Signs and symptoms of stroke includes sudden onset of hemiplegia, monoplegia or paraplegia with or without facial weakness, sudden aphasia, sudden loss of consciousness or sudden onset of homonymous hemianopia. Knowing these signs one can easily identify that the particular patient had stroke. If the symptoms recover faster within few minutes to 24hrs then the patient had TIA which is actually warning sign of major stroke and these patients should be evaluated properly. Once we identify stroke it becomes important to get imaging done to classify stroke whether it is ischemic stroke or hemorrhagic stroke. One can directly do MRI where diffusion and perfusion can be done to identify viable tissue by diffusion/ perfusion mismatch and if possibly MR angiogram to primarily locate site of occlusion. This imaging should be preferably done in place where treatment of stroke is also available which must include endovascular treatment because this will save precious time.  As “TIME IS BRAIN”

Pathophysiology of ischemic stroke is simple. Normally every 100 mg of brain receives 50 to 55 ml of blood every minute to supply nutrients and oxygen to brain. If there is reduction of even 25% of blood then the brain cells starts to die and if the blood supply at this point of time is restored then the cell functions can be restored back to near normal. These arteries may be blocked due to emboli, thrombus or atherosclerotic narrowing. The central area of ischemic zone is called as ‘UMBRA’ which dies within 10-15 minutes but the periphery of the UMBRA which is called as PENUMBRA will die within 6 hrs and can be saved; thus usual time to restore blood supply is 6 hrs after the onset of symptoms which is called as GLODEN PERIOD OF 6 HRS. And the blocked arteries should be tried to open within this golden period of 6 hrs to minimise brain damage and maximise faster recovery.

There are various treatment options. If the patient comes to hospital within 3 hrs then intravenous thrombolytics like rtPA should be given and this is standard treatment given since 1996. After this time period if patient comes to hospital within 3 to 6hrs then intra-arterial thrombolytics like rtPA should be tried and this is been proved useful by various trials like PROACT trials. Combination of both intravenous and intra-arterial thrombolytics is also proved to be beneficial. Intra-arterial thrombolytics should be tried irrespective of neurological impairment if the patient comes to hospital within 6 hrs. Then comes other novel way of treating ischemic stroke that is mechanical thrombectomy. In this procedure the thrombosed artery is opened by thrombectomy devices like MERCI device or PHENOX clot retriever. Many a times stent like SOLITAIRE can be used to remove the clot with success rate of almost 90% and this is proved in recent trials like SWIFT trial. Alternatively embolus can be aspirated by suction device like PENUMBRA. Suction device has the advantage of opening the large sized arteries like ICA if they are occluded by the clot. Time window can be extended to 8 hrs if mechanical thrombectomy is done.

Hemorrhagic stroke due to venous thrombosis can also be treated by these endovascular means where microcatheter is placed into the thrombosed intracranial sinus and continuous infusion of thrombolytic drug is given for 2-3 days with continous assessment of recanalisation with fairly good success rate. Ruptured aneurysms can also be treatment by coiling. Ruptured or unruptured arteriovenous malformations can be treated by onyx injection or by glue injection. ALL THIS TYPE OF TREATMENT IS POSSIBLE IN OUR VIKRAM HOSPITAL BANGALORE.