Neurology diagnoses and treats disorders of the nervous system, including the brain, spinal cord, and nerves, as well as thought and memory.
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The pharmacological cornerstone of acute ischemic stroke therapy is intravenous thrombolysis, commonly known as tPA (tissue Plasminogen Activator) or the newer agent, TNK (Tenecteplase). These are enzymatic drugs that activate plasminogen to plasmin, which then dissolves the fibrin mesh holding a clot together.
Administration is time-critical. The standard window is 4.5 hours from the “last known well” time. Beyond this, the risk of the drug causing bleeding into the brain (hemorrhagic transformation) typically outweighs the benefit. Strict checklists are used to exclude patients with high bleeding risks, such as recent surgery or anticoagulation use.
For strokes caused by a Large Vessel Occlusion (LVO), chemical thrombolysis alone is often insufficient to dissolve the massive clot volume. Endovascular Thrombectomy is the standard of care. A neurointerventionalist threads a catheter through the femoral or radial artery up into the brain.
Using devices like “stent retrievers” (which mesh with the clot) or large-bore aspiration catheters (which suck the clot out), the vessel is mechanically recanalized. This procedure has a greatly extended window—up to 24 hours in selected patients who show salvageable penumbra on advanced imaging. The “Number Needed to Treat” (NNT) for EVT is astonishingly low, making it one of the most effective procedures in all of medicine.
Hemorrhagic stroke requires a completely different approach. The goal is to stop the bleeding and prevent the hematoma from expanding. If the patient is on blood thinners, immediate reversal agents (like Andexanet alfa or Idarucizumab) are administered. Aggressive blood pressure reduction is initiated immediately to reduce the hydrostatic pressure driving the bleed.
Surgical intervention is debated and case-specific. Generally, deep bleeds are managed medically, while large superficial bleeds or those compressing the brainstem may be surgically evacuated. Newer minimally invasive techniques using endoscopes to suck out the blood clot are currently being investigated to reduce secondary injury from iron toxicity.
The days following a stroke are critical. Patients are managed in a Stroke Unit or Neuro-ICU to prevent secondary injury. This involves maintaining “euglycemia” (normal blood sugar), “normothermia” (avoiding fever), and optimizing oxygenation. Fever is particularly neurotoxic to the ischemic brain and is treated aggressively.
“Permissive hypertension” is a concept used in ischemic stroke where blood pressure is allowed to run high (up to 220/120 in non-thrombolysed patients) to force blood through collateral vessels into the ischemic penumbra. Conversely, malignant cerebral edema (severe swelling) may require Decompressive Hemicraniectomy—temporarily removing part of the skull to allow the brain to swell outward rather than crushing the brainstem.
Rehabilitation is not just physical training; it is neurological therapy. The brain possesses “neuroplasticity,” the ability to rewire itself. After a stroke, healthy neurons can sprout new connections to bypass damaged areas and take over lost functions. This process is driven by repetitive, task-specific practice.
Therapies include Constraint-Induced Movement Therapy (forcing the use of the weak limb), mirror therapy, and robotic-assisted gait training. Speech therapy helps rewire language networks in aphasia. The timing is crucial; early mobilization (getting out of bed within 24-48 hours) is generally encouraged to prevent deconditioning, though very intense high-dose therapy too early can potentially be harmful.
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All procedures have risks, including damaging the vessel or causing a bleed, but for a large stroke, the risk of leaving the clot (permanent severe disability) is usually much higher than the risk of the procedure.
If the brain vessel is blocked, the brain relies on high pressure to push blood through tiny side-channels (collaterals) to keep the dying tissue alive; lowering it too soon can cause the stroke to worsen.
Sometimes patients improve on the table, but often it takes time for the blood flow to restore function; tPA improves the odds of a good recovery, it doesn’t guarantee an immediate cure.
This refers to the goal of treating stroke patients within 60 minutes of their arrival at the hospital door to maximize the amount of brain saved.
No, the infarct core (dead tissue) becomes a scar and does not regrow; recovery comes from “rewiring”—teaching the surviving healthy brain tissue to take over the jobs of the dead cells.
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