脑卒中又称“脑血管意外”(cerebral vascular accident，CVA)，是一种急性脑血管疾病，包括缺血性脑血管病(如脑血栓形成、脑栓塞等)及出血性脑血管病(如脑出血、蛛网膜下腔出血等)。缺血性卒中的发病率高于出血性卒中，但是后者的死亡率较高。长期以来，脑卒中都习惯于采用非手术治疗，随着神经外科技术的进步，目前出血性卒中及缺血性卒中都可采用手术治疗。

A stroke, sometimes referred to as a cerebrovascular accident(CVA), cerebrovascular insult(CVI), or colloquially brain attack is the loss of brain function due to a disturbance in the blood supply to the brain.This disturbance is due to either ischemia(lack of blood flow)or hemorrhage.

Ischemia is caused by either blockage of a blood vessel via thrombosis or arterial embolism, or by cerebral hypoperfusion.Hemorrhagic stroke is caused by bleeding of blood vessels of the brain, either directly into the brain parenchyma or into the subarachnoid space surrounding brain tissue.As a result, the affected area of the brain cannot function normally, which might result in an inability to move one or more limbs on one side of the body, failure to understand or formulate speech, or a vision impairment of one side of the visual field.

A stroke is a medical emergency and can cause permanent neurological damage or death.Risk factors for stroke include old age, high blood pressure, previous stroke or transient ischemic attack(TIA), diabetes, high cholesterol, tobacco smoking and atrial fibrillation.High blood pressure is the most important modifiable risk factor of stroke.Cerebrovascular disease was the second leading cause of death worldwide.An ischemic stroke is occasionally treated in a hospital with thrombolysis(also known as a “clot buster”), and some hemorrhagic strokes benefit from neurosurgery.Treatment to recover any lost function is termed stroke rehabilitation, ideally in a stroke unit and involving health professions such as speech and language therapy, physical therapy and occupational therapy.

D: Hello! What brings you to the hospital?

P: Doctor, I got a severe headache.I feel like my head will explode.

D: Oh wow, I am sorry to hear that! When did the headache start, and what were you doing then?

P: It started about 1 hour ago.I was on the toilet.I was pushing hard because I was constipated.

D: Do you have any other unusual feelings? Such as neck stiffness, nausea, vomiting?

P: Yes, I have some neck pain and nausea, but have not vomited.

D: Ever vomit?

P: Not yet.

D: Did you pass out?

P: No.

D: Does your face, arm, or leg feel numbness or tingling,especially just one side of your body?

P: No, I don’t feel any of that.

D: Did you have any trouble speaking or understanding other people’s speech?

P: No.

D: Did you have any changes in vision, such as loss of vision?

P: No, but when the headache occurred I could not see for a while.

D: Have you ever experienced this situation before?

P: I have headaches several times in the past several weeks, but not as bad as this time.This is really the worst headache I ever had!

D: Since when did you began having headaches?

P: About one and half month ago.

D: Did you go see a doctor for that?

P: No, I thought I was catching a cold and didn’t pay too much attention.

D: Do you have any other medical problems? Such as high blood pressure, heart disease, high cholesterol or other problems?

P: No, I am not aware of any medical problems.I hardly ever take any medications.

D: Any medical problems that runs in your family?

P: My parents are healthy, but my little brother died from a brain bleed(cerebral hemorrhage)nine years ago.Is this disease genetic?

D: I am not sure about that since I don’t know the exact details of your brother’s situation.Do you smoke?

P: No.

D: What about alcohol?

P: I drink occasionally, but not too much.

D: Okay good, I’m going to do a quick physical exam if you don’t mind.I think you may need a CT scan in order to clarify the diagnosis.

D: After my assessment and results from the imaging study, I think you need to be admitted to the hospital for further monitoring and treatment.

P: Hi doctor, could you tell me about my condition? Is it serious?

D: Don’t worry; let me explain it for you.You are suffering from bleeding inside the brain, called subarachnoid hemorrhage.When a hemorrhage occurs, a person may experience headache, numbness,or even coma.This condition can occur rapidly, and you are lucky to have come to the hospital in time.

P: What’s the reason of the bleeding? Did any blood vessel rupture?

D: Most cases of SAH are due to trauma, but it is not your case.The other cases are related to brain aneurysms, which are abnormalities within the brain’s arteries.The most common cause of primary SAH is a congenital “berry” aneurysm.It is called a berry aneurysm because it forms a cluster of sac-like pouches in a cerebral vessel—looking like a cluster of berries.These aneurysms swell up and weaken the walls of arteries over time.When the blood pressure suddenly increases for some reason, for example when a person is stressed or pushing hard during a bowel movement, the aneurysm ruptures, quickly bleeds and forms a clot.In some cases, trauma to the brain during an injury can cause aneurysms and result in a subarachnoid hemorrhage.

