Brain attack (stroke) occurs when blood vessels supplying blood to a specific part of the brain suddenly become blocked by a clot or get ruptured.

Brain cells must have a continuous supply of oxygen and other nutrients from the blood in order to function. To meet this demand of the millions of cells of the brain, blood is pumped continuously from the heart to the brain via several blood vessels. When this continuous blood supply is disrupted, brain cells begin to die and a brain attack results.

Brain attacks fall into several major categories, based on whether the disrupted blood supply is caused by a clot blocking blood vessel (also known as an ischemic stroke) or rupture of a blood vessel (known as a brain hemorrhage). Since each type of brain attack has a different type of treatment, it is important to determine the cause of the stroke, as well as the location, as quickly as possible.

Warning Signs of a Brain attack

Your body may warn you by the sudden appearance of one or more of the symptoms listed below. Your physician or a relative/colleague or even a passerby may also identify certain signs or symptoms that are indicative of brain attack. Familiarize yourself with the following important rescue signs. Remember RESCUE i.e.

• Reduced power or paralysis of one side (weakness of face/arm/leg)
• Eye problem (loss of vision in one or both eyes)
• Speech problem (difficulty in speaking)
• Confusion (difficulty in understanding)
• Unsteadiness (loss of balance or vertigo)
• Excruciating headache (worst headache of life)

Transient Ischemic Attacks (TIAs)

About one-third of all Brain attacks are preceded by one or more “mini attacks” known as transient ischemic attacks (TIAs). TIAs can occur days, weeks or even months before a brain attack.

TIAs are caused by temporary interruptions in the blood supply to the brain. The symptoms occur rapidly and last a relatively short time, usually for a few minutes. For instance, if you experience a sudden loss of vision, or weakness in an arm or leg that disappears, you might be having a TIA.

Because TIAs are temporary and the body soon returns to normal, it is easy to ignore them or to believe that the problem has disappeared. However, it is dangerous to ignore TIAs, because the underlying problem that caused the TIA continues to exist. TIAs are often early warning signs of a more serious and debilitating brain attack in the future.

Rescue! Do not waste time

If you or someone you know experiences any of the rescue signs listed above, it is extremely important to seek emergency help right away. Call ‘Brain Rescue’ immediately for urgent transportation to Medanta Brain Rescue center even if you think that you are getting better or if the symptoms seem to disappear.

Typically, patients do not seek help for a day or more after the first symptoms appear. They often believe that oil massage or bed rest will improve their symptoms. By that time, it is usually too late for new treatments to be effective. Recognizing and responding to the rescue signs of brain attack — as soon as they appear — gives the patient the best chance for an optimal recovery. Brain attack is an emergency! It is as severe as heart attack and often even more hazardous than it.

Remember, if you can save time you can save your brain.

As soon as a brain attack patient arrives in the triage or on receiving call for such patient our Brain Rescue team is activated immediately. The ability to pinpoint the precise location of a brain attack and determine the extent of damage is of critical importance in making treatment decisions during an brain attack emergency. Based on symptoms and findings on examination our “Brain Rescue” team quickly determines whether the brain attack is an ischemic event or a hemorrhagic event so that appropriate medical therapy can be started without delay. To obtain diagnostic information, it is likely that several of the following diagnostic studies will be performed during an evaluation for brain attack.

Computerized Tomography (CT) Scan: CT scan is generally the first diagnostic test done after a patient with a suspected stroke arrives in the emergency room. This test rapidly distinguishes between an ischemic or hemorrhagic stroke and involves the use of low-dose x-rays to visualize the brain.

CT Angiography (CTA): A CT scanner can obtain an angiogram as well. However, an injection is required for a CTA so that the injected material (contrast dye) flowing through the brain arteries can be scanned, thereby producing a picture of the blood vessels. This study demonstrates a three-dimensional anatomical view of the cerebral blood vessels and detects any abnormality in the blood vessels like blockage of the blood vessel by a blood clot or aneurysm (ballooning of a weak vessel). We prefer doing CTA in all brain attack patients who come to us within 12 hours of symptom onset, so that site of the occlusion can be determined. In cases of large blood vessel occlusion we take the patient in the endovascular lab where angiography of brain vessels is done (like coronary angiography) and clot busting drug can be injected directly in the clot itself.

