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Cerebrovascular Surgery: The Three-Part Series on Stroke (I)
Cerebrovascular surgery is a specialised field within neurosurgery, responsible for the prevention, emergency care, and rehabilitation of strokes, forming what is commonly referred to as the “three-part approach” to stroke management. This article, drawing from clinical experience and case studies, will explore the first part of stroke management: prevention. We will also discuss common misconceptions about stroke prevention and the complications that may arise from congenital cerebrovascular anomalies.
Many individuals underestimate the risks associated with strokes and have various misconceptions about prevention. The following points aim to clarify these misunderstandings.
Exercise, diet, managing the “three highs,” and blood tests alone cannot fully prevent strokes.
Many people believe that regular exercise, a healthy diet, abstaining from smoking and alcohol, and managing the “three highs” (hypertension, hyperglycaemia, and hyperlipidaemia) through simple electrocardiograms and blood tests for glucose and cholesterol are sufficient to prevent strokes. However, this is an overestimation of the efficacy of basic preventive measures and an underestimation of the complexity of stroke etiology. The majority of stroke patients suffer strokes due to congenital or acquired abnormalities in the brain or neck vessels, which are structural issues within the vasculature. While basic preventive measures can reduce and delay the development of acquired vascular diseases, they are not designed to detect pre-existing congenital or previously acquired vascular abnormalities.
Observations reveal that many stroke patients exhibit normal cholesterol levels in their blood, highlighting that blood tests are not a foolproof method for stroke prevention. Cholesterol in the bloodstream behaves like oil in a bowl of soup; it floats on the surface or adheres to the sides of the bowl. Similarly, when a syringe is inserted into the soup, it may not capture the oil. Cholesterol adheres to the walls of blood vessels, causing vascular disease, narrowing, and blockages, which can lead to ischaemic strokes. Additionally, cholesterol can weaken vessel walls, resulting in aneurysms and haemorrhagic strokes.
The human body is akin to a car, which, by law, requires regular maintenance to ensure that all its parts are functioning correctly and that no safety issues arise while driving. Blood tests are akin to examining a car’s fuel, which does not provide insight into the wear and tear or safety of the vehicle’s internal components. Therefore, to prevent cerebrovascular accidents such as strokes, it is essential not to rely solely on blood tests but to employ three-dimensional angiography to conduct a comprehensive assessment of the body’s vasculature.
Strokes can occur at any age and are not exclusive to the elderly or middle-aged.
Now, let’s discuss Congenital Cerebral Arteriovenous Malformation (AVM). Many believe that strokes are closely linked to age, which is a misconception. Strokes can affect individuals of any age, even children, because strokes are caused by cerebrovascular diseases, and every person, regardless of age, has the potential to develop congenital or acquired cerebrovascular conditions. In children and adolescents, haemorrhagic strokes can result from congenital AVM.
Case Study: A Four-Year-Old Child
A four-year-old boy, previously healthy and symptom-free, suddenly experienced severe head pain while out shopping with his mother, followed by a rapid loss of consciousness. Upon hospitalisation, he was diagnosed with a ruptured congenital AVM, leading to a severe haemorrhagic stroke. Although he was saved from the brink of death, the stroke caused irreversible damage to his brain, resulting in severe disability. He remains bedridden and unable to communicate.
Case Study: Pregnant Women
Two young women, aged 15 and 16, along with a 39-year-old woman, all previously healthy and without any history of headaches, suddenly suffered severe haemorrhagic strokes at different stages of pregnancy (early, mid, and late). After experiencing excruciating headaches, they quickly lost consciousness. Emergency craniotomies were performed to evacuate the haematoma and reduce intracranial pressure. Both young women, along with their babies, made a full recovery without any lasting effects. However, the 39-year-old woman, while her baby survived, remained in a vegetative state and passed away after five years in a coma.
Stroke Prevention and Cerebrovascular Screening: The First Step
Case Study: Defusing the Bomb Before it Explodes
A 16-year-old boy and a 56-year-old man underwent detailed health examinations despite being asymptomatic. Three-dimensional angiography revealed congenital cerebral arteriovenous malformations in both patients. Following consultation with specialists and a period of observation and conservative treatment, they underwent minimally invasive endovascular surgery combined with radiation therapy. The abnormal vessels were successfully treated, effectively defusing the “brain bomb” they were born with and significantly reducing the risk of future haemorrhagic strokes.
Conclusion
From the above cases in cerebrovascular surgery, it is clear that congenital cerebral arteriovenous malformations, when detected early through three-dimensional angiography, can be effectively treated by neurosurgeons before symptoms manifest, thereby preventing future tragedies.
Three-dimensional cerebral angiography screening in a physical examination.
A severe haemorrhagic stroke caused by the rupture of a congenital cerebral arteriovenous malformation.
Three-dimensional cerebral angiography revealed a congenital arteriovenous malformation in the left brain.