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Middle Cerebral Artery Stroke Causes, Symptoms, and Treatment

• What the MCA Is

A middle cerebral artery (MCA) stroke occurs when blood flow from the MCA, one of the largest arteries of the brain, is suddenly interrupted ( ischemia ) or altogether stopped ( infarction ). The loss of blood flow causes tissue death , leading to serious and potentially permanent brain injury.

MCA strokes are most often the result of a blood clot that travels from outside the brain, such as from the heart or carotid artery , and causes a partial or complete blockage of the artery. However, an MCA stroke can also be caused by a ruptured artery. This is known as a hemorrhagic stroke .

This article takes a closer look at the MCA as well as the symptoms and causes of MCA strokes. It also explains how MCA strokes are diagnosed and treated and what to expect during rehabilitation.

What Is the Middle Cerebral Artery?

The arteries in your brain come in symmetrical pairs. Each one has a left and right artery. The MCAs are vital blood vessels that branch off from the internal carotid arteries.

The internal carotid arteries are branches of the common carotid arteries . Those are large blood vessels in your neck.

The MCA is the largest branch of the internal carotid arteries. It can be involved in large strokes.

What Does the MCA Do?

Arteries in the brain carry blood that’s rich in oxygen and nutrients to the brain. Each artery supplies a different section of the brain. That section is called the “territory” of that artery.

The MCAs supply a large territory in the brain that is involved in:

• Processing sensory information related to touch, taste, and temperature
• Processing audio and encoding memory
• Aiding communication between areas of the brain
• Movement, expressive language, and the ability to work toward a goal

When blood flow to these areas is impaired, they have a hard time carrying out their functions.

MCA Stroke Symptoms

MCA strokes are the most common type. Their symptoms are the ones people usually associate with strokes, such as:

• Weakness and/or numbness on one side
• Facial droop
• Language deficits

An MCA stroke may also cause:

• Sensory deficits
• Visual defects

These affect the opposite side of the body from the artery. Thus, a stroke in the right MCA causes symptoms on the left side of the body.

How to Tell if Someone Is Having a Stroke

The acronym BE FAST is often used by health educators to describe stroke symptoms affecting b alance, e yes, f ace, a rm, s peech, and t ime. Call 911 or seek emergency care if you or someone else experiences:

• Sudden loss of balance on one side
• Vision changes in one eye or double vision
• One-sided facial drooping
• Loss of function or sensation in one arm
• Slurred speech
• Trouble finding a word or getting words out

Click Play to Learn All About MCA Strokes

This video has been medically reviewed by Chris Vincent, MD .

The MCA is a large blood vessel. Large-vessel strokes affect more of the brain than strokes in small vessels. If the MCA itself is blocked, the result is a large-vessel stroke that affects its entire territory.

If only a small branch of the MCA is blocked, it causes a small-vessel stroke. This impacts a small section of the MCA’s territory and is often less serious.

MCA strokes are generally caused by a blood clot that travels from outside the brain. Typically, it’s from the heart or carotid artery. Then the clot gets lodged in the MCA and blocks blood flow.

This is called an embolic stroke . This type of stroke can sometimes be caused by other debris in the bloodstream, such as plaque that has broken off from an atherosclerotic plaque.

When the clot causing the blockage originates in the arteries of the brain, the stroke is called a thrombotic stroke.

Risk factors for MCA strokes include:

• Heart disease
• Carotid artery disease
• General stroke risk factors such as high cholesterol, hypertension, and diabetes

MCA strokes are among the most easily recognized types of stroke.

Even so, your healthcare provider will likely use multiple labs and tests to confirm the diagnosis. These may include:

• A neurological exam to determine affected brain regions
• Electrocardiogram (EKG) to check electrical conduction of the heart, which may be irregular and associated with the cause of the stroke
• Lumbar puncture (spinal tap) to check for hemorrhagic stroke (rupture of a weakened blood vessel)
• Blood tests to look for known risk factors, including clotting disorders, high cholesterol, and diabetes
• Computed tomography (CT) scan to quickly check for a brain bleed
• CT angiography , a common follow-up study after CT to find a blood vessel blockage
• Magnetic resonance imaging (MRI) or MR angiography (MRA) can help provide insight about the cause of the stroke and detect any related brain tissue damage

Other tests and imaging may be performed depending on your symptoms.

Treatment and Rehabilitation

Treatment for an MCA stroke can be divided into two parts: initial treatment and rehabilitation.

Initial Treatment for MCA Stroke

Urgent treatment may include:

• Tissue plasminogen activator (tPA) or tenecteplase, medications that can dissolve blood clots
• Other blood thinners
• Careful management of blood pressure, blood sugars, electrolytes, and fluids
• Surgery to remove pressure on vital brain regions

MCA Stroke Rehabilitation

Rehabilitation after a stroke can be intensive and prolonged. It may involve physical, occupational, and speech therapy. It's recommended that those who qualify and have access to services in an inpatient rehabilitation facility receive care there in preference to a skilled nursing facility.

Blocks or ruptures in the MCA lead to MCA strokes. The resulting loss of blood, oxygen, and nutrients can cause brain damage and impair function in the regions that get blood from the MCA.

Treatment includes blood thinners, surgery to relieve pressure, and management of several vital signs. Recovery may involve multiple types of therapy, depending on the symptoms. Recovery from an MCA stroke may take some time, particularly if the entire MCA was blocked, resulting in a large stroke.

