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NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 81 OF 100
A 56-year-old man was admitted to the neuro ICU 2 days ago with a large acute ischemic left middle cerebral artery infarct. He now exhibits increasing lethargy, leading to somnolence, increasing blood pressure, a heart rate of 44, irregular respirations, and a less reactive left pupil. The patient is immediately intubated for airway protection. Which of the following is the best strategy to reduce mortality and potential morbidity given the patient’s neurologic changes?
A. Initiation of an IV drip of 3% saline solution at 30 mL/h
B. Decrease the respiratory rate to hypoventilation
C. Consultation with neurosurgery for decompressive hemicraniectomy and durotomy **
D. Initiation of an IV heparin drip with a fluid bolus for a target goal PTT of 60 to 80 sec
E. Initiation of IV thrombolysis for extension of stroke ischemia
** = Your answer
DESTINY, DECIMAL, and HAMLET studies assessed the efficacy of decompressive hemicraniectomy and durotomy on mortality and morbidity rates, measured as a modified Rankin score at 1 year. The data suggest decompressive hemicraniectomy and durotomy performed within 48 hours of stroke reduces morbidity and mortality rates in patients with a large acute ischemic infarction, with a number needed to treat of approximately 2 for a mortality benefit. Initiation of IV heparin or rtPA is not indicated if there is a concern for impending herniation due to malignant edema. Although sodium management is appropriate initially to address elevated intracranial pressure, definitive treatment remains decompressive hemicraniectomy and durotomy.
* Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007 Mar;6(3):215-222.