Management of Large Hemispheric Infarction

LHI patients with signs of respiratory insufficiency or neurological deterioration should be intubated immediately.

Extubation should be attempted in LHI patients who meet the following criteria, even if communication and cooperation cannot be established.

Tracheostomy should be considered in LHI patients failing extubation or in whom extubation is not feasible by 7–14 days from intubation.

We recommend analgesia and sedation if signs of pain, anxiety, or agitation arise in LHI patients.

We recommend the lowest possible sedation intensity and earliest possible sedation cessation, while avoiding physiologic instability and discomfort in LHI patients.

We recommend against the routine use of daily wakeup trials in LHI patients. Caution is particularly warranted in patients prone to ICP crises. Neuromonitoring of at least ICP and CPP is recommended to guide sedation, and daily wake-up trials should be abandoned or postponed at signs of physiological compromise or discomfort.

We suggest dysphagia screening in the early phase of LHI. Dysphagia can be assessed once the patient is weaned from sedation and ventilation.

LHI patients with dysphagia should receive a nasogastric tube as soon as possible.

We suggest that high NIHSS scores and persisting dysphagia on endoscopic swallowing should prompt discussion with the family on placement of a PEG tube between weeks 1 and 3 of the ICU stay.

We recommend that hypoglycemia and hyperglycemia should be avoided in LHI. Intermediate glycemic control (serum glucose level 140–180 mg/dl) should be the target of insulin therapy in LHI patients.

We recommend that intravenous sugar solutions should be avoided in LHI.

We recommend maintaining a hemoglobin of 7 g/dl or higher in LHI patients.

Clinicians should also consider specific situations such as planned surgery, hemodynamic status, cardiac ischemia, active significant bleeding, and arteriovenous oxygen extraction compromise when determining the ideal hemoglobin for a patient.

Consider reducing blood sampling wherever possible in order to decrease the risk of anemia in LHI.

We recommend early mobilization to prevent DVT in hemodynamically stable LHI patients with no evidence of increased ICP.

We recommend DVT prophylaxis for all LHI patients upon admission to the ICU and for the duration of immobilization.

We recommend using IPC for DVT prophylaxis.

We recommend using LMWH for DVT prophylaxis.

We recommend against the use of compression stockings for DVT prophylaxis.

We suggest that oral anticoagulation be reinitiated 2–4 weeks after LHI in patients at high thromboembolic risk.

We suggest that earlier re-initiation of oral anticoagulation should be based on clinical risk assessment and additional diagnostic tests (e.g., prosthetic valve, acute DVT, acute PE, or TEE showing intracardiac thrombus).

We suggest using aspirin during the period of no anticoagulation in LHI with AF or increased thromboembolic risk, provided surgery is not imminent.

We recommend that clinicians follow current blood pressure management guidelines for ischemic stroke in general when caring for LHI patients. Maintain a MAP >85 mmHg in ischemic stroke without hemorrhagic transformation. Lower SBP to <220 mmHg.

We suggest avoiding blood pressure variability, especially in the early phase of LHI treatment.

We recommend against using steroids for brain edema in patients with LHI.

Barbiturate therapy is not recommended in patients with LHI because the risks outweigh the benefits.

We suggest considering hypothermia as a treatment option in patients who are not eligible for surgical intervention.

If hypothermia is considered, we suggest a target temperature of 33–36  C for duration of 24–72 h.

We suggest maintaining normal core body temperature.

We suggest a horizontal body position in most patients with LHI. However in patients with increased ICP, we suggest a 30  backrest elevation.

We recommend using mannitol and hypertonic saline for reducing brain edema and tissue shifts in LHI only when there is clinical evidence of cerebral edema.

We suggest using osmolar gap instead of serum osmolality to guide mannitol dosing and treatment duration.

Hypertonic saline dosing should be guided by serum osmolality and serum sodium.

We recommend using mannitol cautiously in patients with acute renal impairment.

We recommend using hypertonic saline cautiously in patients with volume overload states (i.e., heart failure, cirrhosis, etc.,) since this agent will expand intravascular volume.

We recommend using early changes on CT and MRI to predict malignant edema after LHI.

We suggest using TCCS as a complimentary test to predict malignant course and possibly as a primary test if the patient is too unstable to be transferred outside the ICU for neuroimaging.

We suggest considering BAEP as a complimentary method to predict malignant course within the first 24 h after MCA infarction, particularly in patients too unstable to be transported to neuroimaging.

We suggest considering EEG in the first 24 h after stroke to assist with predicting clinical course in LHI.

We suggest that continuous and quantitative EEG represent a promising non-invasive monitoring technique and a tool for estimation of prognosis after LHI that might be useful in the future pending further stud .

Invasive multimodal monitoring has not been sufficiently studied, and therefore cannot be recommended in the routine management of LHI.

We recommend DHC as a potential therapy to improve survival after LHI regardless of patient age.

In patients older than 60 years, we recommend taking in consideration patients and family wishes, since in this age group, DHC can reduce mortality rate but with a higher likelihood of being severely disabled.

There is currently insufficient data to recommend against DHC in LHI patients based on hemispheric dominance.

To achieve the best neurological outcome, we recommend performing DHC within 24–48 h hours of symptom onset and prior to any herniation symptoms.

We recommend a size of 12 cm as an absolute minimum for DHC. Larger sizes of 14–16 cm seem to be associated with better outcomes.

We suggest that that lobectomy or duraplasty should only be considered as an individualized treatment option.

We suggest that the resection of the temporal muscle should only be considered as an individualized treatment option.

We suggest that the decision to perform DHC should depend on values and preferences of patients and relatives regarding survival and dependency.

We suggest that future research use QoL as an outcome measure in LHI patients.