Brain attack

“The Brain Attack”
Prevention and Treatment
DR. MUNISH K. AGGAWAL (MBBS, MS, M.Ch.)
CONSULTANT NEUROSURGEON
MATA CHANAN DEVI HOSPITAL
ENDOVASCULAR NEUROSURGEON
JAIPUR GOLDEN HOSPITAL
TRAINED IN ENDOVASCULAR NEUROSURGERY AT
MEMORIAL HEALTH UNIVERSITY MEDICAL CENTER, SAVANNAH,
GEORGIA, USA
A stroke occurs when blood flow to part of the brain is interrupted, which is why it's sometimes called a "brain attack. It occurs when a blood clot blocks a blood vessel or artery in the brain. Ischemic strokes account for 80 percent of all strokes. Hemorrhagic strokes, which account for the other 20 percent, occur when a blood vessel in the brain ruptures and causes bleeding. According to the National Institute of Neurological Disorders and Stroke (NINDS), about 700,000 people have a stroke each year--500, 000 first strokes and 200,000 recurrent strokes. Stroke is the leading cause of long-term disability and the third-leading cause of death for Americans after heart disease and cancer. Time Is Brain
When blood flow to the brain stops, brain cells are deprived of oxygen and nutrients. "A stroke is a
medical emergency because brain cells start dying quickly," says John R. Marler, M.D., a neurologist
and associate director for clinical trials at the NINDS. And treatment is most effective when given
promptly.
Activase (alteplase), a genetically engineered version of tissue plasminogen activator (t-PA), is the
only drug approved by the Food and Drug Administration for treating the sudden onset of ischemic
stroke. The drug dissolves blood clots that block blood flow to the brain, improving the chance for
recovery and decreasing disability. But the drug must be given within three hours after stroke
symptoms begin. It has not been shown to be effective beyond three hours.
"The longer blood flow is cut off and the longer treatment is delayed," Marler says, "the more likely it is
that the patient will suffer permanent damage." Stroke experts commonly refer to the sense of urgency
in stroke treatment with this expression: "Time is brain."
The most common symptoms of stroke are
 Sudden weakness or numbness in the face, arms, or legs, especially on one side of the body  Sudden confusion, or difficulty speaking or understanding speech  Sudden vision problems, such as blurry vision or a partial or complete loss of vision in one or both  Sudden dizziness, trouble walking, or loss of balance and coordination  Sudden severe headache with no known cause. Other symptoms that are less common, but still important, are sudden nausea, vomiting, brief loss of
consciousness, or decreased consciousness, such as fainting and convulsions.
Sometimes, people experience a transient ischemic attack (TIA), also called "mini-stroke," which
also requires prompt medical evaluation. When a TIA occurs, stroke symptoms may last only
temporarily and then disappear. Most TIA symptoms disappear within an hour, but they may persist up to 24 hours. About 1 in 4 people who have a TIA go on to have a bigger stroke within five years. Stroke may have been prevented if the TIA had been detected and appropriately treated. Doctors may recommend drugs or surgery to reduce the risk of stroke in people who have had a TIA. TIA is to stroke what chest pain is to heart disease. It's a warning sign that shouldn't be ignored. According to the National Stroke Association (NSA), 25 percent recover with minor impairments, 40 percent experience moderate-to-severe impairments that require special care, 10 percent require care in a nursing home or other long-term care facility, and 15 percent die shortly after the stroke. Risk Factors
Stroke can strike without warning. A condition called atrial fibrillation also can increase the risk of
having an embolic stroke.
Most strokes occur because blood clots develop directly in the brain. These are known as thrombotic
strokes. The most common cause is atherosclerosis, a process in which fatty deposits form in the
vessel walls of the brain. Stroke and heart disease share some of the same controllable risk factors:
high blood pressure, cigarette smoking, high cholesterol, diabetes, physical inactivity, and obesity.
These factors raise the risk for plaque build-up in the arteries, which in turn raises the risk of the
formation of blockages and blood clots. A stroke sometimes occurs because plaque develops in the
carotid artery, the main blood vessel in the neck that leads to the brain.
High blood pressure is perhaps the biggest risk factor for stroke. Men have a greater stroke rate than
women but women usually live longer and therefore more women are disabled or die from stroke each
year. Having a family history of stroke and getting older also raise stroke risk. In addition, having one
stroke or TIA increases the risk of having another stroke.
Small Window of Opportunity
