Deborah Howell (Host): Stroke can happen at any age, without warning. In this podcast, we'll shine the light on ischemic strokes, including their signs and symptoms, and the critical importance of calling 911 as soon as signs of stroke occur. Our guest today is Dr. Reza Jahan, a leading physician and renowned expert in Interventional Neuroradiology and a key member of the Comprehensive Stroke Center at Long Beach Medical Center, which specializes in the endovascular treatment of cerebrovascular disorders, including ischemic strokes. Welcome, Dr. Jahan.

Dr. Reza Jahan: Thank you very much for having me here. It's a pleasure to do this podcast with you.

Host: Lovely to be with you today. So, please tell us, if you will, what is an ischemic stroke and how does it differ from other types of strokes?

Dr. Reza Jahan: Yeah. Let me begin by telling you what a stroke is first of all. A stroke is a sudden impairment of neurologic function. Now, what does that mean? Basically, it's a sudden impairment in functions that our brain controls. What are those? Well, movement is a function that our brain controls. Sensation is a function that our brain controls. Speech, vision, balance, these are functions that our brain controls. And a sudden loss of these functions, one or some of them or all of them, is called a stroke.

Now, there are different causes for a stroke, and those causes are divided into two main categories. One is called a hemorrhagic stroke, or a bleeding stroke, wherein bleeding in the brain causes damage to the brain tissue and hence the symptoms that I mentioned. That's one type of stroke. Again, that's the hemorrhagic or bleeding stroke. We're talking about something else. We're talking about the other category in stroke, and that is an ischemic stroke.

Now, what is an ischemic stroke and how does it differ from a hemorrhagic stroke? An ischemic stroke is not a bleed in the brain, but rather a blockage in the blood vessels that bring blood to the brain. And of course, like all other organs in our body, the brain needs blood for delivery of oxygen and nutrients. And once that blood supply is cut off, the brain begins to die. The brain tissue begins to die and get damaged, and that will cause symptoms as well, same symptoms that you may get with a bleeding stroke. So when you look at somebody's symptoms, you can't distinguish, you cannot distinguish a bleeding stroke from an ischemic stroke. Only with imaging can you do that, where you have a CAT scan or MRI that shows the blood or shows the clogged artery. And so, imaging is the only way to know. Symptoms are identical, but ischemic stroke, again, is caused by a blockage in the blood vessel in the brain, cutting off the brain tissue of important nutrients and oxygen.

Host: That was beautifully explained. And so, let's talk about those signs and symptoms of an ischemic stroke that people should be aware of.

Dr. Reza Jahan: Yeah. I think I alluded to some of them, but we have an acronym that I think is very helpful for people to recognize some of the most common symptoms of a stroke. That acronym is BEFAST, B-E-F-A-S-T. BEFAST. And let me go through and tell you what all of those letters stand for.

B is balance. When somebody is experiencing stroke, they may have trouble with balance, sudden trouble with their balance. E is eyes. Somebody who's experienced stroke may have sudden blindness in part of their vision or in one eye or the other. Also, they may have double vision. So, eye problems like that are potentially a sign of stroke. F stands for face. People who are experiencing a stroke often have some drooping of their face on one side or the other. And that's, again, sudden onset of that. That's something else to watch out for. A stands for arm, arm weakness or paralysis. S stands for speech, the speech will be off. And T is a reminder for people to call 911 should they experience any of these symptoms. So, BEFAST, a great acronym that tells you some of the most common symptoms of a stroke and a reminder to BE FAST. Because the faster you get to treatment, the better your chances of a complete recovery.

Host: What do they say, time is brain or...?

Dr. Reza Jahan: That is correct. One of my colleagues did a calculation some time ago, and it is estimated that with a clogged blood vessel, a clogged artery in the brain, every minute, we lose about 2 million nerve cells, about 2 million. You know, fortunately, we're born with about 300 billion or so, but 2 million nerve cells, not a small number. And so, the faster you get to treatment to open up that clogged artery, the less the damage and the higher the chance for you to make it near complete or complete recovery.

Host: All right. We hear you loud and clear. So, what should people do if they suspect they or someone around them is experiencing a stroke?

Dr. Reza Jahan: The number one thing they need to do is, of course, after recognizing those symptoms, is to call 911. And fortunately, the emergency medical services in LA County is set up now to recognize patients that are having a stroke and take them immediately to the nearest stroke center. And it is even more sophisticated than that.

If you're having a mild stroke, they take you to a primary stroke center, which can give you a life-saving clot-busting drug. But if you're having a more severe stroke, they will take you to somewhere like Long Beach that can not only give you the clot buster, but also have the capabilities to do the procedures that I do, wherein we go into the brain and physically remove the blood clot. Those are comprehensive stroke centers that are capable of doing that. So, the emergency medical services actually triage stroke patients in the field and decide what type of stroke center to take them to. So, fortunately, that is really, really helpful in getting people to where they can get the help they need as fast as possible.

