 Hello everyone, I am Dr. Guru Prasad Vasurkar, senior consultant and neurologist at Manipal Hospital, Ashwantpur. 29th of October every year is celebrated as World Stroke Day. On the eve of World Stroke Day, today we have my colleagues from Department of Neurology and Neurosurgery to have a health awareness talk. Hello everyone, I am Dr. Mahadevappa, consultant neurologist at Manipal Hospital, Ashwantpur. Hi, I am Dr. Raghuraam, consultant neurosurgeon and spine surgeon at Manipal Hospital, Ashwantpur. Hello, I am Dr. Avinash, I am consultant neurosurgeon and neuroendovascular surgeon working at Manipal Hospital, Ashwantpur. Stroke is an emergency. Stroke is a leading cause of disability all across the globe, including our country, India. It's a second leading cause of mortality after coronary disease. So on this day of World Stroke Day, all the organizations related to stroke care organize events to increase the awareness of stroke among the public. So as a part of this, we are having the health awareness talk among our colleagues. So at the onset, I would like to ask my colleague Dr. Mahadev to tell us about what is stroke and what are the types of stroke. Hello everyone, stroke is a neurological emergency. In Kannada language, what we say as a Pashvavayu or in some regional Kannada languages we say as a Lakwa, is basically a sudden disruption in the blood flow to the neuronal tissue. So it can occur either due to a clot in the blood flow or due to sudden rupture of the blood vessels. So coming to the types of stroke, basically we divide broadly into two categories, ischemic stroke or hemorrhagic stroke. Basically the ischemic stroke is due to the blockage of the blood vessels. In common terms, we call as a clot in the blood vessels, which causes decrease in the blood flow, which can lead to neuronal cell death. Similarly, hemorrhagic stroke is sudden rupture of the blood vessels, which causes a blood to accumulate in the neuronal tissue and causes decreased blood flow to the neuronal tissue. So basically, the ischemic stroke is the most common one, occurs in 80 to 85% of the cases and remaining 15 to 20% of cases is a hemorrhagic stroke. Adding to what Dr. Mahadev has mentioned now, there is also a type of stroke called venous stroke, where you can have blocked venous system carrying blood from brain, also leading to stroke. So this happens in specific categories of people like pregnant women or young males or females. There is also an entity called transient ischemic attack, where there can be a transient symptoms of what we call it stroke symptoms and that can improve on its own. Now I would like to request my neurosurgical colleague Dr. Avinash to tell us more about the incidence and prevalence of stroke in our country and the world and what is the impact of stroke on the society as such. So as far as the incidence and the prevalence of stroke is concerned, no country is immune to stroke. Every country in the world has some amount of, you know, patients being affected by stroke. But as a overall world when we consider, the incidence is roughly divided into two categories. Like, you know, one is Southeast Asian and African countries, which have a different prevalence and incidences. Whereas the Western European and American countries have a different set of incidence and prevalence. But overall, in general what happens is the incidence in Southeast Asian and African countries is quite high as compared to the Western countries and also is the fact that the occurrence of stroke in Engage is more prevalent in our subcontinent as compared to the Western subcontinents. As far as the incidence in India is concerned, roughly about 100 to 150 people per lakh. In the sense, if you have a geography of 1 lakh people, about 100 to 150 people in a year can develop a stroke and prevalence, when we talk about prevalence, prevalence is a number of stroke patients present in that geography at that particular moment. When you count them, that is the number of stroke patients which are present in that geography. So, prevalence of a stroke in India is anywhere between, you know, 40 to 700 per 1 lakh population. Again, it varies from one state to another state and, you know, most of the Eastern parts of India as well as the Northeast states have more prevalence as compared to the Western part of India. As you can understand, the burden of stroke in the society is quite huge, which includes our country. And then as Dr. Avinash mentioned, there is a difference in our country as well. That also, because as we understand, hypertension is the single most common risk factor for stroke in the population. And the use of salt varies from areas to areas. So, our coastal belt in the East side and Northeast consume a lot of salt, you know, excess salt in their diet. That also could be a reason why we see much more, you know, stroke prevalence in such areas. So, coming to the next part of our talk. So, I would now request Dr. Raghuram, my neurosurgical colleague to tell us about what are the symptoms patients present when you say stroke and what are the risk factors for stroke? Hi. So, like I think we have already been elucidating the same fact that it is very, very important for us to identify these strokes early. So, obviously, when we have to identify them early, we need to know what are the symptoms so that the person or the common public can reach out to the nearest doctors so that they can be treated in the right time. So, to make it easier, the stroke society has come out with the mnemonic. It's called FAST, F-A-S-T. So, the easiest thing