What is the management approach for a patient presenting with cerebral infarction?

Management of Cerebral Infarction

Patients with cerebral infarction should be admitted to an intensive care or stroke unit for close monitoring and comprehensive treatment, with early neurosurgical consultation for potential surgical intervention if significant swelling develops. 1

Initial Assessment and Triage

• All patients presenting with cerebral infarction should be evaluated immediately in a stroke unit by both a neurologist and a neurosurgeon, particularly those with risk factors for developing space-occupying brain edema 1
• Transfer to a higher level center is reasonable if comprehensive care and timely neurosurgical intervention are not available locally 1
• A baseline severity score should be performed as part of the initial evaluation 1
• Frequent monitoring of level of arousal and ipsilateral pupillary dilation is essential in patients with supratentorial ischemic stroke at high risk for deterioration 1
• For cerebellar stroke, frequent monitoring for level of arousal or new brainstem signs is critical 1

Neuroimaging

• A non-contrast CT scan of the brain is the first-line diagnostic test and modality of choice to monitor patients with hemispheric cerebral or cerebellar infarcts with swelling 1
• Frank hypodensity on head CT within the first 6 hours, involvement of one-third or more of the MCA territory, and early midline shift are useful in predicting cerebral edema 1
• MRI DWI volume measurement within 6 hours is useful, with volumes ≥80 mL predicting a rapid fulminant course 1
• Serial CT findings in the first 2 days help identify patients at high risk for developing symptomatic swelling 1

Medical Management

General Measures for Patients at High Risk for Space-Occupying Infarction

• Close neurological and cardiovascular monitoring in an intermediate or intensive care stroke unit 1
• For territorial cerebellar infarctions, monitoring for up to 5 days, even if the patient seems stable 1
• Ensuring sufficient cerebral oxygenation 1
• Prophylaxis and treatment of hyperthermia 1
• Correction of hypovolemia with isotonic fluids 1
• Avoid oral intake of food and fluids 1
• Elevation of the upper part of the body between 0° and 30° during periods of increased intracranial pressure 1
• Treatment of hyperglycemia >8 mmol/L 1
• Avoid antiplatelet agents if craniectomy is likely to be performed 1

Management of Cerebral Edema

• Osmotic therapy is reasonable for patients with clinical deterioration from cerebral swelling associated with cerebral infarction 1
• Mannitol (0.25 to 0.5 g/kg IV over 20 minutes every 6 hours, maximum dose 2 g/kg) can be used to lower ICP 1
• Hypertonic saline is an alternative to mannitol and may be more effective in some cases 1
• Mild hyperventilation (target PaCO2 30-35 mmHg) in intubated patients may temporarily reduce ICP, but benefits are short-lived 1
• Hypothermia, barbiturates, and corticosteroids are not recommended due to insufficient data on their effectiveness 1

Surgical Management

For Supratentorial Hemispheric Infarction

• Decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically despite medical management 1
• Surgery should be performed before signs of herniation appear for optimal outcomes 1
• The number needed to treat (NNT) for survival with decompressive craniectomy is approximately 2 1
• There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age 1

For Cerebellar Infarction

• Suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically 1
• Ventriculostomy to relieve obstructive hydrocephalus should be accompanied by decompressive suboccipital craniectomy to avoid upward cerebellar displacement 1
• Early surgical intervention is crucial as delayed intervention may cause additional and irreversible brain damage 1

Airway and Ventilation Management

• Endotracheal intubation is indicated for persistent or transient hypoxemia, obstructed upper airway with pooling secretions, apneic episodes, or respiratory failure 1
• Rapid sequence intubation is preferred for patients requiring airway management 1
• For intubated patients, normocapnia should be maintained; prophylactic hyperventilation is not recommended 1
• Short-acting anesthetics such as propofol or dexmedetomidine can be used for patient comfort while maintaining hemodynamic stability 1

Prognosis and Outcomes

• In-hospital mortality in cardioembolic stroke (27.3%) is higher compared to other subtypes of cerebral infarction 2
• Despite decompressive craniectomy for swollen hemispheric supratentorial infarcts, approximately one-third of patients will be severely disabled and fully dependent on care 1
• Surgery after cerebellar infarct generally leads to acceptable functional outcomes in most patients 1
• Early deterioration is common in the first few hours after ICH onset, with more than 20% of patients experiencing a decrease in GCS of 2 or more points between prehospital assessment and initial ED evaluation 1

Common Pitfalls and Caveats

• Delaying neurosurgical consultation can lead to missed opportunities for timely intervention 1
• Failure to recognize early signs of deterioration can result in worse outcomes 1
• Relying solely on clinical examination without serial imaging may miss progressive swelling 1
• Prophylactic hyperventilation without evidence of increased ICP may be harmful 1
• Treating with corticosteroids is not supported by evidence and should be avoided 1
• Ventriculostomy alone without decompressive surgery in cerebellar infarction can lead to upward herniation 1