New Weakness on the Stroke Unit
A 59-year-old woman was admitted 36 hours ago with a left middle cerebral artery territory infarct. She initially had a dense right hemiparesis and expressive aphasia, with NIHSS 14. Overnight the nurse reports that she is more drowsy, her right pupil is now 4 mm and sluggish while the left is 2 mm and reactive, and her right arm, previously plegic, now shows intermittent extension posturing. BP 172/96, HR 58, respirations 14 and irregular. Her aphasia makes formal language testing difficult. She is on aspirin, atorvastatin, and a normal saline infusion at 75 mL/h. No anticoagulation.
1. Interpret the change in her neurological status and explain the physiological reasoning behind the findings.
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This is a neurological emergency until proven otherwise. The combination of declining consciousness, a newly dilated and sluggish right pupil, intermittent extensor posturing of the right arm, bradycardia, hypertension, and irregular respiration is a classic pattern of raised intracranial pressure with early uncal herniation. The physiology explains the sequence: a large left hemispheric infarct becomes edematous, typically peaking around days 2 to 5, and mass effect pushes the medial temporal lobe over the tentorial edge. The right pupil dilates because the right oculomotor nerve is compressed, and the right arm extends because the corticospinal tract is compromised at the level of the brainstem, producing decerebrate posturing. Bradycardia with hypertension and irregular breathing reflects brainstem compression and impaired autoregulation, sometimes described as a Cushing-type response. The drowsiness indicates failing cortical function from mass effect rather than simply the original infarct. The normal saline at 75 mL/h is not itself the cause but hypotonic or excessive fluids can worsen cerebral edema, so the fluid plan should be reviewed. Aspirin is a bleeding risk consideration but not the primary driver here. The key point is that the change is not explained by the original stroke alone; it signals a new or evolving mass effect requiring immediate action.
2. List your immediate actions in priority order and explain the rationale for each, including what you would avoid.
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First, call for senior help and activate the stroke or critical care team while staying with the patient. Position her with the head of the bed elevated about 30 degrees to promote venous drainage, keeping the neck neutral and avoiding compression of the jugular veins. Secure the airway if her GCS continues to fall, and give supplemental oxygen to maintain adequate saturation, because hypoxia worsens secondary injury. Obtain urgent non-contrast head CT to confirm edema and mass effect and to exclude hemorrhagic transformation, and arrange urgent neurosurgical review for possible decompressive hemicraniectomy, since this is time-critical in a deteriorating patient with a large infarct. Treat raised intracranial pressure with osmotherapy such as mannitol or hypertonic saline according to local protocol, while monitoring sodium, osmolality, and renal function. Control blood pressure according to stroke and neurocritical care guidance, avoiding both excessive hypertension and abrupt hypotension that could reduce perfusion. Check glucose, electrolytes, and temperature, and treat fever. Review the fluid prescription to avoid hypotonic fluids. Avoid routine corticosteroids, which are not effective for cytotoxic edema from infarct and may worsen outcomes, and avoid aggressive hyperventilation except as a brief bridge to definitive treatment. Do not delay imaging or neurosurgical discussion while awaiting laboratory results.
3. The CT confirms a large left MCA infarct with 8 mm midline shift. The family asks about surgery. Explain the considerations you would present to them.
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I would explain that the scan shows swelling of a large area of the brain, which is pressing on surrounding structures and causing the deterioration. Decompressive surgery, usually a hemicraniectomy in which part of the skull is temporarily removed to allow the swollen brain room, can reduce pressure and may be life-saving. The evidence supports considering it in younger patients with large hemispheric infarcts, generally within the first 48 hours, and it improves survival and functional outcome in selected groups, but it does not reverse the stroke itself. Many survivors remain dependent and have significant disability, and this patient has aphasia and a dense hemiparesis, so the likely functional outcome is a central part of the discussion. I would be honest that age, existing deficits, and the timing of deterioration all influence the likely benefit, and that the decision is made jointly by the stroke and neurosurgical teams. I would also explain the alternatives: continued medical management of intracranial pressure, which may not control the swelling, and comfort-focused care if the family judges that survival with severe disability is not consistent with her wishes. I would ask whether she had expressed preferences, involve the family in shared decision-making, document the discussion, and ensure the conversation is repeated with the surgical team present so the information is consistent.