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