Management of Large Hemispheric Infarction
Recommendations
Airway Management
LHI patients with signs of respiratory insufficiency or neurological deterioration should be intubated immediately.
(Very Low, Strong)Extubation should be attempted in LHI patients who meet the following criteria, even if communication and cooperation cannot be established.
(Very Low, Strong)• Absence of oropharyngeal saliva collections
• Absence of demand for frequent suctioning
• Presence of cough reflex and tube intolerance,
• Free of analgesia and sedation.
Tracheostomy should be considered in LHI patients failing extubation or in whom extubation is not feasible by 7–14 days from intubation.
(Low, Weak)Hyperventilation
We recommend against prophylactic hyperventilation in LHI patients.
(Very Low, Strong)Analgesia and Sedation
We recommend analgesia and sedation if signs of pain, anxiety, or agitation arise in LHI patients.
(Very Low, Strong)We recommend the lowest possible sedation intensity and earliest possible sedation cessation, while avoiding physiologic instability and discomfort in LHI patients.
(Very Low, Strong)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.
(Very Low, Strong)Gastrointestinal Tract
We suggest dysphagia screening in the early phase of LHI. Dysphagia can be assessed once the patient is weaned from sedation and ventilation.
(Very Low, Weak)LHI patients with dysphagia should receive a nasogastric tube as soon as possible.
(Very Low, Weak)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.
(Very Low, Weak)Glucose Control
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.
(Very Low, Strong)We recommend that intravenous sugar solutions should be avoided in LHI.
(Very Low, Strong)Hemoglobin Control
We recommend maintaining a hemoglobin of 7 g/dl or higher in LHI patients.
(Very Low, Strong)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.
(Very Low, Weak)Consider reducing blood sampling wherever possible in order to decrease the risk of anemia in LHI.
(Very Low, Weak)Deep Venous Thrombosis Prophylaxis
We recommend early mobilization to prevent DVT in hemodynamically stable LHI patients with no evidence of increased ICP.
(Very Low, Strong)We recommend DVT prophylaxis for all LHI patients upon admission to the ICU and for the duration of immobilization.
(Very Low, Strong)We recommend using IPC for DVT prophylaxis.
(Moderate, Strong)We recommend using LMWH for DVT prophylaxis.
(Low, Strong)We recommend against the use of compression stockings for DVT prophylaxis.
(Moderate, Strong)Anticoagulation
We suggest that oral anticoagulation be reinitiated 2–4 weeks after LHI in patients at high thromboembolic risk.
(Very Low, Weak)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).
(Very Low, Weak)We suggest using aspirin during the period of no anticoagulation in LHI with AF or increased thromboembolic risk, provided surgery is not imminent.
(Very Low, Weak)Blood Pressure Management
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.
(Low, Strong)We suggest avoiding blood pressure variability, especially in the early phase of LHI treatment.
(Low, Weak)Steroid Therapy
We recommend against using steroids for brain edema in patients with LHI.
(Low, Strong)Barbiturate Therapy
Barbiturate therapy is not recommended in patients with LHI because the risks outweigh the benefits.
(Low, Strong)Temperature Control
We suggest considering hypothermia as a treatment option in patients who are not eligible for surgical intervention.
(Low, Weak)If hypothermia is considered, we suggest a target temperature of 33–36 C for duration of 24–72 h.
(Low, Weak)We suggest maintaining normal core body temperature.
(Very Low, Weak)Head Position
We suggest a horizontal body position in most patients with LHI. However in patients with increased ICP, we suggest a 30 backrest elevation.
(Very Low, Weak)Osmotic Therapy
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.
(Moderate, Strong)We suggest using osmolar gap instead of serum osmolality to guide mannitol dosing and treatment duration.
(Low, Weak)Hypertonic saline dosing should be guided by serum osmolality and serum sodium.
(Moderate, Strong)We recommend using mannitol cautiously in patients with acute renal impairment.
(Moderate, Strong)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.
(High, Strong)Neuroimaging by CT and MRI
We recommend using early changes on CT and MRI to predict malignant edema after LHI.
(Low, Strong)Ultrasound
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.
(Low, Weak)Evoked Potentials
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.
(Very Low, Weak)EEG
We suggest considering EEG in the first 24 h after stroke to assist with predicting clinical course in LHI.
(Very Low, Weak)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 .
(Very Low, Weak)Invasive Multimodal Monitoring
Invasive multimodal monitoring has not been sufficiently studied, and therefore cannot be recommended in the routine management of LHI.
(Low, Weak)Surgical Management
We recommend DHC as a potential therapy to improve survival after LHI regardless of patient age.
(High, Strong)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.
(Moderate, Strong)There is currently insufficient data to recommend against DHC in LHI patients based on hemispheric dominance.
(Low, Strong)To achieve the best neurological outcome, we recommend performing DHC within 24–48 h hours of symptom onset and prior to any herniation symptoms.
(Moderate, Strong)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.
(Moderate, Strong)We suggest that that lobectomy or duraplasty should only be considered as an individualized treatment option.
(Low, Weak)We suggest that the resection of the temporal muscle should only be considered as an individualized treatment option.
(Low, Weak)Ethical Considerations
We suggest that the decision to perform DHC should depend on values and preferences of patients and relatives regarding survival and dependency.
(Low, Weak)Quality of Life (QoL)
We suggest that future research use QoL as an outcome measure in LHI patients.
(Low, Weak)Recommendation Grading
Disclaimer
Overview
Title
Management of Large Hemispheric Infarction
Authoring Organization
Neurocritical Care Society
Publication Month/Year
January 21, 2015
Last Updated Month/Year
June 27, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Emergency care, Hospital, Operating and recovery room, Radiology services
Intended Users
Radiology technologist, physician assistant, physician, nurse practitioner, nurse
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D020520 - Brain Infarction, D002544 - Cerebral Infarction, D007238 - Infarction, D020244 - Infarction, Middle Cerebral Artery
Keywords
stroke, large hemispheric infarction, LHI, malignant middle cerebral infarction
Source Citation
Torbey, M.T., Bösel, J., Rhoney, D.H. et al. Evidence-Based Guidelines for the Management of Large Hemispheric Infarction. Neurocrit Care 22, 146–164 (2015). https://doi.org/10.1007/s12028-014-0085-6