What is the management and treatment for a suspected right middle cerebral artery stroke?

Management of Suspected Right Middle Cerebral Artery Stroke

Treat suspected right MCA stroke as a medical emergency equivalent to acute myocardial infarction, with immediate brain imaging (CT scan) to differentiate ischemic from hemorrhagic stroke, followed by intravenous alteplase within 3 hours of symptom onset if eligible, or mechanical thrombectomy within 6-24 hours based on advanced imaging criteria. 1, 2

Immediate Stabilization and Time-Critical Assessment

• Stabilize airway, breathing, and circulation (ABCs) first, particularly in patients with decreased consciousness or brainstem involvement who are at high risk for airway compromise 1, 2
• Determine the exact time of symptom onset (defined as when patient was last at baseline) as this is the single most critical piece of information for treatment eligibility 1, 2
• Transport immediately to a comprehensive stroke center with thrombectomy capability when interfacility travel time differences are short, avoiding hospitals without stroke treatment resources 1, 2
• Complete neurological examination using validated stroke scales (NIHSS) to quantify deficit severity and guide treatment decisions 2, 1

Emergent Diagnostic Workup (Within 25-45 Minutes of Arrival)

Brain Imaging (Highest Priority)

• Obtain non-contrast CT brain immediately to exclude hemorrhage and identify early ischemic changes 2, 1
• A physician skilled in CT interpretation must be available to evaluate for hyperdense MCA sign (indicating thrombus), loss of gray-white differentiation in the insular cortex, lentiform nucleus attenuation, and sulcal effacement 2, 3
• Early infarct signs involving >1/3 of MCA territory do NOT exclude rtPA treatment within 3 hours if symptom onset time is well-established, though some experts express concern about unfavorable risk-benefit ratio 2
• CT angiography should be obtained to identify large vessel occlusion for thrombectomy candidacy 2, 1

Laboratory Studies (Obtained Simultaneously)

• Complete blood count, electrolytes, renal function, glucose, coagulation studies (aPTT, INR), troponin, and ECG 1, 2
• Fasting lipids and inflammatory markers (ESR/CRP) 2, 1

Acute Reperfusion Therapy

Intravenous Thrombolysis (0-3 Hour Window)

• Administer IV alteplase (rtPA) for eligible patients presenting within 3 hours of symptom onset, as this is highly effective for improving functional outcomes 1, 2
• Maintain blood pressure <180/105 mmHg during and for at least 24 hours after thrombolytic therapy 1, 4
• Do NOT give aspirin for 24 hours after rtPA administration to minimize hemorrhagic transformation risk 1, 4

Mechanical Thrombectomy (0-24 Hour Window)

• Perform endovascular thrombectomy for large vessel occlusion in eligible patients within 6 hours, or up to 24 hours if advanced imaging (perfusion/diffusion mismatch) demonstrates salvageable tissue 2, 4
• Multiple randomized trials demonstrate superiority of rapid thrombectomy with or without IV alteplase for achieving functional independence 2

Management of Massive MCA Infarction

For patients <60 years old with extensive hemispheric infarction and deteriorating neurological status, perform decompressive hemicraniectomy within 48 hours, as this substantially reduces death and disability 2, 4

• Urgent neurosurgical consultation is mandatory for patients with "malignant" MCA syndrome showing progressive brain swelling 2
• Serial neurological examinations are essential as up to 30% of stroke patients deteriorate within the first 24 hours 4
• Repeat CT scan immediately if clinical deterioration occurs to assess for hemorrhagic transformation or mass effect 2, 4

Post-Acute Medical Management (After Thrombolysis Window)

Antiplatelet Therapy

• Administer aspirin 160-325 mg within 24-48 hours of stroke onset (but 24 hours after rtPA if given) 1, 4, 2
• This provides small but meaningful benefit in reducing early recurrent stroke 4

Blood Pressure Management

• Do NOT aggressively lower blood pressure unless >220/120 mmHg, as this can worsen cerebral perfusion 4, 2
• Maintain permissive hypertension in the acute phase to preserve collateral flow to ischemic penumbra 4

Monitoring and Complication Prevention

• Admit to specialized stroke unit with continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation and serious arrhythmias 4, 2
• Monitor and aggressively treat fever >38°C, as hyperthermia worsens neurological outcomes 4, 2
• Control blood glucose carefully, correcting both hyperglycemia and hypoglycemia 4
• Initiate gradual early mobilization and use intermittent pneumatic compression devices for DVT prophylaxis 4, 2

Secondary Prevention Workup

• Carotid duplex ultrasound urgently for all patients with carotid territory symptoms who are potential revascularization candidates 2
• Transthoracic echocardiography to identify cardioembolic sources 4
• Extended cardiac monitoring beyond initial 24 hours to detect paroxysmal atrial fibrillation, which fundamentally changes long-term anticoagulation strategy 4

Critical Pitfalls to Avoid

• Never delay treatment to obtain MRI when CT is immediately available and patient is within thrombolysis window 2, 1
• Never routinely anticoagulate acute ischemic stroke patients, as urgent anticoagulation increases hemorrhagic transformation risk without reducing early recurrent stroke 4, 2
• Never use prophylactic antiseizure medications; these are indicated ONLY for documented seizures 4, 2
• Never miss the hyperdense MCA sign on CT, as persistence of this finding on follow-up imaging after thrombolysis predicts poor functional outcome 5, 3
• Never assume normal initial CT excludes stroke; early parenchymal signs (insular ribbon loss, lentiform nucleus attenuation, sulcal effacement) are present in 94% of cases and predict infarct extent and poor outcome 3