Causes of Increased Tentorial Density and Management Strategies for Posterior Circulation Stroke

When a suspected case of brainstem or cerebellar infarction arises, immediate medical attention is crucial. The golden window for intravenous thrombolysis is within 3 to 4.5 hours from symptom onset. Administering clot-dissolving therapy during this timeframe significantly improves patient outcomes by restoring blood flow to ischemic brain tissue. However, not all patients are eligible for thrombolytic treatment—careful evaluation is required to rule out contraindications such as recent surgery, bleeding disorders, or hemorrhagic stroke. Accurate diagnosis through neuroimaging, including non-contrast CT and MRI, helps differentiate between conditions that mimic ischemic stroke and true cerebral infarction.

Advanced Reperfusion Therapies: Beyond Thrombolysis

In cases involving large vessel occlusion and extensive infarction, especially in the posterior circulation, endovascular mechanical thrombectomy (also known as arterial clot retrieval) may be considered within 6 hours of symptom onset. While mechanical thrombectomy has shown remarkable success in anterior circulation strokes, its efficacy in posterior circulation events—such as those affecting the basilar or vertebral arteries—is somewhat more limited due to anatomical challenges and later presentation times. Nevertheless, timely intervention can still lead to meaningful neurological recovery, particularly when performed at comprehensive stroke centers equipped with advanced imaging and interventional neuroradiology capabilities.

Secondary Prevention and Pharmacological Management

For critically ill patients who are not candidates for acute reperfusion therapies, dual antiplatelet therapy becomes a cornerstone of secondary prevention. This typically involves combining aspirin with clopidogrel to reduce the risk of recurrent thrombotic events. The regimen is usually initiated within 24 hours post-stroke, provided there is no evidence of hemorrhagic transformation. Alongside antiplatelet agents, high-intensity statin therapy—such as atorvastatin 80 mg daily—is strongly recommended to stabilize atherosclerotic plaques, lower LDL cholesterol, and exert pleiotropic effects including anti-inflammatory and endothelial-protective actions.

Blood Pressure Optimization in Acute Stroke Care

Maintaining optimal blood pressure is essential during the acute phase. Hypertension must be carefully managed to prevent further vascular injury, while excessive hypotension should be avoided to ensure adequate cerebral perfusion. A target systolic blood pressure of 130–140 mmHg and diastolic pressure between 70–80 mmHg is generally advised, unless comorbidities dictate otherwise. Continuous monitoring and individualized treatment plans help balance these competing demands, particularly in elderly patients or those with pre-existing cerebrovascular disease.

Supportive Care and Early Rehabilitation

During the initial 24–48 hours, patients should remain in a supine position to minimize hemodynamic fluctuations caused by positional changes. Sudden sitting or standing can lead to orthostatic shifts in cerebral blood flow, potentially worsening neurological deficits. Once vital signs are stable and the patient's condition has plateaued, early mobilization under medical supervision should be encouraged. Initiating physical, occupational, and speech therapy as soon as possible plays a critical role in enhancing functional recovery and reducing long-term disability.

In summary, increased tentorial density on imaging may signal underlying pathology such as venous congestion, hemorrhage, or ischemic edema in the posterior fossa. Prompt recognition, timely reperfusion strategies, meticulous supportive care, and rapid transition to rehabilitation collectively form the foundation of modern stroke management, significantly improving survival rates and quality of life for affected individuals.