so that any of these four symptoms, if you see, you should immediately rush them to the nearest hospital, if not, at least to a physician so that they can quickly analyze and then appropriately take treatment options. F stands for facial asymmetry. So, if you notice any member of your family having a change in the shape of the face, like one side of the face is not moving, they're not able to close their eyes properly or the mouth is pulled to one side when they're trying to talk and open their mouth. So, these are very, very important and subtle signs. And if you notice any of them, they're important to be immediately shown to a physician. The second one is A, which is arm, which can be either upper limb or lower limb. That means the leg's arms or the hand arm. So, if there is any weakness, that means you are unable to move any of the hands or the legs. Usually, it happens on one side of the body. That's how the stroke presents. So, if it happens on any particular side or some patients may not even have weakness, they may even just complain of numbness and some kind of an imbalance while walking, which also is very, very important because some part of the brain, which is called as the cerebellum or the back part of the brain, controls our balance. So, if there may not be a gross weakness but if this patient is trying to walk and he has imbalance, then that is also a very important sign for us or a symptom for us to pick up and then rush him to the doctor. S is speech. So, if you notice the patient's speech is not as it was before, he's become very slow or the speech is not clear. He's not able to pronounce the words properly. That is another important symptom. And the last and the most important thing is the time. So, why are we included time as a symptom or in the part of the mnemonic is to make everyone understand that time is very, very important when it comes to a brain stroke because the more we delay, more the number of neurons that die in the brain. So, to prevent that from happening as soon as we notice any of these symptoms, which I just elucidated like facial asymmetry, weakness or imbalance and speech problem or sudden collapse. Some patients like Dr. Mahadev told you all before can have what is called as a hemorrhagic stroke and these patients suddenly collapse. So, if any of these things happen without losing any time, please rush them to a physician. The physician will evaluate if it is possible for you or you stay close to a bigger hospital, better you rush them to a bigger hospital so that an immediate action can be taken and we can try to reverse whatever things that we can and reduce the morbidity of the patient. Speaking about the risk factors, I already mentioned hypertension is the single most commonest risk factor for stroke, either ischemic stroke or hemorrhagic stroke, more so in hemorrhagic stroke. What are the other risk factors? Diabetes, as we all know, India is the diabetes capital of the world. We are seeing much more people with diabetes these days. Dislipidemia, smoking, excess alcohol intake and there are less common risk factors and sedentary lifestyle, off-late stress, sedentary lifestyle also becomes significant risk factors for having stroke. When you speak about stroke, it's mostly we talk about middle age, about age of 40 years, you know, elderly. But we also see strokes in extremes of ages. We also see strokes in young people in adolescence and even childhood. Now you would like to ask Dr. Mahadev about a childhood stroke. Yes, so whether the stroke occurs in children or young individuals, definitely. It occurs at any age group of people. It can start from just after birth to the elder most people. So the thing is, like previously known that strokes are very uncommon in young individuals, children and just born people, but that has gone now. Stroke is becoming more and more common in the young children, late children and adolescents also. The only thing is, like the etiology, I mean, what are the causes of the stroke, how the stroke presents and what are the risk factors for these age groups, it just differs. Even though the incidence of the stroke occurring in the children is increasing and increasing, but the early diagnosis is still lagging and also sometimes there is a misdiagnosis also because the clinical profile of children is different from the adults. So speaking about that, the young children or early neonates, the presentation of stroke will be just like decrease in the responsiveness, excessive crying, low intake. Sometimes decreased movement of one side of the body and sometimes the restlessness, lethargic behavior. So these kinds of episodes, we usually neglect. So these kinds of symptoms hint us to evaluate in the line of stroke and also the etiology, what are the causes of stroke and how different they are compared to the elderly people. So elderly people, as Dr. Guru Prasasar said, the causes are like diabetes, hypertension, dyslipidemia. So these are smoking, age, these are the risk factors. But in Engage, the most common risk factors are infections, especially in the neonates and early children. Then comes the congenital heart diseases, then comes the developmental malformations, then structural hemoglobinopathies like sickle cell anemias, then vascular malformations, autoimmune disorders like vasculitis. So these are the things we have to keep in mind and try to evaluate in this line to find the cause for stroke in the young individuals. And also the treatment, most of the treatment it is taken from the adults, but we have to treat the cause in the young