What is the immediate management for a suspected ischemic stroke with right-sided body weakness and ipsilateral hypodensity on CT scan?

Immediate Management of Large Territory Ischemic Stroke with Extensive Hypodensity

This patient has extensive left hemispheric and cerebellar hypodensity on CT indicating a large established infarction, which is a contraindication to IV thrombolysis, but mechanical thrombectomy should be urgently pursued if she is within the appropriate time window and has a documented large vessel occlusion. 1, 2

Critical Initial Assessment

Determine exact time of symptom onset immediately - this is the single most important factor determining treatment eligibility. 1, 3

• If within 3-4.5 hours: The extensive hypodensity (involving left frontal, occipital, parietal, temporal, and cerebellar regions) represents frank hypodensity involving more than one-third of the MCA territory, which is a Class III contraindication to IV rtPA 1
• The ipsilateral cerebellar involvement suggests either posterior circulation involvement or diaschisis, requiring urgent vascular imaging 1

Immediate Imaging Protocol

Obtain CT angiography (CTA) of head and neck immediately to identify large vessel occlusion, even though IV thrombolysis is contraindicated by the extensive hypodensity. 1, 4

• CTA is strongly recommended during initial imaging evaluation if mechanical thrombectomy is contemplated and should not delay other management 1
• The brain imaging study must be interpreted within 45 minutes of patient arrival by a physician with expertise in reading CT studies 1, 3

Blood Pressure Management

Do NOT aggressively lower blood pressure in this patient who is not receiving thrombolysis. 1

• For patients NOT receiving acute reperfusion therapy, consider lowering blood pressure only if systolic BP >220 mmHg or diastolic BP >120 mmHg 1
• A reasonable target is to lower blood pressure by 15-25% within the first day 1
• Permissive hypertension is appropriate to maintain cerebral perfusion in the setting of large territory infarction 1

Mechanical Thrombectomy Consideration

If CTA demonstrates proximal large vessel occlusion (left ICA or M1 MCA), proceed directly to mechanical thrombectomy despite the extensive infarction, provided: 2, 4

• Time from symptom onset is within 6 hours (or up to 24 hours with advanced imaging selection) 4
• NIHSS ≥6 2
• Prestroke modified Rankin Scale 0-1 2
• Even with extensive early infarct signs, patients may still benefit from endovascular therapy 2

Target door-to-groin puncture time <110 minutes to maximize functional outcomes. 2

Antiplatelet Therapy

Administer oral aspirin 325 mg within 24-48 hours after stroke onset since this patient is not receiving thrombolysis. 3, 5

• Aspirin should be started as early as possible after excluding hemorrhage 5
• Do NOT give aspirin if mechanical thrombectomy is planned until after the procedure 3

Supportive Care Measures

Implement the following immediately: 3, 4

• Maintain oxygen saturation >94% with supplemental oxygen 3, 4
• Check blood glucose immediately and correct if <50 mg/dL or >180 mg/dL 3, 4
• Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias 3
• Treat fever >38°C with antipyretics 3, 4
• Provide prophylactic subcutaneous heparin or low-molecular-weight heparin for DVT prophylaxis given restricted mobility 3, 5

Monitoring for Malignant Edema

This patient is at extremely high risk for malignant cerebral edema given the extensive left hemispheric involvement. 2

• Monitor neurological status closely with serial examinations every 1-2 hours initially 3
• Watch for signs of deterioration: declining level of consciousness, pupillary changes, worsening weakness 2
• If patient is <60 years old, discuss decompressive hemicraniectomy with neurosurgery early, as this reduces mortality by approximately 50% when performed within 48 hours 2
• Osmotherapy (mannitol or hypertonic saline) and hyperventilation should be available for acute deterioration from increased intracranial pressure 3

Critical Pitfalls to Avoid

Do NOT administer IV rtPA - the extensive hypodensity involving multiple vascular territories is an absolute contraindication due to unacceptably high hemorrhage risk. 1

Do NOT use corticosteroids for cerebral edema management - they are not recommended and provide no benefit. 3

Do NOT delay vascular imaging - even though thrombolysis is contraindicated, identifying a large vessel occlusion is critical for thrombectomy decision-making. 1

Do NOT routinely anticoagulate with full-dose heparin - urgent anticoagulation is not recommended for improving neurological outcomes in acute ischemic stroke. 3, 5