Infarctus cérébral grave : quelle prise en charge ?

Acute management of ischemic stroke (IS) is based on general and specific therapies, including antithrombotic or thrombolysis when possible. General treatments aim at stabilising the critically-ill patient, in order to limit the cerebral infarct growth. The general management includes the vital function monitoring as well as the prophylaxis and treatment of early complications. IS prognosis is variable but relatively severe. Half of the patients remain neurologically impaired and the mortality rate in the first month is about 10%. Thus, some severe IS may need intensive care management, sometimes associated with specific and aggressive treatments like intra-arterial thrombolysis and decompressive surgery. In these situations, the mortality rate is very high (50 to 90%) as well as the risk of severe neurological impairments (25 to 70% of patients remain severely impaired). Such high disability and mortality rates raise controversies about the benefits of mechanical ventilation. IS catastrophic prognosis may lead to discuss withdrawal or withhold of the treatments. Thus, case-to-case decisions are based on the IS prognosis factors as well as the patient's wishes, in order to obtain shared decisions.