Middle Cerebral Artery Stroke

Middle cerebral artery (MCA) stroke describes the sudden onset of a focal neurologic deficit resulting from hemorrhagic or ischemic disruption of the MCA's blood supply. ^[1]

The MCA is by far the largest cerebral artery and is the vessel most commonly affected by cerebrovascular accident (CVA). The MCA supplies most of the outer convex brain surface, nearly all the basal ganglia, and the posterior and anterior internal capsules. Infarcts that occur within the large distribution of this vessel lead to diverse neurologic sequelae. These neurologic deficits and their correlation with specific MCA territories has long been researched.

Research has also focused on the correlation between specific neurologic deficits after MCA stroke and differing outcomes and prognoses. Such efforts are important in ascertaining who may benefit from emergent antithrombotic therapies. Furthermore, these research efforts may later allow physiatrists to target rehabilitative efforts more effectively in appropriately selected patients who may derive benefit.

This article focuses more on the postacute care and rehabilitation of patients with MCA stroke. However, evidence-based practice of acute stroke care obviously needs to be carried over into the rehabilitation setting. This is particularly true because patients are ideally being admitted to such settings quite early after their event. The American Heart Association guidelines are an excellent resource for standards of stroke care. Certified centers for stroke care have proven to have better outcomes in terms of morbidity, mortality, and eventual functional outcome relative to those without such specialization. ^{[2, 3]}

Covid-19

The cytokine storm and resultant, hypercoagulable state induced by coronavirus disease 2019 (COVID-19) appears to be an independent risk factor for stroke. The incidence of stroke is reported to be 1-6% in patients who test positive for COVID-19. In addition, the rate of stroke in patients under age 50 years with COVID-19 has been found to be seven-fold greater than the pre-COVID rate. Moreover, many such patients with stroke had no premorbid vascular risk factors. ^[4]  Initially, the incidence of COVID-19–associated stroke was greatest in the "old or very old,” with the most commonly affected territory being that of the MCA (55.6% of ischemic cases, based on a small cohort). ^[5]  However, with the collection of much more data, the average age has been found to be similar to that of non-COVID patients, at around 65 years.    

Rehabilitation for patients recovering from COVID-19–related pneumonia and more common complications is a formidable task due to the significant diversity of presentation and multiple organ systems potentially involved. Patients with stroke due to COVID-19 also require significant care to maintain oxygenation with exertion, to slowly improve endurance, and to help facilitate resolution of delirium from long intensive-care stays. Dysphagia presents both from prolonged intubation as well as stroke. Successful functional restoration requires close collaboration of a team that includes respiratory and pulmonary specialists and dieticians, as well as the traditional rehabilitation providers. ^[6]

Knowing and using objective criteria in recommending a rehabilitation plan best suited for a patient is imperative. Maximizing functional outcome and independence and targeting expensive resources to patients who will benefit are very important roles for physiatrists and other rehabilitation specialists.

Acute inpatient rehabilitation is the most intense and expensive rehabilitation setting in terms of hours of therapy provided each day. Acute rehabilitation, compared with rehabilitation at a skilled nursing facility, does appear to result in lower mortality, decreased hospital readmission, higher likelihood of return home in the short- and longer term, and greater improvement in motor and cognitive function. ^{[7, 8]}  Physicians, therapists, and nurses involved in acute rehabilitation are expected to work within a collaborative or interdisciplinary model that differs from the transdisciplinary or multidisciplinary models found in most settings. Multidisciplinary care plans occur when each team member uses his or her own expertise to develop individual care goals. Interdisciplinary teams (IDTs) strive to build on each other’s expertise to formulate common, shared goals; improved patient outcomes have repeatedly been shown with this strategy. ^[9]  

The basic criteria for admission to acute rehabilitation are as follows:

• Potential for significant functional improvement but with the patient requiring at least two therapy disciplines in a reasonable period
• Sufficient medical stability 
• Willingness and ability to participate in at least 3 hours of therapy per day, 5-6 days per week

Subacute inpatient rehabilitation is generally offered at a skilled nursing facility or long-term acute care hospital. Patients requiring more complex medical care, such as mechanical ventilation or advanced wound care, often undergo at least initial rehabilitation at a long-term acute care hospital. Skilled nursing facilities and long-term acute care hospitals generally, but not always, offer fewer hours of therapy per week, with such facilities not bound to a minimum number of therapy hours per day.

Home health and outpatient therapy are provided to patients after they complete their inpatient therapy as well as to individuals who are less impaired after a stroke.

Contraindications

There are very few indications for no therapy, and evidence suggests that earlier mobilization translates to better long-term patient outcomes.

Ideally, rehabilitation should begin immediately after a patient is admitted for stroke, barring additional medical issues aside from the stroke itself. ^[10]

The American Heart Association guidelines have become a widely used standard of care for individuals with either ischemic and hemorrhagic stroke. Comprehensive review of these guidelines is outside of the postacute stroke focus of this article. However, certain elements are quite relevant to the rehabilitation setting.

Certified stroke center

Patients should be directed to medical centers designated and accredited for the interdisciplinary care of stroke patients. Improved outcome in terms of mortality, length of stay, return to home, patient function, and cost of care have all been shown to be superior in care centers consistent in American Heart Association guideline–based practices. ^[11] These centers must track and document consistent interdisciplinary practices in the care of stroke patients that are shown to improve outcomes. This care includes, but is not exclusive to, the following:

• Appropriate and expedient use of intravenous (IV) thrombolytic therapy and/or cerebral thrombectomy using interventional radiology*

• Dysphagia screening

• Venous thromboembolism prophylaxis

• Discharged on antithrombotic therapy*

• Anticoagulation therapy for atrial fibrillation (AF)/flutter*

• Discharged on statin medication*

• Discharged on antihypertensive medication or documentation stating why contraindicated

• Stroke education

• Smoking cessation education

• Assessed for rehabilitation

*Denotes care for ischemic, but not hemorrhagic, stroke.

Determining etiology

Determining the cause of stroke, while important in preventing recurrence, is not always possible. Around 25-30% of CVAs are cryptogenic; compared with strokes of known origin, these are more likely to recur. Many cryptogenic strokes are thought to be embolic in nature and to arise from cardiac arrhythmia. Finding abnormalities such as paroxysmal or asymptomatic AF leads to definitive anticoagulation with warfarin or oral heparinoid, which greatly reduces the recurrence risk.  

