What is the most appropriate immediate and subsequent management for a patient with an acute right middle cerebral artery (MCA) stroke?

Management of Acute Right Middle Cerebral Artery Stroke

For an acute right MCA stroke, immediately administer IV alteplase 0.9 mg/kg (maximum 90 mg) if the patient presents within 4.5 hours of symptom onset AND proceed urgently with mechanical thrombectomy using stent retrievers if large vessel occlusion is confirmed on CT angiography—both therapies are complementary and should not be delayed for one another. 1, 2, 3

Hyperacute Phase (0-6 Hours): Time-Critical Interventions

Immediate Neuroimaging

• Obtain non-contrast CT brain immediately upon arrival to exclude hemorrhage and assess for early ischemic changes 1, 3
• Perform CT angiography urgently to identify large vessel occlusion (M1 or M2 segment) 1, 2
• Target door-to-imaging time of less than 25 minutes, as every 30-minute delay reduces probability of favorable outcome by 10.6% 2, 3

Intravenous Thrombolysis Protocol

• Administer IV alteplase 0.9 mg/kg (maximum 90 mg) with 10% as bolus over 1 minute and remaining 90% infused over 60 minutes if within 4.5 hours of clearly defined symptom onset 1, 2, 3
• Target door-to-needle time of less than 60 minutes 2, 3
• Blood pressure must be reduced to <185/110 mmHg before alteplase administration 2, 3
• Maintain BP ≤180/105 mmHg during and for 24 hours after thrombolytic therapy 1, 2

Endovascular Thrombectomy Criteria

Proceed immediately with mechanical thrombectomy if ALL of the following are met: 1, 2

• Prestroke modified Rankin Scale (mRS) score 0-1
• Large vessel occlusion confirmed on CT angiography (M1 or proximal M2 segment)
• Age ≥18 years
• NIHSS score ≥6
• ASPECTS ≥6 on non-contrast CT
• Groin puncture can be initiated within 6 hours of symptom onset

Technical Aspects of Thrombectomy

• Use stent retrievers (Solitaire FR, Trevo) as first-line devices over other mechanical thrombectomy devices (Class I; Level of Evidence A) 1
• Employ a proximal balloon guide catheter or large-bore distal-access catheter in conjunction with stent retrievers to maximize recanalization rates 1
• The technical goal is TICI grade 2b/3 angiographic result to maximize probability of good functional outcome 1
• Do not delay IV alteplase to wait for endovascular therapy—both are complementary 2, 3

Acute Monitoring Phase (0-24 Hours)

Post-Thrombolysis Surveillance

• Monitor neurological status and vital signs every 15 minutes during and for 2 hours after alteplase infusion 2, 3
• Continue monitoring every 30 minutes for 6 hours, then hourly until 24 hours post-treatment 2, 3
• Maintain BP ≤180/105 mmHg throughout the 24-hour monitoring period 1, 2
• Perform repeat head CT at 24 hours or immediately if any neurological deterioration occurs 2

Antiplatelet Therapy Timing

• Delay aspirin initiation for 24 hours after thrombolysis 1, 2, 3
• After 24-hour post-thrombolysis CT excludes hemorrhage, initiate aspirin 150-325 mg daily 2, 3
• Do not administer any antiplatelet agents or anticoagulants during the first 24 hours post-rtPA due to increased bleeding risk 2, 3

Malignant MCA Syndrome Management (24-48 Hours)

Early Recognition and Surgical Intervention

For patients developing malignant cerebral edema with extensive MCA territory infarction, decompressive hemicraniectomy should be performed within 48 hours as a life-saving measure 1, 4, 5

Criteria for considering hemicraniectomy: 1

• Infarction size greater than 50% MCA territory on visual inspection, or ischemic lesion volume >150 cm³
• Evidence of significant edema and mass effect on imaging
• Progressive neurological deterioration despite medical management
• Age 18-60 years (strongest evidence; Class I, Level A)
• Age 60-80 years may be considered but with higher likelihood of survival with severe disability (Class I, Level B)

Medical Management of Cerebral Edema

• Elevate head of bed to 30 degrees and maintain neutral neck position 5
• Administer osmotherapy with mannitol (0.25-1 g/kg) or hypertonic saline (3% or 23.4%) for intracranial hypertension 5
• Maintain normothermia with antipyretic drugs if temperature rises above 37.5°C 6
• Treat hyperglycemia if glucose >155 mg/dL 6
• Consider ventriculostomy for acute hydrocephalus 5

Urgent Neurosurgical Consultation

• Initiate neurosurgical consultation immediately for patients meeting criteria for potential hemicraniectomy 1
• Expedite transfer to comprehensive stroke center with neurosurgical capabilities if not already at one 1
• Discuss with patient/family that surgery reduces mortality by approximately 50% but may result in survival with moderate-to-severe disability (mRS 3-4) 1, 4

Stroke Unit Care and Secondary Prevention

Specialized Stroke Unit Management

• Admit to geographically defined stroke unit with specialized nursing staff 2, 3
• Begin frequent brief mobilization within 24 hours if no contraindications 2, 3
• Stroke unit care reduces mortality and disability across all stroke types and severities 3

Secondary Prevention Workup

• Obtain transthoracic echocardiography to assess for cardioembolic sources 3, 7
• Consider transesophageal echocardiography if cardioembolic source suspected but not identified on transthoracic study 3, 7
• Initiate statin therapy for lipid lowering regardless of baseline levels 3
• Begin antihypertensive therapy for long-term blood pressure control before discharge 3

Critical Pitfalls and Caveats

Time-Dependent Errors

• Never delay IV thrombolysis to obtain advanced imaging (perfusion/diffusion MRI) if patient is otherwise eligible based on non-contrast CT 3
• Never wait to assess clinical response to IV rtPA before pursuing endovascular therapy—this approach worsens outcomes (Class III; Level of Evidence B-R) 1
• Recognize that symptomatic intracranial hemorrhage occurs in approximately 6.4% of rtPA-treated patients, requiring vigilant monitoring 3

Anticoagulation Contraindications

• Do not use full-dose anticoagulation (IV or subcutaneous heparin) for acute ischemic stroke treatment—it increases hemorrhage risk without improving outcomes 3, 7
• Current anticoagulant use is an absolute contraindication for IV rtPA 2

Surgical Timing Considerations

• Emergency carotid endarterectomy (CEA) is generally not performed in acute stroke settings due to high risk of adverse events, especially when the deficit is large 1
• The exception is when a new deficit occurs immediately after CEA, requiring urgent correction of technical issues 1
• Angioplasty and stenting of proximal cervical stenosis at time of thrombectomy may be considered, but usefulness is uncertain (Class IIb; Level of Evidence C) 1

Age-Related Considerations for Hemicraniectomy

• For patients over 60 years, hemicraniectomy significantly reduces mortality (38% vs. 18% survival without severe disability) but no patients achieve good functional outcomes (mRS 0-2) 1
• Discussions must include realistic expectations about likelihood of survival with significant disabilities requiring assistance with most activities of daily living 1