What is the treatment for an evolving occipital parietal infarction?

Treatment of Evolving Occipitalparietal Infarction

For an evolving occipitalparietal infarction, immediate medical management should be initiated with osmotic therapy, followed by surgical intervention with decompressive craniectomy if neurological deterioration occurs despite maximal medical therapy. 1

Initial Assessment and Monitoring

• Closely monitor level of consciousness and neurological status, as deterioration may indicate increasing cerebral edema and potential brainstem compression 1
• Evaluate for signs of obstructive hydrocephalus, which may occur as a complication of posterior circulation infarcts 1
• Perform frequent neurological examinations to detect early signs of deterioration, including changes in pupillary response and motor function 1

Medical Management

First-line Interventions

• Elevate head of bed to 30° to help venous drainage 1
• Initiate osmotic therapy with one of the following options:
  • Mannitol 20% (0.25-0.5 g/kg IV over 20 minutes, every 6 hours, maximum 2 g/kg) 1
  • Hypertonic saline (3%, 7.5%, or 23.4% solutions) 1
• Maintain serum osmolality between 300-310 mOsmol/kg 1
• Maintain cerebral perfusion pressure (CPP) >60 mmHg using volume replacement and/or vasopressors if needed 1

Additional Medical Measures

• For patients with severe deterioration, consider:
  • Profound sedation, analgesia, intubation, and controlled mechanical ventilation (target PaCO2 of 35 mmHg) 1
  • Correct factors that may exacerbate swelling: hypoxemia, hypercarbia, and hyperthermia 1
• Note that corticosteroids have insufficient evidence and are not recommended for cerebral edema management in ischemic stroke 1

Surgical Management

Indications for Surgical Intervention

• Surgical intervention is indicated for patients with:
  • Neurological deterioration from brainstem compression despite maximal medical therapy 1
  • Development of obstructive hydrocephalus 1

Surgical Options

• For obstructive hydrocephalus: Emergency ventriculostomy is a reasonable first step 1
• If ventriculostomy fails to improve neurological function or if significant mass effect persists:
  • Perform decompressive suboccipital craniectomy with dural expansion 1
  • For cerebellar infarction: Craniectomy up to the transverse sinus with opening of the foramen magnum, durotomy, and enlargement duroplasty 1
  • Consider removal of necrotic cerebellar tissue during surgery 1

Postoperative Management

• Intensive care monitoring with ICP and CPP monitoring 1
• Obtain control CT scan after 24 hours or earlier if signs of intracranial hypertension are present 1
• Initiate thromboembolic prophylaxis with subcutaneous low-dose heparin or low molecular weight heparin from the second postoperative day 1
• Begin early rehabilitation once patient is stabilized 1

Family Discussion and Prognosis

• When discussing decompressive suboccipital craniectomy for cerebellar infarction, inform family members that outcomes can be good after surgery 1
• The prognosis for cerebellar infarcts is often favorable if there is no evidence of brainstem infarction 1
• Early intervention is crucial for improving outcomes, as 85% of patients progressing to coma die without intervention 1

Special Considerations

• Correct any coagulation disorders before surgical intervention 1
• If the patient received thrombolysis or antiplatelet therapy, ensure coagulation factors are normalized before surgery 1
• For patients who have received antiplatelet drugs, consider preoperative platelet transfusion 1
• Early transfer to a facility with neurosurgical expertise should be considered for patients at risk for malignant brain edema 1

Remember that timely intervention is critical in managing evolving occipitalparietal infarctions to prevent permanent brainstem injury from tissue displacement and brain shift.