Stroke

There are two main types of stroke:

• 80% are ischaemic strokes 
• Clots in arteries travels along the bloodstream and becomes lodged in the brain, reducing or blocking blood flow that part of the brain
• 20% are haemorrhagic strokes (higher mortality)
• Blood vessels leaks or ruptures, causing blood to accumulate in or around brain tissues

Symptoms

• Trouble speaking (e.g., slurring) or understanding what others are saying.
• Sudden paralysis or numbness of the face, arm or leg, often on one side of the body. The side of the mouth droops when smiling.
• Sudden problems seeing in one or both eyes (e.g. blurring, blackened or double vision) .
• A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered consciousness.
• Trouble walking with loss of balance and coordination.

Causes

• Ischaemic stroke is caused by the severe reduction of blood flow to a region of the brain by a blocked vessel
• The blockade or narrowing of blood vessel is often due to fatty deposits in arteries that break off, or blood clots in the vessels, and travel to the brain and gets lodge in the brain
• Haemorrhagic stroke is caused by conditions that affect your blood vessels, which include:
• Uncontrolled high blood pressure
• Use of blood thinning medications
• Bulges and weak spots in your blood vessel walls (aneurysms, cavernoma, arteriovenous malformations)
• Trauma to the head (such as an accident)

Diagnosis

• History and neurological examination
• CT brain scan (with special sequence that can visualise blood vessels)
• Consecutive CT brain scans in the first 6 to 24 hours after stroke to monitor changes in size of blood clot over time
• MRI brain scan to look for underlying cause such as tumour or vascular abnormalities

Treatment of Haemorrhagic Stroke

Medical management

Medical management is usually employed with smaller sized blood clots. Over time, the blood clot will resolve by themselves. 

• Oral medications are aimed at keeping the blood pressure within control. 
• There is no medication that directly treats the blood clot in haemorrhagic stroke. 

Surgery to remove blood clot

If the blood clot is large enough to cause significant symptoms, surgery should be considered.

• Minimally invasive surgery (early surgery)
• A tube-like device is inserted along the natural folds of the brain. 
• The device displaces the normal healthy brain, instead of cutting through them, to access the blood clot usually located deep in the brain.
• Minimally invasive surgery allows a smaller opening in the skull and lesser trauma to the surrounding normal brain (when compared to conventional craniotomy).
• As the opening in the skull is small and no skull bone is removed, further surgery to replace the skull is not required.
• Craniotomy (opening of skull) to remove clot
• An large opening in the skull is made to provide access to the clot
• Often performed in an acute emergency setting
• Decompressive craniectomy: 
• In some patients with brain swelling, the skull may not be put back immediately in the same procedure
• Instead, the opening in the skull will be repaired after a few months in another surgery called Cranioplasty.

Summary