Large hemispheric infarct in an 82-year-old: reperfusion, decompression and a divided family
An 82-year-old woman who lives alone, with mild vascular dementia (baseline mRS 2), was last seen well at 08:00 and found on the floor at 14:00 with dense left hemiplegia, forced gaze deviation and neglect; NIHSS 22. She takes apixaban 5 mg twice daily for atrial fibrillation, last dose at 07:00. CT shows a right MCA territory infarct with ASPECTS 4 and no haemorrhage; CTA shows a right M1 occlusion; CT perfusion shows a large core with a small penumbra. Her daughter, who holds a health-care power of attorney, says 'do everything, she was always a fighter', while her son says she once told him she would never want to be 'a vegetable'. There is no thrombectomy service on site at night; the nearest centre is 3 hours by road, and there is no ICU bed available for post-thrombectomy care. INR 1.3, creatinine 130 µmol/L.
1. Is she a candidate for reperfusion therapy? Discuss intravenous thrombolysis and mechanical thrombectomy, including the practical constraints.
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Intravenous thrombolysis: no. She took apixaban 7 hours before presentation; thrombolysis within 48 hours of a DOAC is contraindicated in guidelines without a normal coagulation profile or specific reversal, and her INR of 1.3 is normal but does not exclude DOAC effect. Andexanet is not indicated here. Combined with a large established core (ASPECTS 4), the risk–benefit is clearly unfavourable.
Mechanical thrombectomy: a genuine but preference-sensitive discussion, heavily constrained by logistics.
- She is within 24 hours of onset, but she would be in the late window, in which benefit requires selection and is concentrated in patients with a small core and salvageable penumbra. Recent large-core trials (SELECT2, ANGEL-ASPECT, RESCUE-Japan LIMIT, TENSION) do show better functional outcomes with thrombectomy in ASPECTS 3–5, but with substantial mortality and dependence; the absolute benefit is modest.
- Her age and baseline mRS 2 reduce the chance of returning to independence.
- Practically: three hours of transfer plus a night without a post-procedure ICU bed means arrival around 20:00 in a patient who may need critical care. A transfer that consumes the window and lands her in a ward without neurocritical support may produce harm rather than benefit.
My approach: discuss with the nearest neurointerventional centre, and be honest with the family that this is not a guaranteed cure. If a bed and rapid transfer can be arranged, offering her the option is defensible; if not, comfort-focused care with active symptom control is equally defensible and should not be presented as 'giving up'.
2. Would you offer decompressive hemicraniectomy if she deteriorates with malignant oedema? Explain the evidence and the reasoning you would use with the family.
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Not by default - this is a preference-sensitive intervention, not an obligation.
Evidence:
- In patients under 60 (DESTINY, DECIMAL, HAMLET), hemicraniectomy reduces mortality and increases the proportion surviving with mRS ≤3, though most survivors still have disability.
- DESTINY II extended this to patients over 60: surgery reduced mortality substantially, but the great majority of survivors were left with mRS 4–5, and very few were independent. Survival was bought at the price of severe disability.
- Her age (82, older than the trial population) and baseline mRS 2 make a poor functional outcome even more likely, and she has mild dementia with no live-in support.
Reasoning:
- Hemicraniectomy does not restore the infarcted tissue; it trades death for survival with severe disability in most elderly patients.
- The son reports a clear prior statement that she would not want to be 'a vegetable'. If that is reliable, decompression is likely contrary to her values.
- The daughter's 'do everything' is an expression of love and grief, not a demand that every procedure must be offered; it needs unpacking.
So: explain the numbers honestly, including that surgery is a legitimate option that some families choose. If there is no clear evidence of her wishes, a time-limited trial of maximal medical therapy with early reassessment is reasonable, but default to comfort-focused care if the family, after informed discussion, cannot accept the likely outcome. Do not present craniectomy as the only 'active' option.
3. How would you handle the disagreement between the daughter and the son, the question of decision-making authority, and the practical medical management over the next 48 hours?
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Capacity and authority. She almost certainly lacks capacity: acute severe stroke with neglect and aphasia/dementia. Capacity is decision-specific and must be assessed and documented. The daughter's 'power of attorney' may not carry statutory authority in the local jurisdiction, and the treating team retains responsibility for acting in the patient's best interests with the family as partners. Involve the hospital ethics committee early if there is entrenched conflict; this protects everyone.
The conversation. Meet the daughter and son together, with a nurse and, if possible, an interpreter or neutral third party. Explore why - the daughter's fear of abandonment, the son's memory of a specific conversation. Ask both what she valued: independence, being at home, recognition of family. Reframe 'doing everything' as 'doing everything that helps her' - antibiotics, oxygen, pain relief, mouth care, sitting out - and distinguish that from interventions that prolong dying. Emphasise that comfort-focused care is active care. Document who said what, and record the goals of care and any limitation of treatment.
Medical plan over 48 hours:
- Admit to a stroke unit or high-dependency bed; airway and swallowing assessment; nasogastric tube if unsafe swallow; nothing by mouth until assessed.
- Blood pressure: permissive hypertension, avoid hypotension; treat only if >220/120 mmHg or if there is another indication.
- Anticoagulation: no immediate apixaban; the infarct is large with high haemorrhagic transformation risk, so delay restarting for roughly 2–4 weeks, and use intermittent pneumatic compression for VTE prophylaxis for the first days rather than heparin.
- Glucose, temperature and sodium control; treat seizures if they occur; early physiotherapy and positioning; pressure-area care.
- Reassess at 48–72 hours with the family; discuss tracheostomy and PEG only if she survives the acute phase, and only if they would serve her goals.