Stroke is a Race Against Time.

If one day a family member suddenly shows signs of confusion, inability to move one side of the body, or difficulty speaking, these are dangerous warning signs from the brain. You must not wait to see if the symptoms improve. In the case of a stroke, if the blocked blood vessel can be reopened quickly, the brain cells on the verge of dying may be saved, and the extent of the stroke can be minimized. Call an ambulance immediately and have the person taken to a hospital that offers the latest stroke treatments. Brain cells die within hours when blood flow and oxygen are cut off. Once brain cells die, they cannot be revived. Restoring blood flow as quickly as possible is crucial to prevent this from happening.

Treatment Techniques

If stroke symptoms occur within four and a half hours, a drug called t-PA, which dissolves blood clots, can be administered via an IV. However, certain conditions must be met to use this drug: the exact time the symptoms started must be known; the CT scan at the hospital must not yet show signs of a stroke; the patient must not have had any injuries or surgeries in the past few weeks, and must not be taking blood-thinning medications. Factoring in the time needed for the CT scan, eligibility checks, and preparation of the medication, the patient must arrive at the hospital within three hours of the onset of symptoms. It is truly a race against time—“Time is brain.”

Recently, if the patient misses the window for t-PA treatment, does not meet the criteria, or if t-PA proves ineffective, newer endovascular treatments can now be added. These treatments involve inserting a thin balloon, suction catheter, spring-like wire, or stent from the thigh into the blocked brain vessel to directly break up, suction, or retrieve the clot. These procedures are called “acute-phase thrombectomy” and can be performed within up to eight hours of symptom onset. This advanced treatment is particularly suited for cardioembolic strokes, which are becoming more common.

Currently, there are three types of thrombectomy devices approved in Japan. The choice of device depends on the location of the blockage and the condition of the blood vessels (such as the degree of atherosclerosis). By the end of 2014, clinical studies in Europe and the U.S. showed that adding thrombectomy to t-PA treatment significantly improved the chances of reopening the blocked vessel and reduced the severity of long-term complications. The faster the vessel is reopened, the better the patient’s outcome. It is crucial to transfer patients with ultra-acute stroke to a facility capable of administering t-PA and performing catheter-based thrombectomy simultaneously.

At our hospital’s neurosurgery department, we have a professional team equipped to provide these treatments and are prepared to respond 24 hours a day.

Self-management of lifestyle-related diseases is crucial.

When a stroke occurs, it often leaves behind lasting effects, and in some cases, it can be life-threatening. Depending on the severity of the aftereffects, caregiving may be necessary, and in some instances, it can result in being bedridden. Stroke is considered the leading cause of becoming bedridden, with around 40% of bedridden cases being attributed to stroke. What’s even more concerning is that once someone has had a stroke, the risk of recurrence increases, especially with ischemic strokes and brain hemorrhages, which have a high recurrence rate.

The main cause of stroke is the hardening of the arteries (atherosclerosis) in the brain. Fragile arteries affected by atherosclerosis can either rupture or become blocked. The four major risk factors for atherosclerosis are high blood pressure, diabetes, abnormal lipid levels (high cholesterol), and smoking. It is important to manage these so-called “lifestyle-related diseases” through self-care and, when necessary, with medication.

To prevent cardioembolic stroke, which is becoming more common, treating arrhythmia (such as atrial fibrillation) and taking blood-thinning medications (anticoagulants) to reduce the likelihood of clots forming in the heart is essential. For treating and preventing the recurrence of atherothrombotic stroke, taking antiplatelet medications to improve blood flow is necessary. Additionally, staying hydrated is important to prevent dehydration, which can thicken the blood and increase the risk of clots. Regular exercise, like walking, helps improve heart and lung function, maintain muscle strength in the legs and hips, and prevent obesity.

If a stroke leaves someone with lasting disabilities and in need of care, it can place a heavy emotional and financial burden on both the individual and their family. Therefore, the most important thing is to focus on preventing strokes in the first place.

What is a Subarachnoid Hemorrhage?

