Management of Right Temporoparietal Frontal Lobe Infarction
Patients with right temporoparietal frontal lobe infarction require immediate transfer to an intensive care or stroke unit for close neurological monitoring, urgent brain imaging within 24 hours, and consideration of reperfusion therapies (IV thrombolysis within 4.5 hours or mechanical thrombectomy within 24 hours for large vessel occlusions), followed by antiplatelet therapy and vigilant monitoring for malignant cerebral edema. 1, 2
Immediate Triage and Transfer
- Transfer to an intensive care or stroke unit is essential to enable close neurological monitoring and immediate access to neurosurgical consultation if cerebral swelling develops 3, 1
- Triage to a higher-level center with neurosurgical expertise and neuromonitoring capabilities should occur urgently if comprehensive care cannot be provided locally 4
- The multidisciplinary team should include neurointensivists, vascular neurologists, and neurosurgeons for optimal management 3
Urgent Diagnostic Evaluation
- Non-contrast CT scan of the brain must be obtained immediately (certainly within 24 hours) as the first-line diagnostic test to differentiate ischemic from hemorrhagic stroke and exclude stroke mimics 3, 1
- MRI with diffusion-weighted imaging (DWI) is more sensitive than CT for detecting ischemic changes and should be performed if available, particularly within 6 hours when DWI volumes ≥80 mL predict rapid fulminant course 3, 4
- Routine investigations should include full blood count, electrolytes, renal function, cholesterol, glucose levels, and electrocardiogram 3
- Carotid and cardiac imaging should be undertaken if an arterial or cardioembolic source is suspected 3
Acute Reperfusion Therapies
Intravenous Thrombolysis
- IV alteplase (0.9 mg/kg, maximum 90 mg) should be administered to eligible patients within 3 hours of stroke onset, improving likelihood of minimal or no disability from 26% to 39% 1, 2
- Treatment within 3 to 4.5 hours still provides benefit, improving functional independence from 30.1% to 35.3% 2
- Blood pressure must be lowered to <185/110 mmHg before rt-PA administration 1
Mechanical Thrombectomy
- For large vessel occlusions causing disabling deficits, mechanical thrombectomy within 6 hours increases functional independence from 26.5% to 46.0% 2
- Extended window thrombectomy (6-24 hours) should be considered if perfusion imaging shows large ratio of ischemic to infarcted tissue, improving outcomes from 18% to 53% 2
Antiplatelet Therapy
- Aspirin 160-300 mg/day should be commenced within 48 hours of acute ischemic stroke onset 3, 1
- For nondisabling strokes or high-risk TIA (ABCD2 score ≥4), dual antiplatelet therapy with aspirin and clopidogrel initiated within 24 hours and continued for 3 weeks reduces stroke risk from 7.8% to 5.2% 2
Blood Pressure Management
- Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg in patients not receiving reperfusion therapies 1
- Overly aggressive blood pressure lowering can worsen outcomes by compromising cerebral perfusion 1
Monitoring for Malignant Cerebral Edema
High-Risk Features
- Frank hypodensity on CT within first 6 hours, involvement of one-third or more of MCA territory, and early midline shift predict cerebral edema 3, 4
- Clinical predictors include high stroke severity scores, nausea/vomiting, and progressive neurological deterioration 4
Neurological Monitoring
- Frequently monitor level of arousal and ipsilateral pupillary dilation, as gradual development of midposition pupils and worsening motor response indicate deterioration 3
- Serial CT scans in the first 2 days are useful to identify patients at high risk for developing symptomatic swelling 3
Medical Management of Cerebral Swelling
- Osmotic therapy (mannitol or hypertonic saline) is reasonable for patients with clinical deterioration from cerebral swelling, targeting serum osmolarity of 315-320 mOsm/L 3, 4
- Elevate head of bed to 30° to reduce intracranial pressure 3, 4
- Restrict free water and correct factors that exacerbate swelling 4
- Brief moderate hyperventilation can serve as a bridge to more definitive therapy 4
- Hypothermia, barbiturates, and corticosteroids are not recommended due to insufficient evidence of benefit 3
Surgical Intervention
- Decompressive craniectomy with dural expansion reduces mortality by approximately 50% in patients ≤60 years who deteriorate within 48 hours 4
- Decrease in level of consciousness attributed to brain swelling is a reasonable trigger for decompressive craniectomy 4
- Early neurosurgical consultation should be obtained to facilitate planning if deterioration occurs 3
Prevention of Medical Complications
- Deep vein thrombosis prophylaxis using subcutaneous heparin or low molecular weight heparin (enoxaparin 40 mg once daily preferred) is essential for immobile patients 1
- Initial assessment by rehabilitation professionals should occur within 48 hours of admission 1
- Early screening for swallowing difficulties, nutrition, cognition, perception, and communication problems is recommended 1
Critical Pitfalls to Avoid
- Every 30 minutes of delay in treatment decreases probability of good functional outcome by 8-14%, making rapid recognition and treatment paramount 1
- Do not switch between DOACs or from DOAC to VKA without clear indication, as this may increase thromboembolic risk 3
- Emergency carotid endarterectomy and immediate EC-IC arterial bypass are not recommended for acute ischemic stroke due to high complication risk 1