Swell Watch (Malignant Cerebral Edema)

FACTS

Hemicranial and posterior fossa swelling secondary to malignant cerebral edema can lead to deadly herniation. This is often a diagnosis of the elderly co-morbid patient and early frank conversations

HPI

universal ROS
  • careful attention to their level of function, degree of dementia

PHYSICAL EXAM

universal neuro exam with emphasis on L.O.C.
Hemisphere Stroke
Posterior Fossa Stroke
ㅤ
careful cranial nerve exam
test bulbar responses (if intubated)

IMAGING

Hemisphere Stroke
Posterior Fossa Stroke
- evaluate for shift
- evaluate for uncal herniation
- evaluate degree of 4th V effacement
- evaluate compression of brainstem
- evaluate aqueduct patency
A/P
Stroke admission/primary
MRI Brain w/o contrast
Counsel patient and family on the fact that DHC is only life (not function) preserving.
  • Hemicrani swell watch
  • Posterior fossa swell watch

Cases

Elderly male with R M2 occlusion

Elderly male with numerous cardiopulmonary comorbidities was found to have an abrupt M2 occlusion (LEFT) with resultant rapidly progressive malignant cerebral edema with sulcal effacement, midline shift. Note that hyperdensity is contrast staining and NOT hemorrhaghic transformation in this case.
Elderly male with numerous cardiopulmonary comorbidities was found to have an abrupt M2 occlusion (LEFT) with resultant rapidly progressive malignant cerebral edema with sulcal effacement, midline shift. Note that hyperdensity is contrast staining and NOT hemorrhaghic transformation in this case.
 

Elderly male with L vertebral occlusion and PICA infarct

notion image
75M with HTN, HLD, DM2, CAD s/p stent presented with acute vertigo and an occipital HA found to have a presumed thromboembolic L vertebral artery occlusion with resultant PICA territory infarct. Neurosurgery was consulted for posterior fossa swell watch.