Carle is a certified Primary Stroke Center, which means we follow the highest national standards proven to achieve fast treatment times and better outcomes. As the only Primary Stoke Center in the region with neurosurgeons and interventional specialists available 24/7 to care for patients experiencing stroke and other neurovascular emergencies, we are ready to provide faster treatments and better outcomes for stroke victims.
Dr. Amrendra Miranpuri – Program Lead, Stroke & Neurovascular Services, Carle Neuroscience Institute, discusses how providers can increase stroke awareness for their patients.
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Stroke Awareness
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Learn more about Amrendra Miranpuri, MD
Amrendra Miranpuri, MD
Amrendra Miranpuri, MD he is the Program Lead, in Stroke & Neurovascular Services, at Carle Neuroscience Institute at The Carle Foundation Hospital.Learn more about Amrendra Miranpuri, MD
Transcription:
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode’s posttest.
Melanie Cole (Host): The National Institutes of Neurological Disorders and Stroke part of NIH, says that more than 795,000 Americans have a stroke and almost 130,000 people die from stroke every year. In fact, stroke is the fourth leading cause of death in this country and the leading cause of serious long-term disabilities, more so than any other disease. My guest today is Dr. Amrendra Miranpuri. He’s the program lead Stroke and Neurovascular Services at Carle Neuroscience Institute. Dr. Miranpuri, tell us about stroke. What are you seeing as far as incidence and awareness? Are providers educating their patients on stroke symptoms and prevention?
Amrendra Miranpuri, MD (Guest): Yeah, so stroke is like you mentioned, it’s a large number of patients that are affected per year. In the United States alone nearly 800,000 people come into the emergency department with stroke symptoms and nearly a little over 100,000 people can be – can actually die from stroke complications. So, the most important thing that we try to get out there in terms of stroke awareness is understanding the signs and symptoms of stroke. But one of the things that we have for our general population and then also for our EMS providers, the folks that are actually seeing these patients at home and picking them up, bringing them to the hospital is an acronym called FAST. So, that stands for F is for face; so, if you see somebody having drooping of one side of their face. The A is for arm weakness; so, if they have one of their arms is not as strong as the other. S is for speech difficulty; so, if they are having a hard time getting their words out or they are not understanding what you are saying or they are just repeating things or their words are just coming out not very clearly. These can all be manifestations of speech difficulties and so if you have any one of those signs, or more than one of those T, the last letter in the acronym is for time. Time to call 9-1-1. And so, we encourage patients to be seen immediately for medical attention and for a workup to be done immediately. We know for stroke patients the number one predictor of good outcome is the time in which they are seen by a provider and diagnosed with a stroke and then potentially being able to have a treatment rendered; those are the patients that are going to have the best outcomes at three months which is typically how we measure success with stroke care is kind of the 90-day outcome.
Melanie: Who is at risk for stroke and does having one stroke put you at risk for another, so you would like providers to know that if their patient has had one stroke, that they need to be watched a little more closely or counseled a little bit more thoroughly?
Dr. Miranpuri: So, the way I try to educate people about stroke is that it is a blood vessel issue, right, so it’s a blood vessel issue in the neck and the brain and so you have got your heart. Your heart is pumping blood to the brain. It’s pumping blood to the heart itself and then you have got blood flow going down to your legs and you have got blood vessels that go to your abdomen. And so, anywhere that you can develop blockages in arteries that go to the brain, so in the neck or in the brain; you can have stroke symptoms. That represents about 80% of stroke that we see is where there is actually a blockage of a blood vessel and that blockage could be right there in that vessel in the neck and or the brain or it could be arising from a blockage elsewhere and it lands inside the brain. And so, this will cause generally, the types of symptoms that we talked about, the face, arm and speech difficulties that these represent the majority of strokes that are in the front part of the brain.