Guidelines call for cardiac monitoring at least 24 hours post–cryptogenic stroke, although some evidence shows that prolonging such monitoring to 72 hours may be prudent in order to detect more at-risk patients. ^[12]  (Arguably, this could in many instances delay rehabilitation admission.) Regardless, rehabilitation providers need to be aware of ongoing stroke work-up to ensure that early and post-acute monitoring transpires.   

Generally, fitting the acute rehabilitation patient with a 30-day monitor does not occur until the individual has been discharged to the community. Coordination of this outpatient care can be challenging but carries an evidence-based benefit. ^[13]  There are, arguably, special cases when earlier monitoring is desirable, as when there is higher concern for a cardioembolic event. The use of telemetry or other event monitors for inpatient rehabilitation patients may be considered when multiple and bilateral areas of cerebral ischemia are present; recurrent embolism is highly likely in these cases, and earlier detection of arrhythmia is advantageous.   

Even with a 30-day monitor,​ cardiac arrhythmias can remain undetected. ^[14]  One study showed that the use of implantable cardiac monitors (ICMs), with monitoring for a year, led to detection of asymptomatic AF in an additional 10% of patients, relative to other detection methods. ^[15]  It would seem that the use of an ICM might be indicated in patients who have already had a recurrent cryptogenic stroke. 

Acute management

Both IV thrombolytic therapy and mechanical thrombectomy should be pursued in a very orchestrated and consistent manner, relying on emergent imaging and screening to ensure that only patients with ischemic stroke and no contraindications receive such therapy. After ischemic stroke, patients should be discharged from acute care on a statin as well as antihypertensive and appropriate antithrombotic and/or anticoagulation medicines, to prevent recurrent stroke. The selection of such medications is dependent on the presence of comorbidities, including AF, coronary artery disease, congestive heart failure, and diabetes.

Dysphagia management/prevention and significance of aspiration pneumonia

The importance of recognizing and proactively managing impaired swallowing should not be underestimated. Dysphagia is seen in 42-67% of patients within the first 72 hours post stroke. ^[16] Per stroke guidelines, a basic swallow screen should be performed by nursing staff before any initial food or drink is provided to a patient. ^[17]  If there are signs or symptoms concerning for dysphagia, such as cough, throat clearing, wet or gurgly vocal quality, altered level of consciousness, or dysarthria, the patient should be further evaluated by a speech therapist. To be clear, the initial screening process is not equivalent to a thorough evaluation of swallowing impairment.

Aspiration is defined as the penetration of food or saliva beyond the vocal cords; the condition is termed silent aspiration if the patient is without symptoms such as cough or throat clear when this penetration occurs. Bedside evaluation for dysphagia is limited by the fact that as many as 40% of patients who aspirate do so silently. In addition to a bedside swallow assessment, there are two different instrumental assessments a speech pathologist may utilize, a modified barium swallow study (MBSS) and a fiberoptic endoscopic evaluation of swallow (FEES). An MBSS is completed in the radiology suite using barium mixed with food and employing videofluoroscopy with a lateral or anteroposterior view.  An FEES is conducted at bedside utilizing an endoscope to view the pharyngeal and laryngeal areas while the patient is provided with oral intake. The speech pathologist will choose the instrumental assessment best suited for the particular patient.

Based on the results of the assessment, patient care goals, and the individual's overall medical status, the speech pathologist will make nutritional recommendations. If dysphagia exists, oftentimes there are short-term management opportunities to facilitate improved oral management as the patient is working to rehabilitate the swallowing complex. Examples of interim dysphagia management include the use of compensatory strategies, diet modification, and/or temporary non-oral nutrition. 

Aspiration pneumonia, resulting from penetration of food, saliva, and gastric acid, has very serious ramifications, including high mortality, increased length of hospital stay, and poor functional outcome. ^[18] Early recognition and treatment of the condition with antibiotics and pulmonary toilet are vital to improving survival. Organisms responsible are often anaerobic; thus, aspiration pneumonia frequently requires antibiotic coverage differing from that for typical community-acquired pneumonia. The exact pathophysiology of aspiration pneumonia is still somewhat under debate, as bronchial inflammation resulting from exposure to gastric acid, as well as bacterial infection, both likely contribute. ^[19]

Deep venous thrombosis and pulmonary embolism

Pulmonary embolism (PE) accounts for 10-25% of mortality in patients after stroke. In addition, symptomatic deep venous thrombosis (DVT) and postphlebitis syndrome impede recovery and function for patients following a stroke. ^[20] Prevention of DVT and PE is achieved either by patient mobilization or pharmaceutical intervention. Dehydration, hemorrhagic stroke, severity of paralysis, and age are all additional risk factors associated with increased likelihood of DVT. ^[21]

Daily, low-dose, low–molecular-weight heparin administered subcutaneously has been shown to significantly reduce the incidence of DVT and PE, compared with unfractionated heparin. The rate of intracranial and major extracranial hemorrhage (1%) was equal between low–molecular-weight heparin and unfractionated heparin. ^{[22, 23]}

Consideration of DVT prevention in patients with hemorrhagic stroke is challenging owing to the significantly higher rate of DVT (relative to ischemic stroke) and the risk of rebleeding. Anticoagulation, using either low–molecular-weight heparin or unfractionated heparin, has shown only a small, nonsignificant reduction in DVT and mortality. Class IV evidence indicates that it is most likely safe to start low–molecular-weight heparin in patients with a nonexpanding hemorrhage 3-4 days post–hemorrhagic stroke.

