Prakash Chandran (Host): Although we often associate strokes with the elderly, the reality is that they can strike almost anyone with little warning. That's why it's crucial to understand what a stroke is, what the warning signs are, and how to act fast if you see someone experiencing symptoms.

Host: Here to spread stroke awareness is Dr. Fawad Shaheen, a neuro-endovascular surgeon with the Health First Medical Group Physician Specialties Office in Melbourne, Florida. Welcome to Putting Your Health First, a podcast by Health First.

I'm your host, Prakash Chandran. So Dr. Shaheen, thank you so much for joining us today. I really appreciate your time. I'd love to get started with the basics. What exactly is a stroke?

Dr Fawad Shaheen: Thank you, Prakash, for having me. It's a pleasure to be here. My name is Fawad. Well, you know, the things with stroke is that there's been a lot of misconceptions around the word stroke. Oftentimes I see patients come to my office. One person will be completely normal walking and talking, and openly state to me with immense confidence, "I've had multiple TIAs, multiple strokes, and here I am." I'll have another patient who'll have one stroke, but will be paralyzed in a wheelchair, unable to talk or walk. And that dichotomy causes a lot of misconceptions around the word stroke. And not only that, we all fear disability. When we talk to people and we ask them, "Are you more afraid of death or disability?" A lot of people fear disability more. And because stroke is so linked to disability, there is this enigma fear around it, and that also dwells into or builds on this misconception.

To understand stroke, the way I try to explain it, to my patients at least, is to take a step back and look at the brain. The brain is an organ that requires a lot of energy. And anytime there's an organ that requires energy, it is very crucial that energy requirement remains consistent. So when we talk about brain injury, we talk about two big categories for brain injury. One is external injury where we all know of traumas, gunshot injuries, people fall and they hit their heads. And then, we have internal injuries. We talk about Alzheimer's, Parkinson's, tumors. And then, there's internal sudden injuries and those internal sudden causes or injuries to the brain are what we call stroke.

Now, the brain needs about 20% of all of our energy that comes to the body at resting. And if there's any interruption in that energy, and when I say energy, I mean blood, oxygen, nutrients, then that results in a stroke and that area of the brain dies. So when we talk about stroke, what it means is that there's either a blockage or an abrupt cessation of that nutrients or blood that carries that oxygen to the brain or there is a bleed that occurs, blood or these nutrients in places where it's not supposed to be crushing the brain. Now, 70 to 80% of all injuries or sudden injuries or stroke, are caused by a cessation of the nutrient supply, and that's what we call ischemic strokes. And about 20% are bleeds in the brain. Because most of these strokes are caused by the cessation of blood, when we use the word stroke, what we mean to say is ischemic stroke, and that is somewhat of a misconception or a cause of confusion. Now, 20 to 30% is called by bleeding in the brain, and we call those hemorrhagic strokes.

Now, another word for a stroke would be a cerebrovascular injury. And so when we have the brain and we have a cessation of blood flow, that means that there is a cessation of blood through those vessels or those tributaries that provide that flow, what we call vascular system throughout our body. And because a stroke is a cessation of blood flow through those vessels, we call that a cerebrovascular injury.

Host: Well, thank you so much for that comprehensive explanation. You know, normally, I just hear there's two different types of strokes, ischemic and hemorrhagic. But the way you have explained it, I really understand the nature of what a stroke is and why there might perhaps be the misconceptions that you spoke about earlier.

Taking a step back, I am curious as to who can have a stroke, because I imagine that there's misconceptions around that as well. You know, I read up at the top that it can affect almost anyone, but maybe you can give us a primer.

Dr Fawad Shaheen: Sure. Strokes can affect anyone. It increases as we get older. What's interesting though is that over the past, say, few years, what we've noticed is with newer treatments that have come out over the past decade, the number of strokes in the older population has been decreasing. But the number of strokes in the younger or middle-aged population, say in their 30s to 60s, has actually been increasing. Moreover, about 20% of all strokes occur in people who are less than 50. Now, childhood strokes, when I mean childhood, I mean less than 18 years of age is very uncommon, fortunately. But we are seeing strokes between the ages of 18 to over 85. Most strokes occurring within that middle range of about the 30s to 70s. So, it's not age discriminatory, unfortunately.