And then there are strokes that occur in the back of the brain which are less common, but still very important to recognize the symptoms of and those can affect the area supplying the base of the brain and the brain stem and so patients can present with sudden onset of dizziness, sometimes it can be hard to sort that out versus vertigo. They can have double vision. They can have difficulty walking. They can have significant balance issues and so these can also be signs and symptoms of a stroke that is occurring in the back portion of the brain. And so, these represent 80% and these patients we really want to identify them quickly to make sure that it is a stroke, that there hasn’t been any bleeding going on in the brain and if all of the checks go properly, you can actually get these patients a medication called TPA, that’s a clot busting drug and the nurse will administer that drug through an IV and it works quite effectively in dissolving the clot in a fair number of patients.
Now there are some patients that will not respond well to that clot busting drug. And these are patients who probably represent about 20% of the strokes that we are talking about of the 80% vessel blocking type of stroke. And for those patients, they will end up having a blockage of a bigger artery in the brain where the clot busting drug that is given through an IV, by the time it actually gets to where that blockage is, it’s not going to be effective in dissolving the clot. It seems to work better in clots that are a little further downstream in the brain and so for these patients, we want to get imaging immediately of the pipes in the brain and we want to look at how much of the brain has already potentially suffered a stroke because sometimes that has happened. Because these are very large strokes. And then there’s going to be this halo of brain that is salvageable, what we call a penumbra and when we get of these images which we are able to get within minutes in the emergency department; we are able to decide whether going up into the brain using small catheters and wires and stents through a leg artery and navigating very carefully up using contrast and x-ray where we can actually physically remove the clot in that large blood vessel. And if that is done in a timely fashion and the patient had good – and the imaging was supportive that here was actually a fair amount of brain that was salvageable; these patients do quite well at 90-days compared to patients who are not offered that treatment. So, we now have these two ways of treating stroke and it works quite effectively.
Then the other side of stroke is the 20% of patients who have not a blockage of a blood vessel, but a blood vessel that is leaking in the brain and that can be from high blood pressure. That can be from an aneurysm which is a weak spot on a blood vessel wall that can leak. Or it can from something called an arteriovenous malformation. And these are the majority of cases that we will sometimes see, and these patients will present oftentimes with a severe headache. They will present maybe with some nausea, vomiting, depressed level of consciousness. Because when you have a bleed in the brain, that’s taking up space in the brain that is not acceptable. The brain only has so much space inside the skull and when you start having bleeding there, it’s taking up space that was supposed to be there just for the brain and its normal contents. And so if the pressure elevates in the brain suddenly, from a brain bleed; the patient can be sleepy, they can have nausea, vomiting, their blood pressure can be high and those patients need to be evaluated immediately with CT scan to look at ways to stop the bleeding from getting worse and then identifying why the bleed happened and treating it, if it requires some type of procedure to shut down that blood vessel or repair that blood vessel.
Melanie: Speak a little bit about after the procedures, after the TPA, what is life like for the stroke victim and the patient and their families and how can other providers be involved in that rehab and life after?
Dr. Miranpuri: Stroke care is a multidisciplinary approach. It’s one of the finest examples of how providers from various specialties have to come together to take care of these patients. They are very dynamic, complex cases. So, invariably, you will have a neurologist, you will have an ED doc, emergency department doctor, you will have a neurosurgeon, you might have an interventional radiologist, you will have physical therapists, occupational therapists, swallow therapists. You will have a pharmacist. You will have a radiology technician who is doing all of these images that we need to get very quickly. You will have a radiologist or a neuroradiologist interpreting these scans. You will have – after the procedure, the patient has to be oftentimes placed in an ICU for a short or long period of time. You will have intensivists taking care of these patients and respiratory therapists managing their ventilators in some cases. And then some of these patients end up having to go to rehab for a period of time. So, the outcomes are variable. Some patients if they come in too late, and there’s a large stroke; unfortunately, there is not much that we can do to reverse the symptoms of the stroke and those patients we are trying to prevent the secondary brain injury that can happen from the bleed in the brain or the large stroke that has already happened. Because the blood vessel was occluded for a prolonged period of time. And so those patients can have a very long, very protracted course where they might end up in ICUs and then rehab versus nursing homes.
