The Acute and Chronic Management of Large Cerebral Infarcts

  • E. M. Manno
  • A. R. Rabinstein
  • E. F. M. Wijdicks
Conference paper


Stroke remains a major source of morbidity and mortality throughout the world representing the third leading cause of death in North America and the second leading cause of death in Asia [1]. Large hemispheric strokes account for a majority of these deaths and represent a significant proportion of stroke patients treated in an intensive care unit (ICU). Our understanding of the secondary processes that occur after the initial stroke has changed our approach to the management of this population. We will review and discuss the new management strategies that have been developed to decrease the morbidity and mortality of patients with large hemispheric infarctions.


Acute Ischemic Stroke Neurological Deterioration Cerebral Edema Middle Cerebral Artery Infarction Decompressive Hemicraniectomy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Adams RA, Victor M (1993) Cerebrovscular disease. In: Adams RD, Victor M (eds) Principles of Neurology McGraw-Hill Inc, New York, pp 669–748Google Scholar
  2. 2.
    Wijdicks EFM (2003) Acute middle cerebral artery occlusion. In: Wijdicks EFM (ed) The Clinical Practice of Critical Care Neurology. Oxford University Press, New York, pp 270–290Google Scholar
  3. 3.
    Ng LKY, Nimmannitya J (1970) Massive cerebral infarction with severe brain swelling: a clini-copathological study. Stroke 1:158–163PubMedGoogle Scholar
  4. 4.
    Ropper AH, Shafran B (1984) Brain edema after stroke: clinical syndrome and intracranial pressure. Arch Neurol 41:26–29PubMedGoogle Scholar
  5. 5.
    Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R (1996) Malignant middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 53:309–315PubMedGoogle Scholar
  6. 6.
    Plum F (1966) Brain swelling and edema in cerebral vascular disease. Res Publ Assoc Res Nerv Ment Dis 41:318–348PubMedGoogle Scholar
  7. 7.
    Ropper AH (1986) Lateral displacement of the brain and level of consciousness in patients with acute hemispheric mass. N Engl J Med 31:953–958CrossRefGoogle Scholar
  8. 8.
    Frank JI (1995) Large hemispheric infarction, clinical deterioration, and intracranial pressure. Neurology 45:1286–1290PubMedGoogle Scholar
  9. 9.
    Kaufmann AM, Cardoso ER (1992) Aggravation of cerebral edema by multiple dose mannitol. J Neurosurg 77:584–589PubMedGoogle Scholar
  10. 10.
    Manno EM, Adams RE, Derdeyn CP, Powers WJ, Diringer MN (1999) The effects of mannitol on cerebral edema after large hemispheric cerebral infarct. Neurology 52:583–587PubMedGoogle Scholar
  11. 11.
    Videen TO, Zazulia AR, Manno EM, et al (2001) Mannitol bolus preferentially shrinks non-infarcted brain in patients with ischemic stroke. Neurology 57:2120–2122PubMedGoogle Scholar
  12. 12.
    The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 333:1581–1587CrossRefGoogle Scholar
  13. 13.
    Furlan A, Higashida R, Wechsler L, et al (1999) PROACT Investigators. Intra-arterial prouro-kinase for acute ischemic stroke: the PROACT II study: a randomized controlled trial. JAMA 282:2003–2011CrossRefPubMedGoogle Scholar
  14. 14.
    Fulgham JR, Ingall TJ, Stead LG, Cloft HJ. Wijdicks EFM, Fleming KD (2004) Management of acute ischemic stroke. Mayo Clin Proc 79:1459–1469PubMedGoogle Scholar
  15. 15.
    Gujjar AR, Diebert E, Manno EM, Duff S, Diringer MN (1998) Mechanical ventilation for ischemic stroke and intracerebral hemorrhage indications, timing, and outcome. Neurology 51:447–451PubMedGoogle Scholar
  16. 16.
    Steiner T, Mendoza G, De Georgia M, Schellinger P, Holle R, Hacke W (1997) Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke 28:711–715PubMedGoogle Scholar
  17. 17.
    Grotta J, Pasteur W, Khwaja G, Hamel T, Fisher M, Ramirez A (1995) Elective intubation for neurological deterioration after stroke. Neurology 45:640–644PubMedGoogle Scholar
  18. 18.
    Ropper AH (1993) Treatment of intracranial hypertension, In: Ropper AH (ed) Neurological and Neurosurgical Intensive Care, 3rd edition. Raven Press, New York, pp 29–52Google Scholar
  19. 19.
    Steiner T, Ringleb P, Hacke W (2001) Treatment options for large hemispheric stroke. Neurology 57(Suppl 2):S61–S68PubMedGoogle Scholar
  20. 20.
    Paczynski RP, He YY, Diringer MN, Hsu CY (1997) Multiple-dose mannitol reduced brain water content in a rat model of cortical infarction. Stroke 28:1437–1443PubMedGoogle Scholar
  21. 21.
    Muizelaar JP, Wei EP, Kontos HA, Becker DP (1983) Mannitol causes compensatory cerebral vasoconstriction and vasodilation in response to blood viscosity changes. J Neurosurg 59: 822–823PubMedCrossRefGoogle Scholar