CT Perfusion Imaging : CT Perfusion images enable us to determine the extent of the brain damage already done as well as extent of the tissue which can still be salvaged. This helps us in deciding right treatment modality like intravenous or intra-arterial thrombolysis (injecting clot busting drug directly in the clot itself) or mechanical removal of the clot.

3. An MRI takes a specialized picture of the brain (MRI) and its vessels (MRA). Instead of using x-rays, powerful magnetic beams are used to generate the picture. The picture of the brain is more detailed than that obtained by a CT scanner but an MRI also takes longer to obtain. Due to its high level of sensitivity, MRI is considered especially useful when there is doubt regarding time of onset or diagnosis. The technology involves use of a strong magnetic field, and is performed in a special room free of metallic equipment.

Digital subtraction Angiography (DSA)

We have one of the best endovascular biplane DSA labs in the World, which makes us leader in treating vascular disorders of the brain including brain attack. If a patient comes to us after 3 hours of window period but before 12 hours, he can still be treated by injecting drug directly in the clot or retrieving it mechanically. This technique is also very effective if a major blood vessel is blocked where conventional intravenous thrombolytic therapy (as discussed below) is not that effective.

Emergency Treatment of Brain attack

Much of the damage caused by a thrombotic or embolic stroke occurs in the first few hours. Drugs that dissolve clots are known as thrombolytic agents. These drugs can dramatically minimize stroke damage.

Thrombolytic Agents: Thrombolytic agents (tissue plasminogen activator or TPA) or clot busting drugs, widely used to dissolve clots that cause heart attacks, are also able to dissolve artery-blocking clots in the brain during the critical early stages of stroke. Early administration of TPA after a brain attack can reduce neurological damage significantly. These medications are most effective when administered within the first three hours of stroke onset. This time window can be extended up to 4.5 hours in a certain group of patients. Intra arterial thrombolysis (injecting clot busting drug directly into the clot itself) has been found to be very effective and is being practiced in all the leading centers of the world that have facilities for the same. The advantage of this technique is that time window is extended and it is effective even in patients who come up to 6 hours. This technique is more effective in patients who have large vessel occlusion. Since Medanta has facilities for MR/CT perfusion (a technique which can identify salvageable tissue) and state of the art endovascular lab, clot can even be removed mechanically with the help of retrieving devices if required.

Medications to prevent Stroke recurrence

There are a number of medications used to help prevent stroke in high-risk patients, particularly those who have had a previous TIA or minor stroke. These drugs fall into two major categories: anticoagulants (such as heparin and warfarin) and antiplatelet agents (such as aspirin, dipyridamole and clopidogrel).

Anticoagulants: These drugs may be given orally, intravenously or subcutaneously. They work by preventing blood clotting. They are also used for deep vein thromboses and pulmonary emboli, and are very effective for preventing stroke in patients with atrial fibrillation (irregularity of heart rhythm), artificial valves or those who are suffering from coagulopathies (factors which increase tendency of the blood to clot). Patients who are on anticoagulants need to monitor their INR (parameter of blood thinning) every 3-4 weeks.

Antiplatelet Agents: Antiplatelet agents work by preventing or reducing the occurrence in the blood stream of a phenomenon known as platelet aggregation. This aggregation can sometimes result in formation of a thrombus (blood clot) that may totally block the artery, break loose or block a smaller artery. By preventing this from occurring, antiplatelet agents can reduce the risk of brain attack in patients who have had TIAs or prior ischemic attacks.

Surgical Techniques

Surgery is an accepted way of preventing stroke for patients with certain conditions. There are a number of conventional surgical techniques that have been in use for some time, including “clipping” aneurysms to prevent further bleeding and removing cerebral vascular malformations. Aneurysms and arteriovenous malformations (bunch of abnormal blood vessels) may also be treated in the endovascular lab where our experts perform the angiography (like coronary angiography for the heart) and block the abnormal vessels using coil/glue/particle. Occasionally in acute situation when brain swelling is increased because of clot or bleed in the brain, patient is taken to the operation theater to do an emergency hemicraniectomy. Hemicraniectomy is a procedure wherein a flap of skull and dura (membranes covering brain) are removed to give brain sufficient space to expand. If this is not done in time, swollen brain can compress the vital centers in the brain and can lead to death.