The patients that we are able to get to in a timely fashion and have not had a significant neurological deterioration or injury from the stroke and we are able to reverse the symptoms of the stroke; the patients can do quite well and then they can oftentimes – they can go home and sometimes we have to send them to rehab for a short period of time to get them just a little bit stronger before getting them back home. But it is variable and along the whole way, of all the people that I just mentioned to you; I think the most important piece is family. This oftentimes I tell stroke patient’s family members; I always remind them that this is not a race, this is a marathon. We do the acute interventions to try to help reverse the effects of the stroke or deal with the secondary complications that may come from the stroke already having happened. And so, we rely on these family members to help us with their family members getting stronger every day and getting them through rehab, getting them back home so that they can be prepared so that when the patient ultimately, hopefully gets home; they are able to take care of their needs if that needs to be done. So, family members play a big role and we try to – everyday when we see these patients, we try to help them understand what things are going to be like, what kinds of issues they may have because of the stroke.
Melanie: And in summary, doctor, if you would just wrap it up for us. Tell other physicians what you would like them to know about stroke awareness and working with their patients on prevention and symptom awareness.
Dr. Miranpuri: Stroke has a lot of common themes with heart disease and oftentimes, we will see patients who are coming in with a stroke and they will have heart issues or sometimes patients with heart issues will come in with stroke symptoms. There is a lot of overlap there because these are vascular conditions. Common risk factors for stroke are in common with heart disease. So, we want to make sure providers are thinking about that when they are taking care of – if a primary care doctor is taking care of one of their patients who may be had open heart surgery and they are in clinic now a few months later and they are seeing them in follow-up to really kind of think about signs and symptoms of TIAs which are mini-strokes and strokes, and thinking about what are potential risk factors. High blood pressure, high cholesterol, diabetes management, obesity, smoking. These are the major risk factors so that if patients have these risk factors leading up to their heart condition; we want to be thinking about managing those risk factors for primary care providers how important that is. Because that will hopefully prevent that patient from having risk factors for having a stroke down the line.
Melanie: Thank you so much doctor, for being with us today. It’s really such important information for providers to hear and for their patients to hear. Thank you again for being with us. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities please visit www.carleconnect.com, that’s www.carleconnect.com. We hope this information gained will be applicable to your work and life. This is Melanie Cole. Thanks so much for tuning in.
Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode’s posttest.
Melanie Cole (Host): The National Institutes of Neurological Disorders and Stroke part of NIH, says that more than 795,000 Americans have a stroke and almost 130,000 people die from stroke every year. In fact, stroke is the fourth leading cause of death in this country and the leading cause of serious long-term disabilities, more so than any other disease. My guest today is Dr. Amrendra Miranpuri. He’s the program lead Stroke and Neurovascular Services at Carle Neuroscience Institute. Dr. Miranpuri, tell us about stroke. What are you seeing as far as incidence and awareness? Are providers educating their patients on stroke symptoms and prevention?
Amrendra Miranpuri, MD (Guest): Yeah, so stroke is like you mentioned, it’s a large number of patients that are affected per year. In the United States alone nearly 800,000 people come into the emergency department with stroke symptoms and nearly a little over 100,000 people can be – can actually die from stroke complications. So, the most important thing that we try to get out there in terms of stroke awareness is understanding the signs and symptoms of stroke. But one of the things that we have for our general population and then also for our EMS providers, the folks that are actually seeing these patients at home and picking them up, bringing them to the hospital is an acronym called FAST. So, that stands for F is for face; so, if you see somebody having drooping of one side of their face. The A is for arm weakness; so, if they have one of their arms is not as strong as the other. S is for speech difficulty; so, if they are having a hard time getting their words out or they are not understanding what you are saying or they are just repeating things or their words are just coming out not very clearly. These can all be manifestations of speech difficulties and so if you have any one of those signs, or more than one of those T, the last letter in the acronym is for time. Time to call 9-1-1. And so, we encourage patients to be seen immediately for medical attention and for a workup to be done immediately. We know for stroke patients the number one predictor of good outcome is the time in which they are seen by a provider and diagnosed with a stroke and then potentially being able to have a treatment rendered; those are the patients that are going to have the best outcomes at three months which is typically how we measure success with stroke care is kind of the 90-day outcome.
