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. 2023 Dec 20;136(24):2912-2922.
doi: 10.1097/CM9.0000000000002885. Epub 2023 Nov 29.

Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction

Xing Hua  1 , Ming Liu  1   2 , Simiao Wu  1   2
Affiliations

Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction

Xing Hua et al. Chin Med J (Engl). .

Abstract

Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.

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Conflict of interest statement

None.

Figures

Figure 1
Figure 1
Operational definitions of severe stroke, large infarction, malignant brain edema, and critically severe stroke. CT: Computed tomography; CTA: CT angiography; DWI: Diffusion weighted imaging; GCS: Glasgow coma score; MCA: Middle cerebral artery; NHISS: National Institutes of Health Stroke Scale score; pc-ASPECTS: posterior circulation Acute Stroke Prognosis Early CT Score.
Figure 2
Figure 2
Management of patients with severe stroke, large infarction, malignant brain edema, or other critically severe stroke. ASPECTS: Alberta Stroke Program Early Computed Tomographic Score; CT: Computed tomography; DWI: Diffusion weighted imaging; GCS: Glasgow coma score; MCA: Middle cerebral artery; NHISS: National Institutes of Health Stroke Scale score.
See this image and copyright information in PMC

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