If you suddenly experience an intense headache unlike anything you’ve felt before, along with nausea and vomiting, subarachnoid hemorrhage might be the cause. This condition occurs when a bulge in one of the brain’s blood vessels (called a brain aneurysm) bursts. The blood from the ruptured aneurysm fills the spaces in the brain, pressing against the entire brain. When pressure inside the brain increases, it becomes life-threatening. Subarachnoid hemorrhages are categorized into five levels of severity based on the patient’s condition when the hemorrhage occurs.

In the mildest cases, a patient might only have a slight headache and may visit their doctor, where it is sometimes mistaken for a cold. On the other end of the spectrum, patients with severe cases may arrive at the hospital with intense headaches, vomiting, or even unconsciousness. The more severe the patient’s condition is upon arriving at the hospital, the worse the outcome tends to be. Though the bleeding from a ruptured aneurysm may stop on its own temporarily, there is a risk it will rupture again within a few hours or half a day. Each time it ruptures, the damage to the brain worsens, quickly leading to a critical condition.

Treatment Techniques

The treatment for subarachnoid hemorrhage begins by preventing the ruptured brain aneurysm from bursting again. Currently, there are two surgical methods for preventing re-rupture: open surgery (craniotomy) and endovascular therapy. After the preventive surgery is successfully completed, the next step is intravenous treatment to address blood vessel spasms (cerebral vasospasm). Severe vasospasms can lead to insufficient blood flow to the brain, causing a stroke (cerebral infarction). If a stroke occurs, it may result in long-term complications such as paralysis or speech disorders.

Additionally, if blood that remains in the brain after the hemorrhage (hematoma) clogs the pathways, the flow and absorption of cerebrospinal fluid (CSF) may be impaired. This can cause CSF to accumulate in the brain’s ventricles, the areas where CSF is produced, leading to their enlargement. This condition is known as hydrocephalus. Since the natural absorption of CSF is disrupted, additional surgery to drain the fluid is necessary.

If hydrocephalus develops during the acute phase, there is a rapid increase in brain pressure, requiring an emergency procedure called ventricular drainage to release the excess fluid. If hydrocephalus occurs during the chronic phase, a shunt surgery is needed to continuously drain the fluid into another part of the body. Currently, there are two types of shunt surgeries: the ventriculoperitoneal shunt, which drains CSF from the brain’s ventricles to the abdominal cavity, and the lumboperitoneal shunt, which drains CSF from the lumbar spine to the abdominal cavity. The choice of surgery depends on the patient’s condition.

Understanding the Risks

When a subarachnoid hemorrhage occurs, various complications arise in the brain. Only after successfully managing the ruptured aneurysm, treating cerebral vasospasms, and addressing hydrocephalus can a patient recover and be discharged in good health. However, the rate of full recovery and return to normal life is still only about 50%. The remaining 50% either succumb to the condition or suffer from severe long-term disabilities, making subarachnoid hemorrhage still one of the most dangerous diseases.

What to Do if One is Found

Recently, more people have become interested in their brain health and are undergoing brain check-ups, leading to an increase in the detection of unruptured brain aneurysms. Naturally, many are concerned about what to do if an aneurysm is found. The risk of a brain aneurysm rupturing naturally is said to be less than 1% per year, but this risk varies slightly depending on the aneurysm’s size and shape. According to brain check-up guidelines, treatment before rupture may be considered in cases where the aneurysm is larger than 5mm, irregular in shape, where there is a family history of subarachnoid hemorrhage, in the presence of multiple aneurysms, or if the patient is young.

Surgical Techniques

There are currently two surgical methods for treating brain aneurysms, and the treatment for both ruptured and unruptured aneurysms is essentially the same. The first method, known as “open craniotomy neck clipping,” is a traditional surgery where a surgical clip is applied to the neck of the aneurysm deep within the brain to prevent blood from entering it. The second method, called “aneurysm coiling,” involves guiding a micro-catheter into the aneurysm from within the blood vessel and filling it with specialized coils to block blood flow into the aneurysm. This is a relatively newer treatment, and various types of coils and catheters have been developed to make the procedure safer. It is currently the most common treatment performed among non-surgical endovascular therapies.

The choice of treatment depends on factors such as the size, shape, and location of the aneurysm, as well as the patient’s age. The most reliable treatment option is selected based on the characteristics of each aneurysm. In recent years, aneurysm coiling has become more popular, but because it requires specialized skills, it is strongly recommended to receive treatment at a facility with certified instructors and specialists.

