Stroke

Disease Description (Causes and Symptoms)

• Definition and pathophysiology: Stroke refers to a condition in which a blood vessel supplying blood to the brain becomes blocked, causing ischemic damage to brain tissue (cerebral infarction), or a blood vessel ruptures and causes bleeding (intracerebral hemorrhage or subarachnoid hemorrhage). In Korea, ischemic strokes are more common, accounting for approximately 80–90% of cases. Major causes include atherosclerosis, embolism (including cardiogenic embolism), hypertensive intracerebral hemorrhage, aneurysm rupture (subarachnoid hemorrhage), vascular malformations, arteritis, blood disorders, and moyamoya disease.
• Main symptoms (sudden-onset neurological deficits)
  • Hemiplegia (weakness in one arm or leg) or loss of sensation
  • Language impairment (aphasia) and speech impairment (dysarthria)
  • Visual field disturbances (unilateral visual field loss) and diplopia
  • Sudden severe headache (especially with subarachnoid hemorrhage), dizziness, nausea, and vomiting
  • Dysphagia (difficulty swallowing) and decreased consciousness
  • Mild symptoms (transient ischemic attack, TIA) may resolve within minutes to several hours, but the risk of future stroke is high

Treatment Methods

• Acute phase (emergency) principles
  • Visit a hospital immediately (determining the time of symptom onset is important). Go to the emergency room immediately when warning signs such as FAST (Face, Arm, Speech, Time) are present.
  • Imaging tests: Non-contrast CT (to check for bleeding), and when necessary MRI (DWI), vascular imaging (CTA/MRA), perfusion imaging (selective), catheter angiography, and other tests are used to identify the lesion and cause.
• Acute ischemic stroke
  • Intravenous thrombolytic (alteplase, tPA): Administered as soon as possible after symptom onset, generally within 4.5 hours (exceptions may apply depending on individual conditions). Blood pressure, bleeding risk, recent surgery, and other factors must be checked before administration.
  • Endovascular treatment (mechanical thrombectomy): This is the standard treatment for large-vessel occlusion. When indicated, the traditional treatment window is within 6 hours of symptom onset, but with appropriate patient selection, treatment may be extended up to 24 hours in some cases (imaging-based selection).
  • Antiplatelet agents (e.g., aspirin): Used during the acute phase and thereafter to prevent recurrence (including in patients unable to receive anticoagulation).
  • Anticoagulants: Long-term anticoagulation (warfarin or direct oral anticoagulants, DOACs) may be considered when the cause is cardiogenic embolism, such as atrial fibrillation.
• Hemorrhagic stroke (intracerebral hemorrhage, subarachnoid hemorrhage)
  • Emergency blood pressure control (the target blood pressure is determined based on the amount of bleeding and clinical status)
  • For patients taking anticoagulants or antiplatelet agents, reversal may be considered (e.g., vitamin K, prothrombin complex concentrate (PCC), idarucizumab, andexanet, etc.)
  • Surgical treatment: For large hemorrhages, hematoma evacuation may be needed. For subarachnoid hemorrhage, aneurysm clipping or coil embolization is required. Structural lesions such as arteriovenous malformations may be treated with surgery or Gamma Knife, among other options.
  • Nimodipine administration is recommended to prevent vasospasm after subarachnoid hemorrhage (e.g., oral nimodipine).
• Rehabilitation and secondary prevention
  • Early rehabilitation (including physical therapy, occupational therapy, and speech therapy) promotes functional recovery
  • Risk-factor management: hypertension, diabetes, dyslipidemia, smoking, obesity, atrial fibrillation (anticoagulation), alcohol intake, and other factors
  • Medications: Statins (used after ischemic stroke to reduce recurrence, regardless of whether dyslipidemia is present), antiplatelet agents, or anticoagulants (depending on the cause)
  • Surgical prevention: When necessary, procedures such as carotid endarterectomy or carotid artery stenting may be performed for symptomatic carotid stenosis
• Lifestyle management (self-care)
  • Actively manage blood pressure, blood glucose, and cholesterol; stop smoking; maintain an appropriate body weight; exercise regularly; limit alcohol intake; and follow a diet (low sodium and high potassium are recommended)

Precautions for This Disease (Points of Caution and Complications)

• Do not delay when symptoms occur, as arriving at the hospital immediately can determine the treatment outcome
• Thrombolytics carry a risk of bleeding, so contraindications (such as recent bleeding, surgery, or severe hypertension) must be checked before administration
• Complications: aspiration pneumonia (due to dysphagia), pressure sores, pulmonary thromboembolism and deep vein thrombosis, spasticity and joint contractures, depression and cognitive decline, seizures, recurrent bleeding, and others
• When receiving anticoagulant or antiplatelet therapy, bleeding risk must be managed (regular monitoring and adherence to medication instructions)
• Be cautious of factors in daily life that may trigger acute worsening: excessive alcohol consumption, strenuous exercise or overexertion, dehydration, severe stress, excessive straining during bowel movements, sudden exposure to temperature changes, and others

Checklist Before an Outpatient Visit (Items to Prepare and Example Questions)

• Items to prepare
  • A list of all medications currently being taken (including prescription drugs, over-the-counter medicines, and supplements), along with the times and doses taken
  • For patients taking anticoagulants, a record of the time the medication was taken and the most recent INR (for warfarin) value
  • Recent hospital or emergency room records (discharge summary, imaging CD, or radiology report)
  • The exact time of symptom onset and a note documenting the progression of symptoms over time
  • Blood pressure and blood glucose records (if possible, measurements from the past several weeks)
  • Comorbidities (hypertension, diabetes, heart disease, etc.) and test results (cholesterol, HbA1c, etc.)
  • Family and caregiving support situation (whether the patient lives alone and whether assistive devices are needed)
• Key information to show the doctor at an outpatient visit
  • The onset of symptoms (date and time) and their progression (whether they improved or worsened)
  • Whether anticoagulants or antiplatelet agents were taken recently
  • A history of stroke or TIA, atrial fibrillation, or heart disease
  • Whether dysphagia, fever, or shortness of breath is present
• Example questions (for patients)
  • What tests will be performed when symptoms occur?
  • Do I need to stop any of the medications I am currently taking?
  • When and how should rehabilitation (physical, speech, and occupational therapy) begin?

General Example Questions to Ask the Doctor

• What is the purpose of this medication (e.g., an anticoagulant or antiplatelet agent), and what side effects can be expected?
• What range of recovery (prognosis) can be expected in my case? How high is the risk of recurrence?
• What activities should I avoid in daily life, and when can I resume driving or return to work?
• What type of rehabilitation should I receive, and how often?

Disease-Specific Example Questions

• Regarding acute ischemic stroke:
  • "The time of symptom onset is unclear (the symptoms occurred at night). Could I be eligible for thrombolysis or thrombectomy? What additional tests are needed?"
• Regarding hemorrhagic stroke (subarachnoid hemorrhage, aneurysm, etc.):
  • "What treatment (clipping or coil embolization) is recommended for my aneurysm (or site of bleeding), and what are the risks of rebleeding and the prospects for recovery?"

(The information above has been compiled based on clinical guidelines and general evidence. Please consult your treating physician for a specific diagnosis and treatment plan based on your individual condition.)