children and adolescents. So as Dr. Raghuram has mentioned, it's very easy to recognize a stroke patient. So you can follow the mnemonic B fast. B is loss of balance, E is sudden loss of vision, F is facial asymmetry, A is arm drift, S is change in speech and T is sudden onset. Now question is, how do we assess once the patient comes to the emergency? How do we assess? But as we mentioned earlier, stroke is an emergency. We don't have a luxury of time where we can spend time for assessing these patients. We need to be very fast, very quick in assessing the definitive assets and also severity of the disease. So assessment also has to be quick. We are all trained for looking at the deficits and we use scales like NH, SS, stroke scale or modified rank and scale to functionally assess them and document what is the amount of deficits and the functional deficit. Going on to the next aspect of thing. So while we are assessing the patients in the emergency, we also need to plan investigations because we need to make sure what is the type of stroke. So this imaging, brain imaging is the most important aspect of stroke diagnosis apart from clinical assessments. So now I would like to request Dr. Raghuram to throw more light on the diagnostic we use in initial assessment of the patient and then working up the patient later. So like all of us have been repeatedly insisting on the importance of time. So the moment you reach to any kind of a center, it depends on what kind of a facility that particular hospital or center has to treat these stroke patients. So if you reach a center where there is a CT scan only and not an MRI, I don't think it is wrong that we should waste any more time in trying to move this patient out. So first obviously you can do what is called as a plane CT with a CT perfusion, which would adequately give us adequate information to make out whether it is a hemorrhagic stroke or whether it is a non-hemorrhagic stroke. So once we know that our treatment plan accordingly changes which my colleagues will be discussing further. So if you find out that it is a non-hemorrhagic stroke based on a CT scan and if you have the facility to do further tests, we can do what is an MRI brain which is actually a very very sensitive study for picking up any change in the oxygenation of the brain or decreased blood supply which can lead to decreased oxygenation in the brain. So there are specific sequences in the MRI brain which will also tell us how much of the remaining brain tissue or the brain tissue which is viable which is called as a penumbra. And when we are doing this MRI study like all of us have been discussing what happens in stroke, primarily there is a block of blood vessel in the brain. We can do what is called as a quick MR angiogram like how you do angiogram for the heart. The MR imaging can also give us an information about the blood vessels in the brain and then we have an idea what to do further depending on where the blockage in the blood vessel is. So when we investigate a stroke we look at ABC that is we look at the arteries like Dr. Raghuram said we look at the vessels we look at the and if you're suspecting a venous stroke we also do a venogram. We're looking at arterial stroke we look at the vessels either it can be MR angiogram or CT angiogram or if required we also do a cerebral angiogram via 4 vessel DSA. We also have advanced imaging in the form of perfusion scan where if the patient has come later in the course of the stroke onset like 4 hours or 6 hours later or a patient has a wake up stroke then you require advanced imaging to say that we have some tissue to be saved whether we need to go and do thrombectomy for such patients and B is looking at the blood. So we look at the risk factors like I said dyslipidemia so we look at you know lipid profile we look at certain sometimes you look at homocysteine levels and in younger people we also look at other auto antibodies to know whether they are having a risk of recurrent stroke and the circulation so these are the way we investigate we also look at heart we look at the neck vessels is there any blockages there we need to also work up for the stroke mechanism. So all these investigations help us to know what is the type of stroke what is the risk of another stroke so investments are very important aspect of the stroke work up. Next part is what is the stroke ready hospital and the stroke unit. So to have all these investigation modalities to have the stroke team which consists of a neurologist neurosurgeon intervention neurologist good rehabilitation team stroke nurse we need to have a full setup to give very good quality care and good outcome because we work as a team no one person can handle this such a complicated clinical situation like a stroke. So stroke ready hospital have this an under one roof and all these times all this procedure have to be done in a time-bound manner. So stroke ready hospitals are the places to go when a person is diagnosed to have a stroke. So there is always a question when patient has symptoms of stroke we need they need they need to go whether to a clinic or a nursing home. This will have only partial care they may be a visiting consultant or they will only have CT scan they will not have facility for a cath lab or an MRI. So we need to patient needs to be educated public need to know that stroke ready hospitals are the ones patients need to reach quickly. Later the rehab care and that can happen later in other type of hospitals but important is to understand that comprehensive stroke care happens in stroke ready