Ongoing research is examining the impact of early mobilization of stroke patients in terms of DVT prevention and other benefits and in the decision as to when chemoprophylaxis should be stopped. ^[24]  The CLOTS (Clots in Legs Or sTockings after Stroke) 3 study does demonstrate modest support for the use of pneumatic compression devices for DVT prevention and mortality reduction. ^[25]

Hypertension management

Permissive blood pressure management is typically pursued acutely in the first 24-72 hours following an ischemic stroke, owing to concern over endangering the penumbra, the area immediately adjacent to infarcted brain tissue. However, elevated blood pressure often improves spontaneously in the days following a CVA. Poor clinical outcomes are associated with both low and very high blood pressure in the acute stage of stroke. Obviously, there are situations in which lowering blood pressure carries a higher risk, such as in the presence of significant carotid or basilar artery stenosis. Significantly lowering pressure when such stenosis exists can compromise blood flow to brain structures distal to the vascular narrowing. Several studies of modest blood pressure control in the early period after a stroke have demonstrated neither significant harm nor improved outcomes as a result of such control. ^[26]  Still, the target blood pressure within the first 24-72 hours after a patient has suffered an acute ischemic stroke is below 220/120 mmHg. In the case of hemorrhagic stroke, pressure management is much more critical and remains important long-term; early on, the target is below 140/90 mmHg. ^[27]

Again, the focus of this article is postacute stroke treatments. After 72 hours, it is prudent and safe to begin normalizing blood pressure, except in the rare case in which the stroke is thought to have been caused by hemodynamic instability. Although subacute target blood pressures are below 140/90 mmHg, evidence has come to support a goal of 130/80 mmHg for small vessel and lacunar infarcts. ^[28]  Guidelines now indicate that it is safe to resume home blood pressure medication as early as 24 hours after a stroke if the patient is neurologically stable and without other contraindications. ^[29]

Smoking cessation

The patient should be educated with regard to the discontinuation of tobacco use. While the risk for stroke is permanently elevated after a prolonged smoking history, it can be greatly reduced with cessation. Within 2 months, the hypercoagulable state induced by smoking resolves. Medication treatments, including therapy with nicotine replacement, bupropion, and varenicline, are effective against smoking. Group and other emotional support have also been shown to be productive. ^[30]  

Stroke education

Patients should be educated regarding the causes of stroke to promote behaviors that will help prevent recurrence. This education also potentially serves to promote better community awareness of the signs and symptoms of stroke, with the hope of leading to earlier recognition and treatment.

Rehabilitation after stroke is often focused on compensatory strategies to restore function rather than improve impairment. ^[31] An example is learning to dress with one arm rather than focus on retraining use of a patient’s hemiparetic upper extremity. Such emphasis on compensatory strategies has increased with cost reduction measures that have resulted in shorter acute rehabilitation lengths of stay. ^[32] These decreased days in inpatient rehabilitation settings have been shown to result in worse discharge outcomes. ^[33] In addition, focus on compensatory techniques to complete functional tasks at the expense of therapy directed toward remediating impairment could facilitate “learned nonuse” of a paretic extremity.

Neural plasticity has been defined as “any change in neuron structure or functions that is observed either directly from measures of individual neurons or inferred from measures taken across populations of neurons.” ^[34] A rapidly expanding body of evidence using animal and human models has shown that specific motor stimulation or movement can induce changes in the motor cortex both on a cellular level and in the representative cortex devoted to limb or finger movement. ^{[35, 36, 37]} The profound implication of these basic research findings has inspired application towards recovery efforts for patients with various neurologic pathologies, including stroke.

Neuroplastic changes have been fostered through traditional therapy, pharmaceutical therapy, and modality-based interventions. The changes are then observed with methods showing new synaptogenesis, as well as alterations in genetic expression, functional imaging, and evoked potential activity. Individualized therapy may someday rely on careful observation of impairment and functional disability as well as on information derived from these sophisticated means of directly observing cortical activity and change. Currently, such endeavors are cost prohibitive, and use of basic science is largely reserved for academic research centers. However, these applications show potential to help even those with chronic impairment, well beyond what was formerly thought feasible in functional recovery. ^{[11, 38]}

Therapy-based interventions for hemiparesis have included robotic stimulation, manual stimulation, electrical stimulation, and constraint-induced movement and/or use of an affected extremity. These all would obviously seem contrary to rehabilitation that is solely devoted to compensatory techniques to complete functional tasks. However, newer therapeutic approaches appear to have potential in linking task-based challenges that also promote recovery of motor and cognitive function in stroke survivors. ^[39] These efforts are practical for allowing patients to be more independent and may also better motivate patients to stay engaged and motivated in their therapy. Ongoing efforts to link and practically exploit the growing understanding of neuroplasticity and translate this to improved stroke recovery make an exciting future in the field of rehabilitation.

Stroke results in electrophysiologic changes in the brain, not just in the area and side of the event, but also in the contralateral cerebral hemisphere. There are inhibitory and excitatory circuits that change with a CVA. Transcranial magnetic stimulation has elucidated the mechanism of some of these changes. Using this modality, numerous studies have shown some early promise in facilitating functional recovery for impairments including those involving hemi-neglect, motor function, manual dexterity, walking, balance, dysphagia, aphasia, and depression. While further studies are needed and standardized devices and protocols must be developed, it appears that transcranial magnetic stimulation will further stroke care and rehabilitation in the future. ^[40]

Särkämö et al found evidence that in patients with MCA stroke, listening to music during their recovery period can aid parts of the brain relating to verbal memory, attention, and language. In the study, the investigators examined magnetic resonance imaging (MRI) scans performed during the acute stage in 49 patients with MCA stroke and 6 months poststroke, including in 16 patients who listened to their favorite music during recovery, 18 patients who listened to audio books, and 15 patients who received no listening materials during their recovery. ^[41]

Patients in each of the three groups were found by 6-month follow-up to have undergone significant increases in the volume of gray matter in their brains. However, in patients with left hemisphere damage, those who listened to music showed greater volume increases in parts of the frontal lobe, specifically the left and right superior frontal gyrus and the right medial superior frontal gyrus, as well as in the limbic region, specifically the left ventral/subgenual anterior cingulate cortex and the right ventral striatum, than did those in the other two groups. According to the authors, a correlation existed between the changes in the above-listed regions of the frontal lobe and enhanced improvement in the patients’ language skills, verbal memory, and ability to focus attention, with a correlation also being observed between changes in the subgenual anterior cingulate cortex and mood improvement. ^[41]

Spasticity

Spasticity is defined, generally, as the velocity-dependent resistance of a muscle to passive range of motion. It is a common finding after MCA stroke and, if not proactively managed, can lead to serious complications, including contracture, pain, and skin breakdown. Contracture describes a fixed loss of range of motion of a joint and can occur from joint pathology, skin contracture after major burns, or, in the case of untreated spasticity, permanently shortened muscle.