Host: That is impressive. All right. Let's talk about some common risk factors for ischemic strokes and how can people reduce their stroke risk.

Dr. Reza Jahan: Yeah. We often refer to these risk factors as modifiable and unmodifiable, and the modifiable risk factors for stroke are very similar to those for heart disease. Whatever damages your heart can also damage the blood vessels in the brain and cause a stroke. So, what can give you a heart attack? Those are the same risk factors that can give you a stroke. They include high blood pressure, obesity, physical inactivity, poor diet, diets that are high in fat and saturated fats, smoking, excessive alcohol intake. These are things that are modifiable and increase your risk of stroke. Also, if you have diabetes, that can increase your risk of stroke. So, keeping your diabetes in check, working with your primary care physician or endocrinologist to keep your diabetes in check is extremely important to reduce your chance of having a stroke.

Now, there are things that are out of our control that we cannot modify that are risk factors for stroke as well. And they include age. The older we get, the greater the chance that we can have a stroke. Nothing we can do about that. Family history and genetics can play a role in increasing your risk of stroke. There are certain genes that may increase your risk of stroke, and those can run in families, not much we can do about those. Then, race and ethnicity also can modify your risk of a stroke. Stroke occurs more often in Blacks, Alaskan Natives, and American Indians and Hispanics compared to whites. So, race and ethnicity can also play a role. And then, your sex can play a role. At younger ages, men are at higher risk of having a stroke. But because women live longer than men, it turns out the lifetime risk is higher in women due to the fact that they simply live longer. So, those are some of the modifiable and unmodifiable risk factors for stroke.

Host: Now, when a patient arrives at the Comprehensive Stroke Center at Long Beach Medical Center with stroke symptoms, what happens next?

Dr. Reza Jahan: We have set up for triage of stroke patients, so that they rapidly get evaluated, imaged, and treated. First of all, again, thanks to what we have set up with the emergency medical services, we get pre-notification prior to patient arrival that a stroke patient is coming in. So, we already know when a patient is en route to Long Beach Memorial with possible stroke, and we make all the preparations necessary to receive that patient and treat them as fast as possible.

And one of our nurses, who is our stroke specialist, available 24/7 to greet stroke patients arriving to Long Beach in the emergency room. And they immediately evaluate the patient and do a neurologic evaluation and arrange for imaging to be done next. Remember I told you that hemorrhagic and ischemic stroke cannot be distinguished by symptoms. They have to be distinguished by imaging. So, the first step in evaluating a patient is really the imaging.

In addition, that nurse gets in touch with the treatment teams so that, for example, if I'm on call down there, I get notified that there's a stroke patient and it's a high probability that it's going to need treatment. They do that based on their initial evaluation. Then, I can get my things set up in the angiography suite for the treatment that I can offer those patients.

So, a lot of these steps are undertaken, even some of them, most of them, even before the patient arrives to Long Beach Memorial. Once they arrive, the nurse greets them. They have a quick stop in the emergency room where vital signs are taken and we make sure that the patient is stable. Then, the patient is taken to imaging. And if imaging shows that they are somebody that I can treat, they go directly to my angiography suite where I put them on the table and do the treatment that is necessary to unclog that blood vessel.

Host: Sounds like a beautiful system. Now, speaking of the treatments, can you explain the minimally invasive treatment options that the Division of Neuroradiology or DINR team at Long Beach Medical Center offers for ischemic stroke patients?

Dr. Reza Jahan: Absolutely. As I mentioned, ischemic stroke is caused by a clogged blood vessel in the brain. Often this blood vessel is clogged by a blood clot. So, our job is to go up there and get that blood clot out, remove that blood clot. And we have a number of devices that are designed for exactly that. Let me explain the devices first before I go into how we get the device into the blood vessels in the brain.

One of the devices that we have is simple. It's a suction catheter. It is simply a catheter that we introduce into the blood vessels in the brain, place it adjacent to where the blood clot resides, and apply suction to the catheter to pull the clot into the catheter and remove it entirely. The medical term for them is aspiration catheters, and aspiration is just a fancy name for suction. Those are aspiration catheters.

We have other devices, and these devices are a little bit more difficult to explain without videos or diagrams, but they're called stent retrievers. And basically, they are metal cages. that are placed and expanded within the blood clot. This metal cage, as it expands, the metal legs on this cage grab the blood clot and then you pull the metal cage out along with the blood clot that is entrapped within this metal cage. These are referred to as stent retrievers. Those are the main two tools that we have, aspiration catheters and stent retrievers for removing blood clots from the brain tissue, from the brain arteries.

