Cerebral infarction

Disease Description (Causes and Symptoms)

• Definition·pathophysiology: This is a condition in which a cerebral blood vessel becomes occluded by a thrombus (or embolus), etc., preventing blood flow from reaching the brain tissue supplied by that vessel and causing ischemia and necrosis. The main causes include (1) thrombus formation due to atherosclerosis of the large vessels or carotid arteries, (2) an embolus originating in the heart (e.g., atrial fibrillation) entering the brain, and (3) small infarctions caused by small-vessel occlusion (perfusion disorder). If the ‘penumbra’ (the area with potentially reversible damage) around the occluded site is reperfused quickly, there is a high likelihood of functional recovery.
• Main symptoms: Sudden weakness on one side of the body (paralysis/sensory loss), speech disturbance (aphasia), visual-field disturbance (visual-field defect), altered consciousness, sudden severe dizziness·gait disturbance, and unilateral abnormalities of the face·arm·leg, etc. Symptoms vary depending on the location of the blocked vessel.

Treatment Methods

• Hyperacute (emergency) treatment
  • Intravenous thrombolytic (IV tPA, alteplase): Administer as soon as possible. The traditional recommended time window is within a maximum of 4.5 hours after symptom onset (the earlier it is administered, the greater the effectiveness). The risk of bleeding and contraindications (recent bleeding·surgery·anticoagulation status, etc.) must be checked.
  • Endovascular mechanical thrombectomy (thrombus removal/endovascular procedure, mechanical thrombectomy): For large-vessel occlusion (e.g., the internal carotid artery·middle cerebral artery), the standard is generally within 6 hours after symptom onset. However, if the extent of damage and the penumbra are assessed using imaging (CT perfusion/MRI diffusion–perfusion), treatment may be extended to up to 6–24 hours in some cases.
• Acute·subacute-phase medication treatment
  • Antiplatelet agents: Aspirin, clopidogrel (Plavix), Sirofeed, etc. are used for primary prevention·secondary prevention. Aspirin in the acute phase is used after considering the balance with the risk of rebleeding.
  • Anticoagulants: In cases of cerebral infarction caused by cardiogenic embolism (e.g., atrial fibrillation), anticoagulation (warfarin, direct oral anticoagulants DOAC) may be considered. The timing of anticoagulation initiation is determined according to the bleeding risk and imaging findings.
  • Blood pressure·blood glucose management, control of cerebral edema (osmotherapy if necessary), and control of fever·infection.
• Procedures·surgery
  • If symptoms recur or carotid artery stenosis is severe (symptomatic), carotid endarterectomy (CEA) or carotid artery stent placement (CEA/stenting) may be considered.
  • If severe cerebral edema·increased intracranial pressure occurs, decompressive surgery (decompressive craniectomy) may be necessary.
• Rehabilitation and secondary prevention
  • Early·continuous rehabilitation, including physical·occupational·speech therapy, is important for improving the prognosis.
  • Treatment of risk factors: management of hypertension·diabetes·hyperlipidemia·smoking·obesity, appropriate anticoagulation for atrial fibrillation, etc.
• Treatment precautions
  • Treatment is ‘time-sensitive’ (time is brain): When symptoms occur, provide the most accurate possible time of onset·time when symptoms began.
  • Thrombolytics·anticoagulants increase the risk of bleeding, so contraindications·precautions (recent bleeding, recent surgery, INR, etc.) must be checked.
  • Blood pressure management: During the acute phase, there are specific target blood pressures before and after thrombolysis (e.g., upper limits before and after tPA administration); do not lower or raise it forcefully on your own.

Checkpoints Before an Outpatient Visit (Including Example Questions)

• Items to prepare (recommended to bring)
  • A list of currently used medications (including anticoagulants·antiplatelet agents) or the medications (medication containers)
  • Copies of the existing medical history (heart disease, hypertension, diabetes, history of surgery·bleeding) and important test records (recent CT/MRI, electrocardiogram, ultrasound examination results, etc.)
  • The time symptoms occurred (exact time or the last time the person was known to be normal), and notes on the course of symptoms (what symptoms began when, and whether they worsened·improved)
  • Allergy history (especially medications and contrast media)
  • Blood pressure·blood glucose measurement records (if available)
• Examples of questions to prepare in advance for the outpatient visit (for patients·caregivers)
  • When did the symptoms first occur?
  • Are you currently taking an anticoagulant (warfarin, DOAC, etc.)? What was your recent INR level (if taking warfarin)?
  • Do you have a recent history of surgery·bleeding?
  • Please organize specific details about difficulties in daily life (walking, speech, eating, etc.) and bring them with you.

Examples of General Questions to Ask the Doctor

• What are the main side effects and risks of this medication (e.g., aspirin/clopidogrel/warfarin/DOAC)?
• In my case, how high is the risk of recurrence, and what medications·lifestyle habits are needed to prevent recurrence?
• When will I be able to resume driving·exercise·work in the future?
• When, for how long, and with what goals should rehabilitation (physical·speech therapy) begin?

Examples of Disease-Specific Questions

• In my case (based on imaging/clinical findings), can I receive a thrombolytic (or thrombectomy)? Until when is the possible time window (time limit)?
• If the heart (e.g., atrial fibrillation) is suspected to be the cause, when should anticoagulant treatment be started, and which medication is appropriate?

(Note: The above is general information; individual diagnosis·treatment decisions may vary depending on the attending physician’s assessment and the results of imaging·blood tests.)