When the FDA approved Activase (t-PA) in 1996, it was the first drug approved to treat acute ischemic
stroke. Made by Genentech of South San Francisco, Calif., the drug is given intravenously to dissolve
the clot or clots that are keeping blood from flowing to the brain. It improves the chance of recovery by
up to 30 percent when used correctly. But there is a major limitation--the need to begin the treatment
within three hours.
The three-hour time window is very limiting. There is also a risk of causing intracranial bleeding. When
someone suffers a stroke, doctors have to run tests to figure out which kind of stroke has occurred
and whether the patient is a candidate for t-PA. Meanwhile, time is ticking away. Hospitals are getting
better at evaluating and treating patients with stroke symptoms quickly.
It has been recommended that TPA can be given for up to 6hrs. of onset if it is given by intra-arterial
route into the blocked artery. Along with this the blockage can be passed by mechanical means at the
same time. This decreases the dose of TPA required to be administered & the risk of hemorrhage &
other drug related side effects. However, this requires the availability of an ENDOVASCULAR
NEUROSURGEON.
Surgeons also may open up a clogged carotid artery with a small balloon and insert a small tube
called a stent to keep the artery open. In August 2004, the FDA approved the Acculink Carotid Stent
System made by Guidant Corp. of Santa Clara, Calif. The stent is intended to prevent stroke by
opening a blocked artery. The Acculink is inserted during angioplasty, a procedure in which the stent
is threaded up to the neck artery via a catheter inserted in the groin.
Preventing Another Stroke
According to the NINDS, about 25 percent of people who recover from a first stroke will have another
within five years, and the chance of death and disability increases with each stroke. The good news is
that there is a lot people can do to prevent a recurrence.
Besides lowering stroke risk through lifestyle changes and medication that lowers blood pressure and
cholesterol, surgery may be beneficial. In a procedure called carotid endarterectomy, surgeons open
up the carotid artery in the neck and scrape out plaque. This is sometimes done for acute stroke, but
the procedure has more of a role in preventing recurrent strokes. Also the stenosed artery can be
dilated by balloon angioplasty & stented in the same fashion as is done for the coronaries with
success rate of up to 97-98%.
The device helps prevent stroke in people who have had a TIA or stroke and who have at least 50
percent blockage of a carotid artery. It also may be used in those who have had no previous stroke
but have a carotid artery that's at least 80 percent blocked and who are not good candidates for the
surgical alternative. The FDA is requiring Guidant to conduct post-approval studies to confirm the
stent's performance in more patients and to assess its long-term safety and effectiveness.
There are two main types of drugs approved by the FDA to prevent a recurrent ischemic stroke.
Antiplatelet drugs, such as aspirin, Plavix (clopidogrel), Ticlid (ticlopidine), and Aggrenox (aspirin and
dipyridamole), prevent clotting by decreasing activity of the platelets--the blood cells that make blood
clot. These drugs are used to prevent recurrent thrombotic strokes.
Anticoagulants, such as Coumadin (warfarin) and heparin, thin the blood to prevent it from clotting and
also prevent existing clots from growing. These drugs are particularly useful in preventing the
formation of clots in people with atrial fibrillation.
Hemorrhagic stroke
Hemorrhagic stokes occur because a blood vessel in the brain ruptures and causes bleeding in the
surrounding brain tissue.
Hemorrhagic strokes can be caused by an aneurysm. Other causes include a group of abnormal
blood vessels called arteriovenous malformation or leakage from a vessel wall that was weakened by
high blood pressure.
One drug, Nimotop (nimodipine), is approved by the Food and Drug Administration for subarachnoid
hemorrhage due to aneurysm. Subarachnoid hemorrhage occurs when a blood vessel ruptures and
bleeds into the space between the brain and the skull.
Hemorrhagic stroke is also sometimes treated with surgery that removes abnormal blood vessels or
places a clip at the base of an aneurysm. Using catheters to place wire coils inside the aneurysm to
abolish it is increasingly treating aneurysms.
FOR MORE INFORMATION

DR. MUNISH K. AGGARWAL
CONSULTANT NEUROSURGEON & ENDOVASCULAR NEUROSURGEON
MATA CHANAN DEVI HOSPITAL, JANAKPURI
JAIPUR GOLDEN HOSPITAL, ROHINI

SHIVAM NEURO & SPINE CLINIC, 42A/GH-2, ANKUR APTTS. PASCHIM VIHAR
DAILY: 6-8PM (SUNDAY BY APPOINTMENT)
TEL: +91 98100 42115

Source: http://shivamneuro.eidentiti.com/doc/Stroke_Prevention_&_Treatment.pdf