Movement, in terms of both passive and active range of motion, is the most important means of preventing loss of range of motion due to spasticity. Appropriate wheelchair positioning is also effective in decreasing spasticity. Bracing, especially at night, allows continuous passive range to tight, spastic muscle. This includes serial casting, which permits gradual increase in range over weeks. ^[42]  Modalities such as ultrasound and neuromuscular electrical stimulation (NEMS) may also be employed. NEMS may specifically be used to stimulate and strengthen antagonist muscles with reverse inhibition and relaxation of spastic muscles. 

Oral medications also are often used for spasticity management, including tizanidine, baclofen, and dantrolene. However, the long-term functional benefit of these drugs is not well demonstrated despite their common use. ^[43]  Moreover, these medications can cause sedation, a fact that should be weighed carefully in patients who already have cognitive impairment and poststroke fatigue. Nonetheless, use of these drugs may be advantageous in patients with comorbid insomnia. Tizanidine has been recommended for chronic spasticity in stroke patients beyond their recovery period. Dantrolene has been associated with hepatotoxicity, especially when used in combination with statin medications. Research is emerging regarding the negative and positive impacts that these drugs have on plasticity. ^{[44, 45]}   

The focal muscular injection of botulinum toxin has demonstrated evidence-based benefit for decreasing arm and leg spasticity and improving functional outcomes. It has become the standard care for muscle spasticity that is functionally limiting or painful or that is impeding the progress of rehabilitation. ^[46]  Local treatment of spasticity has definite advantages, especially with regard to avoidance of sedation. Several botulinum toxins are used in this way, along with phenol blocks of pure motor nerves. However, phenol injections are more painful and can cause muscle damage. Diffuse spasticity is difficult to treat with focal injections, but trial injections of local anesthetic in patients with diffuse spasticity can allow a short-lived view as to whether targeted muscles will benefit from more permanent treatment with botulinum toxin or phenol.   

Finally, the surgical implantation of an intrathecal baclofen pump has been shown to benefit patients with particularly severe spasticity. ^[47]

Pain

Pain is not unusual and results from a variety of etiologies. The most common is shoulder pain of the effected side and is seen in 70-84% of patients with hemiplegia. ^[48] Shoulder pain appears to be far more correlative with spasticity than subluxation. ^[49] The anatomy and management of subluxation is therefore briefly covered in a later section. Treatments for spasticity as described previously are therefore more challenging depending on related shoulder pain. The use of analgesics and spasticity medications again needs to be weighed carefully against possibly compromising patient function and cognition.

Lack of sufficient shoulder joint range of motion can result in frozen shoulder, in which the patient has lost movement in various planes. This late and generally avoidable complication is often permanent and markedly limiting to long-term patient function. Conversely, aggressive range of motion can also be problematic owing to altered scapulohumeral rhythm seen in many stroke patients.

The interdisciplinary team should therefore focus on appropriate glenohumeral range of motion, with particular focus on external rotation and maintaining scapular mobility. Family and other caregivers should be made aware of injury potential of an unstable shoulder and should be educated on how to assist the patient in avoiding potentially harmful movements. Specifically, movements that can cause traction to the joint, as when the arm dangles or impingement seen in overhead activity and stretching, should be avoided. ^[50]

Centrally mediated pain is also seen in 12-25% of patients with hemiplegia. This is formally described as complex regional pain syndrome type I or reflex sympathetic dystrophy. ^[48] The most common presentation is shoulder-hand syndrome, which manifests as pain in both the hand and shoulder, usually sparing the elbow and forearm. The phenomenon follows stages of development, with initial and often severe allodynia, followed by skin and muscle atrophy and decreased range of motion, and, finally atrophy and deformity, over several months. Clinical examination reveals pain with metacarpal flexion and passive range of the shoulder that is often rapid.

The most important preventive treatments are appropriate range of motion and desensitization. ^[48] However, if these continue to become less tolerable and effective, further diagnostic workup, including triple-phase bone scanning, may be needed.

Treatments, aside from the therapy described, include high-dose steroids, with a relatively slow taper over 2 weeks. A successful, pain-relieving, stellate ganglion block is therapeutic and is considered the criterion standard in the diagnosis of complex regional pain syndrome type I. Other medications used for this pain include gabapentin, tricyclic antidepressants, NSAIDS, carbamazepine, and nifedipine. ^[42]

Shoulder subluxation

Shoulder subluxation has long been used to describe lack of alignment of the humeral head in the glenoid fossa. While inferior subluxation is perhaps the most overt presentation, potential causes are multiple, as are other types of malalignment.

Measurement of inferior subluxation is not consistently indicative of the severity of subluxation. ^[48] The position and motion of the scapula must be carefully evaluated and monitored to achieve effective therapy. In addition, spinal alignment after stroke toward the side of paresis can also alter the angle of the glenoid fossa relative to the humerus.

Bracing and wheelchair positioning for shoulder subluxation is still a longstanding topic of debate. These interventions still show no benefit in terms of pain or function but also have not been shown to cause adverse shoulder contracture according to a recent literature review. ^[51] A lap tray or forearm gutter splint in wheelchair-bound patients is commonly used. Slings such as Bobath, as well as Kinesio tape, are frequently used for patients during gait and standing activity.

