A 58-year-old woman presents with sudden-onset right hemiplegia and global aphasia. NIHSS is 20. CT head shows a large left MCA territory hypodensity involving more than 50% of the territory with a 6 mm midline shift. GCS is 10. According to evidence-based guidelines, what is the definitive management to reduce mortality and improve outcome?

• A Decompressive hemicraniectomy within 48 hours of symptom onset ✓
• B IV thrombolysis with alteplase followed by mechanical thrombectomy
• C High-dose dexmannitol and hyperventilation to reduce intracranial pressure
• D Supportive care with IV fluids and antiplatelets, reassessing in 72 hours

Explanation

Pooled trials show decompressive hemicraniectomy reduces mortality and improves functional outcome in patients under 60 with malignant MCA infarction when performed within 48 hours. Thrombolysis is contraindicated if hypodensity involves >1/3 of the MCA territory. Mannitol is a temporizing measure, not definitive management for malignant edema.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.