What is the management for a cerebral infarct (stroke)?

Management of Cerebral Infarct (Stroke)

Patients with acute cerebral infarction require immediate admission to an intensive care or stroke unit with multidisciplinary care including neurologists, neurointensivists, and neurosurgeons, with treatment focused on airway protection, blood pressure management, identification of candidates for thrombolysis within 3 hours, and early recognition of life-threatening cerebral edema requiring decompressive craniectomy. 1

Immediate Triage and Initial Assessment

• Transfer all patients with large territorial strokes to an intensive care or stroke unit immediately for close monitoring and comprehensive treatment, as clinical deterioration occurs in 25% of patients (one-third from stroke progression, one-third from brain edema, 10% from hemorrhage, and 11% from recurrent ischemia). 1

• Obtain early neurosurgical consultation to facilitate planning of decompressive surgery if the patient deteriorates, particularly for large hemispheric or cerebellar infarcts. 1, 2

• Transfer to a higher-level center is reasonable if comprehensive care and timely neurosurgical intervention are not available locally. 1, 2

Acute Thrombolytic Therapy (Within 3 Hours)

• Intravenous recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) is strongly recommended for carefully selected patients who can receive the medication within 3 hours of symptom onset, as this is the only proven acute intervention to improve outcomes. 1

• Safe use of rtPA requires strict adherence to NINDS selection criteria, close observation, and careful ancillary care. 1

• Intra-arterial thrombolysis may be considered for selected patients beyond 3 hours, though patient selection criteria and effectiveness have not been fully established. 1

Airway and Ventilation Management

• Perform endotracheal intubation for: persistent or transient hypoxemia, obstructing upper airway with pooling secretions, apneic episodes, hypoxemic or hypercarbic respiratory failure, generalized tonic-clonic seizures, or recent aspiration. 1

• Use rapid sequence intubation with standard agents (depolarizing agents, fentanyl, lidocaine, or propofol are not deleterious). 1

• Maintain normocapnia (PaCO₂ 30-35 mmHg) after intubation; prophylactic hyperventilation provides no benefit and should only be used as a temporizing measure for increased intracranial pressure. 1

• Use low doses of short-acting anesthetics (propofol or dexmedetomidine) for sedation if needed to avoid hypertension, anxiety, or ventilator dyssynchrony. 1

Blood Pressure Management

• Avoid aggressive blood pressure lowering in acute ischemic stroke unless extreme elevations are present, as lowering blood pressure can worsen cerebral perfusion. 1

• Avoid antihypertensive agents that induce cerebral vasodilation. 1

• Maintain adequate mean arterial blood pressure at all times, though evidence-based target levels are not established. 1

Medical Management of Cerebral Edema

Cerebral edema occurs in all infarcts but is especially problematic in large-volume infarcts, typically peaking 3-4 days after injury. 1

Preventive Measures:

• Elevate head of bed 20-30 degrees to assist venous drainage. 1, 2
• Restrict free water to avoid hypo-osmolar fluid administration. 1
• Avoid excess glucose administration and maintain normoglycemia (glucose <8 mmol/L). 1, 2
• Minimize hypoxemia and hypercarbia. 1
• Treat hyperthermia aggressively. 1, 2
• Ensure sufficient cerebral oxygenation and correct hypovolemia with isotonic fluids. 2

Treatment of Increased Intracranial Pressure:

• Mannitol 0.25-0.5 g/kg IV over 20 minutes can be given every 6 hours (maximum 2 g/kg total) to lower ICP, though it has not been proven to improve outcomes. 1

• Hypertonic saline is associated with rapid decrease in ICP in patients with clinical transtentorial herniation. 1

• Hyperventilation induces cerebral vasoconstriction and reduces ICP but provides only short-lived benefit and should be considered temporizing only. 1

• Do not use corticosteroids, hypothermia, or barbiturates for ischemic cerebral edema, as they lack evidence of benefit. 1, 2

Neuroimaging for Predicting Cerebral Edema

• CT findings predictive of cerebral edema include: frank hypodensity within the first 6 hours, involvement of one-third or more of the MCA territory, and early midline shift. 1

• MRI DWI volumes ≥80 mL within 6 hours predict a rapid fulminant course. 1

• Serial CT scans in the first 2 days are useful to identify patients at high risk for developing symptomatic swelling. 1

Decompressive Craniectomy for Hemispheric Infarction

Decompressive craniectomy with dural expansion should be considered in patients with large hemispheric infarcts who continue to deteriorate neurologically despite maximal medical therapy. 1

Key Points for Decision-Making:

• For patients <60 years old: When decompressive craniectomy is performed within 2 days after supratentorial ischemic stroke, nearly 3 of 4 patients survive, but nearly half will be severely disabled and nearly half will suffer from depression. 1

• For patients ≥60 years old: Good information is lacking, and expectations may not be as high as for younger patients. 1

• Counsel families that one-third of surviving patients will be severely disabled and fully dependent on care even after decompressive craniectomy. 1

• Despite severe disability, many patients and families rate good quality of life despite severe functional handicap. 1

Management of Cerebellar Infarction

Cerebellar infarction requires particularly close monitoring due to risk of brainstem compression and obstructive hydrocephalus. 2

Monitoring for Deterioration:

• Watch for: decreased consciousness (GCS <12 or decline ≥2 points), pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses, bradycardia, irregular breathing, sudden apnea. 2

• Monitor for fourth ventricular compression and hydrocephalus on imaging. 2

Surgical Management:

• Decompressive suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically from brainstem compression. 1, 2

• If obstructive hydrocephalus develops: Emergency ventriculostomy is reasonable as a first step, but must be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. 1, 2

• Critical pitfall: Do not perform ventriculostomy alone without planning for decompressive craniectomy, as this can cause upward herniation. 2

• Prognosis after cerebellar infarct surgery is generally good with acceptable functional outcomes in most patients. 1, 2

Antiplatelet and Anticoagulant Therapy

• Aspirin can be administered within the first 48 hours due to reasonable safety and small benefit. 1

• Urgent anticoagulation cannot be routinely recommended as it has not been shown to lessen early recurrent stroke risk and can increase brain hemorrhage risk, especially in moderately severe strokes. 1

• Initiate thromboembolic prophylaxis with subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids for immobilized patients. 2

Additional Supportive Care

• Avoid oral intake of food and fluids initially in patients at risk for aspiration. 2

• Comprehensive stroke unit care including rehabilitation should be provided to all patients. 1

• Evaluate for stroke etiology to guide secondary prevention strategies. 1

Common Pitfalls to Avoid

• Do not delay neurosurgical consultation until deterioration occurs; early involvement is essential for optimal outcomes. 2

• Do not use routine intracranial pressure monitoring or cerebrospinal fluid diversion in swollen supratentorial hemispheric ischemic stroke. 1

• Do not aggressively lower blood pressure in acute ischemic stroke, as this can worsen outcomes. 1

• Despite intensive medical management, death rate with increased ICP remains 50-70%, underscoring that medical interventions are temporizing measures only. 1