What additional treatments can be given to a patient with acute ischemic stroke due to right M1 middle cerebral artery occlusion who cannot be transferred for endovascular thrombectomy?

Management of Acute Ischemic Stroke with Right M1 Occlusion When Transfer is Not Feasible

If endovascular thrombectomy transfer is not possible, immediately administer intravenous alteplase (0.9 mg/kg) if the patient is within 4.5 hours of symptom onset and has no contraindications, as this remains the standard of care and achieves recanalization in approximately 50% of large vessel occlusions. 1, 2

Immediate Medical Management

Intravenous Thrombolysis

• Administer IV alteplase within 4.5 hours of symptom onset as the primary reperfusion strategy when mechanical thrombectomy is unavailable, targeting door-to-needle time under 60 minutes. 1, 2, 3
• The dose is 0.9 mg/kg (maximum 90 mg), with 10% given as bolus and remainder over 60 minutes. 2
• Do not withhold IV thrombolysis even if early infarct signs involve >1/3 MCA territory, as these patients still benefit and the presence of these signs does not independently increase adverse outcome risk. 3

Blood Pressure Management

• Maintain blood pressure ≤180/105 mmHg during and for 24 hours after thrombolytic therapy to minimize hemorrhagic transformation risk. 2, 3
• Use rapidly titratable agents (labetalol, nicardipine) to achieve precise control. 1
• Avoid aggressive blood pressure lowering in patients not receiving thrombolysis, as cerebral perfusion may depend on elevated pressures. 1

Alternative Reperfusion Strategies

Intra-arterial Thrombolysis (If Available)

• Consider intra-arterial fibrinolysis within 6 hours of symptom onset if your facility has interventional capabilities but lacks mechanical thrombectomy devices, though this is now considered a second-line approach. 1, 4
• Intra-arterial urokinase achieved 73% complete recanalization (TIMI 3) and 18% partial recanalization (TIMI 2) in M1/M2 occlusions in community hospital settings. 4
• This approach requires proof of vessel occlusion on angiography and can be performed by interventional radiologists with neuroradiologic skills. 4

Adjunctive Antithrombotic Therapy

• Administer aspirin 160-325 mg within 24-48 hours after stroke onset, but delay for 24 hours if the patient received IV thrombolysis. 2
• Do not administer antiplatelet agents within the first 24 hours after thrombolytic therapy due to increased hemorrhage risk. 2

Critical Monitoring and Supportive Care

Neurological Monitoring

• Monitor for malignant cerebral edema, particularly in patients under 60 years with large MCA territory infarctions, as this develops in approximately 10% of cases. 3
• Serial neurological assessments every 15 minutes for the first 2 hours, then hourly for 24 hours. 1
• Repeat CT imaging at 24 hours or immediately if neurological deterioration occurs. 1

Hemorrhagic Transformation Surveillance

• Symptomatic hemorrhage risk increases 8-fold with early edema or mass effect on CT after rtPA administration. 3
• Immediate CT imaging is required if sudden neurological deterioration, severe headache, acute hypertension, nausea, or vomiting develops. 1
• If symptomatic hemorrhage occurs, reverse anticoagulation immediately and consider neurosurgical consultation. 1

Surgical Considerations

Decompressive Hemicraniectomy

• Prepare for potential decompressive hemicraniectomy within 48 hours if the patient develops malignant edema with declining consciousness, as this reduces mortality by approximately 50% in young patients with large MCA infarctions. 1, 3
• Early neurosurgical consultation is warranted for patients with complete MCA territory involvement or those showing early signs of mass effect. 1

Common Pitfalls to Avoid

• Do not delay IV thrombolysis while attempting to arrange transfer, as every 30-minute delay decreases the chance of good outcome by 8-14%. 2
• Do not withhold thrombolysis based solely on imaging showing early infarct signs, as these patients still derive benefit. 3
• Do not administer aspirin or other antiplatelet agents within 24 hours of thrombolytic therapy, as this significantly increases hemorrhage risk. 2
• Do not aggressively lower blood pressure below 180/105 mmHg in the acute phase unless the patient received thrombolysis, as collateral perfusion may depend on elevated pressures. 1, 2

Outcome Expectations

• IV alteplase alone achieves recanalization in less than 50% of M1 occlusions, with particularly poor results in proximal occlusions. 5
• Without successful recanalization, M1 occlusions carry high morbidity and mortality, emphasizing the importance of maximizing all available medical therapies. 6, 7
• Even partial recanalization (TIMI 2) improves outcomes compared to persistent occlusion. 4