Epidemiological Recommendations.
1. The terminology and definitions of severe cerebral hemispheric and cerebellar edema due to cerebral infarction should be standardized, which would facilitate the advancement of multicenter and population-based studies on the incidence, epidemiology, risk factors, and prognosis of the disease. (I; C)
2. Additional data are needed for the selection of decompressive craniectomy, including differences in physician, hospital, health system, or patient characteristics. (I; C)
Definitions and recommendations for clinical presentation.
1. Clinical data should be used to identify patients at high risk for infarction and edema, such as vascular occlusion. (I; C)
Recommendations for neuroimaging.
1. Head CT features predictive of cerebral edema include significant hypointense findings on head CT within 6 h, involvement of >= 1/3 MCA distribution area, and early midline shift. (I; B)
2, Measurement of MRI DWI infarct volume within 6h is a useful method, with volumes >= 80 ml predicting a rapid onset of disease. (I; B)
3, Brain plain CT is the first-line diagnostic method and can also be used as a monitoring method for hemispheric or cerebellar infarct edema. Serial CT is performed in patients at high risk of symptomatic edema within 2 days of onset. (I; C)
Triage.
1. Basin strokes of large size should be admitted to the ICU or stroke unit for close monitoring and comprehensive treatment. (I; C)
2. If comprehensive treatment and neurosurgical treatment is not available at the hospital, the recommendation should be to transfer the patient to a high level center. (IIa; C)
Airway and mechanical ventilation are recommended.
1. Blood carbon dioxide levels should be maintained in the normal range. (IIa; C)
2. Tracheal intubation should be considered in cases of decreased level of consciousness causing poor oxygenation or inability to clear secretions. (IIb; C)
3.No withdrawal of sedative prophylactic hyperventilation. (III; C)
Hemodynamic and blood pressure management.
1. Appropriate medications should be given to treat malignant arrhythmias and continuous cardiac monitoring should be performed. (I; C)
2. There is a lack of valid data to recommend targets for systolic and mean arterial pressure. In severe hypertension, antihypertensive medication may be given. Specific blood pressure targets have not been established. (IIb; C)
3. Adequate isotonic fluids may be considered. (IIb; C)
4. Hypotonic or hypotonic fluids are not recommended. (III; C)
5. Prophylactic use of osmotic diuretics is not recommended before the onset of cerebral edema. (III; C)
Management of blood glucose
1. Hyperglycemia should be avoided, and it is recommended to control blood glucose within the range of 140-180 mg/dl. (I; C)
2. Intensive glucose management (<110mg/dl) is not recommended, but insulin infusion is beneficial to avoid severe hyperglycemia. (IIb; C)
3. Hypoglycemia should be prevented whenever it occurs. (III; C)
Management of body temperature.
1. The management of body temperature is an important part of the basic treatment and should be controlled in the normal range. (IIa; C)
2. The efficacy of using therapeutic hypothermia before cerebral edema is unclear. (IIb; C)
Management of ICP.
1. Routine ICP monitoring is not recommended in hemispheric ischemic stroke. (III; C)
2. Ventriculostomy should be performed in cerebellar infarction combined with obstructive hydrocephalus, but decompressive craniectomy should be performed subsequently or concurrently. (I; C)
Other medical treatment.
1. Subcutaneous low-molecular heparin should be used to prevent the occurrence of DVT. (I; C)
2. In stroke with edema, intravenous heparin or combined antiplatelet agents are not recommended. (III; C)
3. Prophylactic antiepileptic therapy is not required in the absence of epileptic seizures. (III; C)
Identification of deteriorating disease.
1. In patients at high risk of worsening episodic ischemic stroke, the clinician should frequently monitor the patient’s level of arousal and whether the ipsilateral pupil is dilated. Progressive centering of the pupil and worsening motor response may also indicate deterioration. (I; C)
2. In patients with cerebellar stroke who are at high risk of deterioration, clinicians should frequently monitor the patient’s level of arousal and emerging brainstem signs. (I; C)
Drug selection.
1. Those with clinical deterioration due to cerebral edema should be given osmotic therapy. (IIa; C)
2. The efficacy of hypothermia, barbiturates, and cortisol for ischemic cerebral or cerebellar edema is lacking evidence and is not recommended. (III; C)
Neurosurgical options.
1, Patients <60 years of age with unilateral mca infarction at 48 h of onset who have deteriorated neurological function despite medical treatment should undergo decompressive craniectomy and dural expansion. The efficacy of delayed decompression is unclear, but should be seriously considered. (i; b)
2. Although the best indication for decompressive craniectomy is unclear, decreased level of consciousness due to cerebral edema can be used as a selection criterion. (IIa; A)
3, The effectiveness of decompressive craniectomy for patients >60 years of age and the optimal timing of the procedure are unclear. (IIb; C)
4. Suboccipital craniectomy with dural expansion should be performed for neurological deterioration after aggressive medical treatment of cerebellar infarction. (I; B)
Biological markers.
1. The value of blood biologic markers to predict ischemic cerebral edema is uncertain. (IIb; C)
2. The value of electrophysiological studies to predict deterioration after hemispheric stroke is also uncertain. (IIb; C)
Prognosis and accounting for condition.
1. Clinicians should inform families that for patients with occupied hemispheric infarction, even after decompressive craniectomy, half of the survivors remain severely disabled and one-third require complete care. (IIb; C)
2. Clinicians should inform families that cerebellar infarcts have a better prognosis after suboccipital craniectomy. (IIb; C)