What is the management of a patient with an acute cerebrovascular infarct involving a large territory?

Management of Acute Cerebrovascular Infarct with Large Territory Involvement

Patients with large territory acute ischemic stroke require immediate transfer to an intensive care or stroke unit with neurosurgical capabilities, early consideration of decompressive surgery within 48 hours if deterioration occurs, and aggressive medical management to prevent malignant cerebral edema. 1

Immediate Triage and Transfer

• Transfer immediately to an intensive care or stroke unit with neuromonitoring capabilities staffed by neurointensivists, vascular neurologists, and neurosurgeons (Class I; Level of Evidence C). 2, 1
• Obtain early neurosurgical consultation even before clinical deterioration to facilitate planning for decompressive hemicraniectomy or ventriculostomy—do not wait for signs of herniation. 2, 1
• Transfer urgently to a higher-level center if comprehensive neurosurgical care is unavailable locally (Class IIa; Level of Evidence C). 2, 1

Emergency Neuroimaging for Risk Stratification

Brain imaging must be completed within 25 minutes of ED arrival and interpreted within 45 minutes to determine eligibility for acute reperfusion therapy. 2

CT Findings Predicting Malignant Edema:

• Frank hypodensity within the first 6 hours (Class I; Level of Evidence B) 2, 1
• Involvement of ≥50% (one-third or more) of the MCA territory (Class I; Level of Evidence B) 2, 1
• Early midline shift (Class I; Level of Evidence B) 2, 1

MRI Findings:

• DWI volumes ≥80 mL within 6 hours predict rapid fulminant course requiring heightened monitoring (Class I; Level of Evidence B). 2, 1
• Perform serial CT scans in the first 2 days to identify patients developing symptomatic swelling (Class I; Level of Evidence C). 2, 1

Vascular Imaging:

• Obtain noninvasive intracranial vascular imaging (CTA or MRA) during initial evaluation if intra-arterial fibrinolysis or mechanical thrombectomy is contemplated, but do not delay IV rtPA if indicated (Class I; Level of Evidence A). 2

Acute Reperfusion Therapy

Intravenous Thrombolysis:

• Administer IV rtPA (0.9 mg/kg) within 3 hours of symptom onset if no contraindications exist (Class I; Level of Evidence A). 2, 3, 4
• Intravenous fibrinolysis is recommended even with early ischemic changes on CT (other than frank hypodensity), regardless of extent (Class I; Level of Evidence A). 2
• Withhold IV rtPA if frank hypodensity involves more than one-third of the MCA territory due to increased hemorrhage risk (Class III; Level of Evidence A). 2

Endovascular Treatment:

• Intra-arterial thrombolysis is an option for large vessel occlusions within 6 hours of symptom onset, particularly for MCA occlusions (Grade B). 2
• Combined IV/intra-arterial approach may be considered for patients with major vessel occlusions who receive IV rtPA but require additional intervention. 2

Medical Management to Prevent Malignant Edema

Head Positioning and ICP Management:

• Elevate head of bed to 20-30 degrees to facilitate venous drainage and reduce intracranial pressure. 1, 5
• Administer osmotic therapy with mannitol (0.25-0.5 g/kg IV every 6 hours) for deteriorating patients with signs of increased ICP. 1

Blood Pressure Management:

• Maintain blood pressure <180/105 mmHg for at least 24 hours after acute reperfusion treatment. 1
• For patients eligible for thrombolytic therapy, blood pressure must be <185/110 mmHg before treatment and maintained <180/105 mmHg for 24 hours post-treatment. 2

Airway and Ventilation:

• Intubate immediately if declining consciousness, inability to maintain patent airway, persistent hypoxemia, or apneic episodes occur. 2, 1
• Use rapid sequence intubation with short-acting anesthetics (propofol or dexmedetomidine). 2, 1
• Maintain normocapnia—prophylactic hyperventilation is not recommended. 2, 1

Additional Medical Measures:

• Restrict free water and avoid excess glucose administration to minimize edema development. 5
• Treat fever >38°C aggressively and investigate sources. 1
• Administer aspirin within 24-48 hours after stroke onset (delayed >24 hours if thrombolysis given). 1, 5
• Use thigh-high intermittent pneumatic compression devices for VTE prophylaxis in patients with limited mobility. 1
• Do not use prophylactic antiseizure medications—only treat documented seizures. 1

Clinical Monitoring

• Monitor level of consciousness and pupillary function frequently—ipsilateral pupillary dysfunction with mydriasis is the most common sign of deterioration. 1
• Cardiac monitoring for at least 24 hours to screen for atrial fibrillation and serious arrhythmias. 1
• Peak cerebral edema typically occurs 3-5 days post-stroke but can accelerate within 24 hours with early reperfusion. 1, 5

Surgical Intervention

Decompressive Hemicraniectomy:

• Perform decompressive hemicraniectomy within 48 hours of symptom onset in patients with massive hemispheric infarction and worsening neurological condition. 1
• Functional benefit is much greater in patients <60 years, though surgery reduces mortality by approximately 50% across all age groups. 1
• Do not wait for elevated ICP measurements—mass effect and herniation can occur without initially elevated ICP in malignant MCA infarction. 1

Cerebellar Infarction:

• Perform ventriculostomy for symptomatic obstructive hydrocephalus after cerebellar infarction. 1
• Decompressive suboccipital craniectomy is indicated if brainstem compression is present, with or without concomitant ventriculostomy. 1

Critical Pitfalls to Avoid

• Never delay neurosurgical consultation—obtain it early, particularly in the first 2-5 days when edema peaks. 1
• Do not wait for clinical deterioration to plan surgical intervention—patients can herniate rapidly once deterioration begins. 2, 1
• Avoid gadolinium-based MR contrast in patients with advanced renal failure (eGFR <30 mL/min/1.73 m²) due to risk of nephrogenic systemic fibrosis. 2
• Do not administer anticoagulants within 24 hours of rtPA administration. 4

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