Ischaemic stroke
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Understanding Ischaemic Stroke: Causes, Management, and Prevention
Introduction to Ischaemic Stroke
Ischaemic stroke is a major global health concern, being the second leading cause of death and a significant cause of disability worldwide. It occurs when an artery supplying blood to the brain is obstructed, leading to a reduction in blood flow and subsequent brain damage . This type of stroke accounts for approximately 71% of all stroke cases.
Risk Factors and Epidemiology
Several modifiable risk factors contribute to the incidence of ischaemic stroke, including hypertension, hyperlipidemia, atrial fibrillation, cigarette smoking, and a sedentary lifestyle . The global burden of ischaemic stroke has increased significantly over the past few decades, particularly in low- and middle-income countries. This rise is attributed to the growing prevalence of these risk factors and inadequate healthcare infrastructure in these regions.
Pathophysiology of Ischaemic Stroke
The brain injury resulting from ischaemic stroke involves a complex series of pathophysiological events, including excitotoxicity, peri-infarct depolarizations, inflammation, and apoptosis. These processes contribute to the damage within the peri-infarct zone or ischaemic penumbra, which is the area surrounding the core of the infarct.
Acute Management Strategies
Intravenous Thrombolysis and Endovascular Thrombectomy
Rapid reperfusion is critical in the management of ischaemic stroke. Intravenous thrombolysis, when administered within 4.5 hours of stroke onset, significantly reduces disability. For selected patients with evidence of salvageable brain tissue, thrombolysis can be beneficial up to 9 hours after onset and even in those who wake up with stroke symptoms. Endovascular thrombectomy is another effective treatment, reducing disability in patients with large vessel occlusion when performed within 6 hours, and up to 24 hours in selected cases.
Haemodilution and Anticoagulation
Haemodilution, aimed at improving blood flow to the affected brain areas, has not shown significant benefits in improving survival or functional outcomes in acute ischaemic stroke. Similarly, early anticoagulation therapy, although reducing recurrent strokes and pulmonary embolism, increases the risk of bleeding and does not provide a net benefit in terms of survival or long-term outcomes.
Secondary Prevention
Secondary prevention of ischaemic stroke involves managing cardiovascular risk factors such as blood pressure, cholesterol levels, and the use of antithrombotic medications. Specific interventions are tailored to the underlying cause of the stroke, such as anticoagulation for atrial fibrillation and carotid endarterectomy for severe carotid artery stenosis.
Genetic and Population-Specific Factors
Genetic factors also play a role in ischaemic stroke, with certain genetic variants being associated with specific stroke subtypes. Additionally, the association of modifiable risk factors with stroke subtypes varies between Asian and Caucasian populations, highlighting the need for population-specific prevention strategies.
Conclusion
Ischaemic stroke remains a significant global health challenge, with increasing incidence and burden, particularly in developing countries. Effective management requires rapid reperfusion therapies, while secondary prevention focuses on controlling cardiovascular risk factors. Understanding the genetic and population-specific factors can further enhance targeted prevention and treatment strategies. Continued research and improvements in healthcare infrastructure are essential to reduce the global impact of ischaemic stroke.
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