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Cerebrovascular Surgery: The Three-Part Series on Stroke (II)
Stroke ranks as the third or fourth leading cause of death in Hong Kong and China, following cancer, heart disease, and infectious diseases. Among survivors of severe diseases, however, stroke remains the top cause of permanent disability.
Comprehensive Check-ups: A Key Method to Identify Hidden Stroke Risk Factors
In recent years, most stroke patients have appeared outwardly healthy, often middle-aged individuals who enjoy physical activities. They may assume that without congenital or acquired health conditions, regular exercise, a healthy diet, good sleep, and abstaining from smoking and drinking are enough to fully prevent stroke. However, this assumption often causes them to miss the crucial step of stroke prevention. Detailed and objective physical examinations, such as three-dimensional imaging of the carotid and cerebral arteries, are the most effective ways to detect the hidden "ticking time bomb" of stroke.
Strokes can strike suddenly, with no prior symptoms, leaving patients and their families unprepared. Recently, stroke has shown a trend towards affecting younger individuals. Congenital cerebrovascular conditions can lead to strokes in patients as young as four to ten years old, while those with acquired carotid or cerebral vascular issues may experience strokes as early as 28 or 29 years old. Additionally, patients between 20 and 50 years old who suffer neck vascular injuries from physical activities, neck massages, or improper spinal adjustments are particularly susceptible. In summary, successful emergency stroke treatment hinges on the combined factors of timing, location, and human intervention.
Timing
Research suggests a substantial difference in emergency outcomes when a stroke occurs during the daytime work hours of 9 am to 5 pm versus the early hours of 3 to 4 am when most people are asleep. The ability to respond during the "golden hour" window is critical.
Location
The location of the patient during the onset is essential. The availability of specialists and appropriate equipment for acute stroke treatment can significantly impact the patient’s survival and recovery potential within the golden hour.
Human Intervention
The presence and actions of friends, family, or the first attending doctor are crucial when a stroke occurs. Friends and family play an essential role in quickly and effectively seeking help, transporting the patient to a facility with 24-hour MRI and CT scanning services, and ensuring the presence of neurosurgeons trained in cerebrovascular treatment. First responders with neurosurgical expertise can directly conduct the necessary diagnostic, triage, and brain-saving procedures within the golden hour, without requiring time-consuming referrals to other specialists. The following case study illustrates the importance of timing, location, and human intervention in emergency stroke treatment.
Case Study
Mr. Law, aged 50, maintained a healthy lifestyle, with no smoking or drinking habits. Six years ago, after staying home due to a cold and fever, he awoke from a nap to find weakness in his left limbs. His sister promptly called for an ambulance, which took him to the nearest public hospital. A CT scan indicated no brain bleeding but could not reveal whether his carotid or cerebral arteries were blocked. CT scanning offers limited value in diagnosing ischaemic stroke since it cannot detect early cerebral ischaemia as quickly as an MRI scan. Furthermore, a CT scan without contrast agents is unable to identify blockages in the carotid or cerebral arteries. At that time, MRI was not a standard procedure in public hospitals for stroke emergencies, nor was it available around the clock.
Despite these limitations, the attending non-specialist doctor presumed that Mr. Law had suffered an ischaemic stroke due to carotid or cerebral artery occlusion, requiring urgent vascular recanalisation. However, the critical 3-4.5 hour window for intravenous thrombolytic medication had passed due to delays in every aspect of the emergency process, including waiting for the ambulance, the journey to the hospital, triage in the emergency room, waiting for CT imaging, and the initial diagnosis by the non-specialist doctor on duty.
Even if the golden window had not elapsed, Mr. Law’s stroke involved large blood vessel blockages in the carotid and cerebral arteries, which intravenous thrombolytics alone could not resolve. This scenario would have required the then-novel emergency intervention of mechanical thrombectomy—a procedure not available in public hospitals at the time. Mr. Law’s sister sought help from a private specialist.
The first step in the private hospital was to conduct an urgent MRI, which confirmed that blood clots were blocking major arteries in Mr. Law's right carotid and cerebral regions, resulting in cerebral oedema and loss of consciousness as well as left-sided limb weakness. The neurosurgeon immediately performed an emergency procedure by threading a hair-thin catheter through Mr. Law’s right thigh, through the femoral artery in his groin, and then guiding it up through the abdominal and thoracic aorta to reach the occluded arteries in the right carotid and cerebral arteries. This emergency mechanical thrombectomy successfully removed all clots within an hour, restoring blood flow. As a result, the symptoms of cerebral ischaemia began to resolve immediately. Upon awakening from general anaesthesia, Mr. Law’s cognitive and motor functions gradually improved. He was later transferred to a public hospital for continued rehabilitation. Six years on, Mr. Law leads a normal life, aside from some minor hand stiffness, and continues to work and enjoy life with his family. Though this case occurred six years ago, public hospital stroke emergency services have since improved, offering better treatment options for patients.
MRI results show complete blockage of Mr. Law’s right carotid and cerebral arteries by blood clots.
A vascular stent was placed to expand the narrowed artery and prevent future strokes.