managing a patient with large hemispheric infarction (lhi) · biogen-10244 may 2019 key...
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Management and Monitoring
Diagnosis
Transfer of Patients
EMS Evaluation
3
2
1
4
Biogen-10244 May 2019
Key Considerations Along the Route
Managing a Patient With Large Hemispheric Infarction (LHI)
EMS Evaluation
Goal: Train personnel to rapidly evaluate and stabilize patients1
• Assess airway, breathing, andcirculation1
• Obtain medical history (eg, time ofsymptom onset)1
• Use prehospital assessment tools(eg, LAPSS,2 RACE,3 FAST-ED4)
• Communicate necessaryinformation to receiving hospital ina timely manner1
1
Goal: Establish protocols to transfer patients to appropriate acute care facility5
• Establish transfer protocols onbasis of− Neuroimaging capabilities− Availability of specialists and access
to telestroke− Stroke severity/time of symptom
onset
Transfer of Patients
Acute stroke–ready
hospital
NIHSS can assess LHI progression and poor outcome6
Guides treatment initiation Decision to perform DHC involves many factors
Dominant hemisphere
NIHSS score >20
Nondominant hemisphere
NIHSS score >15
Primary stroke center
Comprehensive stroke center
2
Goal: Assess clinical and neurological characteristics
• Conduct neurological exam toevaluate neurological deficit7
• Perform neuroimaging to assesslesion size/location and presenceof LVO1
− NCCT can exclude intracranialhemorrhage and stroke mimics8
− CTP helps identify patients forreperfusion treatment8
− DW-MRI is sensitive and specific inidentifying acute infarctions1
Diagnosis
3
Goal: Prevent progression from LVO to LHI
• Perform thrombectomy inappropriate patients withinrecommended timetables7
• Monitor clinical status (NIHSS,11
Glasgow coma scale,12 oculomotorexam13) to assess diseaseprogression7
• Assess need for DHC to relievehigh ICP14; this procedure mayincrease the likelihood of survivaland offer positive patient outcomes15
Providing prompt feedback to the multidisciplinary stroke team on protocols and procedures may improve patient outcomes16
Management and Monitoring
4
Types of facilities5
Timing9
Possibledisability9
Patient/Caregiver
preference10
CTP, computed tomography perfusion; DHC, decompressive hemicraniectomy; DW-MRI, diffusion-weighted magnetic resonance imaging; EMS, emergency medical services; FAST-ED, Field Assessment Stroke Triage for Emergency Destination; ICP, intracranial pressure; LAPSS, Los Angeles Prehospital Stroke Screen; LHI, large hemispheric infarction; LVO, large vessel occlusion; NCCT, noncontrast computed tomography; NIHSS, National Institutes of Health Stroke Scale; 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. 5. Higashida et al. Stroke. 2013;44:2961-2984. 6. Kimberly andSheth. 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. 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. 16. Xian et al. Circ Cardiovasc Qual Outcomes. 2017;10:e003227.
Biogen-10244 February 2019