What is the management approach for a patient presenting with cerebral infarction?

Management of Cerebral Infarction

Patients with cerebral infarction require immediate transfer to an intensive care or stroke unit for close neurological monitoring, with urgent brain imaging to guide reperfusion therapy decisions within the critical time window. 1

Immediate Triage and Stabilization

Transfer all patients with suspected cerebral infarction to a stroke unit or neuroscience intensive care unit immediately to enable comprehensive monitoring and rapid intervention. 1 If your facility lacks neurosurgical expertise or comprehensive stroke care capabilities, arrange immediate transfer to a higher-level center rather than delaying definitive care. 1

Critical Initial Assessment

• Obtain non-contrast CT scan of the brain immediately as the first-line diagnostic test to differentiate ischemic from hemorrhagic stroke and exclude stroke mimics. 1, 2
• Perform baseline severity scoring using the National Institutes of Health Stroke Scale (NIHSS) to standardize assessment and communication between providers. 1
• Document time of symptom onset (or time last known normal) precisely, as this determines eligibility for reperfusion therapies. 1

Acute Reperfusion Therapy

Administer intravenous rt-PA (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset after excluding hemorrhage on CT. 1, 2 This represents the single most effective intervention for reducing disability and mortality in acute ischemic stroke.

Blood Pressure Management for Thrombolysis

• Lower blood pressure to <185/110 mmHg before administering rt-PA and maintain <180/105 mmHg for 24 hours post-treatment. 1, 2, 3
• In patients NOT receiving thrombolysis, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg, as overly aggressive blood pressure reduction can worsen outcomes by compromising collateral flow to the penumbra. 1, 2, 3

Antiplatelet Therapy

Start aspirin 160-300 mg within 48 hours of stroke onset in patients not receiving thrombolysis or after the 24-hour post-thrombolysis period. 1, 2 Do not administer antiplatelet agents if decompressive craniectomy is likely, though their use does not constitute an absolute contraindication to surgery. 1

Recognition and Management of Cerebral Swelling

High-Risk Features Requiring Intensive Monitoring

Monitor patients intensively if they present with any of these high-risk features for malignant cerebral edema: 1

• Frank hypodensity on CT within first 6 hours involving one-third or more of the middle cerebral artery (MCA) territory 1
• DWI volume ≥80 mL on MRI within 6 hours, which predicts rapid fulminant deterioration 1
• Early midline shift on initial imaging 1
• Large territorial cerebellar infarction, which requires monitoring for up to 5 days even if initially stable 1

Clinical Signs of Deterioration

Monitor frequently for declining level of arousal and ipsilateral pupillary dilation in supratentorial strokes, as these indicate impending herniation. 1 Gradual development of mid-position pupils and worsening motor response also signal deterioration. 1

In cerebellar infarction, watch for new brainstem signs including pupillary anisocoria, pinpoint pupils, loss of oculocephalic responses, bradycardia, and irregular breathing patterns. 1

Medical Management of Cerebral Edema

Osmotic therapy with mannitol or hypertonic saline is reasonable for patients with clinical deterioration from cerebral swelling. 1 However, the evidence supporting aggressive medical measures for malignant brain edema is limited. 1

Do NOT use corticosteroids for cerebral edema complicating ischemic stroke, as they lack efficacy and increase risk of infectious complications. 1

Do NOT use hypothermia or barbiturates, as insufficient data support their use in ischemic cerebral swelling. 1

Neurosurgical Intervention

Decompressive Craniectomy for Hemispheric Infarction

Decompressive craniectomy is effective and potentially lifesaving for malignant edema of the cerebral hemisphere. 1 The number needed to treat is approximately 2 to prevent one death or case of severe disability. 1 However, many survivors remain severely disabled and fully dependent on care despite surgery. 1

Obtain early neurosurgical consultation for all patients at high risk for malignant edema to facilitate timely surgical planning if deterioration occurs. 1

Cerebellar Infarction Management

Decompressive surgical evacuation of space-occupying cerebellar infarction is effective in preventing herniation and brainstem compression. 1 This intervention has better functional outcomes than hemispheric decompression, with most patients achieving acceptable functional status. 1

Place a ventricular drain for acute hydrocephalus secondary to cerebellar infarction. 1

Prevention of Complications

Venous Thromboembolism Prophylaxis

Administer subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids for thromboembolic prophylaxis. 1, 2 Enoxaparin 40 mg once daily is more effective than unfractionated heparin 5000 IU twice daily. 2

Consider intermittent pneumatic compression and elastic stockings as adjunctive measures. 1

Do NOT use therapeutic anticoagulation with full-dose heparin during the acute phase of cerebral infarction. 1

Seizure Management

Do NOT use prophylactic anticonvulsants, as they are not recommended and lack evidence of benefit. 1

Treat recurrent seizures after stroke with antiepileptic agents selected based on specific patient characteristics. 1

Airway and Supportive Care

Intubate patients with declining consciousness, inability to maintain patent airway, persistent hypoxemia, or apneic episodes. 1 Maintain normocapnia; prophylactic hyperventilation is not beneficial. 1

Elevate head of bed to 30 degrees in patients with increased intracranial pressure. 1

Treat hyperthermia, correct hypovolemia with isotonic fluids, and treat hyperglycemia >8 mmol/L. 1

Early Rehabilitation

Arrange initial assessment by rehabilitation professionals within 48 hours of admission. 2 Early screening for swallowing difficulties, nutrition needs, and cognitive/communication problems is essential. 2

Critical Pitfalls to Avoid

• Every 30 minutes of delay in treatment decreases probability of good functional outcome by 8-14%—time is brain. 2
• Avoid emergency carotid endarterectomy or immediate EC-IC arterial bypass for acute ischemic stroke due to high complication risk. 2
• Do not delay urgent treatments (BP lowering, coagulopathy reversal) while awaiting ICU bed or transfer—initiate in the emergency department. 1
• Recognize that severity scales should not be used as singular indicators of prognosis when making treatment decisions. 1