P: I never experienced a head injury.At what age do people get these? Did my brother suffer from the same disease?

D: Aneurysmal hemorrhage may occur at any age but is most common from age 40 to 65.According to the clinical data, women are more likely to develop SAH than men.It is difficult to tell if it is the same disease, but some researches revealed the aneurysm demonstrate familial aggregation.

P: Do I need to do other tests?

D: In order to find out if there are any aneurysms ruptured, you may need an imaging study called brain angiography to evaluate blood flow patterns within your brain.The test can be used to detect an aneurysm or some other abnormality, and could be performed with CT or MR.Digital subtraction angiography is the most accurate method for diagnosis of the disease currently.You may also need an electrocardiogram(EKG).The dramatic stress on the brain during a subarachnoid hemorrhage can trigger chemical changes within your heart muscle.These changes can stress the heart muscle and may result in a heart attack, even if your heart arteries are not narrowed by atherosclerosis.

P: How is this treated?

D: First of all, we will give you medication to relieve the symptoms and prevent complications such as permanent brain damage.Then we are going to find ways to repair the source of bleeding.If the hemorrhage is due to an aneurysm rupture, then surgery is needed.

P: Can you tell me more about the surgery?

D: The surgery involves a craniotomy then aneurysm clipping to close the aneurysm, or done interventionally with endovascular coiling by placing coils in the aneurysm and stents in the blood vessel to cage the coils to reduce the risk of further bleeding.Aneurysm clipping requires brain surgery.The brain surgeon places a small metal clip across the base of the aneurysm.Endovascular clipping is a less invasive procedure.The doctor inserts a thin flexible tube,called a catheter with a metal coil at the end into a blood vessel.The doctor then threads the catheter into the brain at the site of the aneurysm.The metal coil is left behind.It blocks blood flow to the aneurysm.The pressure inside the aneurysm will be much lower and the risk of recurrent bleeding is reduced.

P: If no aneurysm is found, then what is the treatment?

D: If no aneurysm is found, you will be closely mentioned by a health care team and may need more imaging tests about 2 weeks later.During this time, you may need to be on strict bed rest to avoid activities that can increase pressure inside your head,including bending over, straining and sudden changes in position.

P: Do I need to take any medications?

D: Of course! We will prevent seizures with anti-seizure medications.Blood pressure control is very important.So the antihypertensive drugs are also used.Because the SAH could cause arterial vasospasms in which the blood vessels constrict and thus restrict intracranial blood flow, Nimodipine is useful and required.We will also give you some pain medications and antianxiety pills to help relieve severe headaches and your anxiety level.You will be given stool softeners or laxatives to prevent straining during bowel movements.

P: Well, thank you, doctor.

D: Hi.What brought you to the hospital this time?

P: I suddenly passed out this morning.

D: Oh, when did it happen and what were you doing at that time?

P: Around 7 o’clock in the morning, I was making breakfast.

D: What happened after that? Did you know about that?

P: I passed out I don’t know what happened.My wife said she saw me slid down by the cabinet, and ran over and help me while I sat on the ground.

D: How long did you passed out?

P: My wife and I are not so sure about that.She was scared.I guess it lasted for about 10 minutes.

D: Did your wife see any other signs or symptoms after you passed out, like body twitches or shakes(convulsions), foaming at the mouth about it?

P: My wife said no.

D: Do you have any other unusual feelings? For example,headache or nausea?

P: No.

D: Do you have any trouble in walking, any dizziness or lack of balance or coordination?

P: Well, I am still a little dizzy.

D: Is there numbness or weakness of the face, arm or leg,especially on one side of the body?

P: Yes, my right hand is a little numb and it feels weak.

D: Did you have any trouble in speaking or understanding other people’s speech?

P: No.

D: Have you ever experienced this situation before?

P: I had similar dizziness for 3 times, but without loss of consciousness.I also have numbness of hands and arms, occasionally.

D: Since when did these symptoms starts?

P: About a year ago.

D: Did you ever see a doctor or go to the emergency room for that?

P: Never.I did not know it was a serious problem at that time.I thought I just needed to take a break.

D: Do you have any other medical problems? Such as high blood pressure, heart disease or other problems?

P: I have high blood pressure and diabetes.

D: Do you take any medications?

