What are the major clinical concerns in the initial days following an ischemic stroke?
Clots may propagate, particularly those due to large artery atherosclerosis. Expeditious identification of this subtype is recommended.
The most life-threatening complication of stroke is herniation due to cerebral edema, which manifests 12 hours to 5 days after onset.
Clinical signs include somnolence, pupillary dilation from third nerve compression, and signs of increased intracranial pressure (nausea, vomiting). Herniation may occur either upward or downward through the tentorium or under the falx cerebri.
Large hemispheric and cerebellar strokes are most likely to cause herniation.
Manipulation of serum osmolarity (mannitol, hypertonic saline) or hyperventilation may be used, though definitive treatment is surgical decompression.
