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Faces Of Stroke

Picking up a stroke early aids in preventing brain damage and complications associated with the condition. Looking at a person’s face can help you understand if they are getting a stroke.

So, how does a face of a stroke patient look like? Read on to know more about it.

A Word About Stroke

A stroke is a condition where a blood vessel supplying to the brain ruptures or is blocked by a blood clot. In either case, a part of the brain cannot receive the nutrients and oxygen required for its survival. And if the blood supply is not retrieved, that part of the brain may be damaged, resulting in various complications.

It is thus crucial to identify a stroke early and treat it immediately. One of the common symptoms can be understood by looking at the person’s face.

What To Look For On The Face?

Symptoms of stroke appear on the part of the body supplied by the damaged brain areas.

F.A.S.T. is an easy way to identify the immediate signs of a stroke.

Face: The face droops on one side or feels numb. You can ask the person to smile. The smile of someone with a stroke is not symmetrical, and lips droop on one side of the face.

In addition to the face, other signs include:

Arm Weakness: The arm may feel numb and/or weak. Ask the person to raise both arms. The affected arm drifts downwards.

Speech Difficulty: The person may find it difficult to speak or have slurred speech. You can also tell them to speak a sentence such as “the sky is blue.” A person with a stroke will find it challenging to say the sentence clearly.

T in the acronym indicates timely intervention. If you feel that someone has a stroke, seek medical care immediately.

Other symptoms of a stroke are:

  • Confusion or lack of responsiveness
  • Vision problems such as double or blurred vision
  • Loss of balance and trouble walking
  • A sudden, severe headache
  • Dizziness
  • Seizures
  • Vomiting or nausea
  • Numbness and weakness in one side of the body

Recovery

Once a stroke is managed, the person can recover within days, weeks, or months, depending on their condition. They can return to their normal activities without needing external aid in most cases. Medicines and physiotherapy aid in faster recovery from a stroke.

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Arterial Ischemic Stroke in Children

Arterial ischemic stroke is a rare but crucial cause of complications in children. Early diagnosis and treatment aid in preventing complications.

Arterial ischemic stroke

An arterial ischemic stroke is an injury in the spine or brain because of impaired oxygen and nutrient supply to the affected area. In most cases, ischemic stroke is caused by damaged or narrowed arteries or obstruction due to blood clots.

Fortunately, children recover quickly and completely as compared to adults. The reason is that young blood vessels and brains adapt quickly after an injury.

While some strokes have none or minimal effects, others can cause complications depending on the part of the brain affected, the severity of the stroke, and how early the treatment was initiated.

Complications may include sensory loss, weakness, language impairment, or visual changes.

Symptoms In Children

Symptoms of arterial ischemic stroke usually appear suddenly and affect one side of the child’s body. Newborns have no symptoms. Infants may have unusual irritability or seizures.

Symptoms in older children include:

  • Numbness or weakness on one side of the body
  • Seizures affecting one side of the body
  • Difficulty in speaking
  • Loss of balance or dizziness
  • Trouble walking
  • Vision problems
  • A sudden severe headache associated with double vision, sleepiness, or vomiting

If your child has any of the mentioned symptoms, seek medical care immediately.

Causes

Two leading causes for obstructed blood vessels in children include:

Blood clots because of:

  • Blood diseases such as clotting factors
  • Severe infections
  • Congenital heart conditions
  • Abnormal blood clotting

Damage to or abnormalities of the arteries because of:

  • Injury to the head or neck
  • Inflammation of blood vessels
  • A tear along lining of a blood vessel

Management

The management of stroke in children is different from adults. A child with a stroke generally receives blood thinning drugs. They help in clearing the clot and improve the blood flow. The clot may be removed using catheter-based devices in certain cases (Uncommon). For inflamed blood vessels causing a stroke, medicines to soothe inflammation are required.

Once the blood flow is retrieved, the child may need some care, including physiotherapy exercises, to have a better quality of life.

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Head, Neck, and Brain Tumor Embolization

What is Head, Neck, and Brain Tumor

Head, neck, and brain tumors are often very complex and may require a combination of special approaches in resolving them. Embolization is an integral part of managing these tumors.

