What are the AHA/ASA guidelines for the management of cerebral and cerebellar infarction with brain swelling in ischemic stroke?

Updated: May 27, 2020
  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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Answer

The American Heart Association and the American Stroke Association have released a guideline for the management of cerebral and cerebellar infarction with brain swelling; recommendations include the following: [122, 123]

  • Selected patients, including those able to handle an aggressive rehabilitation program, may benefit from decompressive craniectomy; younger patients may benefit most, and surgery is not recommended for patients older than 60 years

  • Clinical evidence of deterioration in swollen supratentorial hemispheric ischemic stroke includes new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size

  • In patients with swollen cerebellar infarction, level of consciousness decreases because of brainstem compression; this decrease may include early loss of corneal reflexes and the development of miosis

  • Standardized definitions are needed to facilitate studies of incidence, prevalence, risk factors, and outcomes

  • Identification of high-risk patients should include both clinical and neuroimaging data

  • Complex medical care of these patients includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control

  • In patients with swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but in patients who continue to deteriorate neurologically, decompressive craniectomy with dural expansion should be considered

  • In patients with swollen cerebellar stroke who deteriorate neurologically, suboccipital craniectomy with dural expansion should be performed

  • After a cerebellar infarct, performance of ventriculostomy to relieve obstructive hydrocephalus should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement

  • As many as one third of patients with swollen hemispheric supratentorial infarcts will be severely disabled and fully dependent on care even after decompressive craniectomy, whereas most patients with cerebellar infarct will have acceptable functional outcomes after surgery


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