Depression

The negative short- and long-term impacts of poststroke depression are difficult to overstate. In short, poststroke depression increases mortality and healthcare usage and worsens short- and long-term functional recovery. In addition, depression has been linked to subsequent loss of regained function, and this loss is often permanent, even after the depression remits. Nonetheless, studies in the United States and abroad have found that depression is more prevalent after stroke and is undertreated. Multiple screening tools have been shown to be reliable in the stroke population. ^[52]

Sertraline, citalopram, venlafaxine, and nortriptyline have all been found to effectively treat depression after stroke. ^{[53, 54]} Whether this treatment improves mortality is still to be elucidated. The FLAME (fluoxetine for motor recovery after acute ischemic stroke) study appeared to show that the antidepressant fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has an independent and positive impact on motor recovery. However, subsequent, larger studies and meta-analysis did not support this initial finding. ^[55]

Urinary incontinence

Optimal management of poststroke urinary incontinence should be a high priority for the interdisciplinary rehabilitation team. Urinary incontinence is observed in approximately 44-69% of patient’s after stroke. ^{[56, 57, 58]} Numerous studies have demonstrated that poststroke urinary incontinence is associated with increased mortality and disability in the acute, postacute, and chronic phase of stroke recovery. ^{[59, 60, 61]} The presence of urinary incontinence in this population is also a major factor that determines a patient’s discharge disposition. ^[62] Poststroke urinary incontinence is associated with increased incidence of depression, ^[63] caregiver burden, ^[64] risk of falling, ^[65] and decline in self-reported quality of life. ^[66]

As the cause of urinary incontinence in stroke survivors is multifactorial, management strategies must be tailored to the individual needs of the patient. Significant consideration should be given to the possible mechanisms for urinary incontinence, including the assessment of premorbid incontinence. Currently, no evidence supports a single optimal treatment regimen for the management of poststroke urinary incontinence. ^[67] Bladder management methods that are successful in the nonstroke population are often used in the management of stroke patients. Currently, poststroke urinary incontinence is managed with behavioral, pharmacological, and surgical interventions. ^{[68, 69]}

Behavioral management techniques include timed voiding, Valsalva and Credé maneuvers, and pelvic floor exercises. Urinary collection devices, intermittent catheterization, and protective garments are used to manage the collection and disposal of urine. ^[57] The Fourth International Consultation on Incontinence Recommendations published in 2009 outline the most recent guidelines for the management of urinary incontinence and specialized management of neurogenic urinary incontinence, including pharmacological and surgical interventions. ^[70]

In the rehabilitation setting, urinary incontinence is traditionally managed by physicians and nurses. A few studies have examined the role of the interdisciplinary rehabilitation team in the treatment of poststroke urinary incontinence.

Urinary tract infection

Because acute stroke patients are entering rehabilitation programs earlier than ever before, it is important to understand the impact of urinary tract infections on this specific population. Patients with a diagnosis of acute stroke are more than twice as likely to develop urinary tract infections as other hospitalized patients, regardless of the use of urinary catheters. ^[71]

Urinary tract infections in poststroke patients also independently predict poor outcomes, including death, prolonged hospitalization, and poorer neurological outcomes. ^[72] Acute stroke patients with hospital-acquired symptomatic urinary tract infections are less likely to be discharged home. ^[73] Additionally, acute stroke patients with symptomatic urinary tract infections are more likely to perform at a lower functional level while participating in an acute inpatient rehabilitation program.

A Cochrane summary completed in 2013 found some evidence, albeit limited, for the benefit of prophylactic antibiotics in nonsurgical patients who undergo bladder drainage. ^[74] More research is clearly needed to evaluate the potential benefit to stroke patients with urinary incontinence and/or neurogenic retention in the acute and postacute setting.

Fecal incontinence

Although common after stroke, fecal incontinence is poorly studied in this population. Up to 40% of stroke survivors experience fecal incontinence in the acute phase of recovery, and up to 19% still experience fecal incontinence at 6 months. ^{[54, 56]}

Like urinary incontinence, fecal incontinence is a predictor of increased mortality. ^{[51, 75]} Urinary and fecal incontinence coexist in 80-90% of acute poststroke patients, and these 2 conditions remain strongly associated in the postacute period. ^[54] Fecal incontinence may also predict the likelihood of discharge to an extended care facility or necessitate home-health nursing services.

Bowel management methods that are successful in patients with other neurologic pathology are often used in the management of stroke patients in the rehabilitation setting. Treatment programs should be individualized and implemented by the interdisciplinary team. Interventions are directed at preventing unplanned bowel movements, preventing constipation, and promoting efficient and effective bowel care. As in other settings, fecal incontinence is often managed with protective garments and appropriate skin care to prevent incontinence-related skin breakdown. Scheduled bowel programs may be used for patients with neurogenic bowel. Physical and occupational therapy interventions are directed at solving functional toileting problems. Although anal sphincter and pelvic muscle strengthening exercises may be used to treat fecal incontinence, their efficacy is poorly studied in this population.

Patient education and consent

Informing patients and family members of the rigors of rehabilitation is essential so that they are empowered to make informed decisions. Family and patient education is imperative to rehabilitation and assures successful return home and to the community. Training of caregivers by therapists and nurses is an essential component of a good rehabilitation program.

Patient instructions

Instructions for patients need to take into consideration both educational level as well as cognitive impairments resulting from the stroke. Paraphrasing, repeating, and presenting instruction verbally, physically, and in writing may be necessary and determined based on the individual needs of the patient.

Mobility and gait-assistive devices

Gait-assistive devices progress from providing a greater amount of stability to providing only slight cues for balance. Front-wheel walkers have a large base of support and are very stable, providing significant stability. A patient with significant upper extremity paresis can use a large base hemiwalker as an alternative and can progress to a quad cane. A 4-wheel walker provides some balance assistance. However, with increased pressure on the walker and dependence for balance, the 4-wheel walker becomes less stable. It is recommended for patients who use an assistive device primarily to assist with endurance. A single-point cane provides the least stability of the assistive gait devices. It provides proprioceptive information for balance only.

Activities-of-daily-living aids

Activities-of-daily-living aids are designed to maximize functional independence with basic daily tasks such as feeding, dressing, and grooming. Basic devices for assistance with meals are built-up silverware handles to assist with grip and plate guards to assist with loading food onto the utensil. A patient with poor proximal shoulder strength can be set up in a deltoid aide apparatus to assist with self-feeding. Multiple assistive aides are available for dressing including, sock aides, button aides, reachers, long-handle shoe horns, and elasticized shoe laces, to name a few.

Purpose of stroke rehabilitation

With any approach to stroke rehabilitation, treatment considerations are primarily based on the patient’s level of impairment. These impairments directly affect the individual's ability to complete functional tasks, including those involving mobility and activities of daily living. Impairments vary in complexity and severity in relation to the location and extent of the infarct. Moreover, the patient’s premorbid functional level can significantly influence mobility and independence during recovery.