Long-term recovery and rehabilitation may take months or even years. However, a good recovery is possible even from very serious strokes. Most people who have an MCA stroke are able to regain some function.

National Heart, Lung, and Blood Institute. What is a stroke?

Chandra A, Li WA, Stone CR, Geng X, Ding Y. The cerebral circulation and cerebrovascular disease I: anatomy . Brain Circ . 2017;3(2):45-56. doi:10.4103/bc.bc_10_17

Aroor S, Singh R, Goldstein LB. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): reducing the proportion of strokes missed using the FAST mnemonic . Stroke . 2017;48(2):479-481. doi:10.1161/STROKEAHA.116.015169

American Stroke Association. Atherosclerosis and stroke .

Dharmasaroja PA, Muengtaweepongsa S. Outcomes of patients with large middle cerebral artery infarct treated with and without intravenous thrombolysis . J Neurosci Rural Pract . 2016;7(1):36-39. doi:10.4103/0976-3147.172149

Czap AL, Sheth SA. Overview of imaging modalities in stroke .  Neurology . 2021;97(20S):S42-S51. doi:10.1212/WNL.0000000000012794

Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association . Stroke . 2021;52(7):e364-e467. doi:10.1161/STR.0000000000000375

Katsanos AH, Psychogios K, Turc G, et al. Off-label use of tenecteplase for the treatment of acute ischemic stroke: a systematic review and meta-analysis .  JAMA Netw Open . 2022;5(3):e224506. doi:10.1001/jamanetworkopen.2022.4506

Winstein CJ, Stein J, Arena R, et al.

Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association .  Stroke . 2016;47(6). doi:10.1161/STR.0000000000000098

By Heidi Moawad, MD Dr. Moawad is a neurologist and expert in brain health. She regularly writes and edits health content for medical books and publications.

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• A 55-year-old man presents to the emergency department for difficulty with speech and weakness in the right upper extremity. He was last known to be neurologically normal 2 hours prior to presentation. He has a medical history of atrial fibrillation, hypertension, hyperlipidemia, and type 2 diabetes mellitus. He smokes approximately 1 pack of cigarettes daily for the past 15 years. Physical examination is notable for 2/5 power in the right upper extremity and word finding difficulty. A non-contrast head CT is performed, which does not demonstrate an intracranial hemorrhage. He is immediately started on alteplase.
• the deficit depends on which area of the brain is affected
• 3rd leading cause of death in the United States
• hypertension
• atrial fibrillation
• mechanical valves
• valvular abnormalities
• patent foramen ovale
• significantly decreased ejection fraction
• hypercoagulable state
• family history
• vascular disease
• the most vulnerable to ischemic hypoxia is the hippocampus
• after 5 minutes, irreversible neuronal damage occurs
• a clot (typically) from one region of the body travels in the blood stream and occludes a vessel supplying the brain
• maximal neurologic deficit occurs at the onset
• large vessel infarcts are commonly due to an embolism
• where an atherosclerotic plaque is found
• typically has a stuttering course
• a non-contrast head CT should be performed in patients presenting with symptoms concerning for stroke and to exclude intracerebral hemorrhage
• CT angiography should be performed to assess for a thrombus and to evaluate the carotid and vertebral neck arteries
• MRI/MRA can aid in assessing infarct volume for further management
• evaluates evidence of an intracardiac shunt or ventricular thrombus
• should be performed immediately in all suspected stroke patients
• complete blood count
• basal metabolic panel
• prothrombin time
• partial thromboplastin time
• cardiac enzymes
• level of consciousness
• ask month and age
• follows commands (blink eye and squeeze hands)
• horizontal eye movements
• visual fields
• facial palsy
• left arm motor drift
• right arm motor drift
• left leg motor drift
• right leg motor drift
• limb ataxia
• language/aphasia
• extinction/inattention
• hyperdense lesion in a non-contrast head CT
• normal MRI brain
• hypertension that can lead to confusion, visual changes, and seizures
• MRI demonstrating cerebral edema in the posterior hemispheres
• stroke symptoms, excluded to have an intracranial hemorrhage, and time since symptom onset is within the last 3-4.5 hours
• history of stroke/head trauma in the past 3 months
• history of intracranial hemorrhage
• major surgery in the past 14 days
• GI or urinary tract bleeding in the past 21 days
• myocardial infarction in the previous 3 months
• arterial puncture at a non-compressible site in past 7 days
• resolving stroke symptoms
• very minor and isolated neurological symptoms
• seizure at the onset of stroke
• persistent hypertension SBP > 185 mmHg or DBP > 110 mmHg
• use of direct thrombin inhibitors (such as dabigatran or argatroban)
• use of factor Xa inhibitors (such as rivaroxaban or apixaban)
• active bleeding or acute trauma with fractures
• platelets 400 mg/dL
• INR > 1.7 or PT > 15 seconds if on warfarin
• elevated PTT if on heparin
• head CT showing hemorrhage or multilobular infarction > 33% of a cerebral hemisphere
• intracranial neoplasm, arteriovenous malformation, or aneurysm
• clopidogrel
• most important management for hypertensive strokes and vascular dementia
• whether or not the patient received tPA
• Intracerebral hemorrhage
• Aspiration pneumonia
• Central post-stroke pain

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