What is the appropriate management for a patient with an acute right Middle Cerebral Artery (MCA) infarct?

Management of Acute Right MCA Infarct

Immediate Emergency Department Management (Within 10 Minutes)

For acute right MCA infarct, immediately administer IV alteplase (0.9 mg/kg) if the patient presents within 3 hours of symptom onset and has no contraindications, as this provides a 35% absolute increase in favorable outcomes. 1

Upon arrival, initiate the following simultaneously:

• Perform 12-lead ECG within 10 minutes to rule out concurrent myocardial infarction, which can occur simultaneously with MCA stroke and would alter management 1
• Administer oxygen via nasal prongs immediately 1
• Obtain non-contrast head CT to exclude hemorrhage and assess early infarct signs—exclude patients with early infarct signs exceeding one-third of the MCA territory from thrombolysis 1
• Establish continuous cardiac monitoring with emergency resuscitation equipment readily available 1

Reperfusion Strategy Based on Time Window

Within 3 Hours of Symptom Onset

• Administer IV rtPA (0.9 mg/kg) immediately as first-line therapy, which reduces mortality by 21% and saves 21 lives per 1000 patients treated 1
• Do not delay IV rtPA even if considering endovascular treatment—patients eligible for IV rtPA should receive it regardless of planned intra-arterial interventions 1

3-6 Hours from Symptom Onset

• Consider intra-arterial thrombolysis with pro-urokinase (9 mg) plus low-dose IV heparin for angiographically confirmed MCA occlusion, which provides a 15% absolute benefit in achieving modified Rankin Scale ≤2 at 90 days (number needed to treat = 7) 1
• MCA occlusions have 88% recanalization rates with IV tPA compared to only 31% for ICA occlusions, making them particularly responsive to thrombolytic therapy 2

Mechanical Thrombectomy Considerations

• Stent retrievers (Solitaire FR, Trevo) are preferred over coil retrievers (Merci) for mechanical thrombectomy 1
• Mechanical thrombectomy should be performed at experienced stroke centers with rapid access to cerebral angiography and qualified interventionalists 1
• Time to reperfusion is directly correlated with outcomes—all efforts must minimize delays to definitive therapy 1

Critical Exclusion Criteria for Thrombolysis

• Early infarct signs exceeding one-third of MCA territory on baseline CT predict poor outcomes and increased hemorrhagic risk 1
• NIHSS score should be between 4-30 for intra-arterial therapy consideration 1
• Symptomatic intracranial hemorrhage occurs in 7-13% of IV rtPA patients versus 1.1% in placebo, requiring careful patient selection 1

Monitoring for Malignant MCA Infarction

Right MCA infarcts can progress to malignant infarction in approximately 10% of cases:

• Monitor for progressive neurological deterioration: worsening hemiparesis, gaze deviation, reduced consciousness, headache, vomiting 3
• Obtain follow-up CT if clinical deterioration occurs to assess for midline shift and extent of hypodensity 3
• Hypodense changes exceeding 50% of MCA territory predict malignant course with up to 80% mortality if untreated 3
• MRI with diffusion-weighted imaging is the gold standard for assessing ischemic core extent 4

Decompressive Hemicraniectomy Decision

If malignant MCA infarction develops, perform decompressive hemicraniectomy within 24 hours of symptom onset to significantly reduce mortality and improve functional outcomes. 5, 3

Favorable prognostic factors for DHC:

• Infarct volume <250 ml 5
• Midline shift <10 mm 5
• Good preoperative Glasgow Coma Scale score 5
• Absence of additional vascular territory involvement 5
• Surgery within 24 hours of ictus achieves 48.9% good functional outcome at 3 months and 64.4% at 6 months 5

Age is not a contraindication—DHC should be performed regardless of age, though patients beyond 60 years have higher likelihood of severe disability 3

Post-Acute Management

• Initiate aspirin 160-325 mg daily for secondary stroke prevention 4
• Target systolic blood pressure <120 mmHg using ACE inhibitors as preferred agents 4
• Perform carotid duplex ultrasound to identify potential stenosis causing MCA territory infarcts 4
• Obtain prolonged cardiac monitoring to screen for atrial fibrillation, as right MCA infarcts may be cardioembolic 4
• If atrial fibrillation is detected, switch from antiplatelet to anticoagulation therapy 4

Common Pitfalls to Avoid

• Do not withhold IV rtPA while arranging endovascular therapy—administer IV rtPA first if eligible 1
• Do not use thrombolysis in patients without ST-segment elevation on ECG if concurrent myocardial infarction is suspected, as this increases cardiac rupture risk 6, 7
• Do not delay DHC beyond 24 hours in malignant infarction—early intervention is critical for favorable outcomes 5, 3
• Do not exclude patients from DHC based on age alone—functional outcomes can be favorable even in elderly patients 3