Common impairments seen with MCA stroke relate to, but are not limited to, neglect/inattention, hemiparesis/hemiplegia, ataxia, perception, bowel and bladder control, cognition, speech/communication, swallowing, and vision, and there are deficits that tend to be specifically associated with infarcts on the left hemisphere of the brain, while others are associated with infarcts on the right. Also, many stroke patients have diffuse cerebrovascular disease and other comorbidities that may result in impaired circulation. ^[76]  Therefore, thorough evaluation is key to the accurate identification of impairments.

Interdisciplinary interventions and evidenced-based practice

Comprehensive stroke rehabilitation programs utilize an interdisciplinary team that works together to implement specialized, individualized interventions. ^[77]

Physical therapists and physical therapy assistants

These movement specialists employ prescribed exercise, hands-on care, and patient education to improve quality of life. ^[78]  Physical therapists and physical therapy assistants can use various outcome measures to provide an objective view of the patient's performance and progress. ^[79]  Physical therapy can address the patient’s needs with regard to balance and dizziness, pain, spasticity, strength, mobility and motor function, sexual function and intimacy, and medical equipment durability.

While working with a patient who has suffered a stroke, a physical therapist will likely utilize neuromuscular facilitation to aid progression toward meaningful, task-specific goals. Primary interventions can be supplemented with the use of adjunctive strategies, including functional/neuromuscular electrical stimulation (FES/NMES), orthoses, supported gait training, and virtual reality. ^{[80, 81]}

Occupational therapists and occupational therapy assistants

Through the therapeutic use of daily activities, occupational therapists and occupational therapy assistants can address needs surrounding self-care, basic and instrumental activities of daily living, cognition, vision/perception, spasticity, sexual function and intimacy, and medical equipment durability. ^[82]  In a postacute setting, consultations and referrals can be made to address the patient’s goals with regard to return to work/school and driving and to find ways to adapt an individual's hobbies and interests.

Speech-language pathologists

The goals of speech-language pathologists are the prevention, assessment, diagnosis, and treatment of speech, language, social communication, cognitive communication, and swallowing disorders. ^[83]  A speech pathologist's role varies greatly with the location of the stroke. Left MCA lesions impact language (aphasia) in the majority of the population, whereas right MCA lesions potentially have a greater impact in the areas of speech (dysarthria), perception, and cognition.

Nursing staff

In an acute rehabilitation setting, registered nurses, licensed practical nurses, and certified nursing assistants provide 24-hour availability to patients while restoring, promoting, and maintaining maximal patient health. ^[84]  The nursing staff manages complex medical issues, delivers hands-on care, and provides ongoing education to the patient and the patient’s family/caregivers. ^[85]  Rehabilitation nurses also often observe patients who are in a more fatigued state, after therapy and at night, and are accordingly a critical link to the team in relating potential decrements in safe self-care and mobility. Registered nurses may choose to pursue the certified rehabilitation registered nurse credential, which validates their professional standing as experienced and dedicated specialists who have achieved a documented level of knowledge. ^[84]

Case managers

Case managers provide quality, cost-effective health and social care services for patients. ^[86]  Community reentry for individuals with a new disability poses highly complex psychosocial and physical challenges. After assessing, monitoring, and coordinating available services and resources based on the patient’s healthcare needs, case managers implement their plans to encourage a smooth transition from the patient’s rehabilitation stay to the individual's discharge destination

Rehabilitation psychologists

Rehabilitation psychologists assess and treat cognitive, emotional, and functional difficulties in patients with new or long-standing disability due to injury or illness. Additionally, they help patients to overcome barriers to participation in activities and help to foster independence and opportunity. ^[87]  Stroke can cause aberrant behavior that impedes effective participation in therapy or safe self-care, and inconsistent and varying approaches to such behavior are unlikely to aid the patient's rehabilitation. Rehabilitation psychologists and counselors are uniquely qualified to provide uniform plans and advice to the therapy team. 

Recreational therapists

Recreational therapists exploit recreational activities as a means of promoting emotional healing and functional progress after disabling events. Potentially, patients are more engaged as their interest is enhanced by an activity that may help to challenge and improve cognitive or motor skills.  Further, recreational therapists can assist people with long-term impairment by providing adaptive techniques that allow patients to enjoy limitless activity in sports, fine arts, and crafts. These opportunities undoubtedly have an impact on self-esteem, inclusion, fitness, and longevity that is not easy to measure. However, recreational therapy is an often underappreciated discipline and is not always available to patients in stroke recovery. Still there is evidence of its benefit in stroke. ^[88]

Evidence-based practice

Healthcare professionals should strive to implement evidence-based practice (EBP) with regard to patient care. However, an average lag time of 17 years has been found between the publication of research and its clinical utilization. ^[89]  Additionally, it has been indicated that only 14% of that research is being adopted by care providers. ^[90]  While studying occupational therapists specifically, Juckett et al identified barriers related to this disconnect: poor consistency in adhering to the EBP, resource limitations (including staffing, time, money, and equipment), and lack of knowledge/confidence surrounding the new EBP interventions. ^[90]  Healthcare professionals must recognize and overcome these barriers if there is any hope of shortening the gap between research and practice.

However, sifting through stroke rehabilitation research to find efficacious interventions can be difficult and time-consuming. Clinical practice guidelines (CPGs) help professionals by providing a systematic review of evidence while detailing the potential harmful and beneficial aspects of interventions. As of March 2021, the most applicable CPGs offering insight into the effectiveness of non-pharmacologic, non-surgical interventions in stroke were:

• The sixth edition (updated 2019) of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation following Stroke ^[91]
• The Department of Veterans Affairs and Department of Defense’s Clinical Practice Guideline for the Management of Stroke Rehabilitation, which was released in 2019. ^[46]

It should be noted, however, that Church et al found that, while CPGs from Europe, Australia, the United Kingdom, and the United States have been rigorously developed, they have limited/basic guidance on exercise for people with stroke. ^[92]

Return to driving

Driving for many individuals represents freedom to access their community, family, and friends when and how they choose. People frequently identify driving as a primary component of their individual level of independence, and the ability to drive is sometimes impacted by the physical and/or cognitive changes that can occur following a stroke. However, the occurrence of a stroke does not necessarily trigger the loss of a driver’s license, and because of this it is important to be familiar with the individual state regulations guiding licensing criteria. 

