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Treatment of Large Hemispheric and Cerebellar Ischemic Strokes
When does the neurologic deterioration occur?
Neurologic deterioration usually occurs within 72 to 96 hours in most patients. Some patients may experience deterioration at 4 to 10 days.
What should be the blood pressure goal?
There are insufficient data to recommend a specific systolic or mean arterial blood pressure target.
Blood pressure–lowering drugs may be considered for the treatment of extreme hypertension.
Specific blood pressure targets have not been established.
What fluids should be used?
Use of adequate fluid administration with isotonic fluids should be considered, while avoiding hypotonic or hypo-osmolar fluids.
What is the role of hyperosmolar therapy?
Osmotic therapy for patients with clinical deterioration from cerebral swelling associated with cerebral infarction is reasonable.
Use of prophylactic osmotic diuretics before apparent swelling is not recommended.
Should Intracranial Pressure be monitored in patients with large hemispheric strokes?
Clinical deterioration is more often the result of displacement of midline structures such as the thalamus and the brain stem rather than of a mechanism of globally increased Intracranial Pressure.
Therefore routine ICP monitoring is not indicated in hemispheric ischemic strokes.
What is the role of surgery in the management of malignant Middle Cerebral Artery stroke?
Decompressive hemicraniectomy reduces mortality by reducing progression to brain death and reduces the probability of permanent coma that eventually may lead to de-escalation of care and death.
Decompressive craniectomy with dural expansion is effective in patients <60 years of age with unilateral MCA infarctions who deteriorate neurologically within 48 hours despite medical therapy.
The effect of later decompression is not known, but it should be strongly considered.
Although the optimal trigger for decompressive hemicraniectomy is unknown, it is reasonable to use a decrease in level of consciousness and its attribution to brain swelling as selection criteria.
The efficacy of decompressive hemicraniectomy in patients >60 years of age and the optimal timing of surgery are uncertain.
Recently the Destiny 2 trial showed improved survival but more moderate to severe disability in patients older than 60 years.
Timing of decompressive hemicraniectomy remains unresolved, but it is generally agreed that the surgery is best undertaken before clinical signs of brainstem compression usually between 24 and 48 hours.
When does peak swelling occur?
Peak swelling occurs several days after the onset of ischemia.
What are the clinical and radiologic markers of deterioration following cerebellar infarction?
Similar to hemispheric infarction, the most reliable clinical symptom of tissue swelling is decreased level of consciousness and thus arousal secondary to brain stem compression and/or obstructive hydrocephalus.
Effacement of the fourth ventricle is a key radiologic marker, followed by basal cistern compression, followed by brain stem deformity, hydrocephalus, downward tonsillar herniation, and upward transtentorial herniation.
What is the role of surgery in the management of cerebellar infarction?
Suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarctions who deteriorate neurologically despite maximal medical therapy.
EVD insertion is recommended in obstructive hydrocephalus after a cerebellar infarct but should be followed or accompanied by decompressive craniectomy to avoid deterioration from upward cerebellar displacement.
