What prognostic predictors have been found for middle cerebral artery (MCA) stroke?

Updated: Aug 09, 2021
  • Author: Daniel I Slater, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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A study by Xu et al suggested that in cases of acute ischemic stroke due to occlusion of the large or middle cerebral arteries, spontaneous recanalization of the arteries is less likely in patients with atrial fibrillation and more likely in those with stage 3 hypertension. The study included 139 patients, with evaluation made of the MCA, carotid artery, and vertebral and basilar arteries. In the 23 who underwent spontaneous recanalization, the prevalence of atrial fibrillation was 0% (versus 29.31% in the other patients), while the prevalence of stage 3 hypertension was 60.87% (versus 32.76% in the other patients). [97]

A study by Elofuke et al indicated that following intravenous thrombolysis for ischemic stroke, disappearance of the hyperdense middle cerebral artery sign (HMCAS) predicts better outcomes, both clinically and radiologically, and that thrombus length alone independently predicts HMCAS disappearance. The median thrombus length in patients in whom the HMCAS disappeared was 11 mm, compared with 17 mm in those whose HMCAS did not disappear. [98]

A multicenter, randomized, open-label study by Albers et al found that although the current recommendation is for eligible patients with stroke to undergo thrombectomy within 6 hours of symptom onset, patients can be successfully treated with thrombectomy between 6 and 16 hours after they were last well. The study involved patients with proximal MCA or internal carotid artery occlusion whose initial infarct size was below 70 mL and in whom the ratio of the volume of ischemic tissue as seen on perfusion imaging to the infarct volume was 1.8 or above. Patients were treated 6-16 hours after they were last known to be well. Compared with patients who received just standard medical therapy, those who underwent thrombectomy plus standard medical therapy demonstrated better functional outcomes, as measured on the modified Rankin Scale at 90 days. Moreover, the 90-day mortality rate in patients who underwent thrombectomy was 14%, compared with 26% in the group that received standard medical therapy alone. [99]

Similar results were obtained in a study by Nogueira et al. The investigators found that in patients with intracranial internal carotid artery or proximal MCA occlusion in whom a mismatch existed between clinical deficit severity and infarct volume, those who underwent thrombectomy plus standard care 6-24 hours after they were last known to be well had better 90-day disability outcomes than did patients who underwent standard care alone in the same time frame. However, the 90-day mortality rate for the two groups did not significantly differ. [100]  Based on this study and the one above it, 2018 guidelines from the American Heart Association/American Stroke Association recommend that eligible patients undergo thrombectomy up to 16 hours after a stroke and state that it is “reasonable” for eligible patients to be treated by thrombectomy 16-24 hours poststroke. [101]

A study by Sundseth et al indicated that in patients with swollen MCA infarction who undergo decompressive craniectomy, involvement of additional anterior and/or posterior cerebral artery territory predicts early in-hospital death, while age, sex, time between stroke onset and decompressive craniectomy, National Institutes of Health Stroke Scale score on admission, pineal gland displacement, postsurgical pineal gland displacement reduction, and size of the craniectomy do not. [103]

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