When considering the treatment of patients with acute stroke, primary prevention focuses on limiting the size of the stroke in evolution. When a patient presents near the actual onset time, time sensitive therapies can be considered. In the case of wake-up stroke (stroke upon awakening), precise onset time is uncertain and treatments often focus on secondary prevention. For patients who present within 24 hours of onset time, catheter-based interventions are sometimes offered if imaging confirms a small territory of stroke injury and a large area at risk is seen in the setting of a large artery filling defect or occlusion. A filling defect of the distal right ICA near the vessel terminus where it branches into the two named vessels, the right MCA and ACA represents a focal stenotic lesion that must be appreciated and treated in a timely fashion with proper precautionary measures to limit stroke progression.
Transfer to a certified stroke center for further work up and management is typically required. The identification of potential regions associated with restricted diffusion that could account for the presenting complaint warrant urgent neurological consultation prior to discharge. Treatment with hypervolemia, permissive hypertension, and antithrombotic medications may be required to limit stroke extension while the etiology of the stroke is identified and the best measures for secondary prevention determined.
At all times, the goal of treatment should be to limit the size of the stroke and further brain injury to regions at risk. MRI should not be presumed normal just because a patient’s symptoms temporarily resolve. Stuttering or fluctuating symptoms are common in stroke patients and resolution of symptoms does not negate the importance of determining symptom etiology and instituting treatment.