performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11. 4. Facial palsy: Ask - or use pantomime to encourage - the patient to show teeth or 0 = Normal symmetrical movements. _____ 1 = Minor paralysis (flattened nasolabial raise eyebrows and close eyes. Score fold, asymmetry on smiling). symmetry of grimace in response to noxious stimuli in the poorly responsive or non- https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 23/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate comprehending patient. If facial 2 = Partial paralysis (total or near-total trauma/bandages, orotracheal tube, tape or paralysis of lower face). other physical barriers obscure the face, these should be removed to the extent 3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face). possible. 5. Motor arm: The limb is placed in the 0 = No drift; limb holds 90 (or 45) degrees appropriate position: extend the arms for full 10 seconds. (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice hit bed or other support. 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) and pantomime, but not noxious stimulation. Each limb is tested in turn, degrees, drifts down to bed, but has some effort against gravity. beginning with the non-paretic arm. Only in _____ the case of amputation or joint fusion at the shoulder, the examiner should record the 3 = No effort against gravity; limb falls. score as untestable (UN), and clearly write the explanation for this choice. 4 = No movement. UN = Amputation or joint fusion, explain:________________ 5a. Left arm 5b. Right arm 6. Motor leg: The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not 0 = No drift; leg holds 30-degree position for full 5 seconds. 1 = Drift; leg falls by the end of the 5-second period but does not hit bed. 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity. noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint _____ 3 = No effort against gravity; leg falls to fusion at the hip, the examiner should record the score as untestable (UN), and bed immediately. 4 = No movement. clearly write the explanation for this choice. UN = Amputation or joint fusion, explain:________________ 6a. Left leg 6b. Right leg 7. Limb ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. 0 = Absent. _____ 1 = Present in one limb. Test with eyes open. In case of visual defect, 2 = Present in two limbs. ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 24/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate are performed on both sides, and ataxia is UN = Amputation or joint fusion, scored only if present out of proportion to explain:________________ weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 8. Sensory: Sensation or grimace to pinprick when tested, or withdrawal from noxious 0 = Normal; no sensory loss. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is affected side; or there is a loss of superficial scored as abnormal and the examiner pain with pinprick, but patient is aware of being touched. should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, and leg. score of 2, "severe or total sensory loss," should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If _____ the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 9. Best language: A great deal of information about comprehension will be obtained during the preceding sections of 0 = No aphasia; normal. _____ 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant the examination. For this scale item, the patient is asked to describe what is limitation on ideas expressed or form of happening in the attached picture, to name the items on the attached naming sheet and expression. Reduction of speech and/or comprehension, however, makes to read from the attached list of sentences. conversation about provided materials difficult or impossible. For example, in Comprehension is judged from responses here, as well as to all of the commands in conversation about provided materials, examiner can identify picture or naming the preceding general neurological exam. If visual loss interferes with the tests, ask the card content from patient's response. patient to identify objects placed in the hand, repeat, and produce speech. The 2 = Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by intubated patient should be asked to write. The patient in a coma (item 1a=3) will automatically score 3 on this item. The the listener. Range of information that can https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 25/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate examiner must choose a score for the be exchanged is limited; listener carries patient with stupor or limited cooperation, burden of communication. Examiner cannot but a score of 3 should be used only if the patient is mute and follows no one-step identify materials provided from patient response. commands. 3 = Mute, global aphasia; no usable speech or auditory comprehension. 10. Dysarthria: If patient is thought to be 0 = Normal. normal, an adequate sample of speech must be obtained by asking patient to read or 1 = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can repeat words from the attached list. If the patient has severe aphasia, the clarity of be understood with some difficulty. 2 = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence articulation of spontaneous speech can be rated. Only if the patient is intubated or has _____ of or out of proportion to any dysphasia, or is mute/anarthric. other physical barriers to producing speech, the examiner should record the score as untestable (UN), and clearly write an UN = Intubated or other physical barrier, explain:________________ explanation for this choice. Do not tell the patient why he or she is being tested. 11. Extinction and inattention (formerly neglect): Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are 0 = No abnormality. 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities. 2 = Profound hemi-inattention or extinction to more than one modality; normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. _____ does not recognize own hand or orients to only one side of space. _____ Adapted from: Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale. Extension to non- neurologists in the context of a clinical trial. Stroke 1997; 28:307. Graphic 61698 Version 8.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 26/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate CT large right hemispheric infarction Head CT showing a large acute right middle cerebral artery territory infarction. CT: computed tomography. Image courtesy of Alejandro Rabinstein, MD. Graphic 120602 Version 1.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 27/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate ASPECTS study form The ASPECTS value is calculated from two standard axial CT cuts: one at the level of the thalamus and basal ganglia (left), and one just rostral to the basal ganglia (right). A: anterior circulation; P: posterior circulation; C: caudate; L: lentiform; IC: internal capsule; I: insular ribbon; MCA: middle cerebral artery; M1: anterior MCA cortex; M2: MCA cortex lateral to insular ribbon; M3: posterior MCA cortex; M4, M5, and M6 are anterior, lateral, and posterior MCA territories immediately superior to M1, M2, and M3, rostral to basal ganglia Reproduced with permission from: Barber, PA, Demchuk, AM, Zhang, J, Buchan, AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000; 355:1670. Copyright 2000 The Lancet. Graphic 72190 Version 1.