What is the primary treatment for a patient with a malignant infarct?

Malignant Infarct Treatment

Decompressive craniectomy performed within 48 hours of symptom onset is the primary treatment for malignant cerebral infarction, reducing mortality by approximately 50% and should be offered to appropriately selected patients who deteriorate neurologically despite medical therapy. 1

Immediate Recognition and Triage

Critical warning signs requiring urgent intervention include:

• Progressive decline in level of consciousness 1
• Pupillary abnormalities (anisocoria, dilation) 2
• Worsening hemiparesis and gaze deviation 3
• Progressive headache, nausea, and vomiting 2

Immediate actions:

• Transfer to intensive care unit or dedicated stroke unit with neuromonitoring capabilities 2, 4
• Obtain urgent neurosurgical consultation to facilitate rapid surgical planning 2
• Perform serial neurological examinations every 1-2 hours to detect deterioration 1

Neuroimaging Criteria

CT findings predicting malignant course:

• Hypodensity involving >50% of middle cerebral artery (MCA) territory 5, 3
• Midline shift ≥5 mm 6
• Mass effect with lateral ventricle compression 2
• Frank hypodensity involving one-third or more of MCA territory 2

Obtain follow-up CT scan within 24 hours or immediately if clinical deterioration occurs. 2

Medical Management (Bridge to Surgery)

General Measures

• Elevate head of bed to 20-30 degrees to optimize venous drainage 1, 7
• Maintain cerebral perfusion pressure >60 mmHg using volume replacement and/or vasopressors 1, 7
• Avoid antihypertensive agents causing cerebral vasodilation 1
• Restrict free water administration and minimize glucose to reduce edema formation 1
• Aggressively treat hyperthermia, hypoxemia, and hypercarbia 1

Osmotic Therapy

Mannitol is the standard treatment:

• Dose: 0.25-0.5 g/kg IV over 20 minutes every 6 hours 1, 5
• Maximum dose: 2 g/kg 1
• Monitor serum and urine osmolality to avoid complications 1

Hypertonic saline is an effective alternative:

• Particularly useful in patients with clinical transtentorial herniation 1
• Target serum osmolarity 315-320 mOsm/L 2
• May produce more rapid ICP reduction than mannitol 1

Important caveat: Medical management alone has limited efficacy—mortality remains 50-70% even with intensive medical therapy without surgery. 1 These measures serve primarily as temporizing interventions while preparing for definitive surgical treatment.

Surgical Treatment: Decompressive Craniectomy

Patient Selection Criteria

Offer surgery to patients meeting ALL of the following:

• Age ≤60 years (though surgery can be considered in older patients with realistic outcome expectations) 1, 2
• Unilateral MCA infarction 1
• Neurological deterioration within 48 hours despite medical therapy 1, 2
• Decrease in level of consciousness 2
• Mass effect on imaging 2
• Other causes of impaired consciousness excluded 2

Timing

Surgery MUST be performed within 48 hours of symptom onset—earlier intervention is associated with better outcomes. 1, 2 Do not delay for further medical management once surgical criteria are met, as the window for effective intervention is narrow. 2

Surgical Technique

• Perform fronto-parieto-temporo-occipital craniectomy 1
• Bone flap diameter ≥12 cm extending up to the midline 1
• Durotomy with enlargement duroplasty is essential 1
• Do NOT remove ischemic brain tissue 1
• Place intracranial pressure monitor for postoperative management 1

Expected Outcomes

For patients ≤60 years:

• Mortality reduction from ~76% to ~42% 2
• 55% achieve moderate disability or better at 12 months 1
• 18% achieve independence (modified Rankin Scale 0-2) at 12 months 1
• 11% achieve moderate disability (able to walk, mRS 3) at 12 months 2

Without surgery: Median survival <2 months, with mortality 50-80%. 1, 8

Special Consideration: Cerebellar Infarction

For cerebellar infarction with brainstem compression:

• Perform suboccipital decompressive craniectomy 7
• Consider cerebrospinal fluid drainage via ventriculostomy for acute hydrocephalus 7
• Surgery leads to acceptable functional outcomes in most patients 5

Critical Monitoring Pitfalls

Important caveat: ICP monitoring cannot substitute for clinical and radiological surveillance. 6 Pupillary abnormalities and severe brainstem compression may occur despite normal ICP values—12 of 19 patients in one study had ICP ≤20 mmHg despite mean midline shift of 6.7 mm. 6 Therefore, clinical deterioration and imaging findings should drive surgical decision-making, not ICP values alone.

Postoperative Management

• Apply lung-protective ventilation and strict glycemic control 2
• Monitor for wound dehiscence, particularly posteriorly 1
• Many patients require tracheostomy and gastrostomy initially 1
• Obtain control CT 24 hours postoperatively or earlier if signs of intracranial hypertension 2
• Wean sedation once no significant intracranial hypertension present 2
• Use antiepileptic drugs only if seizures occur—prophylactic use is not indicated 2