Management of Acute Left MCA Infarct After 7 Days of Event

Assessment and Monitoring

Imaging should be performed to assess for mass effect from cerebral edema, significant midline shift, and hypodensity extending beyond 50% of the MCA territory on CT, according to the American Heart Association, as stated in Circulation 2

Blood pressure should be monitored frequently (at least every 6 hours) during this period, and target blood pressure values of 160 mm Hg systolic and 90 mm Hg diastolic are recommended by the American Heart Association, as stated in Stroke 3
Avoid aggressive blood pressure reduction, particularly agents that cause cerebral vasodilation, as recommended by the American Heart Association, as stated in Circulation 2

Aspirin (325 mg daily) should be administered within 24-48 hours after stroke onset if not already started, as recommended by the American Heart Association, as stated in Stroke 4
For patients who have not received antiplatelet therapy yet, initiate aspirin therapy, as recommended by the American Heart Association, as stated in Stroke 4 and 5

Position the patient with head of bed elevated at 20-30 degrees to help venous drainage, as recommended by the American Heart Association, as stated in Circulation 2
Restrict free water to avoid hypo-osmolar fluid that may worsen edema, as recommended by the American Heart Association, as stated in Circulation 2
Correct factors that could exacerbate swelling, including hypoxemia, hypercarbia, and hyperthermia, as recommended by the American Heart Association, as stated in Circulation 2
For patients with significant edema and increased intracranial pressure, mannitol may be used at 0.25-0.5 g/kg IV administered over 20 minutes every 6 hours (maximum dose 2 g/kg) as a temporizing measure, as recommended by the American Heart Association, as stated in Circulation 2

Decompressive hemicraniectomy has been shown to significantly reduce mortality in patients with malignant MCA infarction, as stated in the International Journal of Stroke, and recommended by the International Society of Stroke 1
Strongest evidence exists for patients under 60 years of age, but may be considered in patients 60-80 years, as stated in the International Journal of Stroke, and recommended by the International Society of Stroke 1
Decompressive hemicraniectomy improves functional outcome in addition to survival, as stated in the International Journal of Stroke, and recommended by the International Society of Stroke 1

Best candidates include patients under 60 years of age (strongest evidence), as stated in the International Journal of Stroke, and recommended by the International Society of Stroke 1
For patients over 60 years, the likelihood of resulting severe disability should be discussed with the patient/family, as stated in the International Journal of Stroke, and recommended by the International Society of Stroke 1

Begin planning for rehabilitation services if not already initiated, as recommended by the American Heart Association, as stated in Stroke 5
Assess functional capacity and ability to perform activities of daily living, as recommended by the American Heart Association, as stated in Stroke 5

Decompressive hemicraniectomy significantly reduces mortality but survivors may have moderate to severe disability, as stated in the International Journal of Stroke, and recommended by the International Society of Stroke 1
Discussions with patients and families should include information about likely outcomes and potential for survival with significant disabilities, as stated in the International Journal of Stroke, and recommended by the International Society of Stroke 1

Medical management alone (including osmotic diuretics) has not been proven efficacious for malignant MCA infarction, as stated in Circulation, and recommended by the American Heart Association 2
The benefit of surgery in older patients (>60 years) is less certain and should be carefully considered on a case-by-case basis, as stated in the International Journal of Stroke, and recommended by the International Society of Stroke 1