J Clin Neurosci. 2011 Feb;18(2):218-22. [PubMed]
Edlow JA, Selim MH. Atypical presentations of acute cerebrovascular syndromes. Lancet Neurol. 2011 Jun;10(6):550-60. [PubMed]
Nishida Y, Irioka T, Sekiguchi T, Mizusawa H. Pure sensory infarct in the territories of anterior cerebral artery. Neurology. 2010 Jul 20;75(3):287. [PubMed]
Bejot Y, Caillier M, Osseby GV, Didi R, Ben Salem D, Moreau T, Giroud M. Involuntary masturbation and hemiballismus after bilateral anterior cerebral artery infarction. Clin Neurol Neurosurg. 2008 Feb;110(2):190-3. [PubMed]
Birenbaum D, Bancroft LW, Felsberg GJ. Imaging in acute stroke. West J Emerg Med. 2011 Feb;12(1):67-76. [PMC free article] [PubMed]
Jensen UR, Weiss M, Zimmermann P, Jansen O, Riedel C. The hyperdense anterior cerebral artery sign (HACAS) as a computed tomography marker for acute ischemia in the anterior cerebral artery territory. Cerebrovasc. Dis. 2010;29(1):62-7. [PubMed]
Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H., American Heart Association Stroke Council. Council on Cardiovascular Nursing. Council on Peripheral Vascular Disease. Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44(3):870-947. [PubMed]
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL., American Heart Association Stroke Council.
Eligibility and absolute and relative contraindications should undergo rapid assessment. Randomized controlled trials have shown that intravenous administration of recombinant tissue plasminogen activator (alteplase) decrease functional disability with an absolute reduction risk of 7%-13% relative to placebo. [21]
Unfortunately, over half of patients arrive after this time window has closed and are not eligible for thrombolysis. Treatment delays may result from failure to ascribe a patients symptoms to stroke, and furthermore, the risk of harm increases with time elapsed from symptom onset. [21] This situation could be of particular concern in ACA strokes, given their sometimes atypical presentation. Endovascular treatment with mechanical thrombectomy (MT) is another proven treatment modality in the management of patients with acute stroke suffering a large vessel occlusion, although treatment efficacy is highly time-dependent. The procedure is available in tertiary hospitals as requires stroke team with the expertise to use timely imaging and intervention. One study evaluating MT in ACA stroke patients found that while recanalization rates were high, the outcomes were otherwise unsatisfactory. The latter was attributed to larger infarct volumes and longer times to recanalization. [22] [23]. New guidelines recommend that in patients with acute ischemic stroke within 6 to 24 hours from last known well and who have large vessel occlusion in anterior circulation, obtaining CTP, DW-MRI, or MRI perfusion is recommended to aid in selection for mechanical thrombectomy. However, this is only with the strict application of imaging or other eligibility criteria from RCTs showing benefit are in selecting patients for MT.