Updates in the Management of Large Hemispheric Infarction
Large hemispheric infarctions (LHI) are estimated to occur in 2-8% of all hospitalized ischemic strokes and 10 15% of all MCA territory infarcts. LHI carry high rates of morbidity and mortality, in fact, if left untreated associated cerebral edema can rapidly progress to transtentorial herniation and death in 40 80% of patients.
Recognized risk factors for progressive cerebral edema include:
- NIH stroke scale > 20 in dominant hemispheric infarct
- NIH stroke scale > 15 in nondominant hemispheric infarct
- Rapid decline in level of consciousness (LOC) indicates effect on contralateral hemisphere (due to ipsilateral swelling)
Evidence based medical strategies for LHI include:
- Positioning: Elevation of the head of the bed (HOB) > 30 degrees
- Glucose control: 140 180 mg/dL (hyperglycemia associated with increased ICP and progression to hemorrhagic conversion)
- Blood pressure control: 15% reduction MAP over 24 hours if BP exceeds 220/120 (likely best accomplished with nicardipine infusion to avoid overcorrection)
- Osmotic therapy: In the deteriorating patient, consider hypertonic saline (23%) with goal Na of 160 mEq/L or mannitol with goal plasma osmolality of 320 mOsm/kg.
- Adjunctive therapies: Prevent fever and hypercapnea
Prophylactic hemicraniectomy
- Consider early neurosurgical consultation for patients with LHI as newer evidence suggests prophylactic hemicraniectomy may improve survival if performed within 24 48 hours.
Bottom Line: Early recognition of large hemispheric stroke is critical as it is associated with a high rate of morbidity and mortality. Aggressive medical management and early neurosurgical involvement may improve outcomes.
References
- Zha AM, Sari M, Torbey MT. Recommendations for management of large hemispheric infarction. Curr Opin Crit Care. 2015;21(2):91-8.
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