What are the recommended acute and secondary‑prevention management options for a patient 48 hours after a large left middle cerebral artery infarct with angiographic non‑visualisation of the left internal carotid artery and left middle cerebral artery?

Management of Large MCA Territory Infarct at 48 Hours Post-Stroke with Complete ICA and MCA Occlusion

At 48 hours post-stroke with complete vessel occlusion, your primary focus must be on preventing death from malignant cerebral edema through urgent neurosurgical evaluation for decompressive hemicraniectomy, combined with intensive monitoring and standard secondary prevention measures. 1, 2

Immediate Priorities

Neurosurgical Consultation and Monitoring

• Transfer immediately to an intensive care unit or stroke unit with neurosurgical capabilities for close surveillance of malignant cerebral edema, as you are at the critical 48-hour window where decompressive surgery remains beneficial 1, 3
• Obtain urgent neurosurgical consultation now, as decompressive hemicraniectomy performed within 48 hours of symptom onset reduces mortality by approximately 50% (from ~76% to ~42%) in patients with massive hemispheric infarction 1, 4
• Perform serial neurological examinations every 1-2 hours to detect early signs of deterioration including declining level of consciousness, progressive weakness, pupillary changes, or signs of herniation 1, 3

Imaging Surveillance

• Obtain repeat non-contrast head CT immediately to assess for:
  • Frank hypodensity involving more than one-third of MCA territory 1, 2
  • Midline shift (≥10mm indicates malignant edema requiring urgent intervention) 4
  • Mass effect with compression of lateral ventricle 2, 3
  • Brainstem compression 1
• Plan serial CT scans every 12-24 hours or sooner if any clinical deterioration occurs 3

Surgical Decision-Making

Indications for Decompressive Hemicraniectomy

Proceed with surgery if the patient develops neurological deterioration with mass effect on imaging, without waiting for specific thresholds. 1, 4

Key surgical criteria include:

• Decrease in level of consciousness with mass effect on CT/MRI 4
• Large MCA territory involvement (≥1/3) with early hypodensity and midline shift 2, 4
• Progressive neurological deterioration despite medical management 1, 3
• Surgery must be performed within 48 hours of stroke onset - you are at the deadline now 1

Contraindications to Surgery

Do not operate if:

• Bilateral nonreactive pupils (not drug-induced) with coma 4
• Severe irreversible brainstem ischemia evident on imaging 4
• All four unfavorable factors present: age ≥50 years, additional vascular territories involved, unilateral pupillary dilation, and GCS <8 4

Medical Management of Cerebral Edema

Osmotic Therapy

• Initiate mannitol 20% (0.25-0.5 g/kg IV every 6 hours) or hypertonic saline if clinical deterioration from cerebral swelling occurs 2, 3, 4
• Target serum osmolarity of 315-320 mOsm/L 2, 3
• Use as a bridge to definitive surgical therapy, not as standalone treatment 3, 4

General Measures

• Elevate head of bed to 30 degrees 2, 3
• Restrict free water administration 2, 3
• Maintain cerebral perfusion pressure >60 mmHg with volume replacement and/or vasopressors if necessary 3, 4
• Avoid antihypertensive agents that cause cerebral vasodilation 2, 3
• Treat fever aggressively (temperature >38°C) as it exacerbates brain swelling 1

Secondary Prevention and General Stroke Care

Antiplatelet Therapy

• Administer aspirin 150-300 mg within 24-48 hours after stroke onset if not already given (you are at 48 hours now) 1
• If aspirin was given earlier, continue current antiplatelet regimen 1

Blood Pressure Management

• Maintain blood pressure below 180/105 mmHg 1
• Avoid aggressive blood pressure lowering that could compromise cerebral perfusion in the setting of large vessel occlusion 1

Cardiac Monitoring and DVT Prophylaxis

• Continue cardiac monitoring for at least 24 hours to screen for atrial fibrillation and arrhythmias 1
• Apply thigh-high intermittent pneumatic compression devices for DVT prophylaxis given limited mobility 1

Comprehensive Stroke Workup

Given complete ICA and MCA occlusion, investigate:

• Cardiac sources of embolism (echocardiography, prolonged cardiac monitoring) 2, 3
• Hypercoagulable states, particularly important in evaluating etiology 2, 3
• Extracranial and intracranial vascular imaging to define extent of atherosclerotic disease 1

Critical Pitfalls to Avoid

• Do not delay neurosurgical consultation - the 48-hour window for effective decompressive surgery is closing 1
• Do not use anticoagulation routinely - it is not recommended in unselected patients with acute ischemic stroke 1
• Do not use prophylactic antiseizure medications - only treat documented seizures 1, 3
• Do not make DNR or palliative care decisions prematurely - defer for at least 24-48 hours after stroke onset to assess response to therapy 2
• Do not rely solely on midline shift measurements - clinical deterioration with mass effect is the primary surgical indication, not absolute millimeter thresholds 4

Prognosis Discussion

With decompressive hemicraniectomy performed within 48 hours:

• Mortality reduces from approximately 76% to 42% 3
• Approximately 11% of surgical survivors achieve moderate disability (able to walk, mRS 3) at 12 months 3
• Functional benefit is much greater in patients <60 years of age 1

The decision to proceed with surgery should involve shared decision-making with the patient (if possible) and family, considering anticipated prognosis for functional recovery. 1