Strokes

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore

Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology

(Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)

Spot a Stroke: BE FAST

Stroke remains a leading cause of death and long-term disability worldwide, including Singapore and Asia, affecting over 10 million people annually [4].

However, recent breakthroughs in diagnosis, treatment, and rehabilitation offer new hope for patients and their families. This summary provides an overview of the latest advances in stroke care, emphasising the critical importance of rapid intervention and highlighting promising new approaches to improve outcomes.

Understanding Stroke

A stroke occurs when there is a disruption of blood flow to the brain, either due to a blockage (ischaemic stroke) or a rupture of a blood vessel (haemorrhagic stroke) [4]. This interruption deprives brain cells of oxygen, causing damage and potential cell death. The effects of a stroke can vary widely depending on the location and extent of the brain injury.

• Ischaemic stroke needs to be quickly identified and treated with anti-platelet and anti-coagulant therapy and endovascular therapy.

• Patients with TIAs and RINDs should be effectively screened with MRA and DSA for treatable carotid artery stenosis.

• Patients with haemorrhage from brain AVMs, aneurysms, cavernomas, and dural AV fistulas should be diagnosed early with CT, MRI, and DSA.

• Some patients require early surgery including microsurgery.

• Selected patients will benefit from endovascular therapy including embolisation, coiling, flow diverters, and others from stereotactic radiosurgery.

  
  

The Urgency of Stroke Treatment

One of the most critical factors in stroke treatment is time. The phrase “time is brain” underscores the importance of rapid intervention to limit cerebral damage [1]. Recent research has reinforced the need for urgent action, even when symptoms appear to resolve quickly.

Transient Ischaemic Attacks (TIAs)

New guidelines emphasise that even brief stroke symptoms, lasting less than an hour (known as transient ischaemic attacks or TIAs), require immediate medical attention [7]. These “warning strokes” can precede a full-blown stroke and should be treated as medical emergencies.

Advances in Stroke Diagnosis

Early and accurate diagnosis is crucial for effective stroke treatment. Recent technological advancements have improved our ability to quickly identify and characterise strokes.

• Portable MRI Technology

Researchers have developed a portable MRI machine that can be brought to a patient’s bedside, potentially reducing delays in diagnosis [4]. This innovation allows for faster imaging and could significantly improve the speed of stroke diagnosis and treatment initiation.

Cutting-Edge Stroke Treatments

The landscape of stroke treatment has evolved rapidly in recent years, with several groundbreaking approaches showing promise.

Endovascular Interventions

• Mechanical thrombectomy, a procedure to remove blood clots from large vessels in the brain, has emerged as a highly effective treatment for certain types of ischaemic strokes [5].

• Bleeding from AVMs can be treated with endovascular embolisation.

• Aneurysms can be occluded with platinum coils or excluded from circulation with flow diverters.

• Subdural haematomas can be treated using endovascular embolisation of the middle meningeal artery.

  
  

Thrombolysis

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) remains a cornerstone of acute ischaemic stroke treatment [1].Recent studies have explored:

• Extending the time window for treatment

• Alternative thrombolytic agents like tenecteplase [8]

  
  

Brain Stimulation Techniques

Non-invasive brain stimulation, such as:

• Repetitive transcranial magnetic stimulation (rTMS)

• Transcranial direct current stimulation (tDCS)…are being studied for their potential to enhance motor recovery after stroke [6].

  
  

Neuroprotective Strategies

Research is ongoing into neuroprotective therapies that could be administered early — potentially even before imaging — to limit brain damage in stroke patients [1].

Rehabilitation and Recovery

Stroke rehabilitation has seen significant advancements, with new technologies and approaches offering hope for improved recovery.

Brain-Computer Interfaces (BCIs)

BCIs are emerging as a promising tool for rehabilitation, allowing patients to control external devices using brain signals [10]. This may help stimulate neuroplasticity and improve motor function recovery.

Virtual Reality and Robotics

Virtual reality and robot-assisted therapies are being integrated into rehabilitation programmes, offering new ways to engage patients and provide intensive, targeted therapy [6][10].

Personalised Rehabilitation

There is a growing emphasis on tailoring rehabilitation strategies to individual patients, considering:

• Stroke type

• Stroke location

• Patient’s specific deficits and goals [3]

  
  

Prevention and Secondary Stroke Risk Reduction

Blood Pressure Management

Recent research highlights the importance of personalised blood pressure management in the acute phase after a stroke [4]. Optimal targets may vary by patient.

Antiplatelet Therapy

Dual antiplatelet therapy (aspirin + clopidogrel) has shown promise in preventing recurrent strokes in certain high-risk patients [8].

Lifestyle Modifications

Encouraging:

• Healthy diet

• Regular exercise

• Smoking cessation…remains a cornerstone of stroke prevention.

  
  

Future Directions in Stroke Care

The field of stroke care is rapidly evolving, with several exciting areas of research underway:

• Cell therapies

  Stem cell treatments for stroke recovery show potential for improving motor function [10].

  
  

• Artificial intelligence

  AI is being explored to enhance diagnosis, treatment selection, and outcome prediction.

  
  

• Telemedicine and telerehabilitation

  Expanding access to specialised care, especially in underserved regions [6].

  
  

• Combination therapies

  Integrating techniques like brain stimulation with robotic rehab and traditional therapy [6].

  
  

The landscape of stroke care is rapidly evolving, with new technologies and treatment approaches offering hope for improved outcomes. From faster diagnosis and more effective acute interventions to innovative rehabilitation techniques, these advancements are transforming the way we approach stroke care.

However, the most critical factor remains rapid recognition and response to symptoms. Public education about warning signs and the importance of immediate medical attention is crucial.

Remember: If you or someone you know experiences symptoms of a stroke, even if they seem to resolve quickly, seek emergency medical care immediately.Every minute counts in preserving brain function and improving recovery.

Stroke Care with Singapore Brain Spine Center

With many years of experience in diagnosing strokes and access to the latest technological advancements, Dr Prem Pillay offers patients the highest standard of care. From accurate diagnosis to tailored treatment plans, our approach ensures the best possible outcomes for individuals affected by this challenging condition.

If you or a loved one has been diagnosed with a stroke, we welcome you to seek consultation with our specialised team. Together, we can develop a comprehensive, evidence-based, and personalised treatment strategy that addresses your unique needs and aims to provide the best chance for a positive outcome.

References

[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC1448697/[2] https://www.mayoclinic.org/diseases-conditions/stroke/diagnosis-treatment/drc-20350119[3] https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2024.1402729/full[4] https://www.yalemedicine.org/news/3-stroke-breakthroughs[5] https://bmjmedicine.bmj.com/content/2/1/e000407[6] https://pmc.ncbi.nlm.nih.gov/articles/PMC10650295/[7] https://www.stroke.org/en/news/2023/01/19/stroke-symptoms-require-emergency-treatment-even-if-they-quickly-disappear-new-report-says[8] https://pmc.ncbi.nlm.nih.gov/articles/PMC8407466/[9] https://www.ihi.europa.eu/news-events/newsroom/umbrella-project-sets-sights-stroke-care-revolution[10] https://pmc.ncbi.nlm.nih.gov/articles/PMC10761524/