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Scott Webb: The month of May is National Stroke Awareness month and it's a great time to have an expert in the field on to discuss the risks, signs, and treatment for stroke. So let's talk with Dr. Aniel Majjhoo, Medical Director of Neurosciences at McLaren Health. This is McLaren's in Good Health, a Podcast from McLaren. I'm Scott Webb. So Dr. Majjhoo, thank you so much for joining me. Let's start here. What is stroke and how prevalent is it?

Dr. Majjhoo: Stroke is defined as a sudden onset of neurologic symptoms such as facial weakness or slurred speech or arm weakness. It is caused by interrupted blood flow to the brain that controls these functions. Now stroke and the United States, we know that it happens about every 40 seconds and every four minutes someone actually dies in our country from a stroke. So that equates to about 130,000 stroke deaths per year and about 900,000 strokes per year. So it is a very important cause of death. It's the number five cause of death in our country. And this is the number one cause of morbidity, meaning people that are disabled and need rehabilitation in our country. The stroke itself, the majority of them, they're broken up into what are called ischemic strokes or not enough blood flow to the brain from a clot. That's probably about 80 to 88% of strokes, and about 10 to 12% of strokes are hemorrhagic strokes or bleeding in the brain. Ischemic strokes, the clot has to come from summer and that clot can come from the heart. Some conditions called like atrial fibrillation, which is like an irregular heartbeat, can form clots in the heart chambers and that can be projected into the brain blood vessels causing that stroke and those symptoms.

There could be interrupted Blood flow caused by a clot that comes from the carotid artery. So there's a condition called atherosclerosis and I'm sure you're familiar with still like high blood pressure, high cholesterol, diabetes. So you get this plaque build up in your carotid arteries and one of those clots can be broken off into the brain causing an ischemic stroke. Or more rarely, but it does happen quite often in certain ethnic populations. You have intracranial atherosclerotic disease where you can have like a local blockage of the blood vessels in the brain causing those ischemic strokes and the hemorrhagic strokes, the bleeding strokes, the ones that you hear about most often are the aneurysmal ruptures so that can present with a patient with sudden onset of the worst headache of their life. These patients have the predisposition or these weak spots in the blood vessels of their brain and with high blood pressure, smoking cigarettes and time, these spots get weaker and the blood vessel actually balloons out and those aneurysms can pop. And about half of those patients even died before even entering the hospital.

Host: You mentioned that the worst headache of your life as being one of the signs of course, but what are the other signs and symptoms of stroke?

Dr. Majjhoo: There's these clever mnemonics that have come out, you probably heard of fast before now. There's a new acronym that's come out called be fast. So B, E and then F A S. T. So B stands for balance. So the sudden onset of loss of balance or vertiginous, room spinning type of experience. The E stands for eyes. So you lose vision, sudden onset of vision of one or both eyes. The F is the sudden onset of facial weakness or drooping. When you look in the mirror and one side of your face looks more predominantly a weaker than the other, and the A stands for arm weakness or numbness of the sudden onset of your arm getting weak or numb on one side of the body or the other. And then the speech, the S stands for a slurred speech or confused speech. So confused speech is where patients actually present with the inability to get the right words out or they are getting the right words out, but they're totally confused, and they don't understand the commands that are what you're trying to explain to them. If you develop any of these symptoms, the T stands for time. Time is of essence that you call 911 to get immediate care.

Host: All right Doctor. So we've talked about the signs and symptoms. Now what are the risk factors for stroke?

Dr. Majjhoo: I'm going to focus on the modifiable risk factors, the things that you can do something about. Some of the modifiable risk factors are things like hypertension or high blood pressure, hyperlipidemia or high cholesterol, smoking cigarettes, diabetes mellitus, atrial fibrillation and irregular heartbeat that we talked about, every eight minutes in our country, someone dies from an Afib related stroke. So it's very important in those patients with Afib and other risk factors that they are on oral anticoagulation medications like Warfarin or Alloquest or Zeralto, these medications that you've heard of I'm sure for blood thinners, they prevent strokes that are very important for these patients. If they have things like carotid artery disease that they consider surgeries for preventative measures like carotid artery stenting or endarterectomy and of course, diet and exercise, and good healthy living diet and exercise daily exercise can help not only be beneficial for cardiovascular reasons, but also for the brain and strokes.