Consult with us

If a brain aneurysm is found, don’t worry alone. Please feel free to consult us to discuss whether treatment is necessary and which treatment method is most appropriate for you.

Stroke Warning Signs

If you suddenly lose strength in one side of your arms and legs, experience slurred speech, or lose vision in one eye but recover within a few minutes, these could be warning signs of an impending stroke. This condition is known as a transient ischemic attack (TIA). When atherosclerotic plaque builds up inside the blood vessels in the neck or brain (a condition known as stenosis), blood flow can become restricted, leading to a stroke. If blood flow stagnates before the narrowing, blood clots (thrombi) can form and travel through the narrowed vessels to the eyes or brain, causing blindness or a stroke. Sometimes, pieces of plaque can break off and travel to the brain, also causing a stroke. These strokes, caused by atherosclerosis, are called atherothrombotic strokes.

Surgical Techniques

Stenosis commonly occurs in the blood vessels of the neck and is known as carotid artery stenosis, which significantly increases the risk of future strokes. This condition must be treated before a stroke occurs. If the stenosis is mild, medication that thins the blood (antiplatelet agents) can be used to monitor the condition. However, if the stenosis is severe, surgical treatment is necessary. There are currently two surgical methods:

1. Carotid Endarterectomy (CEA): In this procedure, performed under general anesthesia in the operating room, the surgeon exposes the affected neck artery and removes the plaque from inside the vessel.
2. Carotid Artery Stenting (CAS): This is performed under local anesthesia in a catheter lab. A balloon catheter is used to widen the narrowed area from inside the blood vessel, and a stent (a mesh-like metal tube) is placed to hold the artery open and push the plaque against the artery walls. This is a form of endovascular therapy. This method leaves no scars on the neck and typically requires a hospital stay of only 4-5 days. Very thin stents are now available for use in the brain’s blood vessels as well.

If the blood vessel is narrowed, it can be widened with a balloon or stent. However, if the vessel is completely blocked (a condition known as **occlusion**), it cannot be opened. Some individuals live without symptoms because their brain’s blood vessels naturally develop alternate pathways (collateral circulation) to bypass the blockage. However, if dehydration occurs, thickening the blood, or if blood pressure drops too low, these natural bypasses may not be sufficient to supply blood throughout the brain, leading to a TIA or stroke. In such cases, an artificial bypass may be necessary to restore blood flow to the affected brain areas. Typically, a bypass procedure connects a vessel from the temple area (superficial temporal artery) to a vessel on the brain’s surface (middle cerebral artery).

Consult with Us

These conditions, including stenosis or occlusion of the neck or brain blood vessels, can be easily examined in an outpatient setting using an MRI (MRA) to visualize the brain and neck vessels or an ultrasound of the carotid arteries. If you have been told during a brain check-up or examination that “the blood vessels in your brain or neck are narrowed or blocked,” please consult with us.

Early Treatment for High Blood Pressure is Key

If high blood pressure is left untreated, it can cause the blood vessels in the brain to develop arteriosclerosis. Over time, these hardened blood vessels become fragile and may either burst or narrow and become blocked. If they become blocked, a cerebral infarction (stroke) occurs; if they burst, a cerebral hemorrhage occurs. For this reason, most cases of cerebral hemorrhage are generally referred to as hypertensive cerebral hemorrhage. Typically, it is caused by the rupture of small blood vessels (perforating branches) that penetrate the brain.

When bleeding occurs within the brain, the resulting mass of leaked blood (hematoma) destroys brain tissue and compresses the surrounding brain areas. Depending on the location of the damage, a variety of symptoms may arise, including hemiplegia (paralysis on one side of the body), sensory disturbances, speech difficulties, and visual field impairments. Since the damaged brain tissue does not regenerate, these symptoms often remain as permanent aftereffects. If the hematoma is large, it can increase intracranial pressure, potentially leading to life-threatening complications.