Now, the causes for strokes in the age populations is also quite different. Older people can get arrhythmias, arteries that are blocked off or narrowed. Younger people have tears in the arteries. They can have things that they're born with, such as clotting disorders or holes in their heart, medications, drugs, cocaine, marijuana. They can all cause strokes in a certain population, particularly in the younger. So, there is a difference in the causes of strokes, depending on age as well.

Host: I know you can't draw direct causation from this, but you said that there was an increase in the younger population getting strokes. Is that due to some of the things that you mentioned, potential drug use or diet or anything like that? Or is there another reason?

Dr Fawad Shaheen: I don't know exactly to be honest with you. We have a lot of hypothesis. Some of it could be that strokes are being diagnosed more frequently or more accurately. We have had better imaging and better understanding of strokes over the past few years. That may be the mainstay of why we're seeing more strokes in the younger ages.

But to be honest with you, I don't think there's a clear understanding of why we're seeing an increased number of strokes in those age populations. Now, smoking was a very common cause, particularly in the older generation. And now, that we have a lot of information that goes out to people to stop smoking and quit smoking, we're seeing a decrease in smoking in the older populations. But why we're seeing that increase of the younger, that's something that I'm not sure I at least have a very clear understanding of. I think the mainstay of that may be related to diagnosing strokes in these populations.

Host: So, I want to move on to signs and symptoms that someone might be having a stroke. What should people be aware of?

Dr Fawad Shaheen: Sure. The easiest way to look at stroke or what symptoms occur is to think about real estate, location, location, location. When we think about the heart, for example, the heart is an organ that does-- I don't want to trivialize it, but it's a pump. It's supposed to provide blood flow to our bodies. Brain is a little more nuanced than that. And to be honest with you, it remains a black box. A lot of it we still don't understand. There's areas of brain that allow us to feel, carry our memories, love, hate, anger. All is there within the brain to a certain extent. Where it is we haven't mapped, or at least it's very difficult to do so consistently. Same thing with ability to move an arm or a leg. We know generally where they are. Same thing with speech, the ability to produce speech, the ability to understand speech, and the ability to articulate what we want to say. Same thing with vision, the ability to understand what our world has as opposed to just using our eyes. So all that is in the brain. And where the injury occurs, wherever there's a lack of blood supply, so to say, or a bleed compressing that area of the brain, that's where the symptoms occur.

Our treatments for stroke carry a risk. Even though it's a 6% risk, they have a certain degree of risk to them. So, what we try doing is treating patients based on symptoms. If it's a mild symptom, then we treat them mildly. If they have severe symptoms, what we call disabling symptoms, and even though that's a little subjective, when they're disabling, then we get very aggressive.

So, the acronym BEFAST is meant to be easy, also cool, BEFAST when it comes to stroke and remind people of what stroke really is. So, the acronym B is for balance, the inability to carry our gait or coordinate ourselves. E is for eyes, when we lose our vision or can't understand what the world has in front of us. F is for face, any type of facial droop. A stands for arms, but what we're trying to say is any weakness in the arms or the legs. S is for speech, both the production of speech, the clarity of speech. And then, T is for headache, a very severe headache that comes upon suddenly. When we talk about stroke symptoms, we want to make sure that people understand that stroke can present as any combination of these symptoms or anything that causes people to be disabled. So in that sense, if there is any symptom that a person feels is disabling, either subjectively or objectively, then they should go to the hospital as soon as possible.

The BEFAST acronym is meant to remind people or help them understand what a stroke is. Now, one of the most important things that I've seen is a lot of people who have a stroke don't recognize that they themselves are having a stroke. So, the BEFAST acronym in a lot of this education that we try and provide for our community is for the people that are actually providing care to those who are at risk for stroke and for bystanders, because they're the people that will understand that a person's having the stroke and then can go ahead and activate EMS.