Now, this procedure has been tested in multitude of clinical trials across many countries, many nations, many ethnicities. And it is highly effective, highly effective in improving patient outcomes, highly effective. It's proven treatment and it's FDA-approved treatment for patients with ischemic stroke. Now, how do we introduce these devices? This is a minimally invasive procedure. There is no open brain surgery required. We simply enter the blood vessels in the body through a blood vessel in the leg, namely in the groin area. And from there, the blood vessels in the body are all connected to each other like the freeways in our country, in our county, in our cities. From the blood vessel in the leg, we can go anywhere in the body.

In this case, we go into the blood vessel in question, the one that is occluded or clogged in the brain. And we introduce devices through this blood vessel in the leg, all the way up into the blood vessel in the brain, remove the clot, come out. At the end, we hold some pressure over the artery to make sure that the artery would be punctured, sort of like when you go give blood and they put a cotton on your arm when you leave to make sure that it doesn't bleed anymore. We kind of do the similar thing to stop the hole that we made in the blood vessel. And then, we put a Band-Aid on it and that's it. You just come out of it with a Band-Aid on your groin and that's the only evidence you had anything done. Really minimally invasive treatment for removal of blood clots, highly effective treatment that really is a life-saving treatment for these patients.

Host: Pretty incredible. So, how does the stroke team ensure that patients experiencing stroke get the most rapid treatment possible?

Dr. Reza Jahan: Yeah. So, some of the strategies that I've already explained to you, the pre-notification is extremely important so that we are aware ahead of time that these stroke patients are coming and that we can set up everything necessary to evaluate them and treat them. So, pre-notification is one. Number two, the fact that we have a stroke nurse that is available 24/7 to greet these patients in the ER. And that stroke nurse serves as a single point of contact for everybody and goes with that patient from ER to imaging to the angiography suite, contacting all the right people at every step to make sure that things are set up ahead of time to make sure that these patients get evaluated and treated as fast as possible.

So, we actually keep track of our door-to-treatment times, when the patient hits the ER door, and how fast they get treatment, and we keep track of those and report those to our certification bodies that certify us as a comprehensive stroke center. And our expectations in terms of what we need to achieve, and we've been excellent at getting very, very optimal and fast door-to-treatment times.

Host: So, good to hear that. I have a final question for you, Dr. Jahan. How does being treated at a comprehensive stroke center like the one at Long Beach Medical Center improve patient outcomes after experiencing a stroke?

Dr. Reza Jahan: Yeah. In 2019, I published a paper that was published in JAMA Neurology, where we looked at a population of patients across the nation that had been treated exactly for this ischemic stroke. Our main objective was to see how time to treatment affects outcomes. Not unexpectedly, we found that the faster people get treatment, the better their outcomes. I've already referred to that, how important it is for patients to get to the hospital fast. Call 911 immediately and get people to the hospital as fast as possible so they can get timely treatment. In that paper, we looked at other factors that determine patient outcomes, namely hospital-related factors. What is it about the hospitals that makes people have better outcomes?

One of the things that we found that is very important is the volume. The volume of ischemic stroke patients that are admitted to that hospital and the volume they get treatment. And that was a definite correlation outcome that hospitals that have higher number of stroke patients that they treat have better outcomes. And that makes sense because they have more practice at it. They're more experienced. Their processes are more efficient because they're so busy.

At Long Beach Memorial, we have consistently been amongst the top three in terms of our ischemic stroke volume in Los Angeles County. So, we're way up there. There are over 20 now comprehensive stroke centers that can do the type of procedure that we do. And we are amongst the top three in volume amongst all of them. So, we treat about 100 or over 100 patients that get the clot buster, and we treat about 100 to 150 patients that get this procedure I explained to you where we go in and remove the blood clot. And that puts us amongst the top three centers in terms of volume in LA County. That, we found, is extremely important and we happen to be up there in terms of our numbers in that regard.

Host: Congratulations on that. Is there anything else you'd like to add to our conversation?

Dr. Reza Jahan: I think the most important thing that I want to emphasize, something that I don't have control over, is what happens outside the hospital. I want people to be very aware of the signs and symptoms of stroke. Remember the acronym I mentioned, BEFAST. B stands for balance, E for eyes, F for face, A for arm, S for speech, T time to call 911. To recognize those signs and symptoms, remember that acronym and call 911 and get to the hospital as fast as possible.

Host: Well, thank you so, so much, Dr. Jahan, for your time and your expertise today. You painted a picture that we can all understand fully, and we really enjoyed having you on the show.

Dr. Reza Jahan: Thank you very much. It was a pleasure talking to you.

Host: And to learn more about the signs of stroke, please go to memorialcare.org/stroke. For more info or to listen to a podcast of this show, please visit memorialcare.org. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.