Embolization refers to a procedure that can block blood flow to an area of the body. The brain or spinal cord tumors can be challenging to remove or may not be accessible for removal.

Reducing or cutting the blood supply to such tumors before the surgery can help to improve the effectiveness and lessen the complications. Thus, it has become adjuvant to the surgical treatment of these tumors.

The endovascular approach is the most common type of widely used approach. It is an invasive surgical procedure used to block blood vessels supplying the tumor thereby making the tumor removal safer and with less blood loss.

Embolization In Treatment Of Tumors

The procedure involves making a tiny incision in your groin area, and a catheter is inserted via a blood vessel (femoral artery). The catheter is guided through the body using X-rays. When the catheter reaches the site that needs to be treated, the material is injected to seal your blood vessel (metal coils, PVA particles, gelfoam, liquid embolics). The material used will be decided by your interventionist.

Embolization of head, neck, and brain tumors may be recommended to treat the cancer growth in the following cases:

  • Carotid body tumors
  • juvenile nasopharyngeal angiofibroma (JNA)
  • Larynx Meningiomas (brain and spine)
  • Cerebral Hemangiopericytomas
  • Paragangliomas: in neck, skull base or ear

Advantages of Embolization

The advantage of embolization includes:

  • To reduce tumor recurrence
  • To control surgically inaccessible arterial sites
  • To allow better visualization of the surgical field and decreased surgical complications
  • To relieve uncontrollable pain
  • To reduce the blood loss during the surgery
  • To reduce the risk of damage to nearby tissues
  • Shorten the operative time and less invasive
  • To increase the chances of complete surgical resection

Preparation

Endovascular embolization is performed in a hospital by an interventional neuroradiologist. It is often performed as an elective preoperative procedure. The following things should be kept in mind:

  • Inform your surgeon about all medications that you take, including prescription, non-prescription, vitamins, and herbal supplements
  • If you smoke or take alcohol regularly
  • If you are having fever.
  • If you are on any blood thinning agents.

Recovery

Depending upon your recovery, you will be asked to stay in the hospital for 1 or 2 days. You might be asked to stay longer if there were any complications during the procedure. Usually, your rate of recovery will determine your discharge. Your comorbidities may also affect your recovery speed. The area where the incision was made may remain sore for several days.

Your physician will ask you to follow up depending on the disease and closely monitor you.

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Can We Prevent A Second Stroke?

To answer the question mentioned above, it is first essential to understand the basics of Stroke.

Keep reading the article to understand and find out if we can prevent second stoke and how we can prevent it?

What is Stroke?

A stroke is a condition that occurs when a blood vessel in the brain bursts and bleeds or when there is a blockage of the blood supply to the brain. Both scenarios (rupture or blockage) prevent blood and oxygen from reaching the brain’s tissues.

Without the supply of oxygen, brain cells and tissues become damaged and begin to die immediately. As the brain cells die, people may experience weakness or paralysis and lose walking or speaking.

There are three main types of strokes they are classified as follows:

  • Ischemic Stroke: This is the most common type of stoke, and it results because of a blood clot that prevents blood and oxygen from reaching an area of the brain
  • Hemorrhagic stroke: This occurs when a blood vessel ruptures. The rupture is mainly due to aneurysms (formation of a balloon and weakening in a part of the artery)
  • Transient ischemic attack: It occurs when blood flow to a part of the part is inadequate for a brief amount of time. Normal blood flow resumes after a short period, and the symptoms during the episode resolve without any treatment. It is known as a ministroke.

Strokes are fatal. The article explains if a person can prevent a second stroke and how it can be prevented.

Can we prevent a second Stroke?

Yes, it is possible to prevent a second stroke. The causes for the second stroke are majorly similar to a primary stroke.

Researchers believe that you are most vulnerable for three months to 1 year after your first stroke. So even after surviving one stroke, you may still need to take a lot of care to prevent the second stroke.

Causes of the second stroke

The causes of one or more strokes mainly remain the as which are as follows:

  • Diabetes: High blood sugar levels damage the blood vessels, increasing the possibility of clot formation in the blood vessel.
  • High blood pressure: Untreated or uncontrolled blood pressure doubles the risk of stroke.
  • High cholesterol: High cholesterol levels in your blood can lead to plaque formation. Thus, it causes a decrease in blood flow to the brain and other parts of the body.
  • Smoking: Smoking causes thickening of the blood and increases plaque formation in the arteries, which eventually may decrease blood flow to the brain or other parts of the body.
  • Obesity: Being overweight increases the odds of stroke and is linked to other diseases (heart diseases, diabetes, and high blood pressure).