In anticipation of a return to driving, one must consider the dynamic nature of the activity as well as the individual’s ability to safely and successfully perform its preparatory components. Among the main areas for assessment are cognition (judgement, attention, problem solving, memory, emotional regulation) and physical performance (sensation, strength, coordination, reaction time, vision). In some cases, a therapist trained in driving-related rehabilitation can provide hands-on training along with education regarding available vehicle accommodations and modifications.

Should a person be unable to safely return to driving, it is important to educate and train that individual with regard to alternative modes of transportation (ie, taxi, bus, train, family, friends). However, the availability of these services will vary from community to community and by setting (urban, suburban, or rural).

Return to work

There are several key components that should be considered regarding a successful return to work. Fatigue management and endurance are important factors, with recognition that fatigue can be physical, mental, or emotional. Increased risk for errors or limited judgement exists when fatigue is present. Many persons benefit from a gradual return to work, starting with partial days to allow for rest and recovery as needed.

Compensatory strategies should be practiced and utilized as appropriate; for example, a visual guide can be used to ensure complete visual gaze across an entire document. Moreover, communication among key players is essential for establishing expectations, providing a safe space, and troubleshooting any ongoing challenges.

Additional treatment considerations

Issues with neglect are commonly seen with a right hemisphere infarct. Patients with neglect have significant impairment in functional mobility. Multiple theories have been advanced on the neurophysiologic basis of neglect, including attention-arousal theory, ^[93] hemispheric specialization, ^[94] disengagement theory, ^[95]  and interhemispheric interaction and inhibition. ^[96]

Two treatment approaches, constraint-induced therapy and partial visual occlusion, involve decreasing the amount of sensory input to the less involved side. ^[97]

With constraint-induced therapy, the less-affected arm is restricted by either an arm sling or a hand mitt. There is extensive research on the efficacy of constraint-induced therapy for the treatment of hemiparesis. Wolf et al completed the first major study on forced-use therapy. ^[98] They defined forced use as, “directing patient effort and attention toward the affected hemiparetic upper extremity to the exclusion of the uninvolved, contralateral limb.” Constraint-induced therapy also has excellent potential for increasing spatial awareness in patients with neglect. Further research has found that active movement of the affected upper extremity could reduce the symptoms of visuospatial neglect. ^{[99, 100]}

Partial visual occlusion also helps to decrease sensory input to the less affected side. This is accomplished by patching or partially occluding a patient’s glasses in the nonneglected hemifield. This encourages head turning and visual scanning to the neglected visual field. ^[101]

Hemiparesis of the contralateral extremities is frequently seen in varying degrees of severity. In addition to limb involvement, impairment in postural stability that affects the patient’s static and dynamic balance is common. Therapeutic handling techniques are based on the concepts of facilitating wanted movements, inhibiting unwanted movements, and using key points of control on the patient’s body to achieve the desired effect. The neuro-developmental technique (NDT), formerly termed the Bobath approach, and neuro-IFRAH (neuro-integrative functional rehabilitation and habilitation) are the primary handling techniques developed for hemiparetic adults. The neuro-IFRAH technique was developed by Waleed Al-Oboudi after many years as a clinical instructor and lecturer, nationally and internationally, for the NDT Association. Both techniques are similar in their emphasis on postural control, quality of movement, and whole body use/function.

Therapeutic progressions begin with static seated balance, emphasizing appropriate midline orientation, and progress to dynamic sitting balance with the ability to incorporate reach into any sitting activity. Reach is in any direction, not defined by distance or extremity. Balance involves the use of the entire body with internal and/or external support. ^[102] Various other tools assist in achieving balance; manual facilitation to trunk postural muscles and extremities, facilitation range of motion, and use of mirrors for visual feedback are examples. Achieving postural alignment is key to achieving successful and efficient weight shifts.

Once achieved, the progression moves to dynamic stability with transitional movements. These are movements from one posture to another or movements within a posture, providing a change in location and/or orientation in space; an is example is a transfer from one surface to another. ^[72]

Once postural stability is functional in sitting, a similar progression can be followed in standing. Standing static balance, weight acceptance, and weight shift are all prerequisites for successful gait training. Assisted balance work in quadruped, half, and tall kneeling on a therapy mat table are effective in challenging balance through transitional movements and increasing supported weightbearing on hemiparetic limbs for increased facilitation. Half and tall kneeling are valuable tools to assist in the progression to standing balance and weight shifting because of their shorter lever arms against gravity. These are also positions in which patients have greater surface area for external base of support, which helps to increase patient confidence and decrease fear of falling.

Gait training typically begins with pregait activities while standing at a hemirail or parallel bars. Pregait training involves the initial skills of lateral weight shift and weight acceptance on and off the hemiparetic limb. Progression is then to forward and retro weight shifts in a staggered-stance position. Strength and motor coordination/control in the trunk and hemiparetic lower limb determine the amount of physical assistance provided by the therapist. Once effective weight shifts have been achieved, the progression continues to reciprocal steps. Functional weight shifting is of primary importance throughout initial gait-training activities in order to prevent dependence on a fixed assistive device for balance.

Body weight support treadmill training (BSWTT) is an available tool to assist with gait training. Patents are suspended in a harness that can support a percentage of their body weight. BSWTT allows therapists to manually facilitate leg advancement and knee control with walking. Partial body weight support allows patients to walk at a higher cadence and to maintain their walking effort for a longer duration. BSWTT positively affects over-ground walking speed, and more severely impaired patients often see greater improvements in gait and balance dysfunction. ^[103]

Poststroke weakness presents a significant barrier to patient safety and functional mobility. Poststroke weakness can be broadly defined as decreased magnitude of force production, slowness to produce force, rapid onset of fatigue, excessive sense of effort, and difficulty with force production in a functional task. ^[104] Therapeutic exercise interventions are frequently based in functional activities such as activities of daily living and mobility tasks. Incorporated into functional tasks are techniques of repetitive motion training consistent with a traditional therapeutic exercise program. Repetition of tasks, in addition to building strength, improves motor coordination, motor control, and sensation of the movement. ^[105]

Multiple medications are often used to manage complications of a middle cerebral artery (MCA) stroke and to decrease the risk of a recurrent stroke. Within each class of medication used, multiple agents may be selected, allowing for tailored therapy.