Surgical Techniques

When a cerebral hemorrhage occurs, if the bleeding is small, it can be treated with IV therapy. However, in cases of life-threatening large hemorrhages, emergency surgery to remove the hematoma by opening the skull is necessary. For moderate bleeding, a less invasive procedure can be performed using specialized instruments. With the aid of computer guidance, a thin tube is precisely inserted to the location of the hematoma, where it is aspirated under local anesthesia (stereotactic surgery). This can be done through a small hole about the size of a one-yen coin, minimizing the burden on the brain. Even though the hematoma is removed through surgery, the damaged brain function does not recover. After surgery, rehabilitation-focused treatment is essential.

Prevention and Control

Cerebral hemorrhage, which used to account for the majority of strokes, has significantly decreased in recent times. This is due to the development of various excellent antihypertensive drugs, leading to better control of high blood pressure. However, there are still cases where individuals who do not treat their high blood pressure or stop taking their medication on their own suffer from cerebral hemorrhages and require emergency care. If you have been diagnosed with high blood pressure, it is crucial not to ignore it. Consult with your primary care physician to adjust your antihypertensive medication to suit your needs. Also, avoid stopping your medication without proper guidance.

Prioritize Managing Lifestyle Diseases

Have you heard the term “silent cerebral infarction”? Sometimes, people who experience no symptoms and are completely unaware may be diagnosed with a cerebral infarction during a brain MRI, such as in a brain check-up. This is often due to small peripheral blood vessels in the brain becoming blocked by arteriosclerosis without the person realizing it. These typically appear as scattered lacunar infarctions in the cerebral hemispheres and are more accurately called “asymptomatic lacunar infarctions.”

These are often found in people in their late 60s and are commonly seen in individuals with lifestyle diseases such as hypertension, diabetes, hyperlipidemia, and a history of smoking. However, even individuals without lifestyle diseases can develop them as they age. The presence of numerous “silent cerebral infarctions” indicates that arteriosclerosis in the brain’s blood vessels is progressing.

Treatment Option

Is it necessary to take blood-thinning medications (antiplatelet agents) if a “silent cerebral infarction” is found? Generally, it is not considered necessary. Instead, prioritizing the treatment of lifestyle diseases that contribute to arteriosclerosis, such as hypertension, diabetes, hyperlipidemia, and smoking, is more important. However, if MRA imaging reveals significant narrowing of blood vessels in the brain or neck, it may be necessary to combine antiplatelet medications. If you are diagnosed with “silent cerebral infarctions,” the first step is to review and address any underlying lifestyle diseases.

Dementia That Can Be Treated with Surgery

Some patients are brought to outpatient department by their families or referred by other doctors because they have recently begun to walk unsteadily, have developed severe memory problems, lost motivation and energy, or have been experiencing urinary incontinence. When a CT or MRI scan of the head is performed, the ventricles in the brain may appear enlarged. This condition is known as hydrocephalus, which occurs when the flow or absorption of cerebrospinal fluid (CSF) in the brain is disrupted for some reason. About 500 ml of CSF is produced daily in the ventricles, and after leaving the ventricles, it circulates through the subarachnoid space around the brain and is finally absorbed in the arachnoid granulations at the top of the brain. CSF plays a role in maintaining a constant volume to protect the brain and spinal cord. When a blockage or absorption problem occurs somewhere in this circulation, the ventricles expand. Since the exact cause of the impaired absorption of CSF is unknown, it is referred to as idiopathic normal pressure hydrocephalus (iNPH). The symptoms can often be mistaken for general dementia and may be overlooked.

Surgical Treatment

In some cases of hydrocephalus, symptoms can improve if surgery is performed to restore the normal flow of CSF. Idiopathic normal pressure hydrocephalus is one such condition. The surgery involves diverting the CSF that can no longer be absorbed by the brain to the abdominal cavity. Currently, there are two surgical methods: the ventriculoperitoneal shunt (VP shunt), which diverts the CSF directly from the ventricles to the abdominal cavity, and the **lumboperitoneal shunt (LP shunt)**, which diverts CSF from the lumbar spine to the abdominal cavity. In both methods, a shunt valve is implanted under the scalp or in the lower back to finely adjust the flow of CSF.

To determine if a patient has a form of hydrocephalus that can be treated with surgery, specific diagnostic criteria have been established. The decision to proceed with surgery is based on these criteria. Initially, an MRI is used to examine the brain in various cross-sections to check for characteristic features of iNPH. If iNPH is suspected, a small amount of CSF is removed from the lumbar spine, and the patient’s gait and cognitive function are assessed before and after the CSF removal to see if there is any improvement. This procedure, known as the **tap test**, requires hospitalization. If the tests suggest that the patient may benefit from surgery, a shunt procedure is scheduled for a later date.

