Brain hemorrhage

1) Disease Description (Causes and Pathophysiology, Main Symptoms)

• Definition: Cerebral infarction is a condition in which a blood vessel supplying the brain becomes blocked, causing ischemia and necrosis in the brain tissue supplied by that vessel. Causes include thrombosis (formation at the site) or embolism (a blood clot that has traveled from another location), with atherosclerosis, heart disease (especially atrial fibrillation), and small-vessel disease (lacune) being the main causes.
• Summary of pathophysiology: Blood flow obstruction → interruption of oxygen and glucose supply → energy depletion → cell membrane destruction, inflammation, and ischemic necrosis → (in some cases) hemorrhagic transformation when blood flow is restored.
• Main symptoms: Symptoms occur acutely and vary depending on the location of the blocked vessel. Typical symptoms include weakness in one side of the limbs (hemiplegia), language impairment (aphasia), visual field disturbance, dizziness and gait disturbance, and altered consciousness. Symptoms often suddenly worsen over several minutes to several hours.

2) Treatment Methods and Precautions

• Initial emergency principles
  • Go to the hospital as quickly as possible (use the emergency medical system). Recording the time of symptom onset (last known normal time) is important and essential for determining eligibility for reperfusion treatment.
  • After checking for hemorrhage with brain (CT) imaging, treatment is determined.
• Acute reperfusion treatment
  • Intravenous thrombolytic agent (IV tPA, alteplase): Generally within 4.5 hours after symptom onset (eligibility and contraindications must be checked). A specialist determines the bleeding risk and indications.
  • Endovascular mechanical thrombectomy (mechanical thrombectomy, EVT): Effective for large-vessel occlusion (e.g., the middle cerebral artery). Generally, treatment within 6 hours after symptom onset is standard, but patients selected through imaging (perfusion studies) may benefit up to 6–24 hours (and in some cases over a wider window) (based on criteria such as DAWN/DEFUSE).
• Antiplatelet and anticoagulant treatment
  • Non-cardioembolic infarction: Antiplatelet agents (aspirin, clopidogrel, etc.). Short-term dual antiplatelet therapy (e.g., 21 days) may be considered for minor cerebral infarction according to dual-therapy guidelines.
  • Cardioembolic stroke (e.g., atrial fibrillation): Anticoagulants (DOACs or warfarin) for secondary prevention. The timing of starting anticoagulation is determined according to the size of the cerebral infarction and bleeding risk (consider initiating within several days to 2 weeks).
  • In patients who have received tPA, starting antiplatelet or anticoagulant therapy is generally avoided within 24 hours after tPA administration.
• Blood pressure, blood glucose, and temperature management
  • When using tPA, blood pressure must be maintained at <185/110 mmHg before administration. Even after reperfusion, a specific target (e.g., <180/105) is recommended. Hyperglycemia, hypothermia, and fever are factors that worsen prognosis.
• Revascularization surgery/procedures
  • Carotid stenotic lesions (symptomatic significant stenosis): Carotid endarterectomy (CEA) or stent placement (the indication depends on the degree of stenosis, timing, and the patient's condition).
  • For intracranial stenosis, selective balloon angioplasty and stenting may be considered (based on clinical experience).
• Secondary prevention and rehabilitation
  • Administration of high-intensity statins (e.g., atorvastatin) (to suppress the progression of atherosclerosis and reduce recurrence).
  • Counseling on smoking cessation, blood pressure, diabetes, lipid management, weight control, and exercise.
  • Early rehabilitation (physical, occupational, and speech therapy) to promote functional recovery.
• Main precautions and risk of complications
  • Risk of cerebral hemorrhage (hemorrhagic transformation), especially when using tPA or anticoagulants — monitoring and strict adherence to indications are essential.
  • In-hospital complications such as aspiration pneumonia, deep vein thrombosis, immobility, and pressure ulcers.
  • Risk of recurrence (high during the first several weeks to months) — secondary prevention is important.

3) Checklist Before an Outpatient Visit (Examples of Items to Prepare and Record)

• Necessary items/materials
  • A list of all medications currently being taken (including prescriptions, OTC medicines, and supplements), with dosage and administration times
  • Results of major previous tests (brain CT/MRI, CTA/MRA, blood tests, echocardiography, etc.) and imaging reports/CDs (if available)
  • Time of symptom onset (last known normal time), pattern of symptom onset (sudden/gradual), and course of symptom changes (time of improvement or worsening)
  • Blood pressure, blood glucose, and electrocardiogram (HR/rhythm) records (if possible)
  • Past medical history (heart disease, hypertension, diabetes, hyperlipidemia, smoking history) and history of surgery or bleeding
• Additional records useful for the outpatient visit
  • Recent history of bleeding or surgery, possibility of pregnancy (women), and allergies (especially those related to anticoagulants or antiplatelet agents)
  • Changes in functioning in daily life (walking, food intake, speech, etc.)

Example questions: Items that patients may find helpful to record in advance

• Time symptoms first began: ______
• Symptoms (e.g., weakness in the right arm, slurred speech): ______
• Whether symptoms improved or worsened and when: ______

4) Examples of General Questions to Ask the Doctor

• "Am I a candidate for tPA (thrombolytic therapy) or endovascular treatment in my case? What are the indications and contraindications?"
• "What are the side effects and precautions for this medication (e.g., aspirin/clopidogrel/anticoagulant)?"
• "When can I restart the medication I was taking regularly (e.g., an anticoagulant)?"
• "How high is my risk of recurrence, and what can I do right now to reduce it?"
• "When should rehabilitation (physical and speech therapy) begin, and how much should I receive?"

5) Examples of Disease-Specific Questions

• "If my cerebral infarction is suspected to be caused by the heart (atrial fibrillation), when should I start an anticoagulant? If there is a bleeding risk, what are the alternatives?"
• "Carotid stenosis was found after my cerebral infarction. In my case, which treatment is more appropriate—surgery (endarterectomy) or stenting? When is the appropriate time for surgery?"

Additional Reference (Brief Summary)

• Time (the time symptoms began) is the most important information in determining the opportunity for treatment. Visit the emergency department immediately when symptoms occur.
• Reperfusion treatment (thrombolytic agents and mechanical thrombectomy) can greatly improve prognosis when eligibility criteria are properly followed.
• Secondary prevention (antiplatelet agents, anticoagulants, statins, and lifestyle improvements) and early rehabilitation are important for long-term prognosis.