Hematologic agents

Medication selection is based on the etiology of the MCA stroke, comorbidities, and past medical history. Commonly used antiplatelet agents include aspirin, dipyridamole/aspirin, and clopidogrel. An increased bleeding risk is common to all of the medications within this class. Of note, prasugrel is contraindicated in patients with a history of stroke ^[106] and ticagrelor is only approved for use in patients with acute coronary syndrome. ^[107] While warfarin remains a common oral anticoagulant, newer agents include apixaban, dabigatran, and rivaroxaban.

Table 1. Hematologic Agents Mechanisms of Action and Considerations (Open Table in a new window)

Antihypertensives

Hypertension is a risk factor for recurrent strokes and is often managed with thiazide diuretics, calcium-channel blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors), and angiotensin receptor blockers (ARBs). A number of studies, including the Heart Outcomes Prevention Evaluation (HOPE) study and the Perindopril Protection Against Recurrent Stroke Study (PROGRESS), support the use of ACE inhibitors with or without the combination of a thiazide diuretic to reduce the reduce the risk of stroke recurrence. ^{[116, 117]} The Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) study supports the use of ARBs to reduce the risk of stroke recurrence. ^[118]

Beta-blockers are generally considered second-line agents but are often used for rate control. Of note, a meta-analysis has suggested higher mortality with atenolol compared with other antihypertensives when used as initial monotherapy for hypertension. ^[119]

Statins

HMG-CoA reductase inhibitors, or statins, have been shown to decrease the 10-year risk for recurrent stroke. ^[120] The individual agent should be selected based on potency needed, drug-statin interactions, and tolerability. Statin potency from lowest to highest based on the maximum dose is fluvastatin, pravastatin, lovastatin, simvastatin, atorvastatin, and rosuvastatin. ^[121]

Antispasmodics

Consider the use of an oral muscle relaxant if spasticity is resulting in pain or is impeding rehabilitation. CNS depression such as drowsiness and dizziness is a common adverse effect of all muscle relaxants.

Table 2. Antispasmodics Mechanisms of Action, Significant Adverse Effects, and Considerations. (Open Table in a new window)

Chemodenervation

Focal muscular injections of botulinum toxin formulations and nerve blocks using phenol have gained greater use for spasticity control. Electromyography (EMG) and electrostimulation or ultrasonographic guidance are often used to minimize side effects and complications such as bleeding or nerve injury. Complications from botulinum neurotoxin injection are rare but include pain in the extremity, muscle weakness, fatigue, nausea, and bronchitis. Despite its rise in popularity, the use of phenol is now becoming less common due to risks that include hypotension, prolonged pain, dysesthesias, site inflammation, and joint fibrosis. Phenol injections require greater expertise but can be more effective for larger muscles, with immediate results. ^[125]

Acetylcholinesterase Inhibitors

The use of acetylcholinesterase inhibitors for neuroprotection came from drug studies of and treatment for Alzheimer disease. Initial trials in patients with stroke demonstrated improvements in aphasia. Studies with donepezil have shown more improvement in aphasia and cognition than they have motor recovery. Also, studies using acetylcholinesterase inhibitors are beginning to demonstrate both early and later benefit without significant adverse drug events or increased mortality. Still, large, double-blinded, placebo-controlled studies are lacking, and research continues. ^[126]

Alpha-adrenergic blockers and anticholinergics

Stroke can lead to urinary retention, bladder urgency, urinary frequency, and incontinence. Bladder scanning is important early after stroke to find and treat retention versus overflow incontinence.

Post-stroke urinary retention in men and women can be improved using alpha-adrenergic blockers such as tamsulosin. This drug is associated with less orthostatic hypotension than terazosin, doxazosin, prazosin, and alfuzosin. ^[127]  In patients with urinary frequency and incontinence but without urinary retention, anticholinergics such as oxybutynin and tolterodine may be used. The newer, longer-acting antimuscarinic agents have fewer adverse effects and may promote better adherence. ^[128]

An important role for the physiatrist, as well as the neurologist, in the postacute care of stroke patients is to discern prognosis based on predictors available. Such assessment is vital in planning and selecting appropriate rehabilitation and in preparing the patient and family for adjustments and adaptations needed to accommodate resultant disability. Early predictors include stroke severity in terms of extent on radiologic studies, National Institutes of Health Stroke scores in the acute setting, age, and other medical comorbidities. Later predictors include social support, bowel and bladder continence, trunk stability, presence of visuospatial disorders such as neglect, and flaccid paralysis. ^{[42, 129]}

Using magnetic resonance vessel wall imaging, a study by Ran et al indicated that in persons with ischemic stroke related to middle cerebral artery (MCA) plaque, those with recurrent stroke tend to have a higher plaque burden than do individuals with a first episode of acute stroke and patients with chronic stroke. ^[130]

A study by Lorente et al indicated that in patients with malignant MCA infarction, higher levels of serum substance P concentrations on days 1, 4, and 8 of the infarction are predictive of 30-day mortality. ^[131]

A study by Topcuoglu et al indicated that the National Institutes of Health Stroke Scale and a computed tomography angiography (CTA)-based modified clot burden score can serve as independent negative predictors for early dramatic recovery and favorable third-month prognosis in acute MCA stroke. The study included 131 patients with acute MCA stroke who underwent intravenous thrombolysis and/or interventional thrombolysis/thrombectomy. ^[132]

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). ^[133]

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. ^[134]

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. ^[135]

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. ^[136]  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. ^[137]

A study by Kandregula et al, using the National (Nationwide) Inpatient Sample database, found that among patients with MCA stroke, those who underwent intravenous thrombolysis plus mechanical thrombectomy had a better disability status at hospital discharge than did those who underwent thrombectomy alone. The investigators reported that the rates of minimal disability at discharge were 23.8% versus 18.2%, respectively, while the rates of moderate to severe disability at discharge were 67.2% versus 73.0%, respectively, and the mortality rates were 8.9% versus 8.6%, respectively. ^[138]

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. ^[139]