Melanie: Who is at risk for stroke and does having one stroke put you at risk for another, so you would like providers to know that if their patient has had one stroke, that they need to be watched a little more closely or counseled a little bit more thoroughly?
Dr. Miranpuri: So, the way I try to educate people about stroke is that it is a blood vessel issue, right, so it’s a blood vessel issue in the neck and the brain and so you have got your heart. Your heart is pumping blood to the brain. It’s pumping blood to the heart itself and then you have got blood flow going down to your legs and you have got blood vessels that go to your abdomen. And so, anywhere that you can develop blockages in arteries that go to the brain, so in the neck or in the brain; you can have stroke symptoms. That represents about 80% of stroke that we see is where there is actually a blockage of a blood vessel and that blockage could be right there in that vessel in the neck and or the brain or it could be arising from a blockage elsewhere and it lands inside the brain. And so, this will cause generally, the types of symptoms that we talked about, the face, arm and speech difficulties that these represent the majority of strokes that are in the front part of the brain.
And then there are strokes that occur in the back of the brain which are less common, but still very important to recognize the symptoms of and those can affect the area supplying the base of the brain and the brain stem and so patients can present with sudden onset of dizziness, sometimes it can be hard to sort that out versus vertigo. They can have double vision. They can have difficulty walking. They can have significant balance issues and so these can also be signs and symptoms of a stroke that is occurring in the back portion of the brain. And so, these represent 80% and these patients we really want to identify them quickly to make sure that it is a stroke, that there hasn’t been any bleeding going on in the brain and if all of the checks go properly, you can actually get these patients a medication called TPA, that’s a clot busting drug and the nurse will administer that drug through an IV and it works quite effectively in dissolving the clot in a fair number of patients.
Now there are some patients that will not respond well to that clot busting drug. And these are patients who probably represent about 20% of the strokes that we are talking about of the 80% vessel blocking type of stroke. And for those patients, they will end up having a blockage of a bigger artery in the brain where the clot busting drug that is given through an IV, by the time it actually gets to where that blockage is, it’s not going to be effective in dissolving the clot. It seems to work better in clots that are a little further downstream in the brain and so for these patients, we want to get imaging immediately of the pipes in the brain and we want to look at how much of the brain has already potentially suffered a stroke because sometimes that has happened. Because these are very large strokes. And then there’s going to be this halo of brain that is salvageable, what we call a penumbra and when we get of these images which we are able to get within minutes in the emergency department; we are able to decide whether going up into the brain using small catheters and wires and stents through a leg artery and navigating very carefully up using contrast and x-ray where we can actually physically remove the clot in that large blood vessel. And if that is done in a timely fashion and the patient had good – and the imaging was supportive that here was actually a fair amount of brain that was salvageable; these patients do quite well at 90-days compared to patients who are not offered that treatment. So, we now have these two ways of treating stroke and it works quite effectively.
Then the other side of stroke is the 20% of patients who have not a blockage of a blood vessel, but a blood vessel that is leaking in the brain and that can be from high blood pressure. That can be from an aneurysm which is a weak spot on a blood vessel wall that can leak. Or it can from something called an arteriovenous malformation. And these are the majority of cases that we will sometimes see, and these patients will present oftentimes with a severe headache. They will present maybe with some nausea, vomiting, depressed level of consciousness. Because when you have a bleed in the brain, that’s taking up space in the brain that is not acceptable. The brain only has so much space inside the skull and when you start having bleeding there, it’s taking up space that was supposed to be there just for the brain and its normal contents. And so if the pressure elevates in the brain suddenly, from a brain bleed; the patient can be sleepy, they can have nausea, vomiting, their blood pressure can be high and those patients need to be evaluated immediately with CT scan to look at ways to stop the bleeding from getting worse and then identifying why the bleed happened and treating it, if it requires some type of procedure to shut down that blood vessel or repair that blood vessel.