hospitals or stroke units. So going to the part of the discussion on stroke Dr. Avinash about what is the type of treatments available for acute stroke patients. So as far as treatment of stroke is concerned again it depends on lot of factors like what is the age of the patient what is the duration of onset of stroke. What is the picture which is seen in the scan. Like broadly other colleagues have mentioned depending on whether it is an hemorrhagic stroke or an ischemic stroke the treatment differs. In case of hemorrhagic strokes like Dr. Raghuram mentioned some of the cases may have to be taken up immediately for surgeries. Whereas in ischemic stroke which is the major bulk of stroke which is about 85% of the strokes. Overall what happens when these patients come to emergency is that once we detect that there is a stroke and a major vessel is occluded there is something called a golden period of arrival to the hospital. If the patient falls in that category of golden period then there is facility for giving intravenous injections within certain period of time. If a patient reaches hospital beyond that certain period of time which our colleagues will going to discuss. If they reach beyond that period golden period then there are certain other mode of treatments available in these patients like between 4 to 8 hours of onset of stroke. If those patients come to the hospital then there is a technique called endonurovascular technique where you go inside the blood vessels with different sized catheters and you suck out the clots and reestablish the circulations. So by this technique we will be able to reestablish the circulation and prevent or reduce the amount of damage to the brain cells. And in some specific type of strokes we can go beyond this 8 hours of window period and like Dr. Gurprasad mentioned with different type of imaging techniques we will be able to detect very small specific group of patients who can even be treated beyond 8 hours even upto 24 and 48 hours. But they are very very limited number of patients so the goal of treatment or the plan of treatment for the patient is to reach the hospital as quickly as possible and all modalities of treatment which are available are basically upto 8 hours beyond which is only a rehabilitation and other modes of treatment. So as Dr. Avinash said the facility for giving this type of advanced treatments whether it is IV thrombolysis or mechanical thromectomy is available only for the set duration that is called window period. So that is only available for first four and a half hours for IV and little extended period for the mechanical thromectomy. So the importance is to reach the hospital as early as possible not to waste time taking references going to multiple doctors and the vital time is wasted and patients may not get the benefit of opening up the vessel by these techniques and the outcome is not eventually good. Having said that there are certain patients who come late or also started on medications in the form of blood thinners what we call anti platelets. Some patients require anti-coagulation if they have a diagnosis of dissection of a vessel or there is a cardiabolic stroke we start on anti-coagulation and these medications have to be continued for life. And we also start on risk modification drugs like statins if they are diabetic hypertensive we start them on medications and there are certain neuroparticle drugs we start them on. So at this stage I want to ask Dr. Mahadev about golden period, window period and door to needle time. These are there are certain quality indicators for you know stroke care. So what do these terms mean in stroke care? Yes, so the punchline for all the neurologists and the neuro interventionist is time is brain and brain is a time. So that is the one important thing and so keeping this in the mind we have to know that as we said before itself there are certain signs where we will get to know that the patient is having a stroke. So if the patient or patient family members they are aware of these signs so there are stroke ready hospitals as our colleagues were telling. So these hospitals have a trained doctors, trained nurses, trained paramedicals, therapists and even trained ambulance staff. So if you call them immediately they will come and assess on spot what is the patient situation, how severe is the condition. They are trained in that way they will assess the blood pressure blood sugars they will keep in continuous touch with the treating doctor. By the time the patient is transferred from the home to the hospital door emergency door the conditions can be pre analyzed. As I said what is a golden hour? Golden hour is a time or a golden period what we say it is a time from the onset of symptom till we intervene till we start the treatment. So as we know every minute there is a chance of losing 1.9 million neurons. So this tells the severity of the effect of the stroke. So as soon as the patient has the symptoms of stroke once all this channelized once the patient reaches to the hospital. So in the emergency ward itself the stroke managing doctor will assess the situation with certain parameters they will assess the severity how much the degree of deficits are there. Then simultaneously on the chair itself they will take the patient to the radiology center they will do the imaging they will reduce the time as much as possible. Because as I said each minute counts each second counts so in that period like how much time you reduce from onset of the symptom till giving the reperfusion therapy that constitutes the golden period or