4.5 Hours – The Golden Period to save a life

According to various studies strokes among youth (age < 45 years) constitutes 15-30% of the total proportions of strokes in India. Early identification and treatment of a stroke are extremely important as it can prevent long term disability and morbidity.

We now present a case of stroke in a young 31-year-old and how early identification and management prevented long term disability:

On 5th September 2018, Mr. Kapil Taneja (name changed) with no known cardiovascular risk factors presented with sudden onset inability to talk, communicate or move the right side of his body since morning. He had no headache, no vomiting, no seizures, and no history to suggest of TIA in the past. He was brought to the hospital for further management.

Upon examination, his vitals were found to be stable with global aphasia, mild right facial weakness and hemiplegia of the right side of the body with Extensor Plantar Reflex on the right side of his body. Non-Contrast CT of the brain showed an evolving left Middle Cerebral Artery (MCA) stroke. He was immediately taken up for stroke protocol MRI which revealed a left Middle Cerebral Artery Ischemic stroke. Thrombolysis with Actilyse 58.5mg (BW-65Kgs) was performed within a window period of 3 hours.

In view of the bad ASPECTS score on the DW-MRI, large vessel occlusion (LVO) was suspected and he was counseled for Digital Subtraction Angiography (DSA) and Mechanical Thrombectomy which his family chose to go ahead with. The DSA showed a proximal M1 Occlusion of the left MCA. He underwent clot suction by the ADAPT technique and complete recanalization was achieved with TICI 3 flow.

During his hospital stay, he improved his strength and was able to walk without support. His comprehension had almost completely recovered, his speech improved and he was able to write his name, home address, draw a clock and speak simple sentences.

If this treatment had been delayed for even one more hour, he would have developed a complete stroke and permanent disability.

The identification of stroke is simplified by the American Heart Association (AHA) by a powerful four-letter word FAST:

F – Facial Dropping
A-Arm Weakness
S – Speech Difficulty
T – Timely Reach Hospital (within 4.5 hours of onset of symptoms)

Once the stroke is identified the most important step is to reach a hospital where a 24×7 CT scan of the brain is available. If the CT scan does not show any bleed, a clot buster drug (Alteplase/Tenecteplase) can be given for dissolution of the clot. The risk of bleeding with this drug is nearly 2/100 patients and chances of functional independence after receiving is nearly 63%.

Remember, the earlier the better! Hence it is extremely important is to reach the hospital within the Golden Period of 4.5 hours.

Up to 30% of the patients who receive this clot buster drug do not improve as they have large strokes or large vessel occlusion (LVO). Even for such cases, there has been an advancement in treatment. A Neuro-Radiologist can go the brain vessels and take out the clot by suction technique. It is shown that 1 out of 2.8 patients who receive this treatment can be functionally independent.

This patient was fortunate as he reached the hospital within the Golden Period and received both the clot buster drug and Mechanical Thrombectomy (clot retrieval) which emphasizes that early identification of stroke and proper treatment can prevent a long term disability. Moreover, stroke is not limited to people aged more than 60 years only.

If we identify a stroke, be it in a movie theatre, metro or even during a morning walk, action taken within the first 4.5 hours can save the person from a long term disability. We should help in preventing the same by getting the patient to a stroke ready hospital without wasting any time.

The writer, Dr. Sahil Kohli, is a Consultant Neurologist at Narayana Superspeciality Hospital, Gurugram

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