Melanie Cole, MS (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And today, we're talking about stroke with Dr. Trevor Gregath. He's the Medical Director of the Bryan Stroke Program and the Division Chair of Neurology at Bryan Health.

Dr. Gregath, it's a pleasure to have you join us today. I'd like you to start by telling us about stroke - the prevalence of it, and there's a couple of different kinds of stroke. Can you explain to people really what that is, what stroke is, and how it differs from something like a heart attack?

Trevor Gregath, MD: Yes, definitely. Thanks, Melanie. Thanks for having me. So stroke, generally speaking, it's an injury to the brain related to a problem with the blood vessels. There are two different types of strokes. The most common one is called an ischemic stroke, which is due to a lack of blood flow to the brain. And most typically, it's due to a blood clot in the artery of the brain that's blocking blood flow there, causing irreversible damage. And the second type of stroke, which is the less common type, is what we call hemorrhagic stroke. And that's due to an issue where a blood vessel will rupture, either within the brain or around the brain and lead to damage that way.

And there's several different types of hemorrhagic strokes, we call them intracerebral hemorrhage, intraventricular hemorrhage and also subarachnoid hemorrhage are some of the ones that we deal with.

Melanie Cole, MS: Dr. Gregath, do we know what causes strokes? Because there's a cardiovascular component and a neurologic component because they affect the brain and you're a neurologist, can you explain a little bit about what we know about the causes?

Trevor Gregath, MD: Yes, definitely. You're exactly right and there is a lot of overlap with the heart, as I already mentioned. This is a blood vessel issue that is happening within the brain, but there's a lot of the same processes happening in the heart. So, the major risk factors that we think of, some of them we can do things to help, and some of them we can't. Like, for one instance, there is advanced age. But some of the more modifiable ones would be chronic high blood pressure, chronic high blood sugar or diabetes and chronic high cholesterol. Then, there's your other things, kind of lifestyle risk factors, things like tobacco use, heavy alcohol use, illicit drugs and those kind of things. And there are many more less common risk factors as well.

Melanie Cole, MS: Well, thank you for that. Now, I think one of the most important things we can discuss here today, and we'll get into risk, but are really the symptoms because people want to know what they're supposed to be looking for. There are acronyms. So, can you tell us a little bit about those symptoms and what is it we are looking for?

Trevor Gregath, MD: Yeah, that's exactly right. There is an acronym, it's called FAST, F-A-S-T. F is face for face weakness or facial droop on one side of the face. A is for arm weakness where you're having trouble lifting or using one arm. The S stands for speech problems, and this could be slurring of the words, difficulty understanding language or even having trouble producing any words at all. And then, the T at the end there is to remind us of time that if you notice any of these symptoms, you should be evaluated immediately. Now, of course, there are a lot of other symptoms that a stroke can present with, but these are just the most common ones that is recommended for the public to be looking out for.

Melanie Cole, MS: It's so important that we're able to recognize those. And while we're recognizing symptoms, it's helpful to know who's at risk. So, can you tell us, like if you've had one stroke before, you're at risk for another one, and you mentioned high blood pressure and diabetes already, but are some people with other conditions more at risk like AFib or obesity? Does that put you more at risk?

Trevor Gregath, MD: Yeah, you're exactly right. Atrial fibrillation is a very common one, which is an abnormal heart rhythm where it beats irregularly. And actually, most patients may not even know they have that rhythm. And obesity, certainly; many of the other risk factors that we had talked about. But yeah, the other thing you mentioned, I think very astutely is if you've had a stroke in the past, that's actually the number one risk factor to predict a future stroke.

Melanie Cole, MS: Now, what do we do if someone thinks they are having a stroke or they think a loved one is, should they be driving that person to the ER? Is it really important to call 911 because there are things that emergency can do before getting to the emergency room?

Trevor Gregath, MD: Yeah, that's a great point. And I think a lot of us kind of feel a sense, like we want to take care of it ourselves sometimes, but we have the emergency medical services EMS in place and highly trained, working with us as well. And it is best to call 911 and go that route because they can ask very important questions and get the ball rolling to see what kind of treatments you might qualify. They can take you to a place that might be better at doing some treatments than other places. So, they can triage you to a place that can give you the appropriate care. And also, it is a critical condition and you want to have a healthcare provider like an EMS to be taking care of you en route to the hospital as well.

Melanie Cole, MS: So, they let the emergency room know that they're bringing somebody in with a stroke, right?

Trevor Gregath, MD: Yeah, that's exactly right. Then, we can be prepared, ready to go and receive you right at the door.

Melanie Cole, MS: What happens then, doc?

Trevor Gregath, MD: Once they get to the door, we have a system in place where it actually happens very quickly. And we send the patient directly to a scanner after kind of looking at them, making sure that they look okay and they'll be safe to go in a scanner, which most stroke patients will be.

