What is the immediate treatment for a middle cerebral artery stroke?

Immediate Treatment for Middle Cerebral Artery Stroke

For acute MCA stroke, immediately administer intravenous alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) within 3 hours of symptom onset if eligible, with 10% given as bolus over 1 minute and the remainder infused over 60 minutes, followed by mechanical thrombectomy with stent retrievers within 6 hours for large vessel occlusions. 1, 2

Time-Critical Initial Stabilization (First 15-25 Minutes)

• Stabilize airway, breathing, and circulation immediately, particularly in patients with decreased consciousness who are at high risk for airway compromise 1
• Determine exact time of last known normal to establish treatment eligibility windows—this is the single most critical piece of information 1
• Obtain non-contrast CT brain within 25-30 minutes of arrival to exclude hemorrhage and identify early ischemic changes 1, 3
• Perform CT angiography simultaneously to identify large vessel occlusion for thrombectomy candidacy 1, 3
• Obtain laboratory studies concurrently: complete blood count, electrolytes, renal function, glucose, coagulation studies (aPTT, INR), troponin, and ECG 1

Intravenous Thrombolysis (0-3 Hour Window)

Eligibility Criteria and Blood Pressure Management

• Blood pressure must be <185/110 mmHg before rtPA administration 2
• If systolic >185 mmHg or diastolic >110 mmHg, give labetalol 10-20 mg IV over 1-2 minutes (may repeat once) or nicardipine drip 5 mg/h, titrating up by 2.5 mg/h at 5-15 minute intervals (maximum 15 mg/h) 2
• If blood pressure cannot be reduced and maintained below these levels, do not administer rtPA 2

rtPA Administration Protocol

• Administer 0.9 mg/kg (maximum 90 mg) over 60 minutes, with 10% given as bolus over 1 minute 2, 1
• Monitor blood pressure every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly for 16 hours 2
• Maintain blood pressure ≤180/105 mmHg during and for 24 hours after treatment 2, 1

Blood Pressure Management During and After rtPA

• If systolic 180-230 mmHg or diastolic 105-120 mmHg: labetalol 10 mg IV over 1-2 minutes, may repeat or double every 10-20 minutes (maximum 300 mg) 2
• If systolic >230 mmHg or diastolic 121-140 mmHg: labetalol 10 mg IV over 1-2 minutes, may repeat every 10-20 minutes (maximum 300 mg) OR nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5 minutes to maximum 15 mg/h 2
• If diastolic >140 mmHg: sodium nitroprusside 0.5 μg/kg per minute IV infusion as initial dose and titrate to desired blood pressure 2

Critical Monitoring

• Discontinue infusion immediately if patient develops severe headache, acute hypertension, nausea, vomiting, or worsening neurological examination 2
• Obtain emergent CT scan if any neurological deterioration occurs 2, 1
• Delay aspirin for 24 hours after rtPA to minimize hemorrhagic transformation risk 1

Mechanical Thrombectomy (0-6 Hour Window, Extended to 24 Hours with Advanced Imaging)

Indications and Timing

• Perform endovascular thrombectomy with stent retrievers for large vessel occlusion (ICA, M1 MCA, or ≥2 M2s) within 6 hours of symptom onset 2, 1
• May extend to 24 hours if advanced imaging (perfusion/diffusion mismatch) demonstrates salvageable tissue 2, 1
• Stent retrievers are preferred over other mechanical devices (Class I, Level of Evidence A) 4
• Target technical goal is TICI grade 2b/3 reperfusion 2, 4

Combined Therapy Approach

• Administer IV rtPA immediately even if endovascular therapy is planned—do not delay rtPA to mobilize thrombectomy resources 2, 1, 4
• Multiple randomized trials demonstrate superiority of rapid thrombectomy with or without IV alteplase for achieving functional independence 2
• The MR CLEAN trial showed adjusted OR 1.67 (95% CI 1.21-2.30) favoring endovascular intervention, with 13.5% absolute difference in functional independence 2

Intra-arterial Thrombolysis (Alternative for Selected Cases <6 Hours)

• Intra-arterial thrombolysis is an option for major stroke <6 hours due to MCA occlusion when performed at experienced stroke centers with immediate access to cerebral angiography 2
• The PROACT II trial showed 40% of patients achieved mRS 0-2 at 90 days with intra-arterial prourokinase versus 25% in controls (P=0.04), with 66% recanalization versus 18% 2
• Symptomatic intracranial hemorrhage occurred in 10% versus 2% in controls 2
• This approach should not preclude IV rtPA administration in otherwise eligible patients 2

Management of Massive MCA Infarction

• Perform decompressive hemicraniectomy within 48 hours for patients <60 years old with extensive hemispheric infarction and deteriorating neurological status—this substantially reduces death and disability 1
• Urgent neurosurgical consultation is mandatory for "malignant" MCA syndrome with progressive brain swelling 1

Post-Acute 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

Blood Pressure Management

• Do not aggressively lower blood pressure unless >220/120 mmHg—maintain permissive hypertension to preserve collateral flow to ischemic penumbra 1

Monitoring and Complications

• Admit to specialized stroke unit with continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation 1
• Aggressively treat fever >38°C and control blood glucose carefully 1
• Initiate gradual early mobilization and use intermittent pneumatic compression devices for DVT prophylaxis 1

Critical Pitfalls to Avoid

• Never delay rtPA treatment to obtain MRI when CT is immediately available and patient is within thrombolysis window 1
• Never routinely anticoagulate acute ischemic stroke patients—the safety of short-term anticoagulation for intraluminal thrombus is not well established 4
• Never use prophylactic antiseizure medications 1
• Never delay IV rtPA to mobilize endovascular resources—give rtPA first if eligible, then proceed to thrombectomy 2
• Do not place nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if patient can be safely managed without them 2
• Obtain follow-up CT or MRI at 24 hours after rtPA before starting anticoagulants or antiplatelet agents 2