What is the prognosis for a patient with a large ischemic impact in the left posterior cerebral artery (PCA) territory and ischemic infarcts in the left middle cerebral artery (MCA) territory involving the left interior frontal lobe, left frontal lobe, and left basal ganglia?

From the Guidelines

The prognosis for a patient with a large ischemic impact in the left posterior cerebral artery (PCA) territory and ischemic infarcts in the left middle cerebral artery (MCA) territory involving the left interior frontal lobe, left frontal lobe, and left basal ganglia is generally poor, with a mortality rate of 20-30% and significant long-term disability expected in the majority of patients. This extensive stroke pattern typically results in significant neurological deficits, including right-sided hemiparesis, sensory loss, visual field defects (likely homonymous hemianopia), cognitive impairments, and possible language deficits 1. Recovery is highly variable and depends on several factors, including the patient's age, pre-stroke health status, timing of intervention, and access to rehabilitation services.

Key Considerations

• Immediate management should focus on preventing stroke progression with antiplatelet therapy (aspirin 81-325mg daily or clopidogrel 75mg daily), blood pressure control (targeting 140-180/90-105 mmHg in the acute phase), and early rehabilitation.
• Long-term disability is likely, with many patients requiring assistance with activities of daily living.
• The involvement of multiple vascular territories suggests either cardioembolic etiology or severe atherosclerotic disease, necessitating thorough cardiac evaluation and aggressive secondary prevention strategies.
• Rehabilitation should begin as early as possible and typically continues for months, though most neurological recovery occurs within the first 3-6 months post-stroke.
• Family education and psychological support are essential components of care as patients and caregivers adjust to potential long-term disability.

Decision Making and Outcomes

Decision making is shared between physicians and families, and discussion is of paramount importance 1. Families have the burden of predicting what the patient would want in this situation, but that usually is the best guide for decision making. In discussion with family members, it is essential to discuss the possibility of depression, lack of initiative, irritability, disinhibition, and being wheelchair-bound.

Evidence-Based Recommendations

The most recent and highest quality study 1 provides recommendations for the management of cerebral and cerebellar infarction with swelling, which is relevant to this patient's condition. The study highlights the importance of early intervention and rehabilitation in improving outcomes. While another study 1 discusses the surgical management of infective endocarditis complicated by embolic stroke, it is not directly relevant to this patient's condition, and therefore, its findings are not considered in this recommendation.

From the Research

Prognosis for Large Ischemic Impact

The prognosis for a patient with a large ischemic impact in the left posterior cerebral artery (PCA) territory and ischemic infarcts in the left middle cerebral artery (MCA) territory involving the left interior frontal lobe, left frontal lobe, and left basal ganglia can be understood by examining the outcomes of similar cases.

• Mortality and Disability: A study on large infarcts in the middle cerebral artery territory found that mortality (17%) and severe disability (50%) were higher in patients with large MCA infarcts compared to other types of infarcts 2.
• Infarct Location and Outcome: Research on early CT signs in acute middle cerebral artery infarction suggests that the location and extent of the infarct can be predicted by early CT signs, and that the presence of multiple signs is associated with extended MCA infarct and poor outcome 3.
• PCA Territory Infarcts: A study on posterior cerebral artery territory infarcts found that the majority of patients had visual abnormalities, and that motor weakness, cognitive and behavioral abnormalities, and ataxia were also common 4.
• Superficial PCA Territory Infarcts: Another study on superficial PCA territory infarcts found that the infarct mechanisms were similar across different types of superficial PCA territory stroke, but that cardioembolism was more frequent in those with cortical PCA territory infarction 5.
• Endovascular Treatment: A case report on endovascular treatment of an acute left middle cerebral artery infarct suggests that successful re-canalization can be achieved even after 6 hours post-stroke, and that the therapeutic time window for endovascular therapy may exceed 6 hours 6.

Factors Affecting Prognosis

Several factors can affect the prognosis of a patient with a large ischemic impact in the left PCA and MCA territories, including:

• Location and Extent of Infarct: The location and extent of the infarct can affect the outcome, with larger infarcts tend to have a poorer prognosis 2, 3.
• Presence of Multiple Infarcts: The presence of multiple infarcts, such as in the PCA and MCA territories, can also affect the outcome 4, 5.
• Time to Treatment: The time to treatment, including endovascular therapy, can also impact the outcome 6.
• Underlying Vascular Mechanisms: The underlying vascular mechanisms, such as cardioembolism or proximal arterial disease, can also affect the prognosis 2, 4, 5.