Prevention

Some tips may help to prevent a second stroke:

  • Taking medication: If your physician has prescribed medications to control cholesterol, diabetes, or blood pressure, make sure you take medications regularly. You should not miss your doses. Even if you feel better, you should not discontinue your medications. Not taking medication is a significant risk factor that may cause stroke again.
  • Exercise: You should work out (cardio) for at least two and half hours a week. Aerobic exercises such as walking and riding a bicycle can help you manage the risk factors of stroke.
  • Healthy lifestyle: You should incorporate healthy eating habits. Avoid junk food and shift to the Mediterranean (fruits and vegetables, whole grains, and low processed foods). Avoid or restrict salt consumption. You should quit smoking and use aids like nicotine patches if you are smoking. It is also best to avoid or quit alcohol consumption.

These changes help reduce the chances of stroke and help manage other diseases such as obesity, diabetes, blood pressure, or high cholesterol.

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What Is the Relevance of Time in Acute Stroke Treatment?

A stroke is a condition where the blood supply to the part of the brain is reduced or blocked, affecting its oxygen and nutrient supply. The main cause is a blood clot in the artery supplying the brain (ischemic stroke).

Without oxygen and nutrients, brain cells begin to die. Hence, stroke is a medical emergency that requires prompt treatment. Early action can significantly reduce damage to brain cells and other complications.

Let’s understand how timely intervention helps anyone with stroke.

Symptoms Of Stroke

To get timely treatment, it’s essential to understand what stroke looks like. While it may not always be easy to pick up stroke, look out for the following symptoms:

  • Face: One side of the face drops while smiling
  • Arms: Try to raise both arms. You may find it difficult to raise one arm, or the arm drifts downwards.
  • Speech: You may have strange or slurred speech
  • Time: If you or anyone has the above signs, it’s recommended to seek emergency medical care.

Relevance Of Time in Acute Stroke Management

According to the American Stroke Association and American Heart Association: “Time lost is brain lost.

Once you reach the hospital, the doctor will ask for your medical history and when you noticed them. They will also run brain scans to understand the type of stroke you have.

As discussed above, the earlier the treatment, the lesser the complications.

Do what does early mean?

Research shows that seeking medical treatment within 3 to 4.5 hours of an acute ischemic has a better outcome. Medical intervention in the mentioned time frame allows the doctor to treat you with a type of clot-busting medicine, known as Tissue plasminogen activator (tPA)

Getting tPA significantly improves your chances of recovering from a stroke. Studies have shown that people getting tPA have a lesser disability than people not getting tPA.  Patients who receive timely tPA have lesser need of long-term care in the nursing home.

The newer treatment Mechanical Thrombectomy can be done even upto 24 hours but not in all patients. It is an excellent technique to treat stroke especially if large artery is blocked. However like tPA earlier the Thrombectomy is done better is the clinical outcome of stroke patients.

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Cerebral Aneurysm Coiling

Cerebral aneurysm is an abnormal dilation or bulge or ballooning of an artery in the brain, mainly occurring where the artery divides. Weakening of the muscular layer of the artery makes it susceptible for this abnormal dilation. It may leak or rupture, which causes bleeding into the brain, resulting in hemorrhagic stroke. A ruptured aneurysm is often life-threatening and requires immediate medical attention.

What is Cerebral aneurysm coiling?

Cerebral coiling or endovascular coiling is a minimally invasive procedure that does not require an incision on the skull. However, it is carried out under general anesthesia. The procedure is performed with the aim to block the blood flow into the aneurysm. A catheter is placed into the artery through your groin or wrist in this technique. That catheter is guided into the brain and into the aneurysm. After reaching the aneurysm, a thin platinum coil is inserted into the aneurysm and detached. Multiple such coils are packed inside the aneurysm, blocking the blood flowing inside the aneurysm, leading to sealing off from the main artery. Over a period, a clot is formed inside the aneurysm, which prevents it from growing or rupturing.The coils remain permanently inside the aneurysm. They are safe and long term.