golden hour. Coming to the window period there is certain time limit which are set by a stroke association that in a ischemic stroke a time of 4.5 hours ideally 3 hours but can be extended to 4.5 hours is a time period which is allowed for doing the IV thrombolysis. In general term what we say clot busters. There are some drugs which are given as intravenous line to burst the clot which has formed in the brain. These are called as tissue plasminogen activators. The usual drug which we use in our institute are tenectoplasm and alteplase. So the window period for IV thrombolysis it is there from 3 hours to 4.5 hours. In some situations where we call as a wake up strokes sometimes we do not know the patient gets up he already has some deficits. In that situation we can use a help of imaging in that we will know we will get to know that whether the stroke is crossed the 4.5 hours or still within the 4.5 hours. Accordingly we plan for IV thrombolysis and in special situations where the centers permits we even advise for a bridging therapy. Basically initially we do the IV thrombolysis where the clot busters in the form of injection is given and if there is a large vessel occlusion what we say LVO. If that is detected in some modalities of investigation as my colleague said MR angiography or CT angiography. If there is a large clot is present in the brain that patient if the clinical parameters or vitals are stable if it is permittable they can be taken for endovascular intervention what we call as mechanical thrombectomy. So with this kind of early intervention and proper treatment the complete deficit can be reversed. Coming to the needle to I mean the door to needle time that technical term means at what time the patient comes to the emergency department from there to how much time it is taken for giving the intravascular thrombolysis. So that decides the door to needle time. So as much as we try to shorten this period that much of neurons we can save in the brain and there is much chances of reversing the deficits is possible. Thanks Mahadev for explaining this in detail. So one of the important quality indicator for any stroke unit or stroke ready hospital is to minimize the door to needle time. So nowadays we look at less than an hour and some of the centers have achieved less than 30 minutes and I think we should strive the responsibility of the treating team to minimize that door to needle time as much as possible. So all this now I have evidence there is significant of a clinical evidence for IV thrombolysis and mechanical thrombectomy these days. We had a lot of trials results coming in the way of last few years where they have shown that opening the vessel is the most important treatment for any patient coming with a stroke and it has to be done in a quick time. Now I want to ask Dr. Avinash who is our intervention neurosurgeon about how effective are these procedures. So like whatever colleagues mentioned about the treatment options. Once the period of IV thrombolysis is over then the patient will have an option of going for neuroendovascular procedures. These are newer advances which are present in the management of stroke patients. This was earlier before 2000 these techniques were not available. This was first started in 2006 and from then onwards there are multiple different techniques available to take out this. In broad terms these are called as mechanical thrombectomies. The effectiveness of mechanical thrombectomies is like if you consider IV thrombolytics gives about 40 to 50% of reopening chances. Then mechanical thrombectomy has almost like 70 to 80% chance of opening the block vessels thereby by improving the outcome of the patients. So we have been discussing about ischemic strokes all this while. As Dr. Avinash mentioned in his opening remark there are two types of strokes. One is ischemic strokes another is hemorrhagic stroke. When you do imaging and you have a brain clot that means there is a rupture of a vessel and there is a bleed inside the brain. Some of these patients require emergency surgery. So now I request Dr. Raghuram to talk about the role of surgery in acute strokes both ischemic as well as hemorrhagic stroke. That's a very important point I think the key message is what Dr. Avinash was saying. So that is something that is really revolutionized treatment and the kind of results and the recovery of the weaknesses that we see are amazing. So it's kind of a life-changing thing for the patient. So if you could reach the hospital in time that's the best. So then there is this other patients who have ischemic stroke but reach late. So when they are reaching late we really don't have any other acute intervention that we can do except starting the blood thinners which Dr. Guruprasad already mentioned. So some of these patients tend to have what is called as progression of a stroke. So this blood clot which is already formed and blocked the blood vessel continues to extend further and block the major vessels of the brain. One of the major vessels of the brain is what is called as the middle cerebral artery which supplies almost half of the brain on each side of the brain. So if that gets blocked and the patients have a large stroke which means almost one half of the brain is having a stroke and that also causes what is called as edema or swelling of the brain. Unfortunately when there is a swelling of the brain the swelling cannot come out because the skull is a very rigid bone unlike a swelling in the abdomen or the hand which tends to push the skin up and come out. So when this swelling does