss in face/arm/leg, hemianopia, and reduced consciousness has a positive predictive value of 0.73 for large MCA infarction 2

Associated Symptoms

• Nausea and vomiting at presentation 1
• History of hypertension or heart failure 3
• Elevated white blood cell count 3

Examination Pitfalls

The right MCA stroke is often underestimated in severity because neglect and visual-spatial deficits are more subtle than aphasia, leading to delayed recognition of malignant infarction. The NIHSS threshold for malignant edema is lower (≥15) for right MCA compared to left MCA (≥20), reflecting this assessment challenge 1. Clinicians must actively test for neglect by having patients bisect lines, draw clocks, or describe both sides of a scene, as patients will not spontaneously report left-sided inattention 1.

Deterioration occurs rapidly between 12-72 hours post-stroke, with brain edema responsible for approximately one-third of clinical worsening cases 1, 3. Serial neurological examinations every 2-4 hours during this window are essential, specifically monitoring level of consciousness, pupillary responses, and development of ipsilateral motor signs 1. Sixteen of 35 deaths in one series were attributable to brain edema, with patients dying at a mean of 5 days post-stroke and at a younger age (mean 57 years) than those dying from other causes 2.