What is the management plan for a patient with a stroke infarct?

Management of Stroke Infarct

The management of stroke infarct requires immediate triage to a stroke unit or intensive care unit with neuromonitoring capabilities, followed by comprehensive treatment including brain imaging, appropriate medical interventions, and prevention of complications. 1

Initial Assessment and Management

• Patients with suspected stroke should be triaged with the same priority as those with acute myocardial infarction or serious trauma, regardless of deficit severity 1
• Immediate brain imaging with CT or MRI is essential to differentiate between ischemic and hemorrhagic stroke and guide treatment decisions 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 diffusion-weighted imaging (DWI) within 6 hours is useful, with volumes ≥80 mL predicting a rapid fulminant course 1

Acute Treatment

• For eligible patients within 3 hours of symptom onset (or up to 4.5 hours in select cases), intravenous recombinant tissue plasminogen activator (rtPA) is strongly recommended 1, 2
• Aspirin can be administered within the first 48 hours due to its reasonable safety profile and modest benefit 1, 2
• Blood pressure management is crucial, with antihypertensive agents avoided unless systolic blood pressure is >220 mm Hg or diastolic blood pressure is >120 mm Hg 2
• Maintain adequate oxygenation, but supplemental oxygen should only be provided to patients with hypoxemia (O₂ saturation <92%) 2, 3

Triage and Hospital Care

• Transfer to an intensive care or stroke unit is recommended for patients with large territorial strokes for close monitoring and comprehensive treatment 1
• Triage to a higher level center is reasonable if comprehensive care and timely neurosurgical intervention are not available locally 1
• Multidisciplinary care teams composed of neurologists, neurointensivists, and neurosurgeons, as well as dedicated stroke nursing, are required to optimally manage complex stroke patients 1
• Neurosurgical consultation should be sought early to facilitate planning of decompressive surgery if needed 1

Management of Cerebral Edema

• Cerebral edema occurs in all infarcts but is especially concerning in large-volume infarcts 1
• Medical interventions to minimize edema development include restriction of free water to avoid hypo-osmolar fluid, avoidance of excess glucose administration, minimization of hypoxemia and hypercarbia, and treatment of hyperthermia 1
• To assist in venous drainage, the head of the bed can be elevated at 20° to 30° 1
• For patients with significant edema and increased intracranial pressure, osmotherapy with mannitol (0.25 to 0.5 g/kg IV administered over 20 minutes every 6 hours, with a usual maximal dose of 2 g/kg) may be used 1
• Hemicraniectomy within 48 hours has been shown to substantially reduce death and disability in selected patients (18-60 years old) with extensive hemispheric infarcts 2

Airway Management

• Indications for endotracheal intubation include persistent or transient hypoxemia, obstructing upper airway with pooling secretions, apneic episodes, and the development of hypoxemic or hypercarbic respiratory failure 1
• Rapid sequence intubation is preferred, with no evidence that depolarizing agents or fentanyl, lidocaine, and propofol are deleterious 1

Prevention and Management of Complications

• Early screening and management of swallowing difficulties is essential to prevent aspiration pneumonia 2
• Deep vein thrombosis prevention through subcutaneous anticoagulants or intermittent external compression stockings is strongly recommended for immobilized patients 2
• Indwelling bladder catheters should be avoided when possible due to infection risk 2
• Monitor for and treat complications including pneumonia, urinary tract infections, pressure ulcers, and falls 2
• Cardiac monitoring for the first 24 hours after stroke may detect intermittent atrial fibrillation not apparent at presentation and the development of potentially lethal early arrhythmias 1

Early Rehabilitation

• Early mobilization is strongly recommended to prevent complications 2
• Assessment and management of mobility, activities of daily living, incontinence, and mood should be undertaken early after stroke 2
• Speech and language pathologists should evaluate and treat all stroke patients for residual communication difficulties 2
• Comprehensive rehabilitation should begin early and include a multidisciplinary team approach 4

Secondary Prevention

• Antiplatelet therapy with aspirin should be initiated within 24 hours of ischemic stroke in all patients without contraindications 5
• Statin therapy should be given in most situations 5
• Antihypertensive therapy should begin within 24 hours, following an initial period of permissive hypertension 5
• Diabetes mellitus should be controlled and patients counseled about lifestyle modifications to reduce stroke risk 5

Special Considerations for Young Patients

• Young stroke patients require evaluation for unique etiologies including arterial dissection, patent foramen ovale, vasculopathies, and coagulopathies 4
• Vocational rehabilitation needs should be addressed as part of the recovery plan 4
• Psychological support is essential, as young stroke survivors often face unique challenges with identity, career, and family responsibilities 4

Common Pitfalls to Avoid

• Delaying transfer to a stroke center or appropriate level of care 1
• Failing to monitor for and treat cerebral edema, especially in large territorial infarcts 1
• Administering prophylactic anticonvulsants to patients who have had stroke but not seizures 1
• Overlooking dysphagia assessment before oral intake, increasing risk of aspiration pneumonia 2
• Inadequate long-term follow-up, especially in younger patients who have a higher lifetime risk of recurrence 4