What is the management plan for a patient with acute ischemic stroke due to focal high-grade stenosis in the right Anterior Cerebral Artery (ACA)?

Management of Acute Ischemic Stroke with Right ACA Territory Infarction

For a patient with acute ischemic stroke due to focal high-grade stenosis in the right A3 segment of the anterior cerebral artery with confirmed infarct, administer IV alteplase 0.9 mg/kg (maximum 90 mg) immediately if within 3 hours of symptom onset, followed by consideration for endovascular mechanical thrombectomy with stent retriever devices if within 6 hours and meeting specific criteria. 1, 2

Immediate Hyperacute Management (Within Minutes of Presentation)

IV Thrombolysis Decision

• Administer IV alteplase 0.9 mg/kg (maximum 90 mg) if the patient can be treated within 3 hours of clearly defined symptom onset, with 10% given as bolus over 1 minute and remaining 90% infused over 60 minutes 2, 3
• Blood pressure must be reduced to <185/110 mmHg before alteplase administration and maintained ≤180/105 mmHg during and for 24 hours after treatment 2
• Target door-to-needle time of less than 60 minutes 2
• Do not delay IV alteplase even if endovascular treatment is being considered 1

Endovascular Thrombectomy Evaluation

Proceed with mechanical thrombectomy using stent retriever devices if ALL of the following criteria are met 1:

• Prestroke modified Rankin Scale (mRS) score 0-1
• Patient receiving or has received IV alteplase within 4.5 hours
• Causative occlusion confirmed on CT angiography (in this case, A3 segment of ACA)
• Age ≥18 years
• NIHSS score ≥6
• ASPECTS ≥6
• Groin puncture can be initiated within 6 hours of symptom onset

Important caveat: The major endovascular trials (MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA, REVASCAT) primarily enrolled patients with ICA or proximal MCA (M1) occlusions, with only A1 or A2 ACA occlusions specifically mentioned 1. A3 segment occlusions are more distal and were not the primary focus of these landmark trials, so the Class I recommendation for endovascular therapy applies less directly to this anatomic location 1.

Practical Approach for A3 Occlusion

• If NIHSS is high (≥6) and significant clinical deficit is present, strongly consider endovascular therapy despite the more distal location, as the general principles of early reperfusion still apply 1
• Stent retrievers (Solitaire FR, Trevo) are preferred over coil retrievers (Merci) if mechanical thrombectomy is pursued 1
• Target reperfusion to TICI grade 2b/3 as rapidly as possible, ideally achieving groin puncture within 6 hours of onset 1

Post-Thrombolysis Monitoring Protocol

Neurological and Vital Sign Monitoring

• Monitor every 15 minutes during and for 2 hours after alteplase infusion 2
• Then every 30 minutes for 6 hours 2
• Then hourly until 24 hours post-treatment 2
• Maintain BP ≤180/105 mmHg throughout this period 2

Hemorrhage Surveillance

• Obtain CT brain at 24 hours post-thrombolysis to exclude intracranial hemorrhage before initiating antiplatelet therapy 1, 2
• Symptomatic intracranial hemorrhage occurs in approximately 6.4% of patients treated with IV alteplase 3

Antiplatelet Therapy Timing

If Thrombolysis Was Given

• Delay initiation of aspirin until after the 24-hour post-thrombolysis CT scan has excluded intracranial hemorrhage 1, 2
• Then initiate aspirin 325 mg daily 2, 4

If Thrombolysis Was NOT Given

• Initiate aspirin 325 mg within 24-48 hours of stroke onset 2, 4
• For high-risk TIA or minor stroke (NIHSS 0-3) of non-cardioembolic origin, consider dual antiplatelet therapy with aspirin plus clopidogrel for 21-30 days, though this patient has a confirmed infarct rather than TIA 1

Stroke Unit Care and Monitoring

Admission and Early Mobilization

• Admit to a geographically defined stroke unit with specialized nursing staff 5
• Begin frequent brief mobilization within 24 hours if no contraindications 5
• Monitor closely for neurological deterioration over 24-72 hours, as ACA territory infarcts can develop edema 5

Monitoring for Malignant Edema

• While malignant edema is more commonly associated with large MCA infarcts, significant ACA territory infarcts can also cause mass effect 1, 5
• If signs of malignant edema develop, consider decompressive surgery urgently (ideally within 48 hours) before significant decline in Glasgow Coma Scale 1

Secondary Prevention Workup

Cardiac Evaluation

• Continuous cardiac monitoring for 24-48 hours to detect atrial fibrillation 5
• Obtain transthoracic echocardiography to assess for cardioembolic sources 5
• Consider transesophageal echocardiography if cardioembolic source is suspected but not identified on transthoracic study 5

Vascular Imaging

• The CT angiography already performed has identified the focal high-grade stenosis in the A3 segment 5
• Determine whether this represents atherosclerotic disease, dissection, or other etiology to guide long-term management
• The usefulness of emergent intracranial angioplasty and/or stenting is not well established and should only be used in clinical trial settings 1

Common Pitfalls and Caveats

Time-Dependent Treatment Efficacy

• Every 30-minute delay in reperfusion reduces the probability of favorable outcome by approximately 10.6% 1
• Earlier treatment within 90 minutes of onset is more likely to result in favorable outcomes 2

Anticoagulation Considerations

• Do not use full-dose anticoagulation (IV or subcutaneous heparin) for acute stroke treatment, as it does not improve outcomes and increases hemorrhage risk 2, 4
• Prophylactic low-dose subcutaneous heparin or low-molecular-weight heparin is recommended only for venous thromboembolism prophylaxis in patients with restricted mobility 4, 6

Blood Pressure Management

• Avoid aggressive blood pressure lowering unless BP exceeds thresholds for thrombolysis (185/110 mmHg pre-treatment, 180/105 mmHg post-treatment) 2
• Permissive hypertension may be beneficial for maintaining cerebral perfusion in the acute phase 2

Distal Vessel Occlusion Considerations

• A3 segment occlusions represent more distal disease than the large vessel occlusions studied in major endovascular trials 1
• Clinical judgment regarding endovascular intervention should weigh the severity of deficit, patient age and baseline function, and local institutional expertise 1
• If endovascular therapy is not pursued or fails, focus shifts entirely to supportive care, secondary prevention, and rehabilitation 2