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  Time Is Brain Dr  Viswanathan   Iyer 2011-03-16 03:31:13  

A 67 year old lady presented to her General Practitioner with sudden history of left sided weakness since 45 minutes. She was a known case of hypertension and dyslipidemia. The doctor suspected stroke and immediately referred her to  a tertiary stroke centre. He informed the stroke team and facilitated the admission procedure in order to save time. By the time we saw her, MR Angiography of the Brain and all blood investigations were done. She was conscious, with grade 2/5 power in the left upper limb and grade 3/5 power in the lower limb. She had left upper motor neuron type of facial palsy. MRA showed area of infarction in the right MCA territory and a large area of ischemia (penumbra). The right MCA was filling poorly. Since it was only 2 hours since symptom onset, we were within window period for Intra-venous thrombolysis. All contraindications for thrombolysis were ruled out and the family consent was taken. rTPA was administered according to the protocol and she was monitored in the Stroke Unit ICU.

The patient did well and power improved in 24 hours. Repeat MRA showed a small area of infarction in the right MCA territory. The ischemic zone was perfused well. The poorly filling Right MCA was now filling well up to the distal cortical branches. At the end of 5 days, she was walking with minimal support of a walker. Upper limb power improved to nearly 4/5.

I.V. rTPA treatment, 0,9 mg/kg, maximum of 90 mg), with 10 % of the dose given as a bolus , followed by an infusion lasting 60 min, is recommended within 3 hours after the onset of ischemic stroke. Intra-arterial treatment of acute MCA occlusion in a 6 hour-time window using pro-urokinase results in a significantly improved outcome. Mechanical thrombolysis using Penumbra Device improves outcome in a 8-9 hour time window.  Time windows in posterior circulation stroke can be extended to 12-24 hours.

Brain attack or STROKE should be considered an Acute emergency like Heart Attack and referred immediately to a Tertiary Stroke Unit. The doctor who sees the patient first has to set the ball rolling by informing the casualty, radiologist and stroke specialist so that the time window is not lost. With protocol based Stroke Units, the outcomes of stroke have improved and with more awareness, we expect more patients to reach in time and get the benefit of Thrombolysis.

The quality of life after a stroke takes a toll on the patient, his family and the society. The time windows make it necessary for all doctors to recognize and refer stroke patients to stroke specialists and units IMMEDIATELY.

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