What is the appropriate acute and secondary management for a 44‑year‑old patient with an acute right middle cerebral artery (MCA) ischemic stroke?

Management of 44-Year-Old Patient with Right Middle Cerebral Artery Stroke

Immediately administer IV alteplase (0.9 mg/kg, max 90 mg) if the patient presents within 4.5 hours of symptom onset and has no contraindications, followed by consideration for mechanical thrombectomy if large vessel occlusion is confirmed on vascular imaging. 1

Hyperacute Phase (First 60 Minutes)

Immediate Imaging and Assessment

• Obtain non-contrast CT within 30 minutes of arrival to exclude hemorrhage and assess for early ischemic changes 2, 3
• Perform CT angiography from aortic arch to vertex to identify large vessel occlusion amenable to thrombectomy 1, 2
• Document the exact "last known well" time as this determines all reperfusion eligibility 2
• Assess stroke severity using NIHSS score 3
• Obtain core laboratory panel (glucose, electrolytes, renal function, CBC with platelets, cardiac biomarkers, PT/INR, aPTT) but do not delay thrombolysis while awaiting results unless clinical suspicion of bleeding disorder or recent anticoagulation 2

Reperfusion Therapy Decision Algorithm

Intravenous Thrombolysis:

• 0-3 hours from onset: Administer IV alteplase 0.9 mg/kg (max 90 mg) with 10% as bolus, 90% over 60 minutes; target door-to-needle time <60 minutes 1, 2, 3
• 3-4.5 hours from onset: IV alteplase is recommended if patient does NOT have all of: age >80, oral anticoagulant use, NIHSS >25, or prior stroke plus diabetes 2
• >4.5 hours: IV alteplase is not recommended 2
• Contraindication: Hypodensity involving >1/3 of MCA territory on CT mandates withholding alteplase 2

Blood Pressure Requirements Before Thrombolysis:

• Must lower BP to <185/110 mmHg before administering rtPA 4, 3

Mechanical Thrombectomy:

• Indicated for proximal MCA (M1) occlusion with pre-stroke mRS 0-1, NIHSS ≥6, ASPECTS ≥6, and groin puncture ≤6 hours from onset 2
• Age 44 is well within the evidence base for thrombectomy benefit 2
• Can be performed with or without prior IV alteplase 1

Intra-Arterial Thrombolysis:

• Consider as rescue therapy within 6 hours for MCA occlusion if patient is ineligible for IV alteplase 1, 2

Acute In-Hospital Management (First 24-72 Hours)

Stroke Unit Admission

• Admit to geographically defined stroke unit with multidisciplinary team (neurologists, specialized nurses, physiotherapists, occupational therapists, speech therapists) 2
• Maintain nurse-to-patient ratio of 1:2 for first 24 hours as 30% of patients deteriorate during this period 2
• For right MCA stroke, monitor closely for cardiovascular complications (myocardial ischemia, atrial fibrillation, arrhythmias) as right hemispheric strokes carry higher cardiac risk 1

Blood Pressure Management

• If NOT receiving thrombolysis: Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 4, 3
• Avoid overly aggressive BP lowering in non-thrombolysis patients as this worsens outcomes 4, 3

Antiplatelet Therapy

• Start aspirin 160-325 mg within 48 hours of stroke onset after imaging excludes hemorrhage 2, 3
• If patient received IV alteplase: Postpone aspirin until >24 hours after thrombolysis to minimize hemorrhage risk 2
• Aspirin is superior to therapeutic anticoagulation for acute ischemic stroke 2

Physiological Parameter Management

• Administer supplemental oxygen only if SpO2 <94% 2
• Avoid glucose-containing fluids unless patient is hypoglycemic; treat hyperglycemia to maintain glucose <300 mg/dL 2, 3
• Control body temperature and treat fever sources with antipyretics 3
• Maintain euvolemia with isotonic normal saline; do not use volume expanders for hemodilution 2

Complication Prevention

DVT/PE Prophylaxis:

• Use subcutaneous LMWH (e.g., enoxaparin 40 mg once daily) which is more effective than unfractionated heparin 5000 IU twice daily 1, 2, 3
• Add intermittent pneumatic compression for additional VTE reduction 2
• Do NOT use elastic compression stockings as they are not beneficial 2

Aspiration Prevention:

• Perform swallowing screening before any oral intake (compulsory quality indicator) 2
• If unable to swallow, place naso-enteric feeding tube within 24 hours 2
• Perform oral hygiene at least three times daily and after meals to decrease aspiration pneumonia 2

Urinary Tract Infection Prevention:

• Avoid routine indwelling urinary catheters due to infection risk 2

Pressure Injury Prevention:

• Use high-specification foam mattresses for high-risk patients 2

Monitoring for Neurological Deterioration

• Continue cardiac monitoring for first 24 hours to detect intermittent atrial fibrillation and arrhythmias 1
• Monitor for cerebral edema which peaks 3-4 days post-stroke but can occur within 24 hours with reperfusion 2
• Watch for depression in consciousness level as critical sign of deterioration 4

Early Mobilization and Rehabilitation

• Mobilize within 24 hours if neurologically and hemodynamically stable 2
• Initial rehabilitation assessment within 48 hours of admission 4, 3
• Begin rehabilitation therapy as soon as medically stable 3

Secondary Prevention (Initiated During Hospitalization)

Antithrombotic Therapy

• Non-cardioembolic stroke: Prescribe clopidogrel 75 mg daily OR aspirin + extended-release dipyridamole (25 mg/200 mg twice daily) at discharge, as these are superior to aspirin alone 2
• If atrial fibrillation detected: Initiate oral anticoagulation at discharge (compulsory quality indicator); oral anticoagulants are superior to antiplatelet agents for cardioembolic prevention 2

Vascular Risk Factor Management

• Start high-intensity statin for all ischemic stroke patients; target LDL <70 mg/dL (1.8 mmol/L) 2
• Initiate antihypertensive medication at discharge regardless of baseline BP (compulsory quality indicator) 2

Carotid Evaluation

• Perform carotid imaging to assess for stenosis 5, 6
• If symptomatic carotid stenosis ≥50% (NASCET criteria), perform carotid endarterectomy within 14 days of symptom onset 2
• Do NOT perform emergency carotid endarterectomy in acute phase due to high complication risk 4, 3

Lifestyle Modifications

• Provide smoking cessation counseling 2
• Advise alcohol reduction to ≤2 drinks/day (men) 2
• Recommend low- to moderate-intensity aerobic activity (≥10 min, ≥4 days/week) 2
• Counsel on dietary sodium <2000 mg/day 2

Discharge Planning

• Arrange specialist stroke rehabilitation team follow-up within 72 hours of discharge 2
• Provide structured patient and family education about stroke causes, risk factors, warning signs, secondary prevention strategies, and proper EMS activation 2
• Review health and social care needs at 6 months and then annually 2

Critical Pitfalls to Avoid

• Every 30 minutes of delay in treatment decreases probability of good functional outcome by 8-14% 4, 3
• Do NOT use routine therapeutic anticoagulation (unfractionated heparin or LMWH) in unselected acute ischemic stroke patients as harms outweigh benefits 2
• Do NOT perform immediate EC-IC arterial bypass due to high risk of intracranial hemorrhage 4, 3
• Do NOT aggressively lower blood pressure in patients not receiving thrombolysis 4, 3