What is the management for an evolving subacute infarction in the posterior left temporal lobe?

Management of Evolving Subacute Infarction in the Posterior Left Temporal Lobe

Patients with evolving subacute infarction in the posterior left temporal lobe should be transferred to an intensive care or stroke unit for close monitoring and comprehensive treatment, with early neurosurgical consultation to facilitate planning for possible decompressive surgery if the patient deteriorates. 1

Initial Assessment and Triage

Neuroimaging

• Obtain non-contrast CT scan as first-line diagnostic test to assess infarct size and monitor for swelling 1
• Consider MRI with diffusion-weighted imaging (DWI) to determine infarct volume; volumes ≥80 mL predict a rapid fulminant course 1
• Look for warning signs on imaging:
  • Frank hypodensity within first 6 hours
  • Involvement of one-third or more of the MCA territory
  • Early midline shift 1

Monitoring

• Monitor level of arousal and pupillary changes frequently
• Watch for gradual development of midposition pupils and worsening motor response, which may indicate deterioration 1
• Serial CT findings in the first 2 days are useful to identify patients at high risk for developing symptomatic swelling 1

General Management Measures

Airway and Positioning

• Elevate head of bed between 0-30° during periods of increased intracranial pressure 1
• Ensure sufficient cerebral oxygenation 1

Fluid Management

• Correct hypovolemia with isotonic fluids 1
• Avoid hypotonic fluids which can worsen cerebral edema 1

Temperature and Glucose Control

• Treat hyperthermia aggressively 1
• Control hyperglycemia (>8 mmol/L) 1

Blood Pressure Management

• For non-thrombolysed patients: upper limits of systolic BP 220 mmHg, diastolic BP 120 mmHg 1
• For thrombolysed patients: upper limits of systolic BP 185 mmHg, diastolic BP 110 mmHg 1
• Avoid arterial hypotension or cerebral hypoperfusion (CPP <60 mmHg) 1

Nutrition and Swallowing

• Avoid oral intake of food and fluids initially 1
• Perform swallowing assessment before allowing oral intake to prevent aspiration 1

Thromboprophylaxis

• Administer subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids 1
• Consider intermittent pneumatic compression and elastic stockings for lower limbs 1

Management of Cerebral Edema and Increased Intracranial Pressure

Medical Management

• Osmotic therapy (mannitol or hypertonic saline) is reasonable for patients with clinical deterioration from cerebral swelling 1
• Avoid corticosteroids as they are not recommended for ischemic cerebral swelling 1
• Avoid sedatives except for specific indications (e.g., benzodiazepines for alcohol withdrawal) 1

Surgical Management

• For patients who continue to deteriorate neurologically despite maximal medical therapy, decompressive craniectomy with dural expansion should be considered 1
• Early neurosurgical consultation is essential to facilitate planning of decompressive surgery if the patient deteriorates 1
• For posterior temporal lobe infarctions with mass effect, temporal lobectomy may be life-saving in cases of imminent herniation 2

Recognition of Deterioration

Clinical Signs of Deterioration

• Decreasing level of consciousness
• Ipsilateral pupillary dilation (one of the earliest signs of deterioration) 3
• Worsening limb power
• Development of extensor posturing 3

Imaging Signs of Deterioration

• Progressive midline shift
• Compression of ventricles
• Signs of herniation (subfalcine, uncal) 1

Transfer Considerations

• Early transfer to a neuroscience center should be considered for patients at risk for malignant brain edema 1
• Transfer should not be delayed if emergency neurosurgical intervention is needed 1
• Auto-acceptance criteria for brain-injured patients should be established within networks 1

Common Pitfalls and Caveats

• Brain edema typically peaks 3-5 days after stroke, but can occur earlier in large infarctions 1
• Ventriculostomy alone for hydrocephalus carries a risk of upward herniation and should be combined with decompressive surgery if significant edema or mass effect is present 1
• Controlled hyperventilation and osmotic agents provide only temporary relief and may be associated with rebound phenomena after discontinuation 1
• Delaying surgical intervention in patients with signs of herniation can lead to poor outcomes 2

By following these guidelines, the management of evolving subacute infarction in the posterior left temporal lobe can be optimized to reduce mortality and improve functional outcomes.