European Stroke Organisation (ESO) guidelines on the management of space-occupying brain infarction

Abstract

Space-occupying brain oedema is a potentially life-threatening complication in the first days after large hemispheric or cerebellar infarction. Several treatment strategies for this complication are available, but the size and quality of the scientific evidence on which these strategies are based vary considerably. The aim of this Guideline document is to assist physicians in their management decisions when treating patients with space-occupying hemispheric or cerebellar infarction. These Guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A working group identified 13 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. An expert consensus statement was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high-quality evidence to recommend surgical decompression to reduce the risk of death and to increase the chance of a favourable outcome in adult patients aged up to and including 60 years with space-occupying hemispheric infarction who can be treated within 48 hours of stroke onset, and low-quality evidence to support this treatment in older patients. There is continued uncertainty about the benefit and risks of surgical decompression in patients with space-occupying hemispheric infarction if this is done after the first 48 hours. There is also continued uncertainty about the selection of patients with space-occupying cerebellar infarction for surgical decompression or drainage of cerebrospinal fluid. These Guidelines further provide details on the management of specific subgroups of patients with space-occupying hemispheric infarction, on the value of monitoring of intracranial pressure, and on the benefits and risks of medical treatment options. We encourage new high-quality studies assessing the risks and benefits of different treatment strategies for patients with space-occupying brain infarction.

Treatments in Ischemic Stroke: Current and Future

“…Another investigation has been conducted on the antidiabetic sulphonylurea glyburide, which has been reported to prevent cerebral edema in an-Eur Neurol 2022;85:349-366 DOI: 10.1159/000525822 terior circulation malignant strokes [121] (NCT01794182, NCT01268683). However, current ESO guidelines [120] suggest against the use of glyburide in routine clinical practice as a means to reduce the risk of mortality or poor outcome in patients with space-occupying hemispheric infarction.…”

“…The European and American Guidelines state that, in patients with space-occupying hemispheric infarction, it is reasonable to use short-term osmotic agents, like mannitol or hypertonic saline. However, the benefit-risk ratio of osmotic therapy and its benefit in reducing the mortality rate or a poor outcome are still unclear [21, 120]. Regarding corticosteroids, there is even more lack of evidence of their efficacy on brain swelling secondary to AIS; moreover, corticosteroids, in standard or high doses, potentially increase the risks of infectious complications.…”

“…For these reasons, major guidelines recommend against their administration for indication. Currently, the only recommended treatment with a reported benefit from RCTs results on mortality and disability is decompressive surgical therapy [21, 120].…”

Treatment of posterior circulation stroke: Acute management and secondary prevention

“…Expert opinion suggests considering suboccipital decompression in selected patients who deteriorate neurologically from impending brainstem compression. 32 , 33 Removal of infarcted cerebellar tissue during this procedure is controversial but may be considered in some situations. An example is shown in Figure 3 .…”

Minor stroke, major questions: How to treat patients with large vessel occlusion and minor symptoms

“…If blood flow is not restored, steady progression and growths of the infarct core in the penumbra [1] will cause severe and irreversible damage. Only a few years ago-some of us will still remember that time before mechanical thrombectomy (MT) became standard of care-we had to discuss indications for decompressive hemicraniectomy to save the lives of patients with malignant infarction [2] far too often. Since 2015, MT for large vessel occlusion has revolutionized stroke reperfusion therapy and it is rare that we need to discuss decompressive hemicraniectomy.…”