Managing Malignant Cerebral Infarction
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Managing patients with malignant cerebral infarction remains one of the foremost challenges in medicine. These patients are at high risk for progressive neurologic deterioration and death due to malignant cerebral edema, and they are best cared for in the intensive care unit of a comprehensive stroke center. Careful initial assessment of neurologic function and of findings on MRI, coupled with frequent reassessment of clinical and radiologic findings using CT or MRI are mandatory to promote the prompt initiation of treatments that will ensure the best outcome in these patients. Significant deterioration in either neurologic function or radiologic findings or both demand timely treatment using the best medical management, which may include osmotherapy (mannitol or hypertonic saline), endotracheal intubation, and mechanical ventilation. Under appropriate circumstances, decompressive craniectomy may be warranted to improve outcome or to prevent death.
No potential conflicts of interest relevant to this article were reported.
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- 3.Adams Jr HP, del Zoppo G, Alberts MJ, et al.: Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007, 38:1655–1711.PubMedCrossRefGoogle Scholar
- 14.Qizilbash N, Lewington SL, Lopez-Arrieta JM: Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev 2002, CD000064.Google Scholar
- 24.Bratton SL, Chestnut RM, Ghajar J, et al.: Guidelines for the management of severe traumatic brain injury. VI Indications for intracranial pressure monitoring J Neurotrauma 2007, 24(Suppl 1):S37–S44.Google Scholar
- 26•.Poca MA, Benejam B, Sahuquillo J, et al.: Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J. Neurosurg 2010, 112:648–657. The authors studied a prospective cohort of 25 patients with a malignant MCA infarction consecutively admitted to an intensive care unit. Intracranial pressure readings were evaluated and correlated with pupillary abnormalities and with midline shift and ischemic tissue volume evaluated in the CT scan. The authors showed that in patients with MCI, pupillary abnormalities and severe brainstem compression may be present despite normal ICP values. Therefore, continuous ICP monitoring cannot substitute for close clinical and radiologic follow-up in the management of these patients.CrossRefGoogle Scholar
- 33•.Larach DR, Larach DB, Larach MG: A life worth living: seven years after craniectomy. Neurocrit Care 2009, 11:106–111. A personal account of an academic anesthesiologist who survived the aggressive treatment of a left MCI. In this paper, the author reflects on the concept of QoL and of the importance of intensive rehabilitation after massive stroke. This paper supports reconsidering the strong bias doctors generally show regarding life and death decisions based on the presumed QoL of survivors.PubMedCrossRefGoogle Scholar
- 35.Hofmeijer J, Kappelle LJ, Algra A, et al.: Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 2009, 8:326–333.PubMedCrossRefGoogle Scholar
- 44.Mori K, Nakao Y, Yamamoto T, Maeda M: Early external decompressive craniectomy with duroplasty improves functional recovery in patients with massive hemispheric embolic infarction: timing and indication of decompressive surgery for malignant cerebral infarction. Surg Neurol 2004, 62:420–429.PubMedGoogle Scholar