Melanie: Speak a little bit about after the procedures, after the TPA, what is life like for the stroke victim and the patient and their families and how can other providers be involved in that rehab and life after?
Dr. Miranpuri: Stroke care is a multidisciplinary approach. It’s one of the finest examples of how providers from various specialties have to come together to take care of these patients. They are very dynamic, complex cases. So, invariably, you will have a neurologist, you will have an ED doc, emergency department doctor, you will have a neurosurgeon, you might have an interventional radiologist, you will have physical therapists, occupational therapists, swallow therapists. You will have a pharmacist. You will have a radiology technician who is doing all of these images that we need to get very quickly. You will have a radiologist or a neuroradiologist interpreting these scans. You will have – after the procedure, the patient has to be oftentimes placed in an ICU for a short or long period of time. You will have intensivists taking care of these patients and respiratory therapists managing their ventilators in some cases. And then some of these patients end up having to go to rehab for a period of time. So, the outcomes are variable. Some patients if they come in too late, and there’s a large stroke; unfortunately, there is not much that we can do to reverse the symptoms of the stroke and those patients we are trying to prevent the secondary brain injury that can happen from the bleed in the brain or the large stroke that has already happened. Because the blood vessel was occluded for a prolonged period of time. And so those patients can have a very long, very protracted course where they might end up in ICUs and then rehab versus nursing homes.
The patients that we are able to get to in a timely fashion and have not had a significant neurological deterioration or injury from the stroke and we are able to reverse the symptoms of the stroke; the patients can do quite well and then they can oftentimes – they can go home and sometimes we have to send them to rehab for a short period of time to get them just a little bit stronger before getting them back home. But it is variable and along the whole way, of all the people that I just mentioned to you; I think the most important piece is family. This oftentimes I tell stroke patient’s family members; I always remind them that this is not a race, this is a marathon. We do the acute interventions to try to help reverse the effects of the stroke or deal with the secondary complications that may come from the stroke already having happened. And so, we rely on these family members to help us with their family members getting stronger every day and getting them through rehab, getting them back home so that they can be prepared so that when the patient ultimately, hopefully gets home; they are able to take care of their needs if that needs to be done. So, family members play a big role and we try to – everyday when we see these patients, we try to help them understand what things are going to be like, what kinds of issues they may have because of the stroke.
Melanie: And in summary, doctor, if you would just wrap it up for us. Tell other physicians what you would like them to know about stroke awareness and working with their patients on prevention and symptom awareness.
Dr. Miranpuri: Stroke has a lot of common themes with heart disease and oftentimes, we will see patients who are coming in with a stroke and they will have heart issues or sometimes patients with heart issues will come in with stroke symptoms. There is a lot of overlap there because these are vascular conditions. Common risk factors for stroke are in common with heart disease. So, we want to make sure providers are thinking about that when they are taking care of – if a primary care doctor is taking care of one of their patients who may be had open heart surgery and they are in clinic now a few months later and they are seeing them in follow-up to really kind of think about signs and symptoms of TIAs which are mini-strokes and strokes, and thinking about what are potential risk factors. High blood pressure, high cholesterol, diabetes management, obesity, smoking. These are the major risk factors so that if patients have these risk factors leading up to their heart condition; we want to be thinking about managing those risk factors for primary care providers how important that is. Because that will hopefully prevent that patient from having risk factors for having a stroke down the line.
Melanie: Thank you so much doctor, for being with us today. It’s really such important information for providers to hear and for their patients to hear. Thank you again for being with us. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities please visit www.carleconnect.com, that’s www.carleconnect.com. We hope this information gained will be applicable to your work and life. This is Melanie Cole. Thanks so much for tuning in.