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Middle cerebral artery syndrome — Clinical Guidelines

Overview

Middle cerebral artery (MCA) syndrome refers to a neurological condition resulting from an occlusion or stenosis affecting the middle cerebral artery, leading to focal deficits typically involving the contralateral face, arm, and sometimes language functions, depending on the specific territory affected 1 10.

Diagnosis

Clinical Presentation: Ipsilateral hemiparesis, aphasia, neglect, and altered mental status 1 10.

Imaging Studies: MRI and CT scans to identify infarction or edema; perfusion imaging can detect hyperperfusion 7 10.

Hemodynamic Assessment: Transcranial Doppler (TCD) for flow diversion and collateral circulation evaluation 9.

Functional Tests: Neurological examination focusing on motor, sensory, and cognitive functions 1 10.

Management

Initial Management: Control hypertension, maintain adequate cerebral perfusion pressure, and manage seizures with anticonvulsants (e.g., levetiracetam) 10 11.

Preventing Complications: Monitor for cerebral hyperperfusion syndrome (CHS) and manage with antihypertensive therapy if necessary 2 7 10.

Rehabilitation: Early initiation of physical, occupational, and speech therapy tailored to deficits 1 10.

Advanced Interventions: Consider repetitive transcranial magnetic stimulation (rTMS) for patients with steno-occlusive disease, though evidence is preliminary 1.

Special Populations

Elderly: Higher risk of complications such as CHS and cognitive decline; careful monitoring and individualized management are crucial 10.

Comorbidities: Patients with significant comorbidities like heart disease may require tailored surgical and medical interventions 15.

Key Recommendations

Monitor and Manage Hypertension in patients at risk for cerebral hyperperfusion syndrome post-procedures to prevent severe complications (Evidence: Moderate 2 7).

Initiate Early Neurological Rehabilitation focusing on motor, sensory, and cognitive functions to optimize recovery (Evidence: Expert opinion 1).

Consider Advanced Imaging Techniques such as perfusion MRI for early detection of hyperperfusion states (Evidence: Moderate 7).

Evaluate Leptomeningeal Collateral Circulation using transcranial Doppler in patients with MCA occlusive disorders to guide treatment strategies (Evidence: Weak 9).

Use Anticonvulsants for seizure management in cases where seizures are a presenting feature or complication (Evidence: Moderate 11).

References

1 Pahk K, Lee SH. Effects of repetitive transcranial magnetic stimulation on improving cerebral blood flow in patients with middle cerebral artery steno-occlusion. Acta neurologica Belgica 2024. link 2 Nishimoto T, Oka F, Okazaki K, Ishihara H. Relationship between cerebral hyperperfusion syndrome and the immediate change of cerebral blood flow after carotid artery stenting evaluated by single-photon emission computed tomography. Neuroradiology 2022. link 3 Nakagawa I, Yokoyama S, Wajima D, Nishimura F, Yamada S, Yokota H et al.. Hyperventilation and breath-holding test with indocyanine green kinetics predicts cerebral hyperperfusion after carotid artery stenting. Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism 2019. link 4 Andereggen L, Amin-Hanjani S, El-Koussy M, Verma RK, Yuki K, Schoeni D et al.. Quantitative magnetic resonance angiography as a potential predictor for cerebral hyperperfusion syndrome: a preliminary study. Journal of neurosurgery 2018. link 5 Ullery BW, Kalapatapu V. Bilateral reperfusion injury after carotid endarterectomy with contralateral carotid occlusion. Vascular 2015. link 6 Mondel PK, Udare AS, Anand SV, Saraf RS, Limaye US. Recurrent cerebral hyperperfusion syndrome after intracranial angioplasty and stenting: case report with review of literature. Cardiovascular and interventional radiology 2014. link 7 Vasquez RA, Waters MF, Skowlund CJ, Mocco J, Hoh BL. Computed tomographic perfusion imaging of non-hemorrhagic cerebral hyperperfusion syndrome and reversal following medical treatment after carotid artery angioplasty and stenting. Journal of neurointerventional surgery 2012. link 8 Trinidade A, Shakeel M, Majithia A, Solbach T, Dhillon RS. Call-fleming syndrome: an extraordinary complication of tonsillectomy. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP 2010. link 9 Kim Y, Sin DS, Park HY, Park MS, Cho KH. Relationship between flow diversion on transcranial Doppler sonography and leptomeningeal collateral circulation in patients with middle cerebral artery occlusive disorder. Journal of neuroimaging : official journal of the American Society of Neuroimaging 2009. link 10 van Mook WN, Rennenberg RJ, Schurink GW, van Oostenbrugge RJ, Mess WH, Hofman PA et al.. Cerebral hyperperfusion syndrome. The Lancet. Neurology 2005. link70251-9) 11 Ho DS, Wang Y, Chui M, Ho SL, Cheung RT. Epileptic seizures attributed to cerebral hyperperfusion after percutaneous transluminal angioplasty and stenting of the internal carotid artery. Cerebrovascular diseases (Basel, Switzerland) 2000. link 12 Tegnér R, Levander M. The influence of stimulus properties on visual neglect. Journal of neurology, neurosurgery, and psychiatry 1991. link 13 Macfarlane R, Moskowitz MA, Sakas DE, Tasdemiroglu E, Wei EP, Kontos HA. The role of neuroeffector mechanisms in cerebral hyperperfusion syndromes. Journal of neurosurgery 1991. link 14 Massironi M, Guariglia C, Pizzamiglio L, Zoccolotti P, Spinelli D. Shape, size and relative space position perception in neglect patients. The International journal of neuroscience 1990. link 15 Kaplan JG, Katzman R, Horoupian DS, Fuld PA, Mayeux R, Hays AP. Progressive dementia, visual deficits, amyotrophy, and microinfarcts. Neurology 1985. link

Middle cerebral artery syndrome