Cerebral artery occlusion

Disease Description (Causes and Symptoms)

Cerebral artery occlusion is a condition in which a thrombus or embolus blocks a major artery supplying blood to the brain (the anterior cerebral artery [ACA], middle cerebral artery [MCA], posterior cerebral artery [PCA], vertebral and basilar arteries, etc.) or one of its branches, blocking blood flow to localized brain tissue. The main causes include cardioembolic events (e.g., atrial fibrillation, endocarditis, heart valve disease), thrombus formation due to atherosclerosis, and aortic valve or carotid artery stenosis. Pathophysiologically, ischemia in the area supplied by the affected vessel leads to neuronal damage, necrosis, and edema.

Main symptoms (vary depending on the affected area)

• Acute onset: paralysis/weakness of one arm or leg (hemiplegia), loss of sensation
• Speech or language impairment (aphasia) or difficulty understanding
• Visual disturbance (hemianopia, visual field defect)
• Decreased consciousness, coma
• Balance, visual, or memory impairment (when the posterior circulation is involved)
• Seizures, abulia
• Symptoms may show specific patterns depending on the occluded artery (ACA/MCA/PCA/vertebral or basilar artery) (e.g., severe motor impairment of the upper limb and face with MCA occlusion; visual and memory impairment with PCA occlusion, etc.).

Treatment Methods and Precautions

• Initial emergency care
  • Immediate non-contrast CT or MRI to rule out intracerebral hemorrhage.
  • Confirming the time of symptom onset (last known well time) is essential.
• Reperfusion therapy (acute phase, within the time window)
  • Intravenous thrombolysis (IV tPA, alteplase): generally within 4.5 hours after symptom onset (selection criteria and contraindications must be checked).
  • Endovascular treatment (mechanical thrombectomy): generally effective for large-vessel occlusion; traditionally most effective within 6 hours, but in selected patients, imaging-based treatment may be performed up to 6–24 hours after onset.
  • Catheter-directed thrombolysis (local thrombolysis) and other treatments may be performed depending on the indication.
• Antiplatelet and anticoagulant therapy
  • Once hemorrhage has been ruled out in the acute phase, antiplatelet agents such as aspirin are started (there are timing restrictions when IV tPA has been administered; usually, treatment begins after 24 hours have passed following tPA administration and the absence of hemorrhage has been confirmed).
  • When the cause is cardioembolic (e.g., atrial fibrillation), long-term anticoagulation (warfarin or a DOAC) is necessary—the timing is determined based on the risk of hemorrhage and the size of the cerebral infarction (at the physician’s discretion).
• Surgical treatment
  • Decompressive craniectomy may be considered for severe cerebral edema or a large MCA infarction.
  • For severe carotid artery stenosis, carotid endarterectomy (CEA) or carotid artery stenting (CEA or CAS) may be considered.
• Conservative and supportive treatment
  • Control of blood pressure, blood glucose, and body temperature; oxygen supplementation; nutritional and fluid management; DVT prevention (early ambulation, compression, and anticoagulation when necessary); and prevention of pneumonia and aspiration.
  • Begin early rehabilitation (physical therapy, occupational therapy, and speech therapy).
• Complications and precautions
  • Hemorrhagic transformation, hypertension and increased intracranial pressure due to cerebral edema, seizures, pneumonia and urinary tract infections, and cardiovascular complications may occur.
  • Manage the risk of bleeding when administering anticoagulants or antiplatelet agents (risk of gastrointestinal bleeding and risk in the event of trauma).
  • Accurately check the indications and contraindications for thrombolysis (recent surgery, bleeding disorders, high INR, etc.).

Checklist Before an Outpatient Visit (Items to Bring and Records, etc.)

Items and information to bring

• List of current medications (including anticoagulants, antiplatelet agents, antihypertensive drugs, and antidiabetic drugs) and allergy information
• A record of the time symptoms began (last known well time) and their progression (time of symptom onset and when they worsened or improved)
• Previous test results and images (CT/MRI/blood tests; if possible, DICOM/CD or the radiology report)
• Information about underlying conditions (atrial fibrillation, hypertension, diabetes, hyperlipidemia, heart disease, etc.) and a recent electrocardiogram (if possible)
• History of recent surgery or bleeding, and pregnancy status
• Family history and lifestyle habits (smoking, alcohol consumption) Examples of items to note when visiting an outpatient clinic (to make it easier to explain to medical staff)
• The exact time the symptoms first appeared
• Current main symptoms (changes in movement, sensation, speech, vision, consciousness, etc.)
• Treatment received in the emergency department or during hospitalization (IV tPA, mechanical thrombectomy, whether surgery was performed) and the timing
• Changes in function at home (ability to perform activities of daily living, walking status, etc.)

Examples of General Questions to Ask the Doctor

• What tests are needed to confirm whether these symptoms are caused by cerebral artery occlusion?
• Am I eligible for reperfusion therapy (IV tPA or mechanical thrombectomy)? What are the risks and benefits?
• What medications will I need to take long term (anticoagulants/antiplatelet agents), and what are the duration of treatment and side effects?
• What blood pressure, lipid, and blood glucose targets are recommended to reduce the risk of recurrence?
• When and for how long should rehabilitation (physical, occupational, and speech therapy) be started?
• When will I be able to drive or return to work?

Examples of Disease-Specific Questions

• If atrial fibrillation is suspected as the cause: "If atrial fibrillation is confirmed, when should anticoagulants be started? Does the timing differ depending on the size of the cerebral infarction or the risk of hemorrhage?"
• If carotid artery stenosis is suspected: "If I have carotid artery stenosis, am I a candidate for carotid endarterectomy or stenting? What would be the timing of surgery and the expected benefits?"