Diagnosis of LHI at a Comprehensive Stroke Center
W. Taylor Kimberly, MD, PhD, reviews the pathophysiology and clinical presentation of LHI. He also discusses the need for early evaluation of neurological function and the benefits and limitations of several imaging modalities.
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Key learnings from Biogen’s ISC 2019 Symposium
EMS Evaluations: Train personel to rapidly evaluate and stabilize patients
Providing prompt feedback to the multidisciplinary stroke team on protocols and procedures may improve patient outcomes.
Goal: Train personnel to rapidly evaluate and stabilize patients1
- Assess airway, breathing, and circulation1
- Obtain medical history (eg, time of symptom onset)1
- Use prehospital assessment tools (eg, LAPSS,2 RACE,3 FAST-ED4)
- Communicate necessary information to receiving hospital in a timely manner1
FAST-ED, Field Assessment Stroke Triage for Emergency Destination; LAPSS, Los Angeles Prehospital Stroke Screen; RACE, Rapid Arterial Occlusion Evaluation.
1. Jauch et al. Stroke. 2013;44:870-947. 2. Kidwell et al. Stroke. 2000;31:71-76. 3. Pérez de la Ossa et al. Stroke. 2014;45:87-91. 4. Lima et al. Stroke. 2016;47:1997-2002.
Goal: Establish protocols to transfer patients to appropriate acute care facility5
- Establish transfer protocols on basis of
- Neuroimaging capabilities
- Availability of specialists and access to telestroke
- Stroke severity/time of symptom onset
5. Higashida et al. Stroke. 2013;44:2961-2984.
Goal: Assess clinical and neurological characteristics
- Conduct neurological exam to evaluate neurological deficit7
- Perform neuroimaging to assess lesion size/location and presence of LVO1
- NCCT can exclude intracranial hemorrhage and stroke mimics8
- CTP helps identify patients for reperfusion treatment8
- DW-MRI is sensitive and specific in identifying acute infarctions1
CTP, computed tomography perfusion; DW-MRI, diffusion-weighted magnetic resonance imaging; LHI, large hemispheric infarction; LVO, large vessel occlusion; NCCT, noncontrast computed tomography; NIHSS, National Institutes of Health Stroke Scale.
1. Jauch et al. Stroke. 2013;44:870-947. 6. Kimberly and Sheth. Neurol Clin Pract. 2011;76(7 suppl 2):S50-S56. 7. Powers et al. Stroke. 2018;49:e46-e110. 8. Birenbaum et al. West J Emerg Med. 2011;12:67-76.
Goal: Prevent progression from LVO to LHI
- Perform thrombectomy in appropriate patients within recommended timetables7
- Monitor clinical status (NIHSS,11 Glasgow coma scale,12 oculomotor exam13) to assess disease progression7
- Assess need for DHC to relieve high ICP14; this procedure may increase the likelihood of survival and offer positive patient outcomes15
DHC, decompressive hemicraniectomy; ICP, intracranial pressure; LHI, large hemispheric infarction; LVO, large vessel occlusion; NIHSS, National Institutes of Health Stroke Scale.
7. Powers et al. Stroke. 2018;49:e46-e110. 9. Torbey et al. Neurocrit Care. 2015;22:146-164. 10. Rahme et al. J Neurosurg. 2012;117:749-754. 11. Kasner. Lancet Neurol. 2006;5:603-612. 12. Weir et al. Q J Med. 2003;96:67-74. 13. Rowe. Brain Behav. 2017;7:e00771. 14. Wijdicks et al. Stroke. 2014;45:1222-1238. 15. Vahedi et al. Lancet Neurol. 2007;6:215-222.