ISCHEMIC STROKE / COMPLICATIONS
Malignant Cerebral Infarction
Created 25/03/2021, last revision 21/01/2023
Definition
Definition- malignant cerebral infarction = extensive infarction with large space-occupying edema
- occurs in up to 10% of patients with supratentorial infarcts
- it is traditionally associated with a high mortality rate (up to 80%) [Hacke, 1996]
- occurs mainly in cases of ICA and MCA occlusions or with posterior circulation strokes (mainly cerebellar infarctions)
- it is characterized by a development of edema within 24 h, clinical deterioration usually in < 72h, sometimes later (e.g., in case of collateral circulation failure and development of infarction in the penumbra
- early surgical decompression reduces mortality and increases the number of younger patients with a favorable outcome according to randomized controlled trials (RCTs)
Predictors of malignant infarction
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Clinical features
- the initial severe neurological deficit with hemiplegia, deviation of eyes and head, high NIHSS, nausea, vomitus
- the posterior circulation infarction is associated with impaired consciousness, oculomotor dysfunction, altered brainstem reflexes, ataxia, and dysmetria
- progressive impairment of consciousness and conus symptoms due to craniocaudal deterioration
- Cushing’s triad is present in advanced stages of intracranial hypertension
- hypertension
- bradycardia
- respiratory disorders
- hypo-, hyperventilation
- Cheyne-Stokes breathing
- apneic pauses
- cardiovascular lability
- cerebellar infarctions are associated with an increased risk of brainstem compression and hydrocephalus development
Diagnostic evaluation
Blood tests
- tests should exclude extracerebral causes of clinical deterioration
- a basic metabolic panel including hepatic enzymes
- minerals, including phosphate
- coagulation and blood count
- toxicology and ASTRUP should be considered in the presence of impaired consciousness not fully explained by structural changes on CT
Imaging methods
- look for expansive behavior of ischemia and a midline shift on CT
- repeat brain CT within the first 48h in high-risk patients [AHA/ASA 2014 I/C]
- use MRI for early detection of large DWI lesions
- prediction of fulminant course within 6 h: DWI lesion > 80-89 mL
- prediction of fulminant course beyond 14 h: DWI lesion > 145 mL
Others methods
- EEG excludes nonconvulsive status epilepticus (unless NCCT correlates with the severe clinical condition)
- TCD / TCCD can be used to monitor blood flow
- occlusion detection (TIBI criteria)
- signs of intracranial hypertension
- ICP monitoring
Differencial diagnosis
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Management
Medical therapy
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- routine intensive care for acute stroke patients → see here
- consider transport to a hospital capable of performing acute decompressive craniectomy
- antiedema therapy
- osmotic therapy Mannitol / NaCl 10% (AHA/ASA 2019 IIa/C-LD)
- there are no data on the benefit of hypothermia, barbiturates, and corticosteroids in stroke patients and they are therefore not recommended
- therapy should be initiated only in patients with developing edema; prophylactic administration of osmotherapy is not recommended
- the effect of conservative treatment in malignant ischemia is usually insufficient and not clearly demonstrated
Surgery
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- preferred in younger patients
- with developing malignant ischemia, don’t wait for the effect of drug therapy (as it has only minimal impact)
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Clinical trials
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