Large Hemispheric Stroke

A 72-year-old female was brought to the emergency with a history of right-sided weakness and inability to speak which was discovered at 5 pm when her family members returned from work. She was well when she had breakfast with them at 7 am. The family said that she had not cooked the morning meal that day. She did not have a significant medical history except that she was on losartan 50 mg once daily for hypertension. On examination, her vital signs were stable. She had global aphasia, right homonymous hemianopia, forced eye deviation to the left side, right upper motor neuron-type facial nerve palsy, and complete plegia of the right upper and lower limbs. Her National Institutes of Health Stroke Scale (NIHSS) score was 22. Her computed tomography (CT) scan done at presentation did not show any abnormality (Fig. 14.1). Due to the lack of facility for mechanical intervention, she was managed conservatively. However, on day 2, her level of consciousness deteriorated. Her repeat CT scan of the head then showed a large hemispheric infarct with significant mass effect (Fig. 14.2). The next day, her level of consciousness further deteriorated and she had to be intubated to maintain airway and prevent aspiration. Further, CT scan of the head was repeated which showed massive midline shift (Fig. 14.3). She underwent decompressive hemicraniectomy the same day, and subsequently improved to a modified Rankin Score (mRS) of 5 after a long stay in the intensive unit care (Fig. 14.4).