  22. 22.
    Prough DS, Zornow MH (1998) Mannitol: An old friend on the skids? Crit Care Med 26: 997–998CrossRefPubMedGoogle Scholar
  23. 23.
    Suarez JI, Queshi AI, Bhardway A, et al (1998) Treatment of refractory intracranial hypertension with 23.4% saline. Crit Care Med 26:1118–1122CrossRefPubMedGoogle Scholar
  24. 24.
    Diringer MN. Zazulia AR (2004) Osmotic therapy: fact and fiction. Neurocrit Care 1:219–233CrossRefPubMedGoogle Scholar
  25. 25.
    Gondim Fde A, Aiyagari V, Shackleford A, Diringer MN (2005) Osmolality not predictive of mannitol-induced acute renal insufficiency. J Neurosurg 103:444–447PubMedGoogle Scholar
  26. 26.
    Maioriello AV, Chaljub G, Nauta HJ, Lacroix M (2002) Chemical shift imaging of mannitol in acute cerebral ischemia. Case report. J Neurosurg 97:687–689Google Scholar
  27. 27.
    Ginsberg MD, Busto RBS (1998) Combating hyperthermia in acute stroke: A significant clinical concern. Stroke 29:529–534PubMedGoogle Scholar
  28. 28.
    Schwab S, Sparnager M, Aschoff A, Steiner T, Hacke W (1997) Brain temperature monitoring and modulation in patients with severe MCA infarction. Neurology 48:762–767PubMedGoogle Scholar
  29. 29.
    The Hypothermia after Cardiac Arrest Study group (2002) Mild therapeutic hypothermia to improve neurological outcome after cardiac arrest. N Engl J Med 346:549–556CrossRefGoogle Scholar
  30. 30.
    Bernard SA, Gray TW, Buist MD, et al (2002) Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 346:557–563CrossRefPubMedGoogle Scholar
  31. 31.
    Schwab S, Georgiadis D, Berrouschot J, Schellinger PD, Graffagnino C, Mayer SA (2001) Feasibility and safety of moderate hypothermia after massive hemispheric infarction. Stroke 32: 2033–2035CrossRefPubMedGoogle Scholar
  32. 32.
    Mayer S, Commichau C, Scarmeas N, Presciutti M, Bates J, Copeland D (2001) Clinical trial of an air-cooling blanket for fever control in critically ill neurological patients. Neurology 56: 292–298PubMedGoogle Scholar
  33. 33.
    Diringer MN for The Neurocritical Care Fever Reduction Trial group (2004) Treatment of fever in the neurologic intensive care unit with a catheter-based heat exchange system. Crit Care Med 32:559–564CrossRefGoogle Scholar
  34. 34.
    Schwab S, Spranger M, Schwarz S, Hacke W (1997) Barbiturate coma in severe hemispheric stroke: useful or obsolete? Neurology 48:1608–1613PubMedGoogle Scholar
  35. 35.
    Delashaw JB, Broaddus WC, Kassall NF, et al (1990) Treatment of right hemispheric cerebral infarctions by hemicraniectomy. Stroke 21:874–881PubMedGoogle Scholar
  36. 36.
    Rieke K, Schwab S, Krieger D, et al (1995) Decompressive surgery in space-occupying hemispheric infarction: Results of an open prospective trial. Crit Care Med 23:1576–1587CrossRefPubMedGoogle Scholar
  37. 37.
    Doerfler A, Forsting M, Reith W, et al (1996) Decompressive craniotomy in a rat model of “malignant” cerebral hemisphere stroke: experimental support for an aggressive therapeutic approach. J Neurosurg 85:853–859PubMedGoogle Scholar
  38. 38.
    Schwab S, Steiner T, Aschoff A, et al (1998) Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 29:1888–1893PubMedGoogle Scholar
  39. 39.
    Kalia KK. Yonas H (1993) An aggressive approach to massive middle cerebral artery infarction. Arch Neurol 50:1293–1297PubMedGoogle Scholar
  40. 40.
    Gupta R, Connolly ES, Mayer S, Elkind MSV (2004) Hemicraniectomy for massive middle cerebral artery territory infarction. A systematic review. Stroke 35:539–543Google Scholar
  41. 41.
    NINDS rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587CrossRefGoogle Scholar
  42. 42.
    Manno EM, Nichols DA, Fulgham JR, Wijdicks EFM (2003) Computed tomographic determinants of neurological deterioration in patients with large middle cerebral artery infarctions. Mayo Clin Proc 78:156–160PubMedGoogle Scholar
  43. 43.
    Lee SJL, Lee KH, Na DG, et al (2004) Multiphasic helical computed tomography predicts subsequent development of severe brain edema in acute ischemic stroke. Arch Neurol 61:505–509CrossRefPubMedGoogle Scholar
  44. 44.
    Serena J, Blanco M, Castellanos M, et al (2005) The prediction of malignant cerebral infarction by molecular brain barrier disruption markers. Stroke 36:1921–1926CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media Inc. 2007

Authors and Affiliations

  • E. M. Manno
    • 1
  • A. R. Rabinstein
    • 1
  • E. F. M. Wijdicks
    • 1
  1. 1.Department of NeurologyMayo ClinicRochesterUSA

Personalised recommendations