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 28/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate MRI large left hemispheric infarction Brain MRI showing a large acute left hemisphere infarction on diffusion-weighted imaging. MRI: magnetic resonance imaging. Reproduced with permission. Copyright 2014 American Heart Association, Inc. Graphic 120601 Version 10.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 29/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate Brain imaging findings before and after hemicraniectomy in malignant MCA infarction (A) Axial cranial CT seven hours after stroke onset. Arrows indicate the margins of the infarction. (B) Axial diffusion-weighted MRI in the acute phase of malignant MCA infarction. (C) and (D) Axial CT on day two after symptom onset after hemicraniectomy. Note that despite decompressive surgery, a compression of the ventricular system with slight midline shifting (C; axial CT at the level of the basal ganglia) and a beginning outward swelling (D; axial CT at the supraventricular level) of the ischemic brain tissue is evident. https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 30/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate CT: computed tomography; MCA: middle cerebral artery; MRI: magnetic resonance imaging. Reproduced from: Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009; 8:949. Illustration used with the permission of Elsevier Inc. All rights reserved. Graphic 120610 Version 1.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 31/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate Decompressive hemicraniectomy for malignant right MCA infarction (Panel A) Head CT scan of a large right MCA infarction before hemicraniectomy. (Panel B) Head CT scan after decompressive hemicraniectomy. MCA: middle cerebral artery; CT: computed tomography. Images courtesy of Alejandro Rabinstein, MD. Graphic 120612 Version 1.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 32/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate Decompressive hemicraniectomy for malignant left MCA infarction (Panel A) Head CT scan of a large left MCA infarction before hemicraniectomy. (Panel B) Head CT scan after decompressive hemicraniectomy. MCA: middle cerebral artery; CT: computed tomography. Images courtesy of Alejandro Rabinstein, MD. Graphic 120611 Version 1.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 33/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate Modified Rankin Scale Score Description 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 6 Dead Reproduced with permission from: Van Swieten JC, Koudstaa PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604. Copyright 1988 Lippincott Williams & Wilkins. Graphic 75411 Version 13.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 34/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate Functional outcome after decompressive hemicraniectomy for malignant midd cerebral artery territory infarction (A) Functional outcome after hemicraniectomy and after medical (conservative) treatment according to the mRS score. (B) Functional outcome after hemicraniectomy and after medical (conservative) treatment according to the mRS score (six months data, five trials). mRS: modified Rankin Scale. https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 35/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate From: Alexander P, Heels-Ansdell D, Siemieniuk R, et al. Hemicraniectomy versus medical treatment with large MCA infarct: a review and meta-analysis. BMJ Open 2016; 6:e014390. Reproduced with permission from BMJ Publishing Group Ltd. Copyright 2016. Graphic 111928 Version 1.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 36/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate General eligibility criteria for three major trials (DECIMAL, DESTINY, HAMLET) evaluating decompressive hemicraniectomy for malignant middle cerebral artery territory infarction Inclusion criteria: Age 18 to 60 years* Clinical deficits suggestive of infarction in the territory of the MCA with a NIHSS score 16 Decrease in the level of consciousness to a score of 1 on item 1a of the NIHSS Signs on brain CT of an infarct of 50 percent of the MCA territory, with or without additional infarction in the territory of the ipsilateral anterior or posterior cerebral artery, or infarct volume 3 >145 cm on diffusion-weighted brain MRI Time from symptom onset to start of surgical decompression <48 hours Written informed consent by the patient or a legal representative Exclusion criteria: Prestroke mRS score 2 Both pupils fixed and dilated Contralateral ischemia or other brain lesion that could affect outcome Space-occupying hemorrhagic transformation of the infarct Life expectancy <3 years Other serious illness that could affect outcome Known coagulopathy or systemic bleeding disorder Contraindication for anesthesia mRS: modified Rankin Scale; MCA: middle cerebral artery; NIHSS: National Institutes of Health Stroke Scale. Four other trials included patients over age 60. Data from: 1. Vahedi K, Vicaut E, Mateo J, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 2007; 38:2506. 2. J ttler E, Schwab S, Schmiedek P, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 2007; 38:2518. 3. Hofmeijer J, Kappelle LJ, Algra A, et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 37/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate open, randomised trial. Lancet Neurol 2009; 8:326. 4. Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6:215. Graphic 108328 Version 2.0 https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 38/39 7/6/23, 12:02 PM Malignant cerebral hemispheric infarction with swelling and risk of herniation - UpToDate Contributor Disclosures David Roh, MD Grant/Research/Clinical Trial Support: Biogen [Large hemispheric ischemic stroke]. All of the relevant financial relationships listed have been mitigated. Rishi Gupta, MD Grant/Research/Clinical Trial Support: Rapid Medical [Endovascular stroke therapy]; Stryker Neurovascular [Endovascular stroke therapy]; ZOLL Medical Corporation [Stroke]. Consultant/Advisory Boards: Cerenovous [Stroke]; Rapid Medical [Endovascular stroke therapy]; Stryker Neurovascular [Endovascular stroke therapy]. All of the relevant financial relationships listed have been mitigated. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. Alejandro A Rabinstein, MD Grant/Research/Clinical Trial Support: Chiesi [Small investigator-initiated project]. Consultant/Advisory Boards: AstraZeneca [Secondary stroke prevention]; Brainomix [AI for stroke diagnostics]; Novo Nordisk [Stroke risk]; Shionogi [Stroke neuroprotection]. Other Financial Interest: Boston Scientific [Adverse event adjudication committee member for stroke risk reduction device in patients with atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/malignant-cerebral-hemispheric-infarction-with-swelling-and-risk-of-herniation/print 39/39