not come out it causes compression and other important structure of the brain which is called as the brain stem. So when that happens these patients become more and more drowsy or become unconscious and then we have some signs which we pick up in terms of checking the size of the pupil or the eyeball and then we know that these patients are progressing and the swelling is too much. So we have a surgery called as decompressive cranictomy. What do we do in this surgery is basically to provide space for the swelling of the brain. So in this surgery what we do we tend to remove at least a 6 to 10 centimeter half of the skull on the affected side of the stroke so that the swelling can come out and not press on the important brain structures. So this thing does not reverse the stroke that has happened. So unlike what Dr. Avinash treatment what he was saying kind of goes ahead and reverses the stroke these are just more to prevent mortality or death threat when it happens. So basically this is to save the patient and subsequently the patients has to go through intense rehab to improve the quality of life that he has. Other important stroke that all of us have been talking from the beginning is when you have a bleeding or a blood clot in the stroke. So when somebody comes to the hospital and we do a scan and we see that he has a bleed and if it is small we still continue what is called as the medical treatment that is to reduce swelling, prevent further worsening and all that. In case when he comes to the hospital in an acute setting and has a very big clot then we again do what is called as the same kind of a surgery that is remove the bone, provide space. In addition to that we try and go into this clot in the brain and try to take out the clot so that the swelling in the brain can come down. So this is called as an evacuation of a hematoma or a clot. So this is an acute kind of a surgical intervention that we do in both ischemic and non-ischemic strokes. Stroke no doubt the first 24 to 45 is the most important part of the stroke management. We do all kinds of interventions, manage these patients. Most of these patients get admitted in ICU. They are closely monitored for their conscious level for the deficits, whether they are improving, whether they are worsening. So we need to clean them under close observation. We have a team of doctors called Intensivist who manage these patients minute to minute. They are closely monitored in the ICU and we also sometimes require repeat imaging to see how much is the swelling of the brain, what is the any other complication like for example we give TPA that is the clot lysing agent, sometimes these patients can have bleeding complications. So we need to closely monitor these patients. Having said that, once we have the acute phase over, these patients require intense rehabilitation. Once we started on blood thinners, they have been investigated, the risk factors have been assessed and they will go on to the next phase of rehabilitation. So any stroke-ready hospital need to have a good rehabilitation team and then they start working on initially, be it speech, be it swallowing, be it limb physio and all. So now I want to request Dr. Mahadev to tell us about the role of rehabilitation in stroke care. Yes, what if once the patient comes after the window paid, so what is the options of treatment at that time? Say for example patient is coming after 24 hours of onset of his symptoms or staying in a remote area where it took a lot of time to reach stroke care hospitals. So what if the patient is not a candidate for thrombolysis? What if the patient is coming with the major deficits? In that case the rehabilitation part plays an important role. Obviously we give the secondary preventive drugs like and clot stabilizing agents in the form of blood thinners and in the form of neuro-suiticals, neurocorrective agents. Along with that the rehabilitation, a good rehabilitation so that at least the patient can reach to a near normal functioning level is very, very important. So considering this as our colleague said a stroke is a leading disability condition worldwide, not only in India and it is the second most common cause of death next to the cardiac causes. So basically the rehabilitation starts from the day one of admission if the patient is getting admitted with the major deficits. So we form objectives like what are the objectives we look into the patient and treating. So basically the objectives of stroke rehabilitation is to restore the functional capability of the patient, the strength, the speech, the swallow, the cognitive part, the psychological issues. These are the things we will concentrate. Second thing we will categorize the patient and we try to make the patient functionally independent. So how quickly the patient becomes functionally independent. Third thing we try to prevent the complications out of the strokes. The patient is getting admitted into the hospital will be exposed to the hospital-related infections, the bed sores, the nutritional deficiencies. So these are the things we have to take care and we have to more important is we have to prevent the recurrence of the stroke. Then we have to give a good mental support and psychological support to the patients. So the key things is regaining the strength, regaining the balance, regaining the swallow and speech functions and avoiding all the hospital-related infections giving good psychological support to the patients. So as I said, the rehabilitation involves the multidisciplinary action. It is not just a work of neurologist. It