Host: Yeah, definitely. And of course diet and exercise, you know, always right there at the top of the list for just about everything. Right. That's, that's just a good practice for all of us. So when we talk about treatments for stroke, what are some of the newer technologies or treatments that you're working with.

Dr. Majjhoo: For the last 25 years, we've had the drug I'm sure you've all heard of, it's called the IVT PA Alta place. It's a clot busting medication that can be given through an IV that goes throughout your entire blood system and goes up in the brain and dissolves those clots that cause ischemic strokes, that drug has some limiting factors. It can only be given within the first three to four and a half hours in some patients from symptom onset. So that's why time is of essence. In addition to that, for the last five years now it's been a standard of care. We've been doing them longer, but there's the stroke surgeries or thrombectomies, which are these minimally invasive surgeries where we can actually stick a catheter through the groin or the wrist, navigate up the blood vessels into the brain and actually physically remove the clot with these devices called stent retriever devices. Or suck out the clot with like a mechanical vacuum devices to pull out the blockages.

These are like some of the emergent treatments for ischemic strokes. For hemorrhagic strokes or aneurysmal ruptures. There's always the neurosurgical procedure called aneurysm clipping where they can do a craniotomy and actually place a clip over the neck of the aneurysm so he can't rebleed. But since the late eighties early nineties we've had these minimally invasive procedures where we can actually stick catheters through the wrist or through the groin, navigate the artery to the brain, to the aneurysm and fill it up with platinum coils or place stents across the neck of them called flow diverters to divert the flow away from these aneurysms. And now we have something called the web device, which is like an umbrella type device that we can actually place in the aneurysmal SAC to divert blood flow away from it. There's also preventative surgeries that you can have. So if you've had a stroke and you have carotid artery disease, there's something called the carotid artery stent where you could put the tall metal tube and do an angioplasty, a balloon angioplasty and stenting of the carotid artery.

There's coratid endarterectomy where a vascular surgeon can make an incision in your neck and pretty much just take out the plaque so you don't have that blockage anymore. There's also new procedure where they can do a T Car, which is kind of like a combination approach where they actually can locally place a stent, make a small incision in your neck, but place a stent locally right into the carotid artery. For atrial fibrillation, if you're not a candidate for oral anticoagulation because you have a fall risk or you have bleeding in the brain and whatnot. There's something called the Watchman device, which is like an umbrella type device that they actually put in the left atrial appendage where the clots are formed so it can not allow clots to be formed in the heart and not be shot off to the brain. And then there's also monitoring devices like a loop recorder, simple loop recorder, which is a recording device that you place into skin over the heart to monitor your heart to see whether you have atrial fibrillation or not. So there's been multiple advances in both the emergent treatment and the preventative treatments for stroke.

Host: So Doctor, let's talk about something that's near and dear to your heart. The McLaren Stroke Network. I know you're so proud of the work you all are doing, especially the awards. The McLaren Flint Stroke Program has been granted for their quality of care provided to stroke patients. So tell us about the network.

Dr. Majjhoo: So the McLaren Stroke Network is comprised of a group of physicians such as myself who are board certified in not only neurology, we have specialized training and fellowship trained and we're certified in vascular neurology or stroke neurology as well as neuro critical care. And also we're sort of triple trained. We also are trained in interventional neurology or the stroke surgeons that we talked about. So when a patient presents to a McLaren Hospital, it doesn't matter if you're in Pontiac and McLaren Oakland or in Petoskey in McLaren Northern, you had the same treatment with no matter what McLaren hospital you present to with stroke like symptoms. So when one of those patients presents with stroke like symptoms, the stroke Network is contacted and the interventional neurologist takes primary stroke call. And within minutes we can see our patients via two-way video conferencing, telemedicine technology and examine the patients, look at their imaging, look at their CAT scans of their brains and their CAT scan angiograms, counsel patients, and talk to them about their risks and benefits of certain treatments and determine whether they're having a stroke or not.

