Management of Cerebral Infarction
Initial Management and Triage
- Patients with suspected stroke should receive high triage priority with early notification to the receiving hospital to ensure selection of a facility with organized stroke unit care 1
- Transfer to an intensive care or stroke unit is recommended for patients with large territorial strokes to enable close monitoring and comprehensive treatment 2
- Triage to a higher-level center is reasonable if comprehensive care and timely neurosurgical intervention are not available locally 2
Immediate Diagnostic Evaluation
- Brain imaging is essential to differentiate cerebral ischemia from intracerebral hemorrhage and exclude stroke mimics 1
- Non-contrast CT scan is the first-line diagnostic test to monitor patients with hemispheric cerebral or cerebellar infarcts with swelling 2
- Frank hypodensity on head CT within 6 hours, involvement of ≥1/3 of MCA territory, and early midline shift predict cerebral edema 2
- MRI with diffusion-weighted imaging (DWI) within 6 hours is useful, with volumes ≥80 mL predicting a rapid fulminant course 2
Essential Diagnostic Tests
- All patients should undergo immediate testing including blood glucose, oxygen saturation, and serum electrolytes/renal function 3
- Thrombin time or ecarin clotting time should be performed if the patient is on direct thrombin inhibitors 1
Acute Treatment
- Intravenous thrombolysis with rt-PA is highly effective for selected patients presenting within 3 hours of stroke onset 1
- Aspirin (160-300 mg/day) should be started within 48 hours of acute ischemic stroke onset 1
- Endovascular treatment options may be considered for eligible patients, particularly those with large vessel occlusions 6
- Osmotic therapy with mannitol or hypertonic saline is reasonable for patients with clinical deterioration from cerebral swelling 7
- Elevation of the head of the bed to 30° is recommended to reduce space-occupying effects of brain swelling 7