Why is Cerebral aneurysm coiling done?

It is an effective treatment for patients having ruptured or unruptured aneurysms. However, it is always done if the aneurysm has already ruptured. Case where bleeding has not occurred the coiling is done after assessing the bleeding risk which depends upon many factors like size/configuration of the aneurysm, age, co-morbidities, medications history etc.

Risks associated with Cerebral aneurysm coiling

Though the procedure is minimally invasive, it may cause some side effects. The complications associated with the procedure are infection, stroke, seizure, allergic reactions, and bleeding.

Post-surgery care

After the surgery, you may be shifted to the intensive care unit for further observation and monitoring. If the coiling is done for unruptured aneurysm the hospital stay might be of 3-4 days. If it is after bleeding has occurred then the hospital stay may extend to 10-14 days. The patient may feel mild tenderness in the groin or leg region. Your physician will provide you with specific detailed instructions regarding the post-surgery.

The following set of restrictions are be expected to be given by the surgeon:

  • Do not consume alcohol as it causes thinning of blood, and you will be at risk of bleeding
  • Do not smoke or use nicotine products
  • Do not lift heavy objects or perform strenuous activities for the next three days
  • Do not drive unless your surgeon says
  • Drink plenty of water to flush out the contrast dye
  • Take the prescribed medications on a timely basis
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Intracranial aneurysm

Intracranial aneurysms are known by various names such as brain aneurysms, cerebral aneurysms, or berry aneurysms or sometimes called ballooning of the brain blood vessels. Most types of brain aneurysms do not show any symptoms. They start showing symptoms when they become large, burst, or begin to leak blood.
To understand more about it, keep reading.

What is an Intracranial aneurysm?

An intracranial aneurysm is an abnormal dilation or bulge or ballooning of an artery in the brain. It mainly occurs due to the weakening of the muscular layer of the artery. The image on a scan often resembles a berry hanging on a stem; hence it is known as a berry aneurysm.
It may leak or rupture, which causes bleeding into the brain, resulting in hemorrhagic stroke. A ruptured aneurysm may be critical and requires immediate medical attention.

Symptoms

Severe headache is an important symptom in an aneurysm. These headaches often are sudden and are deemed as the worst headache ever experienced. Other symptoms include:

  • Stiff neck
  • Nausea
  • Vomiting
  • Double or blurred vision or change in vision
  • Confusion
  • Drooping eyelid
  • Loss of consciousness
  • Sensitivity to light
  • Pain above or behind the eye
  • Weakness on one side of the body or face
  • Dilated pupils

Causes

There are various risk factors, which may contribute to the formation of aneurysms. They are listed as follows:

  • Aging
  • Genetics (history of intracranial aneurysm in the family)
  • Smoking
  • High blood pressure
  • Severe head injury or trauma
  • Use of cocaine or other drugs
  • Congenital abnormality
  • Infection
  • Excessive alcohol consumption
  • Women are at a higher risk
  • Other disorders such as Ehlers-danlos syndrome, fibromuscular dysplasia, Marfan syndrome, and autosomal dominant polycystic kidney disease

Diagnosis

Family history is taken at the beginning to understand the history of a brain aneurysm in the family. If you are experiencing any of the above symptoms, your physician may ask you to undergo any of the following screening tests:

  • CT scan of the brain
  • MRI of the brain
  • Cerebrospinal fluid test
  • Cerebral angiogram (DSA)

Treatment

The ideal treatment option depends on various factors such as size, location of the aneurysm, medication condition of the patient, availability of other treatment options, and age of the patient. The goal of the treatment involves preventing the aneurysm from bleeding or bleeding again. The following are some of the commonly available treatment options:

  • Endovascular Coiling treatment: In this treatment, the surgeon inserts a catheter (a hollow plastic tube) into the blood vessel (artery) and threads it through your body to the affected region. The entire treatment is then done through this tube/catheter by packing the aneurysm with coils from within.
  • Surgical clipping treatment: In this procedure, the surgeon identifies the aneurysm and the artery that is affected. The procedure involves removing a skull section to enter the affected region. The neurosurgeon places a tiny clip on the affected artery to stop the blood flow.
  • Flow diverters treatment: This newer treatment option diverts the blood flow away from the affected region. The diversion created restricts the blood movement within the affected area and promotes healing.

