Brain Stroke Treatment: Understanding The Role Of Neurosurgery

A brain stroke is a medical emergency that occurs when the blood supply to the brain is interrupted or reduced. Brain stroke is of two main types: ischemic stroke: caused by a blockage in a blood vessel supplying the brain, and hemorrhagic stroke: caused by a burst blood vessel or a tiny balloon (aneurysm) or nidus (AVM) of vessels in the brain causing brain hemorrhage. Regardless of the type, the impact on the brain can be profound, resulting in long term disability, cognitive impairments or even death and therefore should be treated without delay (ACT FAST).

Several factors contribute to the development of a stroke, and it is crucial to be aware of them to take preventive measures. Lifestyle choices, dietary habits, stress, smoking, and physical inactivity are significant risk factors that can increase the likelihood of experiencing a stroke. Additionally, medical conditions such as high blood pressure, diabetes, and obesity can also increase the risk. Understanding these factors and taking proactive steps to mitigate them are crucial for preventing strokes.

Although stroke is primarily managed by neurologists, neurosurgeons have a very important role in stroke management,

What neuro-interventional/neurosurgical procedures are required for ischemic stroke?

The recent update in the management of acute stroke involving large blood vessels of the brain is Mechanical Thrombectomy: ischemic strokes, particularly those caused by large blood clots blocking major brain arteries, this procedure can be used for emergency removal of the clot. In this procedure (mechanical thrombectomy), we perform a small puncture in the femoral artery in groin, and travel via that to the brain, reach the part of the blood vessels which is blocked by the clot and suck it out to remove the clot via a simple suction aspiration technique or deploy a fishing net type stent to catch the clot (solumbra technique) and then remove it emergently to restart the blood flow in the brain. But this procedure is recommended only up to 18-24 hours maximum, as there is permanent damage to the brain cells after 24-hour period, and the procedure may not yield good results. Therefore, we recommend all patients with acute stroke to reach tertiary care hospital with a neurosurgeon and neurologist without any delay, so that he/she can be saved with this procedure. Don't ignore act FAST.

What neurosurgical procedures are required for hemorrhagic stroke?

Patients with large brain hemorrhage, which compresses the brain inside the skull may need time-tested emergency neurosurgery called decompressive hemicraniectomy (removal of a part of the skull temporarily) to remove hemorrhage, halt the bleeding and relieve pressure inside brain. This is where neurosurgery can make a life-saving difference.

Recent advancements in stroke neurosurgery, like minimally invasive surgery (MIS): endoscopic/microscopic removal of the hemorrhage is performed with the idea of minimally damaging the brain tissue and going inside brain via a small hole and are available nowadays at major centres. But these techniques are not for all patients and can be beneficial only for selected cases of hemorrhagic stroke, and are therefore judiciously recommended by neurosurgeons.

Another type of hemorrhagic stroke, subarachnoid hemorrhage, is caused by bleeding into the space between the brain's surface and the covering layers of brain (meninges). This is usually caused by brain aneurysms, balloon like projections in brain blood vessels, blasting like a timebomb leading to severe bleeding in brain. Neurosurgery can be instrumental in treating this condition as well. Techniques like aneurysm clipping- putting clip at neck of aneurysm and closing it off, via microscopic surgery or endovascular coiling- packing the aneurysm via coils to seal it off via angiographic route (without opening the skull) prevent bleeding again. The surgery is always done by the neurosurgeon under microscope, whereas the later procedure of coiling can be performed by primarily by a neurosurgeon, but can also be performed by a neurologist or a radiologist trained in neurointervention. Such patients have highest risk of rebleeding in first 24 hours and should be treated urgently without much delay at major hospital by a neurosurgeon.

How to prevent stroke?

Despite the recent advances in neurosurgery, prevention should always be the goal achieved by understanding and addressing the risk factors that contribute to strokes can significantly reduce their incidence.

Seek urgent medical attention: any warning signs of a stroke, such as sudden weakness or numbness, speech difficulties, or severe headache, seek immediate medical attention. "Time is Brain"- More time you lose more brain is damaged.

In conclusion, understanding the risk factors and making positive lifestyle changes, frequent medical check-ups, we can reduce the risk of stroke. In case of acute stroke, irrespective of the type, one must reach a major hospital with a neurologist and neurosurgeon to get urgent medical treatment. Recent advances in Neurosurgery plays a crucial role in the treatment of strokes, avoiding disability and improving the quality of life and functional independence.

(Dr Parth Jani, Consultant Neurosurgeon, HCG Hospital, Ahmedabad
Fellow in Stroke and Neurointervention, Fellow in Cerebrovascular Neurosurgery, PGIMER Chandigarh, M.Ch Neurosurgery, PGIMER Chandigarh, M.S General surgery (Gold Medallist), MBBS)

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