Once we go to the scanner, we do a CT scan of the head. Some people call that a CAT scan. We also will get a look at the blood vessels with a thing called a CT angiogram to look at the blood vessels in the head and the neck. And once we've had that imaging, that's where you'll have a provider in the emergency room do a specific kind of examination to see what kind of stroke symptoms you are having. Is it more on the mild side or is this a moderate to severe one? And what kind of treatments should we be looking to get?

Melanie Cole, MS: Well then, tell us a little bit about those treatments, because you've got more tools in your toolbox now, Dr. Gregath, and there's more things that you can do for people. So, speak about some of those interventions, kind of in order that you would use them and there's even surgical interventions now.

Trevor Gregath, MD: Yes, that's exactly right. It's a really exciting time for neurology and stroke care. We do have some really good options to treat patients that come in with very specific criteria that we look for. The first one that we evaluate for is a clot-busting medicine called tPA. And there's a couple of them that you may hear about in the news.

The one that's been used for a long time is called alteplase. And there's a newer one, which is approved now called tenecteplase, which we have been using and adopted. And that's a little bit more simple to use and faster to use, which is very important. We always have a saying that time is brain. You want to get these treatments as quickly as possible to save the brain, which leads to better outcomes. So, the first thing we do is evaluate for that tPA to see if you meet criteria. Some of that criteria involves getting to the hospital within a certain time of when you were last feeling your normal self. It depends if you are on any strong blood thinners. We want to make sure that it's a safe medicine and you don't want to cause bleeding with adding another strong blood thinner to one that you're already on.

And then, there's many other risk factors, depending on your past medical history and blood pressure and things like that. And this medication does lead to better outcomes overall than if you do not get the medication. There is a second treatment, which is even newer, really developing over the last 10 plus years. It's been used a little bit even before 10 years. But really, the data has been emerging that there's a really great treatment called mechanical thrombectomy that some patients will qualify for.

When there is a blood clot in a major blood vessel of the brain leading to a lack of flow to the majority of the brain, then we can consider if we can go in and remove the blood clot via this procedure called mechanical thrombectomy. Essentially, what it is is we have a specialist here that takes a series of tubes and wires, enters an artery in the groin, and is able to go up to that artery all the way up in the brain and deploy a device to basically remove it from there and restore the blood flow. And that's by far the best thing we can do for a patient that's having that major kind of stroke and it leads to drastically improved outcomes.

Melanie Cole, MS: Dr. Gregath, you mentioned when you talked about symptoms, the T in fast, which is time, and time is brain. That's what you all doctors say. Time is brain. Along with that time, the use of tPA has its own time limit, doesn't it? So, tell listeners why it's so important that they call 911 right away because there's a window for which you can do these things.

Trevor Gregath, MD: Yeah, that's exactly right. And the window extends out to four and a half hours from when we can be confident that you were last your normal self. So, it's not when the symptoms started. It's just a little bit confusing sometimes. Because some patients might wake up and say, "Gosh, I'm having some weakness on the right side of my body." What's really important is getting here when we know that you were last your normal self. So, time is super important. Getting EMS involved, get us activated, ready to receive you, have more information when we do receive you. And even within that timeframe of say four and a half hours, giving that tPA at one hour is drastically better than giving that tPA at three hours or even four hours. It's going to make it much more likely that you'll be able to get back to the things you love doing.

Melanie Cole, MS: You've been so informative, Dr. Gregath. As we get ready to wrap up, what advice would you like to give listeners about the important information you've given here today? And if you'd like to go over a little bit about life after stroke and what your team is like and that the fact that there is a multidisciplinary team that works with patients when they've had a stroke and after they've had a stroke to resume that quality of life.

Trevor Gregath, MD: Yes, absolutely. I think some extra things I'd like to just kind of briefly touch on is that the best treatment is really prevention. So, most importantly, working with your primary care doctor, make sure that you're doing everything you can to not show up to the hospital in the first place.

You know, make sure that you're exercising regularly, eating a good heart, healthy diet, avoiding the processed foods and eating more of the whole foods and making sure those risk factors that we talked about are really under control as best as you can.

If things do end up leading you here, we have a multidisciplinary team. We have the cutting-edge of stroke care in every single discipline here, including neurology, the emergency room, radiology, the nursing staff, internal medicine, you name it. We are on the cutting-edge in doing everything we can here. And once we're here and we've treated you, there's the post-stroke care, which is dealing with the ramifications of it. And we have a great rehab facility here that we work with and really great rehab in town as well. So, yeah, we kind of have it all covered here, so we're happy to give this care. And we truly are on the cutting-edge of all of these treatments

Melanie Cole, MS: Thank you so much, Dr. Gregath, for joining us today and giving us such a great education on stroke and the importance of prevention. Really great information. And I'd like to thank our Bryan Foundation partner, Union Bank and Trust. To listen to more podcasts from our experts, please visit BryanHealth.org/Podcasts. That concludes this episode of Bryan Health Podcast. I'm Melanie Cole. Thanks so much for joining us today.