What is the management approach for an older adult with a history of hypertension, diabetes, and cardiovascular disease diagnosed with malignant cerebral infarction?

Management of Malignant Cerebral Infarction in an Older Adult with Multiple Comorbidities

Decompressive hemicraniectomy performed within 48 hours of symptom onset is the only proven life-saving intervention for malignant middle cerebral artery (MCA) infarction, reducing mortality from 80% to approximately 20-30%, though in patients over 60 years, survival often comes with moderate to severe disability (mRS 4-5). 1

Immediate Recognition and Diagnosis

Clinical identification requires:

• Severe hemiparesis, gaze deviation, and higher cortical dysfunction (aphasia if dominant hemisphere) with progressive decline in consciousness 2, 3
• National Institutes of Health Stroke Scale (NIHSS) score typically >15-20 4
• Glasgow Coma Scale showing downward trend in first 24-48 hours 4

Imaging criteria for malignant course:

• CT showing hypodensity involving >50% of MCA territory 1, 3
• Diffusion-weighted MRI demonstrating infarct volume >145 cm³ has 100% sensitivity for predicting malignant course within 6 hours 4
• Early midline shift >4mm on CT predicts herniation 3

Intensive Care Unit Management

All patients require neurointensive care monitoring: 1, 2

• Continuous intracranial pressure (ICP) monitoring if available
• Frequent neurological assessments every 1-2 hours
• Serial CT imaging at 24 hours and with any clinical deterioration 2

Medical management (temporizing measures only):

• Osmotherapy with mannitol 0.25-2 g/kg IV over 30-60 minutes or hypertonic saline 1, 5, 2
• Head of bed elevation to 30 degrees 2
• Endotracheal intubation with mechanical ventilation targeting PaCO₂ 30-35 mmHg if deteriorating 2
• Avoid hyperthermia; treat fever >37.5°C with acetaminophen 1

Critical caveat: Medical management alone does NOT reduce mortality or improve outcomes—these are bridge therapies only while surgical decision-making occurs 2, 6

Surgical Decision-Making: Decompressive Hemicraniectomy

For patients <60 years old:

• Hemicraniectomy within 48 hours (ideally <24 hours) is strongly recommended 1
• Reduces mortality from 71% to 22% (OR 0.19,95% CI 0.13-0.51) 1
• Increases favorable outcomes (mRS 0-3) with OR 2.04 (95% CI 1.03-4.02) 1
• Surgery must include large bone flap (≥12 cm diameter) and duraplasty 1, 6

For patients ≥60 years old (applicable to this case):

• Surgery remains life-saving but requires careful shared decision-making 1
• DESTINY II trial showed 38% vs 18% survival without severe disability at 6 months (OR 2.91,95% CI 1.06-7.49) 1
• No patients achieved good functional outcome (mRS 0-2) at any age >60 years 1
• Most survivors require assistance with most bodily needs (mRS 4-5) 1
• Discussions must explicitly address likelihood of survival with severe disability and caregiver burden 1

Surgical technique considerations:

• If ICP >30 mmHg persists after hemicraniectomy, anterior temporal lobectomy reduces mortality from 100% to 33% 4
• Ultra-early surgery (<6 hours) may further improve outcomes compared to 6-24 hour window 4

Management of Comorbidities During Acute Phase

Hypertension management:

• Permissive hypertension in acute stroke phase; avoid aggressive lowering unless SBP >220 mmHg or DBP >120 mmHg 1
• After stabilization, resume antihypertensive therapy targeting <140/90 mmHg (or <130/80 mmHg given diabetes) 1, 7

Diabetes management:

• Avoid hypoglycemia which triggers arrhythmias 1
• Target glucose 140-180 mg/dL in acute phase 7
• HbA1c goal ≤7% does not prevent recurrent stroke but reduces microvascular complications 7

Cardiovascular monitoring:

• Continuous cardiac telemetry for minimum 24 hours to detect atrial fibrillation or life-threatening arrhythmias 1
• ECG changes (ST depression, QT prolongation, T-wave inversion) are common and may not represent true myocardial ischemia 1

Secondary Prevention After Stabilization

Antiplatelet therapy:

• Aspirin 75-325 mg daily, clopidogrel 75 mg daily, or aspirin-dipyridamole combination 7
• Clopidogrel may be preferred in diabetic patients based on CAPRIE subgroup analysis 7

Statin therapy:

• High-intensity statin (atorvastatin 80 mg) targeting LDL <70 mg/dL 1, 7
• Proven to reduce recurrent stroke risk by 16% and ischemic stroke by 22% 1

Blood pressure control:

• Target <130/80 mmHg given diabetes and multiple cardiovascular risk factors 1, 7
• Combination therapy with ARB (already on losartan), calcium channel blocker, and thiazide diuretic 1

Prognosis Communication

Key points for family discussions:

• Without surgery: 80% mortality within 1 week 1, 6
• With surgery in patients >60 years: 60-70% mortality or survival with severe disability 1
• Realistic expectation: survivors typically require 24-hour care, cannot walk independently, and have significant cognitive impairment 1
• Quality of life considerations must weigh heavily in surgical decision 1