What is the management of hemispheric syndrome?

Management of Hemispheric Syndrome

Decompressive craniectomy is recommended as the primary intervention for patients with hemispheric syndrome who show clinical deterioration despite maximal medical therapy to reduce mortality and improve outcomes. 1

Definition and Clinical Presentation

Hemispheric syndrome refers to a severe neurological condition typically resulting from a large hemispheric stroke with significant cerebral edema. Clinical presentation includes:

• Decreased level of consciousness
• Ipsilateral pupillary dysfunction (varying degrees of mydriasis)
• Adduction paralysis
• Progressive worsening of limb power
• Contralateral Babinski sign (due to brainstem notching against tentorium)
• Late development of abnormal respiratory patterns (central neurogenic hyperventilation, ataxic patterns)

Initial Management

Transfer and Monitoring

• Immediate transfer to intensive care or specialized stroke unit
• Frequent neurological assessments focusing on:
  • Level of consciousness
  • Pupillary changes
  • Motor responses
  • Respiratory patterns

Airway and Oxygenation

• Ensure airway protection and adequate oxygenation
• Consider intubation if decreased level of consciousness threatens airway protection
• For intubated patients:
  • Maintain normocapnia (avoid prophylactic hyperventilation)
  • Use short-acting anesthetics (propofol or dexmedetomidine) if needed for patient comfort

Positioning and General Measures

• Elevate head of bed 0-30° during periods of increased intracranial pressure
• Avoid oral intake initially; perform swallowing assessment before allowing oral intake

Hemodynamic Management

• Use isotonic saline as maintenance fluid; avoid hypo-osmolar fluids
• Correct hypovolemia with isotonic fluids
• Blood pressure management:
  • For non-thrombolysed patients: maintain systolic BP <220 mmHg and diastolic BP <120 mmHg
  • For thrombolysed patients: maintain systolic BP <185 mmHg and diastolic BP <110 mmHg
  • Avoid arterial hypotension (maintain cerebral perfusion pressure >60 mmHg)

Management of Cerebral Edema

Medical Management

• Osmotic therapy for clinical deterioration from cerebral swelling:
  • Mannitol or hypertonic saline
  • Note: These provide only temporary relief and may cause rebound phenomena
• Aggressive treatment of hyperthermia
• Control hyperglycemia (>8 mmol/L or >144 mg/dL) 1
• Consider reversing anticoagulation in patients on warfarin after careful risk assessment
• Discontinue combination antiplatelet therapy (aspirin + clopidogrel) but may continue aspirin alone
• Use subcutaneous heparin or low-molecular-weight heparin for deep venous thrombosis prophylaxis

Surgical Management

• Decompressive craniectomy with dural expansion is recommended for patients who continue to deteriorate neurologically despite maximal medical therapy 1
• Timing: Ideally within 48 hours of stroke onset for patients <60 years old
• For cerebellar infarcts with swelling, suboccipital decompressive craniectomy is recommended
• If hydrocephalus is present in cerebellar strokes, ventriculostomy may be needed in conjunction with decompressive surgery

Special Considerations

Age Considerations

• Decompressive craniectomy shows clear benefit in patients <60 years old
• For patients >60 years old, evidence is less robust, but surgery may still be considered on an individual basis 1

Family Discussion

• Engage in shared decision-making with families
• Discuss realistic outcomes:
  • Nearly 3 of 4 patients <60 years survive with decompressive craniectomy performed within 2 days
  • Nearly half will be severely disabled and half will suffer from depression
  • One-third of surviving patients may remain fully dependent on care 1
  • Discuss potential for depression, lack of initiative, irritability, disinhibition, and being wheelchair-bound

Prognosis

• Mortality after large ischemic strokes with cerebral edema remains 20-30% despite interventions
• Approximately one-third of patients with hemispheric stroke are unable to walk without assistance and need continuous nursing care
• Cerebellar infarcts generally have better outcomes after surgical intervention compared to hemispheric infarcts 1
• There is often a discrepancy between physical disability and quality of life, with many patients and families rating quality of life as good despite severe functional handicap 1

Risk Factors for Cerebral Edema Development

• Age <50 years
• Signs of acute infarct on imaging
• Hyperdense artery sign
• Blood glucose >128.5 mg/dL
• Decreased level of consciousness 2

The management of hemispheric syndrome requires prompt recognition, aggressive medical management, and timely surgical intervention when indicated to optimize outcomes and reduce mortality.