Pneumocephalus

Stroke (Cerebrovascular disease)

1) Disease description (causes and symptoms)

• Definition: A group of diseases collectively referring to cerebral infarction (ischemic stroke), in which cerebral blood vessels become blocked and brain tissue becomes necrotic, and cerebral hemorrhage (hemorrhagic stroke), in which a blood vessel ruptures and blood leaks into or around the brain.
• Major causes
  • Ischemic: Atherosclerotic thrombosis, embolism (including cardiogenic embolism), carotid artery stenosis, etc.
  • Hemorrhagic: Hypertensive intracerebral hemorrhage, rupture of a cerebral aneurysm (subarachnoid hemorrhage), arteriovenous malformation, etc.
  • Other: Blood coagulation disorders, arteritis, moyamoya disease, etc.
• Summary of pathophysiology
  • Ischemic: Reduced blood flow → energy depletion → neuronal necrosis and surrounding responses (inflammation and edema)
  • Hemorrhagic: Direct tissue damage and compression caused by hematoma formation, secondary ischemia, and cerebral edema
• Major symptoms (sudden-onset focal neurological deficits)
  • Weakness/paralysis of one side of the limbs (hemiplegia), reduced sensation
  • Language impairment (aphasia), speech articulation disorder (dysarthria)
  • Visual field disturbances, reduced visual acuity, diplopia
  • Dizziness, ataxia (lesions of the cerebellum/brainstem)
  • Difficulty swallowing (dysphagia), severe headache (especially in subarachnoid hemorrhage), decreased consciousness
  • Temporary neurological symptoms (transient ischemic attack, TIA) are warning signs of stroke

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2) Treatment methods

• Initial evaluation (emergency)
  • Immediately check for hemorrhage with non-contrast CT or MRI → distinguishing ischemic from hemorrhagic stroke is key to determining treatment
• Ischemic stroke (acute phase)
  • Intravenous thrombolytic (alteplase, IV tPA): Consider administering as soon as possible after symptom onset (the generally recommended criterion is within a maximum of 4.5 hours; indications and contraindications must be checked)
  • Mechanical thrombectomy (endovascular reperfusion): Prompt procedure for large-vessel occlusion (mostly within 6 hours; based on imaging criteria, it may also be considered for some patients within up to 24 hours)
  • Acute-phase supportive care: Management of blood glucose, body temperature, blood pressure, and pulmonary complications; DVT prevention
  • Secondary prevention: Antiplatelet agents (aspirin, clopidogrel); anticoagulation (DOAC or warfarin) in the presence of atrial fibrillation; high-intensity statin for hyperlipidemia; blood pressure and diabetes control; smoking cessation and weight management
  • When vascular stenosis is the cause: Carotid endarterectomy (CEA) or stent placement for carotid stenosis, etc.
• Hemorrhagic stroke
  • Emergency blood pressure control (preventing excessive increases in blood pressure), discontinuation and reversal of anticoagulants and antiplatelet agents (if necessary)
  • Surgical hematoma evacuation may be considered if there is a large hematoma or neurological deterioration
  • Subarachnoid hemorrhage: After confirming the aneurysm by angiography, clip ligation or coil embolization (to prevent rebleeding), and medications to prevent vasospasm, such as nimodipine
• Rehabilitation and recovery-phase treatment
  • Early physical, occupational, and speech therapy (including swallowing therapy)
  • Emotional support (depression management) and a multidisciplinary approach for functional recovery
• Precautions (self-care)
  • In cases of dysphagia, prevent aspiration pneumonia, prevent falls, and manage medication use and bleeding risk
  • Strictly manage risk factors (hypertension, diabetes, hyperlipidemia, atrial fibrillation, etc.) even after the acute phase

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3) Checklist before an outpatient visit (items to bring · medical history and records · example questions)

• Recommended items to bring
  • A list of all medications currently being taken (including dosage and dosing times), especially anticoagulants/antiplatelet agents, antihypertensive medications, and antidiabetic medications
  • Recent test results (CT/MRI reports, blood tests, electrocardiogram, ultrasound, etc.) or images/CDs
  • Medical history: Hypertension, diabetes, atrial fibrillation, previous stroke/TIA, heart disease, and surgical history
  • Time of symptom onset (very important if known accurately)
• What the patient and caregiver should record before the outpatient visit
  • Time of symptom onset and how the symptoms have changed (whether they have improved or worsened)
  • Changes in daily functioning (walking, speaking, swallowing, etc.), and whether there have been any recent falls or decreased consciousness
  • Bring records of blood pressure and blood glucose (self-measured values), if available
• What the doctor will commonly ask at the outpatient visit (examples)
  • "When did the symptoms begin? Did they occur suddenly?"
  • "Have you recently experienced chest pain, an irregular heartbeat (palpitations), or a stabbing headache?"
  • "Are you currently taking any medications, especially medications that affect blood clotting?"

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4) Examples of general questions to ask the doctor

• "What type of stroke did I have (ischemic/hemorrhagic), and what caused it?"
• "Did I have an indication for reperfusion treatment (or surgery)? What treatment do I need now?"
• "What medications should I take to reduce the risk of recurrence, and for how long? What are the side effects?"
• "When can I resume daily activities (driving, returning to work, exercising)?"
• "How should my target blood pressure, cholesterol, and blood glucose levels be established going forward?"

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5) Examples of disease-specific questions

• Questions about ischemic stroke
  • "How did you evaluate whether my symptoms were caused by an embolism or a thrombus (atherosclerosis)? Was I tested for a cardiac cause (atrial fibrillation)?"
• Questions about hemorrhagic stroke
  • "Was it confirmed whether the cause of the hemorrhage was an aneurysm (or an underlying disease)? What additional procedure or surgery is needed to reduce the risk of rebleeding?"

(The treatment, prognosis, and risk of recurrence vary depending on the test results and the findings of neuroimaging and cardiac examinations. Please consult specifically with your attending physician based on the test results.)