Malignant MCA syndrome

Question 1

What is the time window for thrombolysis?

Answer 1

Within 4.5 hours of symptom onset

Question 2

What is the thrombolysis dose in acute stroke?

Answer 2

• Alteplase
• 900 mcg/kg (up to 90mg) over 60mins
• First 10% as an injection, rest as an infusion.-

Question 3

What is the management of malignant MCA syndrome?

Answer 3

Resuscitation in ABCDE approach correcting abnormalities as they are found
Neuroprotection and stabilisation:
- head up 30-40
- avoid pyrexia, hypoxia, hypotension
- pCO2 4.5-5
- pO2 >12
- sedation and paralysis
- target MAP 80-90 assuming raised ICP

ICP management:

• deepen sedation - may need barbiturate coma
• osmotherapy
• neurosurgical intervention - decompressive craniotomy ( age <60, within 48hrs) - improves survival but neurological outcomes not great (DESTINY I/II, DECIMAL, HAMLET)