What is the further management and workup for a patient presenting with an acute left Middle Cerebral Artery (MCA) stroke, headache, aphasia, verbal aggression, confusion, and weakness in the left leg?

Acute Left MCA Stroke: Further Management and Workup

This patient requires immediate IV alteplase if within 3 hours of symptom onset (or up to 4.5 hours in selected cases), urgent CT angiography to identify large vessel occlusion for potential endovascular thrombectomy, and comprehensive stroke unit admission with aggressive management of behavioral symptoms and medical complications. 1

Immediate Hyperacute Management

Time-Critical Reperfusion Therapy

• Determine exact time last known well (not when symptoms discovered) as this defines treatment eligibility for thrombolysis 1
• Administer IV alteplase 0.9 mg/kg (maximum 90 mg) if within 3 hours of onset: 10% as bolus over 1 minute, remaining 90% over 60 minutes 2, 1
• Extended window (3-4.5 hours) may be considered in carefully selected patients, though evidence is weaker 3
• Blood pressure must be <185/110 mmHg before alteplase and maintained ≤180/105 mmHg during and after administration using labetalol, nicardipine, or clevidipine 1

Critical Exclusion Criteria to Check

Before administering alteplase, verify the patient does not have: platelet count <100,000, INR >1.6, glucose <50 or >400 mg/dL, prior stroke within 3 months, major surgery within 14 days, or history of intracranial hemorrhage 1

Urgent Vascular Imaging for Endovascular Therapy

• Obtain CT angiography immediately (do not delay for this if within thrombolysis window) to identify large vessel occlusion of the left MCA 2, 1
• Endovascular thrombectomy is indicated for proximal MCA (M1 or proximal M2) occlusion within 6 hours, or up to 24 hours with favorable perfusion imaging 2, 1
• Stent retrievers (Solitaire, Trevo) are preferred over older coil retrievers for mechanical thrombectomy 2
• Do not delay IV alteplase while arranging endovascular therapy—both can be given sequentially 2, 1

Comprehensive Initial Workup

Essential Imaging

• Non-contrast CT brain was likely already done to exclude hemorrhage and assess early ischemic changes 2
• CT angiography from arch to vertex to identify vessel occlusion location and assess for carotid disease 2
• Consider CT perfusion if beyond standard time windows to identify salvageable penumbra and guide extended-window treatment decisions 2, 4

Laboratory Investigations

Complete immediately but do not delay thrombolysis awaiting results unless clinically indicated (e.g., INR if on warfarin): 2

• CBC with platelets
• INR, aPTT
• Glucose (point-of-care acceptable)
• Electrolytes, creatinine, eGFR
• Troponin
• ECG (can be deferred until after thrombolysis decision unless hemodynamically unstable) 2

Neurological Assessment

• Document NIHSS score to quantify stroke severity and track progression 2
• The combination of aphasia and left leg weakness suggests left MCA territory involvement with likely moderate-to-severe deficit 2

Management of Behavioral Symptoms

Verbal Aggression and Confusion

• These symptoms reflect acute stroke pathology affecting frontal-temporal regions and are not contraindications to thrombolysis 2
• Ensure airway protection given confusion and potential aspiration risk 2
• Avoid sedation if possible as it obscures neurological monitoring, but if patient safety requires it, use short-acting agents 1
• Reorient frequently and maintain calm environment with consistent caregivers
• Screen for hypoxia, hypoglycemia, and urinary retention as reversible causes of agitation 2

Seizure Precautions

• Do not use prophylactic anticonvulsants but have short-acting medications available if seizures occur 1
• Confusion may represent post-ictal state if seizure occurred—this does not exclude thrombolysis 2

Post-Thrombolysis Monitoring Protocol

Intensive Neurological Surveillance

• Monitor every 15 minutes during and for 2 hours after alteplase infusion, then every 30 minutes for 6 hours, then hourly until 24 hours 2, 1
• Immediately stop infusion and obtain emergent CT if severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs 2, 1
• Check for symptomatic intracranial hemorrhage which occurs in approximately 6% of treated patients 2

Blood Pressure Management

• Maintain BP ≤180/105 mmHg during and after thrombolysis 2, 1
• Increase monitoring frequency if systolic BP >180 or diastolic >105 mmHg 2

Hemorrhage Management Protocol

If symptomatic hemorrhage suspected: stop alteplase, obtain stat CT, check CBC/PT/INR/aPTT/fibrinogen, administer cryoprecipitate and tranexamic acid, consult hematology and neurosurgery 1

Stroke Unit Care and Supportive Management

Admission and Early Rehabilitation

• Admit to geographically defined stroke unit with specialized nursing staff 2, 1
• Begin frequent brief mobilization within 24 hours if no contraindications 1
• Assess swallowing before any oral intake given aphasia and aspiration risk 1
• Start rehabilitation assessment within 48 hours including speech therapy for aphasia 1

Physiological Parameter Control

• Monitor temperature every 4 hours for 48 hours; treat fever >37.5°C with antipyretics as hyperthermia worsens outcomes 1
• Maintain glucose 140-180 mg/dL; avoid both hyperglycemia and hypoglycemia 1
• Ensure adequate hydration but avoid hypotonic fluids that worsen cerebral edema 2

Antiplatelet Therapy

• Start aspirin 160-325 mg at 24-48 hours after ruling out hemorrhage on follow-up imaging 2, 1, 3
• Delay aspirin for 24 hours if alteplase was given 2, 1

Secondary Prevention Workup

Cardiac Evaluation

• Continuous cardiac monitoring for 24-48 hours to detect atrial fibrillation 2
• Echocardiography (transthoracic initially, consider transesophageal if cardioembolic source suspected) 2

Vascular Assessment

• Carotid imaging already obtained with CTA; assess for stenosis requiring intervention 2
• Consider hypercoagulable workup in young patients or those without clear risk factors 2

Monitoring for Complications

Cerebral Edema and Malignant MCA Syndrome

• Monitor closely for deterioration over 24-72 hours as large MCA infarcts can develop life-threatening edema 1
• Do not use corticosteroids for cerebral edema 1
• Consider decompressive hemicraniectomy urgently (ideally within 48 hours) if signs of malignant edema develop before significant GCS decline 1
• Osmotherapy (mannitol or hypertonic saline) for acute deterioration while arranging surgical consultation 1

Medical Complications

• DVT prophylaxis with subcutaneous heparin or LMWH given immobility 3
• Aspiration pneumonia prevention through NPO status until swallow screen passed 1
• Urinary catheter only if absolutely necessary to reduce infection risk 2

Critical Pitfalls to Avoid

• Every 30-minute delay decreases good outcome by 8-14%—prioritize speed over comprehensive workup 1
• Do not withhold thrombolysis due to behavioral symptoms alone—confusion and agitation are stroke manifestations, not contraindications 2
• Do not delay imaging for ECG or chest X-ray unless hemodynamically unstable 2
• Do not allow blood pressure to remain elevated thinking it improves perfusion—this increases hemorrhage risk post-thrombolysis 2, 1
• Obtain 24-hour follow-up imaging before starting antiplatelets to exclude hemorrhagic transformation 2, 1
• Do not discharge from ED—all stroke patients require admission for monitoring and workup completion 2