Cerebral infarction is a common and frequent disease. It is characterized by high morbidity, high mortality and high disability. According to the third national cause of death survey, cerebrovascular disease has replaced malignant tumors as the first factor causing death of our residents. So once you have a cerebral infarction, what should you do? As the saying goes, if you have a disease, treat it early. The treatment effect and regression of any disease depends largely on the early or late time of consultation, and this is especially true for cerebral infarction! A one-minute interruption in cerebral blood flow results in the loss of 1.9 million neurons. A five-minute interruption can cause irreversible damage. Time is brain, time is life, and the resuscitation of cerebral infarction needs to compete for time! Depending on the patient’s time window of onset, doctors will adopt different treatments for patients with cerebral infarction. The three most effective treatment methods, called the three sharp tools, can help patients overcome the disease of cerebral infarction and save their neurological functions and even their lives to the maximum. What are the three tools of cerebral infarction treatment? The first is intravenous thrombolysis, the second is interventional therapy, and the third is decompression of the bone flap. These three tools are determined by different time windows after the onset of the disease. Different patients and different consultation times determine whether and how they can be implemented. We say that the decision is up to the physician and the decision is up to the patient. If the patient cannot be seen within the effective time window, the doctor has no space or opportunity to perform his or her 18 skills. The opportunity for treatment is up to the patient to decide, and the physician is only helping to implement it. Let’s talk about how to implement these three sharp tools. Since cerebral infarction is the necrosis of brain cells caused by the blockage of blood vessels by blood clots. Then the most effective treatment measure should be blood vessel recanalization and blood flow restoration. How to restore blood flow should be the most important treatment for cerebral infarction, which has the greatest impact on the prognosis. The first two of the three tools we mentioned are how to make the blood vessels reopen and restore the blood flow. Let’s start with the first weapon: intravenous thrombolysis. If a patient with a cerebral infarction can be seen promptly after the onset of the disease and be given the thrombolytic drug r-tPA within 4.5 hours, the benefit of thrombolysis will be 10 times greater than the risk. However, if the time window for intravenous thrombolysis is missed. Then if the thrombolytic drug is given intravenously again, the embolus will not only not dissolve easily, but also the risk of bleeding will be very high. In this case, doctors are afraid to give intravenous thrombolytic therapy again. So does it mean that any patient with cerebral infarction can be given intravenous thrombolytic therapy as long as he or she arrives at the hospital within the time window? Therefore, for intravenous thrombolysis, doctors have strict screening criteria with strict indications and contraindications. This requires the patient to have some tests done urgently to help the doctor make a decision. These tests include, head CT, routine blood work, blood coagulation and some other basic laboratory tests. The doctor decides whether to use intravenous thrombolysis based on the results of these tests and the overall condition of the patient. If it is not appropriate, thrombolytic drugs cannot be used. If the test results support thrombolysis and the doctor determines that there are no contraindications to thrombolysis and thrombolysis is needed, the patient and family must sign an informed consent form. The purpose of the informed consent form is to allow the patient and family to share the benefits and risks of thrombolysis with the physician. This is a time when the patient and the physician need to fight together to fight the disease for time. At such times, the family’s trust in the physician is particularly important. If the trust is high, the time spent on communication will be reduced and the time brought to the treatment will be increased. If the communication is difficult, the family is indecisive, asking endless questions, and the doctor spends too much time on explanation, then the time left for the patient will be greatly reduced, and finally, even if they agree, the efficacy of the medication will be greatly reduced because of the time delay. If the delay is long and the drug cannot be used within the time window, the thrombolytic drug can no longer be used. Therefore, we remind patients that when doctors decide on a treatment, the first thing they think of is the need of the disease and will not mix with other problems. Especially for critically ill patients, trust in the doctor is essential. This will give the patient more time and opportunity to be rescued. The second weapon is interventional treatment, including arterial thrombolysis, mechanical embolization and stent placement. If intravenous thrombolysis does not dissolve the thrombus, the vessel is not recanalized, blood flow is not restored, or the patient is seen too late and misses the time window for intravenous thrombolysis, what should we do? At this time, we can also choose interventional treatment, also called endovascular treatment. This means that a needle is inserted from the patient’s femoral artery and a specific contrast agent is injected into the cerebral vessels to see the site and extent of the blockage. Then the thrombolytic drug is injected directly into the site of the clot, which is what we call arterial thrombolysis. If the embolus is very large or the onset of the disease is too long, the embolus cannot be dissolved by arterial thrombolysis, and a specific device can be used to retrieve the embolus. We call this stent implantation, and this is one of the methods we commonly use. However, there are strict indications and contraindications for the use of this method, and there are also certain risks. It requires signed consent from the family. The time window for arterial thrombolysis is 6 hours for anterior circulation and 24 hours for posterior circulation according to the guidelines. The time window for stent implantation is not specified and has to be evaluated based on the patient’s time of onset, age, size of the infarct area, and the establishment of collateral circulation. Regardless of which case is chosen, the goal of the doctor and the family is always the same: to minimize sequelae and complications, to save the maximum number of brain cells, cerebrovascular and to the patient’s life, to maximize the benefit and minimize the damage. But doctors are human beings not gods. A doctor’s correct decision does not necessarily mean that the patient’s prognosis is definitely good. The prognosis of a patient depends on many factors, sometimes unpredictable and difficult for the doctor to control. This is what we often refer to as a high-risk profession. This high risk is reflected in the fact that patients are very different from each other and it is not up to the doctor to decide. The third tool is decompression of the bone flap. If the patient is treated with intravenous thrombolysis and endovascular therapy and still has poor outcomes, or if the patient is seen too late and misses the time window for these treatments, what then? If the infarction is small and the patient only has limb paralysis, which is not life-threatening, then we can take conservative treatment and give comprehensive treatment such as anti-platelet aggregation, anticoagulation, plaque stabilization, blood pressure stabilization, blood circulation, brain cell nutrition, prevention of complications and early rehabilitation. However, if the patient has infarction of large vessels, such as malignant middle cerebral artery syndrome, acute internal carotid artery occlusion, or large infarction of the cerebellum. These lesions can develop brain herniation at any time, leading to central respiratory and circulatory failure and causing the patient’s death. What do we do for this type of patients? It is not enough for our neurologists to give mannitol, glycerol fructose, tachyphylaxis, albumin and other dehydrating agents to save the patient’s life. This is when we need to call in the neurosurgeon to help. The usual practice is to remove a large piece of the skull from the side of the infarct so that the necrotic brain cells expand outward instead of compressing the normal brain cells on the opposite side. This preserves the function of the brain cells on the opposite side and thus saves the patient’s life. This method is an approach in cases where there is no alternative. The purpose of this treatment is only to preserve life, and it will not help the function of necrotic brain cells. Therefore, most of the patients who survive by this treatment are left with severe physical disabilities, and many are even in a vegetative state. This has caused many unbearable burdens to families and society. These three tools I mentioned above, what to implement and how to implement them, our neurologists have mastered very well. However, the key to how well they are implemented is the time window in which the patient is seen and the individual patient’s situation. We often say that the most appropriate method and drug is used on the most appropriate patient at the most appropriate time. Only when the right time, method and patient are chosen will our treatment be successful. The decision to treat rests with the physician and the decision to treat rests with the patient. If the patient cannot reach the hospital within the time window, even the most brilliant doctor will be helpless, unable to help, and can only sigh with sorrow! Therefore, time is brain and time is life. Thrombolysis – there is no time to lose!