What is the initial management of a massive stroke?

Management of Massive Stroke

Patients with massive stroke require immediate transfer to a neurosurgical center, aggressive monitoring for brain swelling with serial neurological exams and repeat CT imaging, and consideration for decompressive surgery within 48 hours—particularly in younger patients (<60 years) where functional benefit is substantially greater. 1

Initial Recognition and Transfer

• Rapidly transfer patients with massive cerebral or cerebellar infarction or hemorrhage to a center with neurosurgical expertise if their condition is deemed survivable, as surgical intervention may be life-saving. 1
• Massive stroke is characterized by large territorial involvement (>1/3 MCA territory), severe neurological deficits, or risk of malignant cerebral edema. 1
• The decision to pursue aggressive management should involve shared decision-making with the patient (when possible) and family, considering anticipated prognosis for functional recovery. 1

Airway and Respiratory Management

• Immediately intubate patients who develop neurological deterioration with respiratory insufficiency to protect the airway and maintain adequate oxygenation. 1
• Supplemental oxygen should maintain saturation ≥94%. 2
• This is critical as massive strokes frequently cause decreased level of consciousness and loss of protective airway reflexes. 2

Monitoring for Cerebral Edema

• Perform serial physical examinations and repeat head CT scans when appropriate to identify worsening brain swelling, which typically peaks 2-5 days after stroke onset. 1
• Monitor for signs of herniation including declining consciousness, pupillary changes, posturing, and Cushing's triad (hypertension, bradycardia, irregular respirations). 1

Medical Management of Increased Intracranial Pressure

• Corticosteroids are NOT recommended for management of cerebral edema and increased intracranial pressure following ischemic stroke, as they provide no benefit and may cause harm. 1, 2
• Osmotherapy (mannitol or hypertonic saline) and hyperventilation are recommended for patients deteriorating secondary to increased intracranial pressure, including those with herniation syndromes. 1, 2
• These are temporizing measures while arranging definitive surgical intervention. 1

Surgical Interventions for Massive Hemispheric Infarction

• Decompressive hemicraniectomy is indicated within 48 hours of symptom onset in patients with massive hemispheric infarction and worsening neurological condition. 1
• Functional benefit is much greater in patients <60 years of age, though the procedure can be life-saving at any age—survivors typically have severe residual neurological impairments. 1
• The procedure involves removing a large bone flap (typically ≥12 cm diameter) and opening the dura to allow the swollen brain to expand outward rather than herniate downward. 1

Surgical Interventions for Massive Cerebellar Infarction

• Ventriculostomy is recommended for treatment of symptomatic obstructive hydrocephalus after cerebellar infarction. 1
• Decompressive suboccipital craniectomy is indicated if brainstem compression is present, either concomitantly with or subsequent to ventriculostomy. 1
• Surgical drainage of cerebrospinal fluid can treat increased intracranial pressure secondary to hydrocephalus. 1

Management of Cerebellar Hemorrhage

• Patients with cerebellar ICH who develop neurological deterioration, have brainstem compression, and/or have hydrocephalus from ventricular obstruction should be treated with decompressive suboccipital craniectomy (with or without ventricular drainage). 1
• Patients with spontaneous ICH (with or without IVH) and symptomatic hydrocephalus should be treated with ventricular drainage. 1

General Supportive Care

• Admit to stroke unit or intensive care unit with continuous cardiac monitoring for at least 24 hours to detect arrhythmias. 1, 2
• Maintain blood pressure <180/105 mmHg if reperfusion therapy was administered. 1
• Monitor and treat fever (temperature >38°C), investigating and treating sources of infection. 1
• Treat documented seizures with appropriate antiseizure medications, but prophylactic anticonvulsants are not recommended. 1
• Encourage gradual early mobilization when safe; use intermittent pneumatic compression devices for DVT prophylaxis in immobile patients. 1

Critical Pitfalls to Avoid

• Do not delay transfer to neurosurgical center while attempting medical management alone—time to decompressive surgery directly impacts outcomes, with the 48-hour window being critical. 1
• Do not use corticosteroids for cerebral edema management, as this is ineffective and potentially harmful. 1, 2
• Do not withhold surgical consultation in older patients without first engaging in shared decision-making—while outcomes are better in younger patients, surgery can still be life-saving in selected older individuals. 1
• Do not miss cerebellar strokes requiring urgent surgical decompression, as these can rapidly deteriorate with brainstem compression and are highly amenable to surgical intervention. 1