What is the prognosis for a patient with acute cortical infarcts in the right frontal, parietal, and occipital lobes, as well as the left pre- and post-central gyri, following normal CT scans and trans-thoracic echocardiogram (TTE) showing non-embolic phenomenon?

Prognosis for Multifocal Cortical Infarcts Post-Operatively

The prognosis is guarded with significant risk for poor functional outcome, given the bilateral multivessel territory involvement affecting eloquent cortex (motor strip) and the large right hemispheric burden, though survival is possible with aggressive management and younger age being favorable factors. 1, 2

Immediate Mortality Risk

• Mortality risk is substantial in the acute phase (first 48 hours to 2 weeks), particularly with right-sided large territorial infarcts involving frontal, parietal, and occipital lobes, which carry risk for malignant cerebral edema and herniation 3, 1
• The bilateral nature of infarcts, particularly involvement of the left motor strip (pre- and post-central gyri), significantly worsens prognosis compared to unilateral lesions 4
• Peak swelling occurs several days after onset of ischemia, placing this patient in the critical window for deterioration 3

Functional Outcome Predictors

Poor Prognostic Factors Present:

• Multivessel territory involvement (right frontal, parietal, occipital PLUS left motor cortex) indicates either cardioembolic shower or watershed hypoperfusion—both associated with worse outcomes 4
• Involvement of additional vascular territories beyond MCA (the impression notes possible ACA or PCA involvement) is an independent poor prognostic factor with significantly reduced survival 4
• Bilateral cortical involvement, even if asymmetric (right > left), substantially increases disability burden 2
• Left motor strip involvement (pre- and post-central gyri extending into hand area) predicts significant motor deficits affecting dominant hand function 1

Potentially Favorable Factors:

• Normal initial CTs suggest the infarcts evolved over time rather than presenting as massive acute occlusion, which may indicate some collateral preservation 5
• Absence of hemorrhagic transformation on current imaging is favorable, as hemorrhagic transformation significantly worsens outcomes in large infarcts 3
• No midline shift currently suggests brain swelling is not yet malignant, though this can evolve 3, 1

Expected Functional Outcomes

• If patient survives the acute phase without malignant edema, expect modified Rankin Scale (mRS) ≥4 (moderately severe to severe disability) based on the bilateral nature and motor strip involvement 4
• The mean survival for poor functional outcome group (mRS≥4) after large cerebral infarction is approximately 34 months, compared to 59 months for good outcomes (mRS≤3) 4
• Complete recovery is unlikely given the extent of bilateral cortical involvement, particularly affecting eloquent motor cortex 6
• Approximately 78% of young stroke patients achieve complete or mild residual disability, but this applies to smaller, unilateral strokes—not this pattern 6

Critical Management Considerations

Monitoring for Malignant Edema:

• Decrease in level of consciousness is a reasonable trigger for considering decompressive craniectomy in the setting of large MCA territory infarction 1
• The optimal window for surgical intervention is within 48 hours of stroke onset, before severe neurological deterioration 1, 2
• Decompressive hemicraniectomy reduces mortality by approximately 50% in patients ≤60 years with unilateral MCA infarction who deteriorate within 48 hours, though functional outcomes remain poor 1, 2

Medical Management:

• Initial management should include restriction of free water, correction of factors exacerbating swelling, head of bed elevation, and avoidance of vasodilating antihypertensives 1, 2
• Osmotic therapy targeting serum osmolarity of 315-320 mOsm/L is reasonable for clinical deterioration from cerebral swelling 1, 2

Age-Related Prognosis

• Age is a critical prognostic factor—patients ≥70 years have mean survival of approximately 30 months versus 59 months for those <70 years after large cerebral infarction 4
• If patient is >60 years, decompressive craniectomy may still be considered but functional outcomes are significantly worse than in younger patients 1

Common Pitfalls

• Do not defer DNR or palliative care discussions beyond 24-48 hours after stroke onset to allow time to assess response to therapy and trajectory 2
• The distribution pattern (multivessel territory) raises concern for either cardioembolic source despite "non-embolic" TTE findings (TEE may be needed) or severe hemodynamic compromise causing watershed infarction 5
• Border zone/watershed pattern in the setting of normal TTE suggests possible severe large vessel stenosis or systemic hypoperfusion that may not have been adequately evaluated 5

Bottom Line Prognosis

Expect severe disability (mRS 4-5) if patient survives, with high risk for mortality in the acute phase from malignant edema. Long-term survival measured in years rather than decades is likely given the poor functional outcome trajectory. The bilateral nature, motor strip involvement, and multivessel territory distribution make this a particularly devastating stroke pattern. 1, 2, 4