Acute Left-Sided Facial Swelling and Increasing Weakness Post-Craniotomy

Immediate Life-Threatening Considerations

The American Heart Association/American Stroke Association guidelines emphasize that deterioration within 48 hours of stroke onset warrants consideration of decompressive craniectomy if medical therapy fails 1, 2
In a patient with acute left-sided facial swelling and increasing weakness within 2 hours post-craniotomy/cranioplasty, the primary concern is recurrent stroke (either ischemic or hemorrhagic) or post-cranioplasty cerebral edema with mass effect, which requires emergent neuroimaging and potential surgical intervention 1, 2

Recurrent ischemic stroke with malignant edema is the most likely diagnosis given the acute timeframe (2 hours) and new weakness in a patient with prior stroke history and baseline hemiparesis 1, 2
Cerebral Venous Thrombosis (CVT) can present with acute neurological deterioration, seizures, and hemorrhagic transformation, particularly relevant in post-craniotomy patients due to venous manipulation during surgery 4, 5

Non-contrast head CT immediately to assess for hemorrhage, edema, mass effect, and herniation 1, 2
CT venography if no hemorrhage identified to rule out venous thrombosis 4, 5
Glasgow Coma Scale score and pupillary examination immediately 8

Do not delay imaging for "observation" in a post-craniotomy patient with acute neurological change 1, 2
Do not assume facial swelling is benign sialadenitis without ruling out intracranial catastrophe first 6, 7
Do not withhold anticoagulation for CVT even if hemorrhagic transformation is present, per AHA/ASA guidelines 5