Neurology · Year 3 · from Neurology

Case 1: Acute Left MCA Stroke - Thrombectomy Candidate

Patient Demographics

  • Age: 72 years
  • Sex: Female
  • Occupation: Retired teacher

Chief Complaint

"She can't move her right side and isn't making sense."

History of Present Illness

Patient was last seen normal at 6:00 AM by her husband. At 8:00 AM, he found her in bed with right-sided weakness and speaking nonsensically. EMS was called and she arrived at the ED at 8:45 AM. Past medical history includes hypertension, type 2 diabetes, and hyperlipidemia. She takes lisinopril, metformin, and atorvastatin.

Neurological Examination Findings

Mental Status:

  • Awake but not following commands
  • Global aphasia - no meaningful speech output, does not follow commands
  • Eyes open spontaneously

Cranial Nerves:

  • Right gaze preference (eyes deviated to left)
  • Right homonymous hemianopia to threat
  • Right lower facial droop (UMN pattern)
  • Dysarthria

Motor Examination:

  • Right upper extremity: 0/5 (flaccid plegia)
  • Right lower extremity: 1/5
  • Left side: Moves spontaneously, antigravity strength

Sensory Examination:

  • Does not respond to noxious stimuli on right
  • Withdraws to pain on left

Reflexes:

  • Right: 3+ with Babinski positive
  • Left: 2+ with flexor plantar response

NIHSS Score: 19

Localization

Lesion Location: Left MCA territory (large vessel occlusion)

  • Global aphasia (Broca's + Wernicke's = left hemisphere)
  • Right hemiplegia (left motor cortex)
  • Right gaze deviation toward lesion (left frontal eye fields)
  • Right hemianopia (left optic radiations)
  • Dense contralateral sensory loss

Neuro Workup

  • CT Head without contrast: Hyperdense left MCA sign, subtle loss of insular ribbon
  • CT Angiography: Left M1 occlusion with good collaterals
  • CT Perfusion:
  • Core infarct: 15 mL
  • Penumbra: 85 mL (Target mismatch - favorable for intervention)
  • ASPECTS Score: 7
  • Labs: Glucose 156, INR 1.0, Cr 0.9, platelets 245K

Diagnosis

Acute left MCA ischemic stroke with large vessel occlusion (LVO) - thrombectomy candidate

Management

Acute Management:

  1. IV alteplase initiated (within 4.5-hour window from last known well)
  2. Emergent mechanical thrombectomy - TICI 3 recanalization achieved
  3. BP goal: <180/105 during first 24 hours post-tPA
  4. Admit to Neuro ICU

Post-Procedure Care:

  1. Repeat CT head at 24 hours - no hemorrhagic transformation
  2. Started aspirin 325 mg at 24 hours
  3. Telemetry monitoring - atrial fibrillation detected
  4. Echocardiogram: Left atrial enlargement, no thrombus
  5. Anticoagulation with apixaban started day 4

Rehabilitation:

  1. Speech therapy for aphasia
  2. PT/OT for right hemiparesis
  3. Dysphagia evaluation - modified diet
  4. Acute rehab placement

Clinical Image

Image Description: CT angiography demonstrating occlusion of the left M1 segment of the middle cerebral artery with absent distal filling.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Jeremy Jones. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/left-mca-stroke-1

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