Year: 2011
Type: article
Abstract: Published with permission from William J. Jones, MD.
Severe hemispheric stroke represents a minority of ischemic strokes, yet is responsible for a disproportionate share of morbidity and mortality. It frequently results from occlusion of the proximal middle cerebral artery (MCA), but can also involve the distal internal carotid artery and anterior (ACA) or posterior cerebral arteries (PCA). Malignant infarction occurs in 10% of stroke victims, and formation of cerebral edema is a common cause for secondary neurologic deterioration. Despite intensive medical and surgical care, prognosis is often poor and mortality may be as high as 60%–80%. Surgical intervention can reduce that mortality compared to medical therapy alone,1 but necessitates a careful exploration of patient preference for acceptable outcomes.
The first step in assessing the patient with an acute neurologic deficit is to ascertain the cause and rapidly institute the appropriate therapy. TIA, intracerebral hemorrhage, or seizure with a postictal Todd paralysis can all be mistaken for an acute hemispheric stroke, particularly in the immediate setting when the dynamic nature of these alternatives may not yet be apparent. The NIH Stroke Scale (NIHSS) score and a rapid CT or MRI scan can be used to aid in the diagnosis. Assuming no contraindications are present, IV thrombolysis should be initiated within 3 hours of the last seen well time and should be considered for patients presenting between 3 and 4.5 hours. For emergency departments that do not possess primary stroke center certification, telemedicine systems may be available to assist with the decision regarding IV thrombolysis. For large hemispheric ischemic stroke, referral to a primary stroke center for intra-arterial and investigational treatment options, neurointensive care expertise, and potential neurosurgical consultation is strongly recommended.
The clinical features of severe hemispheric infarction are well-described. Key clinical bedside tests can interrogate the areas of dysfunction …
Source: Neurology
Authors: W. Taylor Kimberly, Kevin N. Sheth
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
Funder: American Academy of Neurology
OpenAlex ID: W2157631503