Identification of the Nature of Acute Middle Cerebral Artery Occlusion and Preferred Strategy for Mechanical Thrombectomy

Acute middle cerebral artery occlusion is a common and critical cerebrovascular disease in clinical practice, characterized by its sudden onset and severe clinical symptoms, posing a substantial threat to neurological function and survival. Therefore, clinicians need to quickly and accurately identify the occlusion type and develop appropriate treatment plans accordingly. In recent years, with the development of neuroimaging technology and a deeper understanding of the pathophysiological mechanisms of acute middle cerebral artery occlusion, various diagnostic methods have been applied to determine the occlusion type. The core treatment goal of acute ischemic stroke is to minimize irreversible neuronal injury and restore effective brain tissue perfusion as soon as possible. Systematic reviews and meta-analyses of multiple randomized controlled trials have consistently confirmed that mechanical thrombectomy (MT) has significant clinical efficacy in acute anterior circulation stroke patients with large vessel occlusion (LVO). Therefore, domestic and international evidence-based guidelines list it as a first-line endovascular intervention for LVO stroke in the early stage of onset (within 6 h; expandable to 24 h with imaging screening). This narrative review summarizes current evidence on diagnostic approaches for different types of acute middle cerebral artery occlusion and mechanical thrombectomy strategies tailored to the presumed occlusion mechanism, with the aim of informing mechanism-based diagnostic assessment and endovascular treatment decisions.