Acute Left Hemispheric Infarct Symptoms and Management

Cardinal Clinical Features

The American Heart Association recommends recognizing right-sided weakness, right-sided sensory loss, and aphasia as typical symptoms of a moderate-sized acute left hemispheric infarct, with the specific symptom constellation depending on the affected vascular territory 1
Right-sided weakness occurs in approximately 77% of acute stroke presentations, with upper extremity motor deficits being a hallmark finding 2
The American College of Cardiology notes that right-sided paresthesia or sensory loss accompanies motor deficits in left MCA territory infarction 1
Aphasia is expected in left hemisphere infarcts affecting language-dominant areas, occurring in approximately 23% of acute stroke presentations, according to the American Academy of Neurology 1, 2
Left homonymous hemianopsia can occur with left hemisphere infarction involving posterior territories, as stated by the American Heart Association 1

The American Stroke Association recommends admitting patients with moderate-sized infarcts to intensive care or stroke units with neuromonitoring capabilities, attended by neurointensivists or vascular neurologists 3, 2
Early neurosurgical consultation should be obtained to facilitate planning for potential decompressive surgery if deterioration occurs, as suggested by the American Association of Neurological Surgeons 3, 2
Frequent assessment of level of arousal and pupillary function is necessary to detect early signs of cerebral swelling, according to the Neurocritical Care Society 2
Frank hypodensity on head CT within the first 6 hours, involvement of one-third or more of the MCA territory, and early midline shift predict cerebral edema (Class I; Level of Evidence B), as stated by the American Heart Association 4, 3
MRI DWI volumes ≥80 mL within 6 hours predict rapid fulminant course (Class I; Level of Evidence B), according to the American College of Radiology 4, 3
Ipsilateral pupillary dysfunction with varying degrees of mydriasis is the most commonly described sign of deterioration, as noted by the American Academy of Neurology 5
Do not delay neurosurgical consultation, as early involvement is critical, particularly in the first 2-5 days, as recommended by the American Association of Neurological Surgeons 3, 6