Brain Stroke has remained a challenge due to the severe lifetime disability associated with the Medieval times. For a long time, the cause of stroke remained a mystery. Many therapies were confined to massages and various manipulations of the non-moving parts of the body for a long time.

However, the unraveling of the Brain and nervous system in the body made it known that insult to the brain is the cause of paralysis. That led to a combination of physical therapy with native medicines. Romans, Greeks, and Chinese made their premier efforts to introduce several native medications. The results were partially successful. Due to a lack of alternatives that remained the gold standard for a long period. Even in India Charaka wrote many descriptions and methods of treatment in traditional Ayurveda which continues even today with many periodic modifications. Later came the conventional medicines that to a great extent ran in families as trade secrets. All this continued without a proper understanding of the exact neurological basis. At the dawn of modern medicine, people started recognizing the Brain as a central control system with nerves spreading to various parts of the body. The right brain controllingthe left side and the left controlling the right side of the body became clear. Further research has shown the metabolic functions of the brain cells, and their control mediated through electrical signals. The energy required for this process is provided by the circulation of blood through the blood vessels of the brain.

Knowing the importance of nature has provided a good buffer system by connecting and interlinking all the blood vessels of the brain to provide collateral circulation. This helps in circumventing blocks and bypassing the system from the neighboring vessels. Despite such protection, these blood vessels can get blocked due to several causes leading to deprivation of blood supply.

This is possible by clear thinking that generates right feelings and right perceptions, without distortions. Misinformation can certainly mislead the thinking ability. Human race is bogged down with such unwanted and un validated information with misconceptions leading to distorted thinking. The energy support and fatigue seems to be another major constraint that determines such thinking and abilities. Some get tired even with simple tasks. The limits of tolerance is so widely variable among individuals. Ultimately it is the thought process that makes or breaks an individual. However, it is difficult explain even today what determines the right thought process, what influences the innate faculties of brain and how the individual choices are made. No doubt each one has their own choices in every aspect of life.

Due to high demand and selectivity, Brain has very poor and limited tolerance to such insults leading to severe structural dysfunction or damage. We realized that quick restoration of blood supply is the only answer to this problem. Time is crucial in determining the extent of brain damage bringing the concept of GOLDEN HOURS in the treatment of stroke. The longer the time the vessel cannot be reopened simultaneously the damage to brain cells is permanent. Initially when blood supply is deprived brain cells will become electrically silent, but remain chemically active. This is the stage they can recover provided the blood supply returns. If not they become metabolically inactive and die. So establishing the blood flow within this time has become crucial to restoring brain function. This is called the revascularisation of the brain. The results demands on the time taken to achieve this goal. Thus the concept of golden hours came into vogue.

The drugs to dissolve the clot were used and the treatment is called Thrombolysis. To begin with, only the first three hours were helpful. The subsequent research and drug modification have increased the golden time up to 6 hours and further modified it to the first 24 hours. This is indeed a boon among developments so that more people with stroke will become eligible for treatment. When it was six hours only 15% of strokes only were eligible. The potential has expanded by many fold today, yet this awareness has not percolated into the society still.

Due to the logistics of reaching the hospital, availability of drugs, and other factors, many could not reap the benefit. Several efforts were made to reduce the time. Quick CT scans and administering the drug either in the CT room itself or in the emergency are being practiced even now. No time should be wasted in doing routine formalities or other investigations. Mechanical Thrombectomy was introduced as an additional advancement wherever Thrombolysis was not possible or not successful. This is done through an angiography with a special device that breaks and removes the entire clot located in the blood vessel thereby re establishing the blood flow. But this needs a stroke center, technology, and skilled professionals. Simultaneously concept of stroke ambulance was tried to reduce the time of diagnosis. The ambulance with a mobile act scan performs brain imaging, and the Thrombolysis will be done right in the ambulance itself all the doorstep of the patient. But this proved to be expensive and not cost-effective. Meanwhile, carotid endarterectomy (removal of clot by open surgery) or carotid Stenting (closed procedure) became popular among the select candidates. Subsequent clinical trials and results proved that every patient with stroke will have varying degrees of carotid stenosis. Though medicines and close observation is fine in asymptomatic ones, following a stroke addressing this stenosis seems to be beneficial. The present studies recommend pre-emptive or prophylactic Stenting following Mechanical Thrombectomy. The present recommendation is, to combine mechanical thrombectomy with carotid Stenting regardless of the degree of stenosis. This seems to augment the blood flow enhancement since the person has had a stroke already. The outcome and degree of recovery have proven to be better with this combination. When the person comes beyond golden hours the blood vessel is occluded, and the only option left with us cerebral bypass surgery. All these procedures not only enhance the recovery but also prevent the risk of further stroke.

Regardless of these interventions identifying all the risk factors and correcting them will remain of paramount importance. Several risk factors and lifestyle modifications have evolved and need to be identified and treated. Blood thinners and the newer version of potential anti-platelet medications remain the mainstay in preventing as well as treating brain stroke. Lifestyle modification, avoiding all insults and toxins, and inculcating good habits go a long way in the management of stroke or brain attack. Rehabilitation will help promote neural plasticity and promoting functional recovery. Yet lot more research and drug discovery to be undertaken to prevent and promote total recovery to reduce the disability and stroke remains the leading cause of disability across the world today.