P: I take nifedipine 1 tablet a day, and metformin 1 tablet each before meals.

D: What does your blood pressure run like at home; what about your sugar levels at home?

P: My blood pressure is usually 160/110mmHg and my blood sugar is around 7～8mmol/L.

D: Got it.How is your family’s health? Especially your parents.Are they still alive? Did they have any significant medical problems or have similar complaints?

P: My father has a history of high blood pressure, and my mother died of cerebral infarction.

D: Do you smoke?

P: Yes, but not so much.About 10 cigarettes one day.

D: Okay, now could you lie down in the bed for me; if it is okay with you, I will go ahead and do a quick exam.

D: Thank you.You can sit up now.I think the next step would be a CT examination to help clarify the diagnosis.

D: After my assessment and exam, I recommend that you be admitted to the hospital for further workup and treatment.

P: Doctor, tell me about what is going on?

D: After physical examination and CT scan I think you are suffering from a TIA, which is short for Transient Ischemia Attack.Let me give you a brief explanation of this disease.As we all know, blood flows through the brain by vessels continuously, supplying oxygen and nutrients such as glucose and carrying out waste such as carbon dioxide.If cerebral artery stenosis or occlusion occurred due to some reasons, such as viscous or arterial blood pressure sudden dropped,the cerebral blood flow is reduced or stopped.If the amount of blood flow through an artery in the brain shrinks, some part of the brain tissues will be ischemic and not work correctly, and some cerebral impairment will happen such as slurred speech, numbness and paralysis.If the ischemic time is short, brain impairment only lasts a short period of time, and will not result in ischemic necrosis.We call this sort of focal cerebral ischemia and the transient neurological deficits as transient ischemic attacks（TIA）.

P: What causes this?

D: TIAs are usually caused by one of three things.First,low blood flow at a narrow part of a major artery carrying blood to the brain, such as the carotid artery.Second, a blood clot in another part of the body breaks off, travels to the brain and blocks a blood vessel in the brain.Third, narrowing of the smaller blood vessel in the brain, blocking blood flow for a short period of time; usually caused by plaque buildup.For you, high blood pressure and diabetes could be the important and direct risk factors for your TIA.Genetics and smoking may be the root causes.

P: What else needs to be done to check?

D: In order to clear the condition, we need to assess your blood vessels information, especially the multiple blood vessels supplying the brain, which the CT of the brain you have done is unable to reveal the information.I think we need to perform a cerebral angiography for the cerebral vascular related information, by CT or MR.Of course, digital subtraction angiography is the most accurate method for diagnosis of the disease currently, which is an interventional procedure, required hospital admission and performed in the operating room.The harm and costs are relatively larger than CTA or MRA.

P: What are the treatment methods?

D: Depending on the severity and situation, we can choose different treatments including drug therapy and surgery.The good news is that 80 percent of all strokes are preventable.It starts with managing key risk factors, including high blood pressure and cigarette smoking.More than half of all strokes are caused by uncontrolled hypertension or high blood pressure, making it the most important risk factor to control.For the less severe cases, if there is no obvious cerebrovascular stenosis, patient can choose drug therapy.Antiplatelets and antihypertensives are the most common and effective choice and we have many other alternative medicines.But for patients with symptoms with cerebral arterial stenosis, surgery may need to be done.

P: Can you tell me more about the surgery?

D: When arteries show plaque buildup or blockage,medical procedures may be needed.Carotid endarterectomy, also called carotid artery surgery,is a procedure in which blood vessel fatty plaque is surgically removed from the carotid artery.Angioplasty or called stenting is performed by the doctors to use balloon angioplasty and implantable steel screens called stents to treat cerebrovascular disease and help open up the blocked blood vessel.

P: If not treated in time what are the consequences?

D: Your current symptoms can ease and we have found no obvious cases of cerebral infarction through your CT scan, suggesting that the major blood vessels in your brain are not yet permanently blocked, nor resulting in permanent loss of function of the brain.But no one can ensure that you also could ease from the stroke next time, and once the cerebrovascular occlusion occurs, it can result in permanent impairment of the nervous system, such as slurred speech, numbness, paralysis,coma, even life-threatening.

P: Can I recover?

D: Currently, diagnostic evaluation and treatment options of these diseases have become more mature, and early detection, early diagnosis, early treatment has improved prognosis for most patients.Of course, you will need aggressive treatment of high blood pressure and diabetes.The lifestyle adjustments, such as eating healthy foods and quitting smoking, may reduce the risk of stroke.It is the only way to avoid and reduce the risk of cerebral infarction.

P: Well, thank you, doctor.