Gregory W. Albers, MD, prepared useful Practice Aids pertaining to large hemispheric infarction for this CME activity titled “Large Hemispheric Infarction: Exploring the Latest Clinical Advances in the Diagnosis and Treatment.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/2YmCBwW. CME credit will be available until September 9, 2021.

1. Access the activity, “Large Hemispheric Infarction: Exploring the Latest Clinical
Advances in the Diagnosis and Treatment,” at PeerView.com/NDJ40
Management of Acute Ischemic
Stroke: AHA/ASA Guidelines1
PRACTICE AID
a
For intravenous eligibility criteria, see current AHA/ASA guidelines. b
Intracranial internal carotid artery or M1 occlusion. c
For DAWN and DEFUSE 3 criteria, see supplemental table 1 in reference.
AHA: American Heart Association; AIS: acute ischemic stroke; ASA: American Stroke Association; ASPECTS: Alberta Stroke Program Early CT Score; CTA: CT angiography; CTP: CT perfusion;
DWI: diffusion-weighted imaging; EVT: endovascular therapy; ICH: intracerebral hemorrhage; LHI: large hemispheric infarction; LKW: last known well; LVO: large vessel occlusion; mCTA: multiphase CT
angiography; MRA: magnetic resonance angiography; NCCT: noncontrast CT; NIHSS: National Institutes of Health Stroke Scale.
1. Ospel JM et al. J Am Coll Cardiol. 2020;75:1832-1843.
Suspected AIS
NIHSS ≥6
No ICH or
stroke mimic
IV alteplase if
indicateda
ICH
NCCT or MRI:
ICH and ASPECTS
mCTA or MRA
Imaging recommendation
LVOb
(includes LHI)
No LVO
No EVT
0-6 h from LKW
and ASPECTS ≥6
6-24 h from LKW
EVT
CTP or DWI: infarct core
quantification
EVT if DAWN/DEFUSE 3
criteria are fulfilledc

2. Treatment Strategies for Patients Who
Have a Large Hemispheric Infarction
PRACTICE AID
Access the activity, “Large Hemispheric Infarction: Exploring the Latest Clinical Advances in the Diagnosis
and Treatment,” at PeerView.com/NDJ40
A Timeline of Evidence-Based Therapies for Treating Patients With an LHI
Tissue plasminogen activator (tPA)1,2
• Initiate within <4.5 hours
• Increases survival in patients
experiencing a severe stroke
Endovascular thrombectomy3-9
• Initiate within 6 hours
(earlier is better)
• Improves patient outcome
over tPA alone
Antithrombotic therapy10
• Initiate within 48 hours
Decompressive craniectomy10
• Dramatically reduced mortality
in patients with a malignant
MCA infarction
• High likelihood of permanent
and severe disability
Antiosmotic therapy10
• Initiate 1-4 days for cerebral edema
• Mannitol and hypertonic saline are
reasonable choices; avoid steroids
and barbiturates

3. Treatment Strategies for Patients Who
Have a Large Hemispheric Infarction
AIS: acute ischemic stroke; AS: ankylosing spondylitis; COX-2: cyclooxygenase-2; JRA: juvenile rheumatoid arthritis; LHI: large hemispheric infarction; MCA: middle cerebral artery; MOA: mechanism of action; MS: multiple sclerosis; OA: osteoarthritis; RA: rheumatoid arthritis;
S1P: sphingosine-1-phosphate; SUR1: sulfonylurea receptor 1; TRPM4: transient receptor potential cation channel subfamily M member 4.
1. Jauch EC et al. Stroke. 2013;44:870-947. 2. Demchuk AM et al. Stroke. 2005;36:2110-2115. 3. Powers WJ et al. Stroke. 2015;46:3020-3035. 4. Campbell BC et al. N Engl J Med. 2015;372:1009-1018.5. Saver JL et al. N Engl J Med. 2015;372:2285-2295. 6. Jovin TG et al. N Engl J Med.
2015;372:2296-2306. 7. Nogueira RG et al. N Engl J Med. 2018;378:11-21. 8. Goyal M et al. N Engl J Med. 2015;372:1019-1030. 9. Albers GW et al. N Engl J Med. 2018;378:708-718. 10. Torbey MT et al. Neurocrit Care. 2015;22:146-164. 11. Stokum JA et al. Annu Rev Pharmacol Toxicol.
2020;60:291-309. 12. Vaprisol (conivaptan hydrochloride). Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021697s005lbl.pdf. 13. Gilenya (fingolimod). Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/
label/2019/022527s031lbl.pdf. 14. Celebrex (celecoxib). Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/020998s054lbl.pdf. 15. https://www.accessdata.fda.gov/scripts/opdlisting/oopd/detailedIndex.cfm?cfgridkey=20165393.
PRACTICE AID
Access the activity, “Large Hemispheric Infarction: Exploring the Latest Clinical Advances in the Diagnosis
and Treatment,” at PeerView.com/NDJ40
Managing Cerebral Edema: Potential Targets, Emerging Therapies, and Mechanisms of Action11
• Emerging therapy: conivaptan
– Currently indicated for hyponatremia12
• MOA: absorbs free water in kidneys
• Emerging therapy: fingolimod
– Currently indicated for relapsing MS13
• MOA: reduces vascular permeability
• Emerging therapy: celecoxib
– Currently indicated for OA, RA, JRA, AS,
acute pain, and primary dysmenorrhea14
• MOA: reduces inflammation
• Emerging therapy: glyburide
– Orphan desgination for severe edema
in patients who had an AIS15
• MOA: conducts monovalent cations
Target:
aquaporin
receptor
Target:
S1P
Target:
COX-2
Target:
SUR1/TRPM4