Determine whether they're having ischemic or hemorrhagic strokes and whether their treatment options, if they are a candidate and we can make the decisions for IB TPA and we can also make the decisions on whether they need a thrombectomy or a stroke surgery or that or an aneurysm coiling. If they need the TPA, they have it administered at the spoke site that they are evaluated at and if they need one of those surgeries, they're either transferred to McLaren Flint, which is a comprehensive Stroke Center or McLaren McComb, which is the a Thrombectomy Capable Center in McComb County. In doing so, we have the same team of physicians who actually evaluate the patients at the bedside in the emergency department operating on the patients and then seeing them in their postoperatively in the neuro ICU as well as in follow-up, administering preventative strategies for these patients for not having a stroke in the future. And we are involved in multiple different research projects through the NIH, the latest cutting edge treatments for not only stroke treatment acutely, but also preventative strategies as well.

Host: That's so great to hear. The patients will see the same faces throughout the process. I'm sure that's comforting and leads to better outcomes. So, Doctor, how can people minimize their risk of stroke?

Dr. Majjhoo: It's important to understand that 80% of strokes are preventable, 80%. So if we build their relationship with a primary care physician and we address their hypertension or high blood pressure or high cholesterol, diabetes, make sure our sugars are controlled. If we have the atrial fibrillation, identifying whether we have atrial fibrillation, irregular heartbeat or not, and whether we need to be on oral anticoagulants or need a surgery to prevent clots to go into the brain or if we have carotid artery disease determine if we need to be on medications or require preventative surgery like a coratid thrombectomy or a stent. These are all important aspects in stroke prevention. And again, diet and exercise, I can't stress that enough. Diet and exercise can help prevent a lot of these risk factors from developing in the first place.

Host: Yeah, for sure. And I know that I'm guilty of treating myself to comfort foods during COVID-19, and the whole diet and exercise thing has been a little murky for a lot of us. And lastly I wanted to talk about COVID-19 specifically and the fact that we're hearing that people who are suffering from heart attacks and strokes and other emerging conditions are not going to hospitals because there are, you know, the fear of COVID-19. And we know, you know, I don't need tell you, time is brain. We cannot have people waiting if they think they're having a stroke, they need to call 911. They need to get to the hospital as quickly as possible. Right?

Dr. Majjhoo: Yeah, I absolutely agree with that. Unfortunately we experienced a similar phenomenon, this bystander effect of COVID-19 so at McLaren and stroke network, we have gathered all of our data for the month of March and April and compared it to University of Michigan and Michigan State, and across the entire state of Michigan, and looked at our numbers of TPA administrations and our stroke surgeries. And there was a decline. And what we have seen is that because of the fears of COVID-19 and going to the hospital and getting infected themselves, a lot of patients are presenting too late and outside the time window for IB TPA for example or outside the time window for those stroke surgeries that we talked about. So May being stroke awareness month. I think it's very important for us to stress the fact that if you are having the symptoms of a heart attack or stroke, you need to go to the emergency department as soon as possible to get treatments because they are time dependent.

Host: Yeah, absolutely, and you mentioned again that May is national stroke awareness month that we just can't emphasize that. Point enough that if you think you're having a stroke or a heart attack or any other emergent condition, please go to the hospital. Call 911. Dr. Majjhoo, thanks so much for sharing your passion and expertise today. Stay well.

Dr. Majjhoo: No, I appreciate that. Thank you. You too.

Host: To learn more about the McLaren Stroke Network or Dr. Aniel Majjhoo, visit mclaren.org/majjhoo that's M, A, J, J, H, O, O. And if you enjoyed this podcast, please share it on your social channels and check out our entire podcast library for topics of interest to you. This is McLaren's in Good Health, the podcast from McLaren. I'm Scott Webb. Stay well.