Because shunt valves are precise devices, their settings can be affected by MRI and other magnetic fields. Patients who have undergone shunt surgery need regular outpatient follow-ups with head CT scans, and they should always inform medical staff if they undergo an MRI.

Beware of Minor Head Injuries

Some patients come to the neurosurgery clinic with symptoms such as a heavy head, weakness in one side of the body, severe memory problems, or a lack of motivation and energy. A head CT scan may reveal old blood (hematoma) on the surface of the brain, known as a chronic subdural hematoma. This condition is often caused by a head injury that occurred 1-2 months earlier. It can happen even from a minor head injury that the person or their family did not consider significant. In rare cases, it can also occur in people who have been taking blood-thinning medications (antiplatelet or anticoagulant drugs) in high doses over a long period.

The dura mater is a tough membrane that sticks firmly to the inner surface of the skull and protects the brain. Veins called bridging veins extend from the dura mater to the brain’s surface. When a head injury occurs, the brain can move and shake within the skull, causing these bridging veins to tear. Because this bleeding is venous, it slowly oozes, stopping and starting over 1-2 months, eventually accumulating as old blood (hematoma) between the brain and the dura mater. This condition is known as chronic subdural hematoma. It tends to occur more frequently in older adults with brain atrophy. If the hematoma is small, it may disappear naturally, but once it reaches a certain size, it can press against the brain, causing headaches, paralysis on one side, dementia-like symptoms, or a lack of motivation.

Surgical Treatment

If natural absorption is not possible, surgery is required to remove the hematoma. The surgery for chronic subdural hematoma is performed under local anesthesia. A small incision, about 3 cm, is made in the scalp above the hematoma, and a hole about the size of a coin is drilled into the skull. The dura mater is then opened, and the old hematoma is suctioned out with a syringe, followed by thorough washing with saline solution. The procedure takes about 30 minutes, and the patient typically stays in the hospital for about a week. In about 10% of cases, the hematoma can recur shortly after surgery.

If you’ve had a head injury and begin to experience a heavy feeling in your head, confusion, or difficulty walking 1-2 months later, you may have a chronic subdural hematoma. A head CT scan is recommended for diagnosis.

Diseases Caused by Contact Between Blood Vessels and Nerves

Have you ever experienced a sharp, excruciating pain in one side of your gums, lower jaw, or cheek, described as “searing like a hot iron,” when chewing food or when something touches your cheek? Or perhaps you’ve noticed involuntary twitching of the muscles on one side of your face, from around your eye to your cheek? The former condition is known as trigeminal neuralgia, and the latter as hemifacial spasm. These conditions are caused by contact between tiny blood vessels and the facial or trigeminal nerves, where the nerves originate from a part of the brain called the brainstem. In trigeminal neuralgia, the pain may initially be mistaken for a dental issue, leading patients to seek dental treatment and sometimes even undergo unnecessary tooth extractions. While these conditions are not life-threatening, the severe pain of trigeminal neuralgia can be so unbearable that some patients consider suicide. Many individuals with hemifacial spasm are also troubled by the cosmetic impact, feeling embarrassed by the involuntary twitching in social settings. For trigeminal neuralgia, pain can be managed with painkillers, and for hemifacial spasm, botulinum toxin injections into the facial muscles can temporarily paralyze the muscles and stop the spasms. However, these conservative treatments only provide temporary relief, and over time, the pain or spasms may become more difficult to control.

Surgical Treatment

To address the root cause of these symptoms, **microvascular decompression surgery**, which separates the blood vessels from the trigeminal or facial nerves, is an effective option. During this procedure, a small portion of the bone behind the ear is removed (about the size of a coin), allowing the surgeon to access the brainstem area through a gap in the brain. A tiny cushion is then placed between the nerve and the contacting blood vessel. After surgery, the facial pain or spasms typically disappear immediately. If you have been suffering from facial pain or spasms for many years, consider getting an MRI to check whether a blood vessel is pressing on your nerve.