What is the management approach for cerebral infarction (stroke) versus cerebral vascular accident (CVA)?

Management of Cerebral Infarction vs. Cerebrovascular Accident (CVA)

Cerebral infarction and CVA refer to the same clinical entity (stroke), and management should follow established stroke protocols focusing on rapid assessment, stabilization, and appropriate reperfusion strategies.

Initial Management and Triage

• Patients with suspected stroke should receive high triage priority with early notification to the receiving hospital to ensure selection of a facility with organized stroke unit care 1
• Transfer to an intensive care or stroke unit is recommended for patients with large territorial strokes to enable 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

Immediate Diagnostic Evaluation

• Brain imaging is essential to differentiate cerebral ischemia from intracerebral hemorrhage and exclude stroke mimics 1
• Non-contrast CT scan is the first-line diagnostic test to monitor patients with hemispheric cerebral or cerebellar infarcts with swelling 1
• Frank hypodensity on head CT within 6 hours, involvement of ≥1/3 of MCA territory, and early midline shift predict cerebral edema 1
• MRI with diffusion-weighted imaging (DWI) within 6 hours is useful, with volumes ≥80 mL predicting a rapid fulminant course 1

Essential Diagnostic Tests

• All patients should undergo immediate testing including 1:

  • Blood glucose
  • Oxygen saturation
  • Serum electrolytes/renal function
  • Complete blood count including platelet count
  • Cardiac ischemia markers
  • Coagulation studies (PT/INR, aPTT)

• Selected patients may require additional tests based on clinical presentation 1:

  • Thrombin time or ecarin clotting time (if on direct thrombin inhibitors)
  • Hepatic function tests
  • Toxicology screen
  • Arterial blood gases
  • Chest radiography
  • Lumbar puncture (if subarachnoid hemorrhage is suspected)

Acute Treatment

Reperfusion Therapy

• Intravenous thrombolysis with rt-PA is highly effective for selected patients presenting within 3 hours of stroke onset 1
• Aspirin (160-300 mg/day) should be started within 48 hours of acute ischemic stroke onset 1
• Endovascular treatment options may be considered for eligible patients, particularly those with large vessel occlusions 1

Management of Cerebral Edema

• Osmotic therapy with mannitol or hypertonic saline is reasonable for patients with clinical deterioration from cerebral swelling 1
• Elevation of the head of the bed to 30° is recommended to reduce space-occupying effects of brain swelling 1
• Clinicians should frequently monitor level of arousal and ipsilateral pupillary dilation in patients with supratentorial ischemic stroke at high risk for deterioration 1
• For cerebellar infarcts, monitor for level of arousal or new brainstem signs to detect deterioration 1, 2

Surgical Interventions

• Decompressive craniectomy should be considered for patients with malignant cerebral edema, particularly in younger patients 3
• In patients with cerebellar stroke who deteriorate neurologically, suboccipital craniectomy with dural expansion should be performed 2
• If ventriculostomy is needed to relieve obstructive hydrocephalus in cerebellar infarction, it should be accompanied by decompressive suboccipital craniectomy 2

Special Considerations

Cerebellar Infarction

• Cerebellar infarcts can deteriorate from brainstem compression, with obstructive hydrocephalus as a secondary manifestation 1
• Clinical signs of deterioration include depression in consciousness level, Glasgow Coma Scale score <12 on admission, or a decline of ≥2 points 2
• Patients with territorial cerebellar infarctions require monitoring for up to 5 days, even if initially stable 2

Cardioembolic Infarction

• Cardioembolic cerebral infarction accounts for 14-30% of ischemic strokes and has the highest in-hospital mortality (27.3%) compared to other subtypes 4
• Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke 4
• Certain clinical features suggest cardioembolic infarction, including sudden onset to maximal deficit, decreased level of consciousness at onset, and co-occurrence of cerebral and systemic emboli 4

Common Pitfalls and Caveats

• Misdiagnosis of stroke is common in prehospital settings, with positive predictive value ranging from 34% for TIA to 70% for stroke 5
• The most frequent stroke mimics include vertigo (19%), electrolyte/metabolic disturbances (12%), seizures (11%), and cardiovascular disorders (10%) 5
• Infarct growth rate shows remarkable heterogeneity among patients, with an estimated average of 5.4 mL/h in patients with large vessel occlusion stroke 6
• In rare cases of synchronous cardiocerebral infarction (concurrent acute ischemic stroke and myocardial infarction), treatment decisions are complex and must be individualized based on the severity of each condition 7