Carotid Endarterectomy / Carotid stenting

Carotid endarterectomy is a procedure used to remove atherosclerotic plaque from the carotid artery when this vessel is blocked. For certain patients with minor attacks or TIAs, carotid endarterectomy is highly beneficial in preventing future brain attacks. This procedure is also beneficial for some patients with blockage of the carotid arteries who have not had previous symptoms. Carotid stenting is a procedure in which blocked carotid artery is opened like what they do in angioplasty of heart and a stent is placed in the artery to keep it open.

Medanta Rehabilitation program following Brain attack

Because of the tremendous advances in brain attack treatment, along with the ever-increasing sophistication of rehabilitation techniques, the outlook for brain attack patients has never been more hopeful. The ultimate goal of rehabilitation is to return the patient to as independent a lifestyle as possible. Successful brain attack rehabilitation is dependent on many factors, including the severity of brain damage and the cooperation of family and friends. Not surprisingly, the attitude of the patient is a key factor in speed and recovery. A positive outlook and high level of determination may facilitate recovery. Depending on the area of the brain affected by the attack, physical and mental damage may be mild or severe, ranging from dizziness and confusion, to sensory loss, to paralysis and even death. Patients with mild attacks or those who obtained successful medical therapy may need little or no rehabilitation. After a brain attack, other blood vessels may be able to take over for the damaged blood vessel. This allows some cells to recover, although others may still die. If the blood supply is cut off due to a clot, the body works to dissolve the clot. This means that the damaged part of the brain can sometimes improve or return to normal without rehabilitation. Most brain attack patients, however, will benefit from some type of rehabilitation.

Preventive arm of Brain Rescue program

There are many positive steps that you can take now to reduce the risk of brain attack. The most common risk factors for brain attack are listed here. These include some conditions that can be changed by lifestyle modification or medical treatment, and some, such as hereditary factors, that cannot be changed. Most of the controllable risk factors for stroke relate to cardiovascular fitness. Because brain attack is a form of cardiovascular disease, it makes sense that keeping your heart and blood vessels as healthy as possible will reduce your risk.

Risk Factors That Can Be Changed

• Hypertension (high blood pressure)
• Smoking
• Heart disease
• High-cholesterol level
• Excess alcohol intake
• Obesity
• Sedentary lifestyle
• Diabetes
• Elevated hematocrit
• Use of oral contraceptives (especially
• (increase in red blood cells)

for women who smoke)

Risk Factors That Cannot Be Changed

• Age
• Race
• Sex
• Family or individual history of stroke or TIA

Regular Medical Check-ups: Risk factors such as heart disease, high blood pressure and elevated blood cholesterol must be monitored by your physician on a regular basis. These risk factors can be changed or, at a minimum, controlled by proper medical treatment and appropriate diet and lifestyle modifications.

Control Blood Pressure: High blood pressure (hypertension) is the single most important risk factor for brain attack. Even mild hypertension, if not adequately treated, increases brain attack risk. In general, blood pressure should be below 140/90. Elevated blood pressure promotes atherosclerosis and puts abnormal pressure on blood vessel walls, which can cause a rupture at a weak spot.

Hypertension is often called the “silent killer” because there may be no obvious symptoms. It is important to check your blood pressure regularly. Controlling blood pressure, whether by a low-sodium diet, weight control, stress management and/or medication, will reduce your risk of brain attack. Remember: medication to control hypertension is effective only if taken on a regular basis, so it is important to follow your physician’s instructions.

Stop Smoking: Studies confirm that smokers have a higher risk of brain attack, regardless of other factors such as age, high blood pressure or heart disease. The risk declines dramatically with a few years of not smoking.

Treat Heart Disease: A variety of heart conditions, including irregular heart rhythms (atrial fibrillation), heart attacks and heart valve disorders, can cause brain attack. Treatment of these disorders can reduce brain attack risk.

Maintain a Healthy Weight: Being overweight strains the heart and blood vessels and is associated with high blood pressure. Obesity also predisposes a person to heart disease and diabetes, both of which increase the risk for brain attack. Keeping your weight at recommended levels for your height and build is a prudent preventive measure.

Exercise Regularly: The percentage of fat in our bodies tends to increase with age. Regular exercise helps keep this increase to a minimum. There appears to be an inverse relationship between exercise and atherosclerosis, i.e., more exercise is linked to lower level of atherosclerosis. If you have not exercised regularly and would like to start an exercise program, or if you have medical problems of family history or serious disease, consult your physician before beginning an exercise program.

