Monday, June 13, 2011


Stroke is a devastating disease. Not only does it kill, but for those who survive, it can leave behind severe disabilities, including inability to move ( bed-ridden ), inability to talk, inability to eat, inability to respond, all of the above, or some of the above. It is therefore a dreaded disease. It usually occurs in patients suffering from hypertension and diabetes. Of course, it is also more common in the older age group. In stroke ( or what some may now call, an acute brain attack ), the brain is suddenly deprived of blood flow, and so the brain cells die from lack of oxygen and nutrition. ( almost like what happens in the heart during a heart attack, therefore the name brain attack )
There are two main kinds of stroke. We call them hemorraghic stroke, when the artery supplyoing that area of the brain ruptures ( usually from a sudden rise in blood pressure ), and so the blood flows out of the blood vessel into the surrounding tissues, and cause pressure effects on the surrounding normal brain tissue, causing it also not to get enough blood flow as the surrounding tissues become compressed. ( The brain after all is enclosed in the bony skull that cannot expand to accommodate the blood leaking out from the ruptured brain artery. The other kind of stroke, is what we term the ischemic stroke. Ischemia is lack of blood supply. This form of stroke is due to blood clots, blocking off the artery preventing blood from flowing, like what happens in a heart attack. There are essentially two kinds of ischemic stroke. When the blockage is due to a small clot, sometimes that small blood clot can flow away, and so the blockage is acute but transient. We call this a minor stroke ( as if like a warning ). Sometimes the blockage is by a large blood clot and so the clot stays and cause a massive loss of blood supply to the brain tissue that it supplies. This is called an major ischemic stroke.
When a stroke presents, the most important thing is to recognise it and seek medical care. Again here, TIME IS BRAIN CELLS. Every minute that we waste, more brain cells are destroyed, and so worse is the outcome. Fortunately, when a major stroke occurs, it is easily recognisable. The patient will stop doing whatever he / she is doing as there is a sudden loss of brain function. If they are standing, they may collapse. If they are eating, they will drop whatever they are holding and cannot eat. If they are talking, they will suddenly lose their speech, of they will have difficulty finding the right words, or they will begin to slur. There will be sudden loss of brain function. The unfortunate ones are those patients who suffered a stroke while sleeping. No one knows, and so treatment can be delayed.
Quickly take him / her to the nearest medical center. There the doctors will quickly assess him, and confirm that a stroke has occurred. The blood pressure will be measured, the ECG done and the blood sugar measured, as these are all important pieces of information. Usually the medical center will alert the neurologist on call, and if there is a brain attack team, the brain attack team will be alerted. A CT scan, or MRI brain scan should be done. This will confirm the diagnosis, distinquish between a hemorraghic stroke and an ischemic stroke, and decide on the treatment strategy.
If this is a hemorraghic stroke ( red infarct ), the outcome is grave. A large bleeding and blood clot in the brain may necessitate brain surgery to remove the blood clot, which is compressing the normal brain tissue. In the acute phase, this can be very hazardous. Some times, when the brain is so swollen, after removing the blood clot, the brain wound cannot be safely closed, and so either the brain is left partially open, only for the wound to be closed later, or sometimes part of the brain may have to be sacrificed and removed, to make enough space to close the brain. All of these measures, are, in one word ugly and the outcome is usually bad ( as least those that I have seen ).
If the stroke is an ischemic stroke ( white infarct ), then the neurologist may advise treatment with thrombolytic agent ( clot buster like in a heart attack ). The time window for reperfusion ( re-establishing blood flow ) is about 3 hours from onset of symptoms. The neurological fraternity is studying if this time window could be extended to 4.5 hours? With the successful use of the IV thrombolytic agent, blood flow is re-established and blood will flow again, hopefully allowing the brain issue to recover, thereby reducing the brain deficit. In fact, this has been found to be so. With successful use of the IV thrombolytic agent, we see a 30% reduction in neurological deficit, over the next 3 months, when compared to those not given IV thrombolytics. But it is wellknown that IV thrombolytics may not improve survival.
In the meantime, the blood sugar should be optimised, and the BP controlled, not too low, and not too high.
After successful medical treatment, the patient should be rehabilitated, with physiotherapy, stroke counselling and medical therapy, including the use of anti-platelet agents idf it is an ischemic stroke.
Patients who have suffered a minor stroke, must know that it is a warning stroke, and will usually be followed by a major stroke so they must seek proper medical therapy to prevent a major stroke, including the use of anti-platelet agents, and good control of hypertension and diabetes.
Remember, recognise a stroke, and seek medical help as soon as possible. TIME IS BRAIN TISSUE.

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