Host: So, I want to unpack that a little bit. So, you talked about that BEFAST acronym, really being a tool to drive awareness around the symptoms of a stroke. But you were saying if that is recognized in someone or yourself, you should go straight to the hospital. What exactly does that mean? Does that mean get in the car and drive there immediately? Does that mean call 911? Talk to us a little bit about that.

Dr Fawad Shaheen: You know, one of the two problems we have when it comes to people with strokes is they need to get to the hospital as quickly as possible. The first thing is recognizing that stroke and the second, as you said, is being able to get to the hospital. What I always recommend is to call 911. Certainly people feel that it may be faster to get into the car and drive their loved one over to the hospital. Some people are having a mild stroke, even feel that they themselves should be driving. The problem with that is that on route, while they're driving, they can get weak. And if they get weak or they deteriorate or get worse, it may make the whole trip more difficult and it may lead to other problems. If they themselves are driving, for example, it can lead to car accidents and whatnot. So, I always tell people to call 911 because EMS not only provides that transport, but they're also trained to recognize the type of stroke a person is having and be able to take them to the hospitals or the centers that can provide the treatment they need as quickly as possible.

Host: Yeah. That is such an important point. There is a sense of pre-triage that is done by professionals on the phone. They can route you to the right place and tell you what to do. So, I'm really glad that you emphasized that. As we start to close, I always want to think about people being proactive. So, is there anything people can do for themselves to reduce their risk of stroke?

Dr Fawad Shaheen: Absolutely. The two things that I tell people is you have to consider whether or not you have a risk of stroke and then, those who don't have any risk of stroke, but are worried about future stroke risk. So for those that have had a stroke or have a risk of stroke according to their physician or their history, then they should do whatever possible to eliminate whatever it is that caused their stroke. So, that means taking their medications, controlling their blood pressure, taking any blood thinners that they need to be on and so on and so forth.

The mainstay of prevention is to prevent people from getting to that point to begin with. And so in that light, there's two things I always tell people to do. One is being active and what I mean by being active is not necessarily going to work every day and being active at work. You know, when we talk about the brain, the brain needs its specific time that it can call its brain time where you spend time exercising, go out for a walk, go out, go to the gym, something that is specific to exercising.

The second thing is we are what we eat, as the old adage goes. So, I always tell people to avoid processed foods. I don't necessarily believe in diets per se, because that implies taking away foods. What I actually tell people to do is to add healthy foods, fruits, vegetables, water, and avoid any sugary drinks, such as sodas, juices, anything that may be processed. And in so doing, when the body receives what it needs, and usually we ourselves will eliminate those foods that are harmful for us. So, those are the mainstay of treatment. And then when it comes to people who have had strokes, anything specific, then, you know, we concentrate on the things that have caused their stroke specifically.

Host: Now, just before we close here, Dr. Shaheen, one question I always like to end with is, given all of your experience working with stroke victims or people that potentially are at risk for having a stroke, what is one thing that you know to be true that you wish more people knew?

Dr Fawad Shaheen: Strokes are serious. You know, a lot of people consider that a stroke is, "I've only had a mini stroke," or "My arm is weak. I can walk it off." But I want everyone to know, if you are having a stroke or you think of the word stroke or if you're having anything that causes them to feel disabled, go to the hospital immediately. Take it very seriously. Don't try to walk it off or treat it yourself, because the treatments that we have are very particular to or very specific in their nature in time. The brain only survives for a short period of time. Beyond that, we really can't bring back brain once it's gone. That's something we can talk about another day, I presume. But for now, what we need people to do is understand that there's only a short period of time they have until the brain dies. So, the faster they can get to the hospital, the better.

Host: That's right. Time is brain. Well, Dr. Shaheen, really appreciate you sharing all this information today. I truly appreciate your time.

Dr Fawad Shaheen: My pleasure. Thanks for having me.

Prakash Chandran (Host): That was Dr. Fawad Shaheen, a neuro-endovascular surgeon with the Health First Medical Group Physician Specialties Office in Melbourne, Florida. For more information and to find out if you are at risk for stroke, you can visit hf.org/stroke. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks for listening to Putting Your Health First. My name's Prakash Chandran. Stay well.