involves multiple sub-specialties to take care of the patient. It involves neurologists, neuro-interventionists, speech therapists, occupational therapists, physiotherapists, psychologists, respiratory therapists. So all of these specialties are collectively they have to work for regaining the functional ability and other aspects of the patient's recovery. So how we do that? So once the patient gets admitted, we have to have a common conversation with all these therapists and we have to involve the family. What we have to do? We have to find the risks involved in the patients. One thing is a deficit and another things are comorbidities like the patient is having diabetes, hypertension or other comorbidities. Then we have to set a goal. We have to involve the family members and we have to involve all the other therapists to start the rehabilitation process. And we have to set a goal by the time the patient gets discharged. We have to be in a situation that at least some deficits are coming back. Then we have to reevaluate day by day. We have to assess the patient. We have to do the improvement in the deficits. Then ultimately we have to create the motivation in the patient and family members. So with this kind of intervention, this kind of therapies, the patient can regain some sort of at least near normal functioning. And coming to the newer advances in rehabilitation, there are some artificial intelligence and robotic therapies are going on. Basically what they'll do in this treatment is they will create the robots which help the patient to move their, which train or help the patient to move their limbs, their arms, their legs. Indirectly using the artificial intelligence, they give the signals to the part of the brain which controls these kind of movements. So over the period of time, the brain starts giving signals and patient can get the functional improvement. So these are not available everywhere, but still the research is still going on and we hope soon we can get it in every centers. So the most important question asked by most of the patient or the patient families is the stroke preventable. Or once the patient is admitted with a stroke, they will have this question that can the stroke come back? So definitely there is a risk of recurrence of stroke in all patients. So that's the reason why compliance with the medications, that is the secondary prophylaxis, beat blood thinners, beat anti-diabetic medications, anti-hypertensives, statins have to be continued for life. And that goes on most of the patients and the doctors can decide what extent and what is the doses to be given. So having said that, lifestyle changes, even primary prevention, that stroke can be prevented. So when we see patients at 30s and 40s coming with headaches, very bad lifestyle, we sometimes start doing primary prevention lifestyle modifications. Like for example, you need to have good amount of exercises, at least half an hour to 45 minutes daily cardio exercises, at least five days a week will definitely help them in preventing this type of vascular events. Medical checkups, hypertension and diabetes will not be coming with symptoms always. It has to be picked up early on in 30s, 40s. When the blood pressure is consistently found to be high, they need to be initiated on medications. Diabetes also. By the time they have osmotic symptoms like polyuria or polydipsia, it will be too late. So we need to be picked up during medical checkups. So these are the ways you need to get the vascular risk factors picked up early and then that has to be treated. Along with that, a person has to be abstained from smoking. Smoking is one addiction which can have a direct impact on prevalence and incidence of stroke. Excess alcohol intake also can lead to hemorrhagic strokes. So that also has to be moderated. So all these interventions in terms of lifestyle modifications, management of vascular risk factors will help in prevention of stroke. So at the end, we want to convey this message. I now request all my colleagues to give a final message to the public and the physicians about acute stroke. Starting from Dr. Mahadev. The bottom line, what I want to say is stroke is treatable if it came on the right time, but it can recur if not adhered to the medications. So complying to the medications and strictly strict follow-up and controlling all the comorbidities can prevent the further episodes of stroke. Dr. Rabram. The same thing what Dr. Guru Prasad just illustrated, the most important thing is in addition to all these medications is to do what is called as primary prevention. That is climbing a very good lifestyle habits. Definitely no smoking, no alcohol or alcohol in moderation is very, very important. Smoking especially has a very high risk factor, not only for brain stroke also for heart attack and also doing good quality exercises every day is very, very important. I know most of the youngsters now would say they're very busy, but please make time for yourself. Make sure at least you do an hour of exercise every day so that you can prevent these devastating medical issues. My side is time is brain, do not delay, rush to the hospital if you find any of the symptoms that we have mentioned, get treated fast. The earlier we treat you, better we can save number of cells. One in four has a risk of having a stroke in the population. The burden of stroke is huge. So as public, as treating physicians, we need to be aware that it can hit anyone in the family, in your community. So be aware of stroke and reach the hospital as early as possible. Thank you.