Treatment of Ischemic Stroke with Large Cerebral or Cerebellar Infarction and Neurological Decline from Brain Swelling
This protocol addresses a high-acuity presentation of ischemic stroke in which a large cerebral or cerebellar infarction produces progressive neurological deterioration driven by brain swelling — a time-sensitive situation requiring early intervention decisions.
Clinical Scenario
Patients with large cerebral or cerebellar infarction experiencing neurological decline from brain swelling. The hemicraniectomy indication applies to unilateral MCA infarction with neurological deterioration within 48 hours despite medical therapy. The cerebellar infarction indication applies when there is brainstem compression or an infarct volume ≥35 mL.
Treatment Approach (Partial Overview)
The structured protocol centres on decompressive surgery within a defined time window. The specific surgical approach differs depending on whether the infarction is supratentorial or in the posterior fossa.
Patient selection thresholds, procedural details, and the full decision algorithm are available in the complete protocol below.
References
DOI: 10.1161/STR.0000000000000513
- In patients with large cerebral or cerebellar infarctions and neurological decline from brain swelling, the use of osmotic therapy as a bridge to a surgical intervention is reasonable to improve functional outcome and reduce mortality.
- In patients ≤60 years of age with unilateral MCA infarctions who deteriorate neurologically within 48 hours from brain swelling despite medical therapy, decompressive craniectomy with dural expansion is beneficial to reduce mortality and improve functional outcome.
- In patients with cerebellar infarction causing neurological deterioration from brainstem compression or volumes ≥35 mL, decompressive suboccipital craniectomy with dural expansion should be performed to improve outcomes and decrease mortality.
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