What is the immediate management for a patient who has already suffered a brain infarction (cerebral infarction)?

Immediate Management of Brain Infarction

Admit the patient immediately to an intensive care unit or specialized stroke unit with neuromonitoring capabilities, obtain early neurosurgical consultation, and implement aggressive supportive care to prevent secondary brain injury while monitoring closely for life-threatening cerebral edema. 1

Initial Triage and Monitoring

Transfer to a specialized center with comprehensive stroke and neurosurgical capabilities is essential for optimal outcomes. 1 The management requires a multidisciplinary team including neurointensivists, vascular neurologists, and neurosurgeons 1.

Critical Monitoring Parameters:

• Frequent neurological assessments focusing on level of consciousness and pupillary changes to detect early herniation 2
• Serial CT imaging within the first 48 hours to identify patients developing symptomatic swelling 1
• Continuous monitoring for signs of increased intracranial pressure 1

Neuroimaging Assessment

Obtain non-contrast CT scan immediately as the first-line diagnostic and monitoring tool 1. Key prognostic findings include:

• Frank hypodensity within 6 hours involving ≥33% of MCA territory predicts malignant edema 1
• MRI DWI volumes ≥80 mL predict rapid fulminant deterioration 1
• Early midline shift on CT indicates high risk for herniation 1

Supportive Care Measures

Head Positioning and Basic Management:

• Elevate head of bed 20-30 degrees to facilitate venous drainage and reduce intracranial pressure 1, 2
• Maintain adequate oxygenation (O₂ saturation >92%) 3
• Avoid hypo-osmolar fluids (such as 5% dextrose in water) as they worsen cerebral edema 1

Physiologic Parameters to Control:

• Treat hypoxia, hypercarbia, and hyperthermia aggressively as these exacerbate elevated intracranial pressure 1
• Maintain blood glucose <8 mmol/L with insulin therapy, as hyperglycemia worsens prognosis 3
• Avoid aggressive blood pressure lowering, particularly with vasodilating agents, as elevated BP may be compensatory to maintain cerebral perfusion 1

Osmotic Therapy

Administer manitol 0.25-0.5 g/kg IV every 6 hours when signs of increased intracranial pressure develop 2. This reduces intracranial pressure and may improve clinical outcomes in patients with large territorial infarctions.

Prevention of Complications

Venous Thromboembolism Prophylaxis:

• Initiate subcutaneous anticoagulation or intermittent pneumatic compression immediately for immobilized patients 1
• Aspirin is an alternative for patients who cannot receive anticoagulants 1

Infection Prevention:

• Monitor closely for pneumonia, especially in immobile or dysphagic patients 1
• Avoid indwelling bladder catheters when possible due to infection risk; use intermittent catheterization instead 1
• Treat infections promptly with appropriate antibiotics 1

Seizure Management

Treat seizures if they occur (risk is 2-23% in acute phase, most commonly within 24 hours) 1. However, prophylactic anticonvulsants are not recommended as there is no evidence supporting their routine use 1.

Surgical Intervention Criteria

For Cerebellar Infarction:

• Decompressive surgical evacuation is potentially life-saving for space-occupying cerebellar infarction 1, 2
• Ventriculostomy placement for acute hydrocephalus from cerebellar mass effect 1
• Surgery leads to acceptable functional outcomes in most cerebellar infarction patients 2

For Hemispheric Infarction:

• Decompressive craniectomy with dural expansion should be considered for patients <60 years with malignant MCA infarction who deteriorate neurologically 2
• Surgery can reduce mortality by approximately 50% in appropriately selected younger patients 2
• Early discussion with patient/family about surgical options is crucial before deterioration occurs 2

Critical Pitfalls to Avoid

• Do not delay neurosurgical consultation—obtain it immediately upon admission, not after deterioration 1
• Do not wait for profound neurological dysfunction before considering surgery; earlier intervention yields better outcomes 1
• Do not aggressively lower blood pressure in patients with large infarctions, as this may worsen cerebral perfusion 1
• Do not use hypo-osmolar IV fluids which exacerbate cerebral edema 1

Timing Considerations

Brain edema typically peaks at 3-5 days after stroke onset, though large cerebellar infarctions can cause problems within 24 hours 1. Close monitoring during this critical window is essential, with serial imaging to detect early signs of deterioration before herniation occurs 1.