A concise guideline for the management of large hemispheric infarction in Taiwan: 2010 Update: A guideline from the Taiwan Stroke Society

In this report, we present comprehensive recommendations for the diagnosis and treatment of large hemispheric infarction (LHI). A systematic literature search was conducted until June 30, 2010. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation (Table 1). The guideline was revised after several official meetings with local experts, and was reviewed by 3 expert reviewers. Early diagnosis of malignant large hemispheric infarction (MLHI) is critical. Studies have shown that using computed tomography (CT) or transcranial sonography to track midline shifting of the cerebrum and applying diffusion-weighted magnetic resonance imaging might contribute to the early recognition of MLHI. Glycerol and mannitol should be administered only when a patient shows evidence of brain edema or mass effect. The effect of barbiturate coma on improving prognosis is inconclusive and requires close monitoring of the patient. Meanwhile, using steroids on patients with stroke is not recommended. The effect of hyperventilation on reducing intracranial pressure is rapid but short-lived, and is used only in emergency situations. The target levels of PaCO2 are 30-35 mmHg. Moderate hypothermia (32-34°C) may be effective in controlling intracranial hypertension, but should be used cautiously along with rigorous monitoring. Timely decompressive craniectomy can probably offer patients a better chance of survival and quality of life. Usually, surgery for MLHI is indicated in patients with clinical deterioration associated with a significant mass effect, as observed on neuroimaging. However, with a reliable indicator of MLHI, early decompressive craniectomy before clinical deterioration may further reduce mortality and lead to a better functional outcome.