Neurocritical Care

, Volume 22, Issue 1, pp 146–164 | Cite as

Evidence-Based Guidelines for the Management of Large Hemispheric Infarction

A Statement for Health Care Professionals from the Neurocritical Care Society and the German Society for Neuro-Intensive Care and Emergency Medicine
  • Michel T. TorbeyEmail author
  • Julian Bösel
  • Denise H. Rhoney
  • Fred Rincon
  • Dimitre Staykov
  • Arun P. Amar
  • Panayiotis N. Varelas
  • Eric Jüttler
  • DaiWai Olson
  • Hagen B. Huttner
  • Klaus Zweckberger
  • Kevin N. Sheth
  • Christian Dohmen
  • Ansgar M. Brambrink
  • Stephan A. Mayer
  • Osama O. Zaidat
  • Werner Hacke
  • Stefan Schwab
Review Article


Large hemispheric infarction (LHI), also known as malignant middle cerebral infarction, is a devastating disease associated with significant disability and mortality. Clinicians and family members are often faced with a paucity of high quality clinical data as they attempt to determine the most appropriate course of treatment for patients with LHI, and current stroke guidelines do not provide a detailed approach regarding the day-to-day management of these complicated patients. To address this need, the Neurocritical Care Society organized an international multidisciplinary consensus conference on the critical care management of LHI. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. The panel devised a series of clinical questions related to LHI, and assessed the quality of data related to these questions using the Grading of Recommendation Assessment, Development and Evaluation guideline system. They then developed recommendations (denoted as strong or weak) based on the quality of the evidence, as well as the balance of benefits and harms of the studied interventions, the values and preferences of patients, and resource considerations.


Large malignant stroke Large hemispheric infarction Cerebral edema Hemicraniectomy Critical care management 



We would like to thank Mathias Luedcke for his help with literature search and the neurocritical care society administrative staff for their administrative support.

Conflict of interest

Michel T Torbey has received speaker honorarium from Genentech, support from NIH. Julian Bösel has received speaker honoraria and travel support from Covidien, Sedana Medical, and Orion Pharma. Denise H. Rhoney declares that she has no conflict of interest. Fred Rincon declares that he has research and salary Support from the American Heart Association (12CRP12050342). He has also received consultant fees from Bard Medical Inc. Dimitre Staykov declares that he has no conflict of interest. Arun Amar declares that he has no conflict of interest. Panayiotis Varelas have participated in Advisory Boards of Pfizer and UCB. Eric Jüttler has received a speaker´s honorarium from BMS/Pfizer, a consultant´s honorarium from Boehringer Ingelheim, and a research grant from the German Research Foundation (Deutsche Forschungsgemeinschaft). DaiWai Wilson declares that he has no conflict of interest. Hagen B. Huttner declares that he has no conflict of interest. Klaus Zweckberger declares that he has no conflict of interest. Kevin N Sheth declares that he received research support from Remedy Pharmaceuticals, Inc for GAMES-RP. Christian Dohmen declares that he has no conflict of interest. Ansgar M Brambrink is Co-PI on an investigator-initiated multicenter trial that is funded by Karl Storz America, Culver City, CA. He also receives research funds from the International Anesthesia Research Society (PI; laboratory experiments), the National Institutes of Health (Site PI; laboratory experiments). Stephan Mayer declares that he has no conflict of interest. Osama O. Zaidat declares that he is on advisory board/consultant/speaker: Stryker, Covidien, and Penumbra, Co-Investigator for Therapy Ischemic Stroke Trial. Werner Hacke declares that he has no conflict of interest. Stefan Schwab declares that he has no conflict of interest.


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Copyright information

© All content, design text and other materials are copyrighted by the Neurocritical Care Society (NCS) 2015

Authors and Affiliations

  • Michel T. Torbey
    • 1
    Email author
  • Julian Bösel
    • 2
  • Denise H. Rhoney
    • 3
  • Fred Rincon
    • 4
  • Dimitre Staykov
    • 5
  • Arun P. Amar
    • 6
  • Panayiotis N. Varelas
    • 7
  • Eric Jüttler
    • 18
  • DaiWai Olson
    • 8
  • Hagen B. Huttner
    • 9
  • Klaus Zweckberger
    • 10
  • Kevin N. Sheth
    • 11
  • Christian Dohmen
    • 12
  • Ansgar M. Brambrink
    • 13
  • Stephan A. Mayer
    • 14
  • Osama O. Zaidat
    • 15
  • Werner Hacke
    • 16
  • Stefan Schwab
    • 17
  1. 1.Cerebrovascular and Neurocritical Care Division, Department of Neurology and NeurosurgeryThe Ohio State University Wexner Medical Center Comprehensive Stroke CenterColumbusUSA
  2. 2.Department of NeurologyUniversity of Heidelberg HeidelbergGermany
  3. 3.Division of Practice Advancement and Clinical EducationUNC Eshelman School of PharmacyChapel HillUSA
  4. 4.Division of Critical Care and Neurotrauma, Department of Neurological SurgeryThomas Jefferson UniversityPhiladelphiaUSA
  5. 5.Department of NeurologyUniversity of Erlangen-NurembergErlangenGermany
  6. 6.Department of NeurosurgeryUniversity of Southern CaliforniaLos AngelesUSA
  7. 7.Neurocritical Care DivisionHenry Ford HospitalDetroitUSA
  8. 8.University of Texas SouthwesternDallasUSA
  9. 9.Department of NeurologyUniversity of Erlangen-NurembergErlangenGermany
  10. 10.Department of NeurosurgeryUniversity of HeidelbergHeidelbergGermany
  11. 11.Division of Neurocritical Care and Emergency Neurology, Department of Neurology, and Neurosciences Intensive Care UnitYale School of Medicine & Yale New Haven HospitalNew HavenUSA
  12. 12.Department of NeurologyUniversity of CologneCologneGermany
  13. 13.Department of Anesthesiology and Perioperative Medicine, Neurology and Neurological SurgeryOregon Health and Science UniversityPortlandUSA
  14. 14.Institute for Critical Care Medicine, Mount Sinai Health SystemIcahn School of Medicine at Mount SinaiNew YorkUSA
  15. 15.Neurointerventional ProgramMedical College of WisconsinMilwaukeeUSA
  16. 16.Department of NeurologyUniversity of HeidelbergHeidelbergGermany
  17. 17.Department of Neurology University of Erlangen-NurembergErlangenGermany
  18. 18.Department of NeurologyOstalb-Klinikum Aalen AalenGermany

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