What is the management and treatment for a patient with a cerebrovascular infarct?

Management of Cerebrovascular Infarction

The management of cerebrovascular infarction requires immediate transfer to an intensive care or stroke unit for close monitoring and comprehensive treatment, with early neurosurgical consultation for potential decompressive surgery in cases of significant brain swelling.

Initial Assessment and Triage

• Transfer to an intensive care or stroke unit is essential for patients with large territorial strokes to ensure close monitoring and comprehensive treatment 1
• Triage to a higher-level center is recommended if comprehensive care and timely neurosurgical intervention are not available locally 1
• Early neurosurgical consultation should be sought to facilitate planning for potential decompressive surgery 1
• Patients with risk factors for developing space-occupying brain edema should be evaluated immediately by both a neurologist and neurosurgeon 1

Neuroimaging

• Non-contrast CT scan is the first-line diagnostic test and modality of choice to monitor patients with hemispheric cerebral or cerebellar infarcts 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 predict cerebral edema 1
• MRI diffusion-weighted imaging (DWI) volumes ≥80 mL within 6 hours predict a rapid fulminant course 1
• Serial CT findings in the first 2 days help identify patients at high risk for developing symptomatic swelling 1

Recognition of Deterioration

• Frequent monitoring of level of arousal and ipsilateral pupillary dilation is crucial in patients with supratentorial ischemic stroke at high risk for deterioration 1
• Gradual development of midposition pupils and worsening of motor response may indicate deterioration 1
• For cerebellar stroke, frequent monitoring for level of arousal or new brainstem signs is essential 1

Medical Management

Airway and Ventilation

• Endotracheal intubation and mechanical ventilation are indicated for patients with declining consciousness and inability to maintain a patent airway 1
• Rapid sequence intubation is preferred, with normocapnia as the ventilation goal 1
• Short-acting anesthetics such as propofol or dexmedetomidine can be used to avoid hypertension, anxiety, or ventilator dyssynchrony 1

Fluid Management

• Use isotonic saline and avoid hypo-osmolar fluids 1
• Fluids without dextrose are preferred 1
• Correction of hypovolemia with isotonic fluids is recommended 1

Blood Pressure Management

• Avoid antihypertensive agents, particularly those that induce cerebral vasodilation 1
• For non-thrombolysed patients, upper limits are systolic BP 220 mmHg and diastolic BP 120 mmHg 1
• Consider intraarterial BP monitoring in cases of BP exceeding upper limits or imminent cerebral hypoperfusion (CPP < 60 mmHg) 1

Osmotic Therapy

• Osmotic therapy is reasonable for patients with clinical deterioration from cerebral swelling 1
• Mannitol (0.25-0.5 g/kg IV over 20 minutes every 6 hours, maximum dose 2 g/kg) or hypertonic saline can be used 1
• There is insufficient data to recommend mannitol or hypertonic saline as a preemptive measure in patients with early CT swelling 1

Temperature Management

• Prophylaxis and treatment of hyperthermia is recommended 1
• Normothermia is preferred, with treatment recommended for temperatures >37.5°C 1

Glucose Management

• Treatment of hyperglycemia >8 mmol/L is recommended 1
• Avoid aggressive glucose control (glucose <126 mg/dL) as it may increase infarct size 1

Positioning

• Elevation of the upper part of the body between 0 and 30° during periods of increased intracranial pressure 1

Thromboprophylaxis

• Thromboembolic prophylaxis with subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids 1
• Consider intermittent pneumatic compression and elastic stockings of the lower limbs 1
• Therapeutic anticoagulation with full-dose unfractionated heparin, low molecular weight heparin, or heparinoids is not recommended during the acute phase 1

Surgical Management

Supratentorial Infarction

• Decompressive craniectomy with dural expansion should be considered in patients with large hemispheric infarcts who continue to deteriorate neurologically 1
• There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age 1
• After decompressive surgery, one should anticipate that one-third of patients will be severely disabled and fully dependent on care 1

Cerebellar Infarction

• Suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarcts who deteriorate neurologically 1
• Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement 1
• Surgery after a cerebellar infarct leads to acceptable functional outcomes in most patients 1

Management of Complications

Infections

• Pneumonia is an important cause of death following stroke and requires early antibiotic therapy 1
• Urinary tract infections are common; indwelling bladder catheters should be avoided when possible due to infection risk 1

Seizures

• Seizures occur in approximately 4-43% of patients within the first days after stroke, most commonly within 24 hours 1
• Status epilepticus, though uncommon, can be life-threatening and requires prompt treatment 1

Nutrition

• Swallowing assessment is crucial before allowing oral intake 1
• When necessary, nasogastric or nasoduodenal tube can be inserted for feeding and medication administration 1

Pitfalls and Caveats

• Delayed intervention may cause additional and irreversible brain damage; a precise management plan should be defined as soon as possible after admission 1
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen edema 1
• Antiplatelet agents should be avoided if craniectomy is likely to be performed 1
• The patient's will should be documented and taken into account whenever possible, as considerable long-term handicap is frequent despite craniectomy 1
• Resuscitation orders should be adapted to the decision whether the patient is a candidate for craniectomy 1