What is the management of a large malignant infarct?

Management of Large Malignant Infarct

Patients with large malignant infarcts require immediate admission to an intensive care or stroke unit with neuromonitoring capabilities, early neurosurgical consultation for potential decompressive hemicraniectomy within 48 hours, and aggressive monitoring for cerebral edema development. 1

Immediate Triage and Admission

• Transfer patients immediately to an intensive care or stroke unit with neuromonitoring capabilities attended by neurointensivists, vascular neurologists, and neurosurgeons (Class I; Level of Evidence C). 1

• Obtain early neurosurgical consultation to facilitate planning for decompressive surgery or ventriculostomy, even before deterioration occurs. 1

• Transfer urgently to a higher-level center if comprehensive neurosurgical care is not available locally (Class IIa; Level of Evidence C). 1

Neuroimaging for Risk Stratification

• CT findings predicting malignant edema include: frank hypodensity within the first 6 hours, involvement of ≥50% of the MCA territory, and early midline shift (Class I; Level of Evidence B). 1, 2

• MRI DWI volumes ≥80 mL within 6 hours predict rapid fulminant course and should trigger heightened monitoring (Class I; Level of Evidence B). 1, 2

• Perform serial CT scans in the first 2 days to identify patients at high risk for developing symptomatic swelling (Class I; Level of Evidence C). 1

Clinical Monitoring

• Monitor level of consciousness and pupillary function frequently as ipsilateral pupillary dysfunction with mydriasis is the most common sign of deterioration. 2

• Cardiac monitoring for at least 24 hours to screen for atrial fibrillation and serious arrhythmias. 1

• Monitor body temperature and treat fever >38°C aggressively, investigating and treating sources. 1

Airway Management

• Intubate immediately if neurological deterioration occurs with respiratory insufficiency (indications include declining consciousness, inability to maintain patent airway, persistent hypoxemia, or apneic episodes). 1

• Use rapid sequence intubation with short-acting anesthetics like propofol or dexmedetomidine for sedation if needed. 1

• Maintain normocapnia; there is no evidence supporting prophylactic hyperventilation. 1

Medical Management

• Elevate head of bed to 20-30° to facilitate venous drainage and reduce intracranial pressure. 3

• Administer osmotic therapy with manitol (0.25-0.5 g/kg IV every 6 hours) to reduce intracranial pressure in deteriorating patients. 3

• Maintain blood pressure <180/105 mmHg for at least the first 24 hours after acute reperfusion treatment. 1

• Administer aspirin within 24-48 hours after stroke onset (delayed >24 hours if thrombolysis given). 1

• Use thigh-high intermittent pneumatic compression devices for venous thromboembolism prophylaxis in patients with limited mobility. 1

• Antiseizure medications only for documented seizures, not prophylactically. 1

Surgical Intervention

For Hemispheric Infarction:

• Decompressive hemicraniectomy is indicated within 48 hours of symptom onset in patients with massive hemispheric infarction and worsening neurological condition. 1, 3

• Functional benefit is much greater in patients <60 years, though surgery can reduce mortality by approximately 50% across age groups. 1, 3

• The surgery must be performed early with a large diameter bone flap to be effective. 4

For Cerebellar Infarction:

• Ventriculostomy is recommended for symptomatic obstructive hydrocephalus after cerebellar infarction. 1

• Decompressive suboccipital craniectomy is indicated if brainstem compression is present, with or without concomitant ventriculostomy. 1, 3

• Surgical evacuation leads to acceptable functional outcomes in most selected patients with cerebellar infarction. 3

Shared Decision-Making

• Engage in early discussion with patient (when possible) and family about treatment options, anticipated prognosis for functional recovery, and goals of care. 1, 3

• Consider that mortality with medical management alone can exceed 80%, while decompressive hemicraniectomy reduces this to 15-40%. 5

Critical Pitfalls to Avoid

• Do not delay neurosurgical consultation—early involvement is critical, particularly in the first 2-5 days when edema peaks. 2

• Do not wait for intracranial pressure elevation—mass effect and herniation can occur without initially elevated ICP in malignant MCA infarction. 1

• Do not perform small craniectomies—the bone flap must be large diameter to be effective. 4