How do you manage a huge parietal infarction?

Management of Huge Parietal Infarction

Immediately transfer the patient to an intensive care or stroke unit with neurosurgical capabilities, as large parietal infarctions can evolve into malignant cerebral edema requiring decompressive hemicraniectomy within 48 hours, particularly in patients under 60 years of age. 1, 2

Immediate Triage and Admission

• Admit to a specialized stroke unit or ICU with neuromonitoring capabilities staffed by neurointensivists, vascular neurologists, and neurosurgeons 1, 2
• Obtain early neurosurgical consultation immediately—do not wait for clinical deterioration, as planning for potential decompressive surgery must begin before edema peaks in the first 2-5 days 1, 2
• Transfer urgently to a higher-level center if comprehensive neurosurgical care is unavailable locally 1, 2

Risk Stratification with Neuroimaging

Perform immediate CT or MRI to assess infarct size and predict malignant edema risk:

• CT findings predicting malignant edema include frank hypodensity within 6 hours, involvement of ≥50% of the MCA territory (or one-third or more), and early midline shift 1, 2, 3
• MRI DWI volumes ≥80 mL within 6 hours predict rapid fulminant deterioration and should trigger heightened monitoring 1, 2, 3
• Obtain serial CT scans in the first 2 days to identify patients developing symptomatic swelling 1, 2

Clinical Monitoring Protocol

• Monitor level of consciousness and pupillary function frequently—ipsilateral pupillary dysfunction with mydriasis is the most common sign of impending herniation 2, 3
• Cardiac monitoring for at least 24 hours to screen for atrial fibrillation and serious arrhythmias 1, 2
• Monitor body temperature and aggressively treat fever >38°C, investigating and treating infectious sources 1, 2

Medical Management

• Elevate head of bed to 20-30 degrees to facilitate venous drainage and reduce intracranial pressure 2
• Maintain blood pressure <180/105 mmHg for at least the first 24 hours after acute reperfusion treatment 1, 2
• Administer aspirin within 24-48 hours after stroke onset (delay >24 hours if thrombolysis was given) 1, 2
• Apply thigh-high intermittent pneumatic compression devices for venous thromboembolism prophylaxis in patients with limited mobility 1, 2
• Use antiseizure medications only for documented seizures, not prophylactically 1, 2

Osmotic Therapy for Deterioration

• Administer mannitol 0.25-0.5 g/kg IV every 6 hours to reduce intracranial pressure in patients showing neurological deterioration 2
• Hypertonic saline is an alternative osmotic agent 4

Airway Management

Intubate immediately if neurological deterioration occurs with respiratory insufficiency: 1, 2

• Indications include declining consciousness, inability to maintain patent airway, persistent hypoxemia, or apneic episodes 1, 2
• Use rapid sequence intubation with short-acting anesthetics like propofol or dexmedetomidine for sedation 1, 2
• Maintain normocapnia—there is no evidence supporting prophylactic hyperventilation 1, 2

Surgical Intervention

Decompressive hemicraniectomy is indicated within 48 hours of symptom onset in patients with massive hemispheric infarction and worsening neurological condition: 1, 2

• Functional benefit is much greater in patients <60 years, though surgery reduces mortality by approximately 50% across all age groups 1, 2
• Surgery should be performed before the patient becomes comatose for optimal outcomes 2
• Ventriculostomy is recommended if symptomatic obstructive hydrocephalus develops 1, 2

Shared Decision-Making

• Initiate early discussion with patient (when possible) and family about treatment options, anticipated prognosis for functional recovery, and goals of care 1, 2
• Management decisions should incorporate patient values and anticipated quality of life outcomes 1, 2

Critical Pitfalls to Avoid

• Do not delay neurosurgical consultation—early involvement is critical in the first 2-5 days when edema peaks 2, 3
• Do not wait for elevated intracranial pressure measurements—mass effect and herniation can occur without initially elevated ICP in malignant infarction 2
• Do not miss right-sided weakness, sensory loss, or aphasia in left parietal infarctions, as these predict larger territory involvement 3
• Do not overlook delirium in right parietal infarctions, which may dominate the clinical picture and mask other neurological signs 5