What is the management approach for a patient presenting with a preferential gaze to the right, suggesting a potential infarct in the left brain hemisphere?

From the Guidelines

The patient with preferential gaze to the right suggesting left hemisphere infarct should undergo immediate neurological evaluation and activation of stroke protocols, with urgent neuroimaging using non-contrast CT to rule out hemorrhage, followed by consideration of intravenous thrombolysis with alteplase or endovascular thrombectomy as indicated. The management approach for such a patient involves rapid assessment using the NIH Stroke Scale and urgent neuroimaging to determine the extent and location of the infarct. According to the guidelines from the American Heart Association/American Stroke Association 1, all patients admitted to hospital with suspected acute stroke should receive brain imaging evaluation on arrival to hospital, with non-contrast CT (NCCT) being the preferred initial imaging modality.

Key Considerations

• The patient should be assessed for eligibility for intravenous thrombolysis with alteplase, which is recommended for patients presenting within 4.5 hours of symptom onset without contraindications 1.
• For patients with large vessel occlusion presenting within 24 hours, endovascular thrombectomy should be considered, as recommended by recent guidelines 1.
• Vital signs must be closely monitored, with blood pressure maintained below 185/110 mmHg before thrombolysis and below 180/105 mmHg after, to minimize the risk of complications.
• Supportive care includes maintaining normoglycemia, normothermia, and proper oxygenation to optimize outcomes.

Secondary Prevention

• Secondary prevention begins with antiplatelet therapy, such as aspirin 325 mg initially, then 81 mg daily, once hemorrhage is ruled out, along with high-intensity statin therapy to reduce the risk of recurrent stroke.
• The preferential rightward gaze results from damage to the left frontal eye field or connections to the pontine gaze center, disrupting the normal balance of gaze control mechanisms, and highlights the importance of prompt and accurate diagnosis and treatment to minimize morbidity and mortality.

Given the time-sensitive nature of stroke treatment, it is crucial to prioritize rapid evaluation and initiation of appropriate therapy to improve outcomes, as emphasized by the guidelines from the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society 1.

From the Research

Management Approach for Preferential Gaze to the Right

The management approach for a patient presenting with a preferential gaze to the right, suggesting a potential infarct in the left brain hemisphere, involves several key considerations:

• Diagnosis: The first step is to confirm the diagnosis of an acute ischemic stroke using imaging techniques such as MRI or CT scans 2, 3.
• Thrombolytic Therapy: Thrombolytic therapy with tissue plasminogen activator (tPA) is a potential treatment option for acute ischemic stroke, but it is typically only effective if administered within 3-4.5 hours of symptom onset 2, 3.
• Neuroprotection: Neuroprotection may be considered as an adjunctive therapy to minimize the harmful effects of ischemic neuronal damage, although its effectiveness in humans is still being researched 4.
• Eye and Head Deviation: The deviation of the eyes and head to one side, known as Prévost's sign, can be an indicator of spatial neglect and may be associated with right hemisphere lesions 5.
• Hemorrhagic Transformation: The risk of hemorrhagic transformation after thrombolytic therapy is a concern, and definitions of clinically relevant cerebral hemorrhage have been proposed to distinguish incidental from clinically relevant hemorrhages 6.

Key Considerations

When managing a patient with a preferential gaze to the right, the following key considerations should be taken into account:

• Time of Symptom Onset: The time of symptom onset is critical in determining the eligibility for thrombolytic therapy 2, 3.
• Imaging Findings: Imaging findings, such as the presence of a PWI/DWI mismatch, can help identify patients who may benefit from thrombolytic therapy 2.
• Neurological Deficits: The presence and severity of neurological deficits, such as spatial neglect, should be assessed and taken into account when developing a management plan 5.
• Risk of Hemorrhagic Transformation: The risk of hemorrhagic transformation should be carefully considered when administering thrombolytic therapy, and patients should be closely monitored for signs of bleeding 6.