What is the management approach for a patient presenting with symptoms of a left hemispheric stroke?

Management of Left Hemispheric Stroke

The management of a patient with left hemispheric stroke requires immediate neuroimaging, rapid assessment of eligibility for thrombolysis and/or endovascular therapy, and prompt initiation of appropriate treatment within established time windows to minimize brain damage and improve outcomes. 1

Clinical Presentation of Left Hemispheric Stroke

Left hemispheric strokes typically present with:

• Right-sided weakness or paralysis (face, arm, and/or leg)
• Aphasia (language deficits)
• Right-sided sensory loss
• Right visual field defects
• Impaired reading, writing, and calculation abilities

These symptoms may be more readily recognized than right hemispheric strokes, potentially leading to earlier presentation 2.

Initial Emergency Assessment

Immediate Priorities (First 5-10 Minutes)

• Assess and stabilize ABCs (Airway, Breathing, Circulation) 1
• Perform rapid neurological examination using standardized stroke scale (NIHSS or CNS) 1
• Check vital signs: heart rate, blood pressure, temperature, oxygen saturation 1
• Check blood glucose (fingerstick) immediately to rule out hypoglycemia 3
• Determine precise time of symptom onset (when patient was last known normal) 1

Urgent Diagnostic Workup (First 25 Minutes)

• Brain imaging should be completed immediately - non-contrast CT or MRI 1, 3
• Vascular imaging (CTA or MRA from aortic arch to vertex) should be performed concurrently 1, 3
• Laboratory tests: CBC, electrolytes, coagulation studies (INR, aPTT), glucose, renal function, troponin 1
• ECG (can be deferred until after acute treatment decisions) 1
• Chest X-ray only if clinically indicated (should not delay treatment) 1

Acute Treatment Decision-Making

Thrombolytic Therapy Assessment

• Determine eligibility for intravenous alteplase (tPA)
• Target door-to-needle time <60 minutes 3
• Standard dose: 0.9 mg/kg (maximum 90 mg) 3
• Time window: generally within 4.5 hours of symptom onset 1

Endovascular Therapy Assessment

• Evaluate for large vessel occlusion (LVO) on vascular imaging 1
• Consider rapid transfer to comprehensive stroke center if LVO identified and endovascular therapy is indicated 1
• Time window: generally within 6-24 hours depending on imaging findings 1

Blood Pressure Management

• Permissive hypertension initially to support cerebral perfusion 3
• For patients receiving thrombolysis:
  • Keep BP <185/110 mmHg before treatment
  • Maintain BP <180/105 mmHg after treatment 1
• For patients not receiving thrombolysis:
  • Avoid aggressive BP lowering unless extremely elevated (>220/120 mmHg) 1

Monitoring and Supportive Care

• Monitor vital signs every 15 minutes during thrombolytic infusion, then every 30 minutes 3
• Maintain oxygen saturation >94% 1
• Maintain normoglycemia (avoid both hyper- and hypoglycemia) 1
• Position head of bed at 30° (unless contraindicated) 1
• Prevent complications: DVT prophylaxis, aspiration precautions, pressure ulcer prevention 3

Management of Cerebral Edema

• Monitor for signs of increased intracranial pressure, especially in large infarctions
• Early neurosurgical consultation for patients at risk of malignant cerebral edema 1
• Consider decompressive craniectomy for patients <60 years with large hemispheric infarctions and significant swelling, ideally within 48 hours 3

Secondary Prevention (Within 24-48 Hours)

• Initiate antiplatelet therapy (aspirin 325 mg initially, then 81-325 mg daily) within 24-48 hours if no contraindications and no thrombolysis 3
• Evaluate for stroke etiology: cardiac monitoring, echocardiography, additional vascular imaging as needed 1
• Begin risk factor modification: antihypertensives, statins, diabetes management, smoking cessation 1

Early Rehabilitation

• Initiate rehabilitation within 24-48 hours if patient is stable 3
• Multidisciplinary approach including physical, occupational, and speech therapy 3
• Special attention to language rehabilitation for aphasia 3

Common Pitfalls to Avoid

• Delaying neuroimaging - CT or MRI should be obtained immediately upon arrival
• Missing the time window for treatment - precise determination of symptom onset is critical
• Overlooking stroke mimics - consider conditions like seizures, migraine, hypoglycemia, or conversion disorder 1
• Inadequate blood pressure management - too aggressive lowering may worsen ischemia
• Delaying transfer when endovascular therapy is indicated at another facility 1
• Neglecting dysphagia screening before oral intake to prevent aspiration

Special Considerations for Left Hemispheric Stroke

• Communication strategies for patients with aphasia
• Early speech therapy consultation
• Assessment of decision-making capacity may be complicated by language deficits
• Increased risk of depression and cognitive impairment requiring early screening and intervention

By following this structured approach to left hemispheric stroke management, clinicians can optimize outcomes through rapid assessment, appropriate treatment selection, and comprehensive care throughout the acute and recovery phases.