Pt. will require additional therapies like:

  • Rehabilitative therapy: This treatment option is opted when damage to the brain occurs from a subarachnoid hemorrhage that affects speech, physical, sensory, or cognitive problems.
  • Medications: Various medications such as calcium channel blockers, pain killers, anti-epileptic medications may be prescribed.
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    Endovascular Management of Epistaxis (Nose Bleeding)

    Epistaxis is characterized by hemorrhage or bleeding from the nose.
    While the majority of the nose bleedings are self-limiting, those not responsive to
    compression, nasal packing or other non-endovascular treatment options may need
    endovascular management. This especially holds for bleeding from the backside (posterior
    cavity) of the nose.
    This article will talk about the management of the epistaxis in the posterior nasal cavity and
    its management.

    Causes

    Some common causes of epistaxis include:

    • Hypertension
    • Blood vessels disorders
    • Fall and injury
    • Blood clotting disorders
    • Upper respiratory tract infections

    However, in some cases, the cause of nose bleeding may not be known.

    Management

    Most cases of epistaxis are in the front side of the nose or in the anterior nasal cavity. They
    are relatively easier to manage. However, the bleeding in the posterior nasal cavity is
    challenging to manage.
    Treatment options of the posterior nasal cavity bleeding include:

    Non-Endovascular Management

    Along with conventional measures, posterior nasal cavity bleeding needs anterior and
    posterior packing to provide adequate compression. It also prevents the bleeding from
    entering the food pipe.
    However, this packing needs removal after 48 hours to prevent infection and other
    complications.

    Endovascular Management

    In cases of recurrent or persistent epistaxis, endovascular management is an excellent option
    with a success rate between 71%-100%. It is also a cheaper and comparatively safer option as
    compared to surgery.
    Your doctor will decide the need for general anesthesia based on your problem and the
    underlying cause. They may advise blood tests to find out the underlying cause.
    The next step is angiogram and embolization. The doctor will first carry out an angiogram for
    evaluating your blood vessels. They will introduce an embolizing agent in the branches of the
    blood vessels, causing epistaxis.
    The doctor will take extra care in deciding the amount of embolizing agent as an additional
    amount may result in blockage of the healthy blood vessel.
    After the procedure, the doctor will decide to remove the nasal packaging depending on the
    condition

    Final Thoughts

    About 95% of the epistaxis originate in the anterior nasal cavity and can easily be managed
    with packaging and compression. However, the remaining 5% of the cases originate from the
    posterior cavity and are more challenging to manage, needing endovascular treatment.
    Endovascular embolization is a safe and effective option compared to surgery.

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    “Vessel Wall Imaging” for detecting the Risk of Intracranial Aneurysm Bleeding

    A ruptured aneurysm results in subarachnoid hemorrhage, which is a severe complication with high mortality rates. To prevent this risk, unruptured intracranial aneurysms (UIA) are managed endovascularly or surgically. However, these treatment options may have their own set of side effects.
    So, patients are selected for these treatment options only when the benefits outweigh the risk. Your doctor will make this decision for you based on the aneurysm rupture risk. The risk can be predicted based on the patient’s age, size of the aneurysm, hypertension, location of the aneurysm, and history of subarachnoid hemorrhage.
    This aneurysm rupture risk can be further refined using high-resolution vessel wall magnetic resonance imaging (HRVWI-MRI). For instance, usually, aneurysms smaller than 7mm are less prone to rupture. However, some patients with small aneurysms do report SAH from aneurysm rupture. So the HRVWI-MRI can detect the aneurysms which need urgent treatment.
    Aneurysm wall enhancement on vessel wall imagining indicates arterial instability and an increased risk factor for aneurysm rupture.

    Benefits

    Silent saccular aneurysms are observed in about 4% of the normal population. A high-resolution vessel wall magnetic resonance imaging can help differentiate an unstable aneurysm from a stable one to decide the urgency for the treatment.

