AHA/ASA Guideline on Stroke With Brain Swelling

February 11, 2014

The American Heart Association/American Stroke Association (AHA/ASA) has issued a new statement on the management of cerebral and cerebellar infarction with brain swelling.

"Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention," the authors write. "Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent."

"Our message is that there are sufficient aggressive options for patients with stroke and brain swelling that can lead to reasonable outcomes," lead author, Eelco F.M. Wijdicks, MD, a neurointensivist at Mayo Clinic, Rochester, Minnesota, commented to Medscape Medical News.

"Over the years, complex management has developed based on good evidence for both medical and surgical management," he said. "This statement has put all that evidence down in one document, which will help those involved in the care of these patients make the right decisions when they see this condition."

Dr. Wijdicks noted that this is the first time that swelling in both types of strokes — hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) — has been addressed in 1 document and all the various complex management options laid out.

"This statement will be relevant to stroke doctors, neurosurgeons, rehabilitation staff, and ER [emergency room] doctors," he said.

The statement, "Recommendations for the Management of Cerebral and Cerebellar Infarction With Swelling," was published online in Stroke on January 30.

High Mortality, Age a Factor

Dr. Wijdicks explained that swelling is typically seen in large strokes, and patients have a high proclivity for dying after brain swelling causes mass effect. "We wanted to look at the options for these patients."

"Early decompressive craniectomy can help many patients, but this is a large surgery involving the removal of half of skull. This is a major undertaking with lots of potential complications. The crucial question is, how do we decide which patients to take to surgery? This has not been answered definitively, but we have listed several criteria that should be taken into account."

In general, younger patients are the ones that could benefit most from surgery, Dr. Wijdicks notes. "They have the greatest chance of a reasonable outcome. For example, a 30-year-old with a major stroke and swelling should be sent for immediate surgery. But it is not recommended for patients over 60."

Other factors that need to be taken into account include the patient's ability to handle an aggressive rehabilitation program and their prior state of health.

Many logistical factors must also be considered. "Patients have to be transferred to a hospital where such surgery can be conducted," Dr. Wijdicks points out. "This may be far away. Young patients with large strokes should be transferred even without swelling, as swelling will probably develop."

The statement notes that clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, level of consciousness decreases as a result of brainstem compression; therefore, this decrease may include early loss of corneal reflexes and the development of miosis.

The authors recommend that standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data.

If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurologic monitoring capabilities is needed, the statement said. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians, such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control.

In swollen supratentorial hemispheric ischemic stroke, the statement advises that routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients age 60 years of age or older.

In swollen cerebellar stroke, the authors state that suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement.

In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients, the statement notes.

Stroke. Published online January 30, 2014. Abstract

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