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New Concepts and Recent Advances in Stroke Management
There must be a revolutionary shift in the traditional perception of cerebrovascular accidents, particularly in the passive acceptance of progressive neurological deterioration and the perceived inevitability of disability or death.
The emerging term "brain attack" reflects a crucial change in understanding—stroke is not a random or unpreventable event. Much like a heart attack, stroke is now recognised as a medical condition that can be prevented, treated, and in some cases, even reversed. It need not result in permanent neurological damage. With therapeutic approaches increasingly mirroring those used in myocardial infarction, patients suffering from acute ischaemic stroke can now anticipate significantly improved outcomes and reduced suffering.
Improving dietary habits, increasing physical activity, maintaining a healthy body weight, and abstaining from smoking and alcohol are all effective measures for preventing stroke.
Time is of the Essence
A stroke refers to the sudden onset of neurological dysfunction caused by a vascular event. There are two primary types of stroke: ischaemic stroke, which accounts for approximately 87% of all cases in Western countries (around 70% in Hong Kong), and haemorrhagic stroke, comprising the remaining 13% (approximately 30% in Hong Kong). Despite being less common, haemorrhagic strokes carry a higher mortality rate, contributing to over 30% of all stroke-related deaths. Importantly, stroke can affect individuals of any age, ethnicity, or gender.
In an ischaemic stroke, a blood vessel in the brain becomes obstructed, disrupting cerebral blood flow and depriving affected brain regions of oxygen. The oxygen-starved brain tissue enters a state of metabolic failure, ceasing normal function and giving rise to clinical symptoms.
Acute ischaemic stroke (AIS) is a critical medical emergency in which prompt intervention is essential to minimise neurological damage. Every minute of untreated large-vessel stroke results in the loss of approximately 1.9 million neurons (equivalent to 32,000 neurons per second and 120 million per hour), along with 14 billion synapses and 7.5 miles of myelinated fibres. It is crucial to recognise that delays in treatment significantly increase the risk of irreversible brain injury. Without timely reperfusion, infarcted brain tissue continues to deteriorate, diminishing the potential benefits of medical therapy. Approximately three hours after onset, irreversible damage to brain cells often occurs, frequently resulting in death. This underlines the critical importance of administering intravenous thrombolysis with rtPA within the first three hours of symptom onset—indeed, time is brain.
Given the time-sensitive nature of stroke, prevention through risk factor screening and control remains the most effective strategy. Equally important is public awareness of stroke symptoms and the ability to access emergency medical services swiftly, both of which are vital to improving clinical outcomes. Fortunately, advances in neurointerventional techniques now allow for effective treatment of AIS within a therapeutic window of up to eight hours from symptom onset.
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Stroke Screening and Prevention
During clinical screening, physicians begin by conducting a thorough medical interview to assess the patient’s own perception of their stroke risk. This helps evaluate the individual’s awareness of their personal health status and family medical history.
The screening process includes:
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Clinical Assessment: A systematic review of the patient’s personal and familial history of chronic conditions such as stroke, diabetes, hyperlipidaemia, hypertension, and cardiovascular disease.
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Laboratory Testing: Comprehensive biochemical analysis of blood glucose metabolism, lipid profile, coagulation function, as well as liver and renal function.
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Imaging Studies: Magnetic resonance imaging (MRI) of the brain, alongside vascular imaging of the carotid and vertebral arteries, is arranged for structural and perfusion assessment.
Building on the outcomes of screening, the management and surgical treatment of acute stroke depend on three critical factors: time, location, and personnel.
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Time: Accurately identifying the time of symptom onset and seeking emergency care without delay;
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Location: Receiving evaluation and treatment at a hospital equipped with CT, MRI, and angiographic facilities;
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Personnel: Consulting a neurovascular specialist capable of delivering comprehensive treatment.
Therapeutic intervention—whether pharmacological or interventional—within the first three hours is vital for survival and strongly influences prognosis. Following clinical assessment, if no contraindications to intravenous recombinant tissue plasminogen activator (iv rtPA) are present, this remains the first-line treatment in settings where Neuro-PCI is not available.
In clinical reality, over 90% of patients with acute ischaemic stroke fail to benefit from iv rtPA either due to delayed arrival at the emergency department beyond two hours of symptom onset or due to misdiagnosis on initial CT imaging. It is therefore imperative to provide patients with thorough information regarding both the risks and benefits of treatment, and to obtain informed consent accordingly.
Neurosurgical Intervention
Surgical Management of Haemorrhagic Complications Induced by iv rtPA
Approximately 6% of patients receiving intravenous rtPA develop intracranial haemorrhage, resulting in more severe cerebral injury. The bleeding tendency associated with rtPA makes neurosurgical rescue procedures more challenging. While surgery may be life-saving, patients remain at risk of significant disability or even prolonged coma.
Decompressive Craniectomy: Craniectomy +/- Lobectomy
Extensive strokes can cause marked cerebral oedema, leading to secondary damage to surrounding brain tissue. This phenomenon most commonly occurs in infarctions of the middle cerebral artery territory and is therefore termed "malignant cerebral infarction" due to its poor prognosis. Although pharmacological measures can alleviate intracranial pressure, some patients require decompressive craniectomy (temporary removal of a section of the skull) or lobectomy to excise necrotic brain tissue. This procedure significantly reduces mortality risk, though many survivors are left with lasting neurological deficits.
In summary, effective stroke management necessitates a multidisciplinary approach, encompassing risk screening, early recognition, and prompt treatment. Emerging strategies not only reduce the incidence of stroke but also improve clinical outcomes, enabling patients to achieve better recovery and quality of life.
During an ischaemic stroke, a blood vessel in the brain becomes obstructed, disrupting blood flow and preventing oxygen from reaching the affected region of the brain.
Up to 80% of strokes are preventable, primarily through effective risk factor management. From a lifestyle perspective, individuals are advised to adopt healthier eating habits, increase physical activity, maintain a healthy weight, cease smoking, limit alcohol consumption, and avoid substance misuse.
From a medical standpoint, preventive strategies include the use of antihypertensive agents to control blood pressure, as well as medications to manage cholesterol and blood glucose levels. Patients with atrial fibrillation should receive anticoagulation therapy, while those with a history of stroke should be placed on antiplatelet therapy. In cases involving structural abnormalities—such as carotid artery stenosis—referral to a neurovascular specialist is recommended to determine the need for prophylactic surgical intervention.