    A thick circumferential pattern of aneurysmal wall enhancement has the highest specificity for differentiating between stable and unstable aneurysms (Circumferential aneurysmal wall enhancement is observed in almost 90% of the unstable aneurysms, allowing refined prediction of the aneurysm rupture risk).

    It also aids in identifying the culprit aneurysm for SAH when multiple aneurysms are present.
    It also aids in diagnosing the following conditions:

    • Eccentric wall thickening in atherosclerotic plaque
    • Concentric wall thickening in vasculitis
    • Minimally enhancing wall thickening in reversible cerebral vasoconstriction syndrome
    • Non-enhancing intracranial carotid stenosis in Moyamoya disease (non-atherosclerotic progressive vasculo-occlusive condition)

    Pitfalls

    As the investigation involves high-resolution imaging, additional time and money are involved.
    Normal enhancement in large intracranial blood vessels near the skull base can be mistaken as arterial wall enhancement.
    Brain Imaging Techniques for Stroke (Banner)
    Imaging techniques are used to:

    • Detect or Exclude hemorrhage
    • Understand the extent of brain injury
    • Identify the underlying cause for stroke
    • Ruling out conditions that mimic stroke such as tumors

    Imaging techniques commonly used are:

    • Computed tomography (CT)
    • Magnetic resonance imaging (MRI)
    • CT/MR angiography
    • CT Perfusion Imaging
    • Digital Subtraction Angiography (DSA)
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    Brain Imaging Techniques for Stroke

    Stroke, whether ischemic (due to blockage in brain’s blood supply) or hemorrhagic (due to bleeding in the brain), can result in long-lasting complications if not attended immediately. Early diagnosis of a stroke — including what type it is — can significantly reduce the patient’s chances of living with a disability.
    Stroke is suspected clinically and can be confirmed with clinical examination and brain imaging techniques. They also help to find out the cause, part of the brain affected and bleeding in the brain. Finally these tests play in planning the treatment and possible outcomes.
    The article talks about various imaging techniques used to confirm the presence of stroke.

    Brain Imaging Techniques

    The first-line tests to assess brain function and its blood supply include:

    • Magnetic resonance imaging (MRI): This test provides cross-sectional images of the brain. It helps in diagnosing a stroke and regions of the brain affected by the stroke. MRI is very sensitive and specific in differentiating ischemic lesions and identifying other conditions that may resemble a stroke.. MRI can uncover any brain damage within 20 minutes of beginning of stroke symptoms.
    • Computerized tomography (CT): it is more widely available in our country. It can very easily diagnose the hemorrhagic type of stroke. In ischemic stroke it may be normal for few hours however it can show us early signs of stroke or impending brain damage. It is more popular to diagnose stroke as it is easy to do, takes less time and is easily available.

    Advanced Stroke and Neurovascular Imaging
    In addition to the above first-line imaging techniques, the mentioned tests are advanced tools that provide additional and critical information about the complexity and location of the stroke.

    • CT angiography: This involves a CT scan along with a dye injected to obtain pictures of blood vessels in the brain. CT angiogram also helps locate blocked or narrow blood vessels, aneurysms, or other abnormal blood vessel formations.
    • CT perfusion: It is a type of CT test used as an adjunct with CT angiography to diagnose stroke. It aids in differentiating ischemic brain areas (penumbra) from the irrevocably damaged brain area (infarct core). Broadly speaking when patients of stroke come late to the hospital, this test can tell us whether giving treatment is going to be beneficial to the patient or not.
    • Magnetic resonance angiography (MRA): This type of test involves MRI to create two- or three-dimensional images of the structure of your blood vessels supplying the head and neck. This test does not involve any injection of the dye so is more useful in patients who have poor kidney function or history of drug allergy.
    • Digital Subtraction Angiography (DSA) / Catheter angiography: this is the gold standard test to detect problems of blood vessels of the brain. This test offers high-resolution images of the blood vessels of the brain, spine or head and neck. Catheter angiography is a minimally invasive technique where a small catheter is introduced in the artery supplying the brain. A dye is injected, and images are taken that show your blood vessels’ structure and the blood flow.
    • Transcranial Doppler (TCD): It is an ultrasound technique that allows your doctor to check the blood circulation within your brain. It is especially useful to detect delayed complications like vasospasm which can occur in hemorrhagic stroke patients