Improve Diet: Consumption of foods high in fat, cholesterol and salt increases the risk for brain attack. The following recommendations are among the most important for brain attack prevention. Ask your doctor for more help in identifying dietary culprits and making appropriate substitutions.

Avoid Excess Fat: High intakes of fat, particularly saturated fat, and cholesterol may contribute to atherosclerosis, which is associated with brain attack. Dietary fat and cholesterol may be reduced by limiting fat or oil added in cooking, trimming fat and skin from meats and poultry, using low-fat or nonfat diary products, boiling and baking foods rather than frying, and limiting eggs to no more than three a week.

Avoid Excess Sodium: Excess sodium in the diet is linked to hypertension. Table salt is the primary source of dietary sodium. There is also “hidden” salt in most processed and canned foods. Disodium phosphate, monosodium glutamate, sodium nitrate or any similar compound in the list of ingredients indicate a high sodium content. Try to eat fresh food whenever possible.

Limit Alcohol Intake: Individuals who drink alcoholic beverages (more than two drinks per day) have an increased risk of brain attack. For heavy drinkers, the risk increases further. Healthy young adults are just as susceptible to the risk of brain attack incurred by heavy alcohol consumption as are older persons.

Treat Diabetes: The association between diabetes and increased brain attack risk seems to be related to the circulatory problems caused by diabetes. Good control of diabetes appears to reduce the cardiovascular complications of the disease.

Reduce Stress: Because stress may increase blood pressure, it is linked indirectly to brain attack risk. A one-time stressful event rarely causes a brain attack, but long-term unresolved stress can contribute to high blood pressure. Stress management, including relaxation techniques, biofeedback, exercise and counseling, appear to be useful in the treatment of high blood pressure, thus lowering the risk of brain attack.

Use of Oral Contraceptives: Oral contraceptives, especially those with high estrogen content, appear to increase the risk of blood clots, including clots that cause brain attack, especially in women over age 30. The risk is even higher in women who smoke. Consult your physician for advice regarding alternative methods of birth control if you have brain attack risk factors and are currently using oral contraceptives. Postmenopausal estrogen use does not appear to increase brain attack risk.

Risk Factors That Cannot Be Changed

Age: The chance of having a stroke increases with age. Two-thirds of brain attacks occur in persons over the age of 65.

Gender: For reasons that are not yet clear, brain attack is 25 percent more common in men than in women.

Race: The incidence of brain attack varies among races for reasons that are probably related to genetic factors. Social factors, such as lifestyle and environment, can also play a part. Asians and African Americans have a higher incidence of hypertension than Caucasians, and also a higher rate of brain attack. Furthermore, they are more likely to suffer brain attacks at an earlier age.

Family or Individual History: A history of cerebrovascular disease in a family appears to be a contributing factor to brain attack. While you have no control over your family history, you can take steps to decrease your risk through diet, exercise and other means discussed in this handbook. If you have experienced a brain attack or TIA in the past, you are at increased risk for having a brain attack in the future. Therefore, all the preventive measures discussed in this section are of particular importance.

Brain Rescue intervention for stroke prevention

To prevent stroke occurrence in patients at risk we do a battery of investigations which includes blood and metabolic tests, vascular screening and baseline brain imaging. With the help of these tests we calculate basal metabolic rate, body mass index, percentage occlusion of brain vessels etc. Under this program we offer our patients body fat mobilization therapy, optimizing blood flow therapies, exercises tailored for them, yoga and rejuvenation therapies and appropriate nutritional advice.

The interdisciplinary team includes:

• Consultants: includes the neurologist, Critical care specialist (intensivist), physician, neurosurgeon, interventional neuroradiologist, and neuro-anesthesiologist
• Registered nurses: assess and coordinate patient needs, administer treatment and provide family instruction
• Patient care assistants: provide personal care and hygiene
• Physical, occupational and speech therapists: provide individualized rehabilitation
• Medical social workers: offer support to patient and family, work to coordinate any appropriate community resources
• Care coordination: oversees hospitalization and coordinates with insurance payers; works to insure follow-up arrangements such as home care
• Dietitians: assist with proper design of nutritional caloric intake