Intro: This is Weekly Dose of Wellness, brought to you by Memorial Care Health System. Here's Deborah Howell.

Deborah Howell (Host): Most of us has known someone or will know someone who suffered from a stroke. Today, we'll explore the life-saving power of clot-busting drugs in stroke treatment, and why every second counts when a stroke occurs. Our guest today, Dr. Nirav Patel, a board-certified neurologist and Chief of Staff at Long Beach Memorial Care Medical Center, explains how these medications work, the critical time window for their effectiveness and the importance of recognizing stroke symptoms early to seek immediate medical care. Welcome, Dr. Patel.

Nirav Patel, MD: Thank you, Deborah, for having me.

Host: I know how busy you are. Thank you so much for joining us today. Diving in, what exactly is a stroke?

Nirav Patel, MD: So actually, there are two types of strokes that many people don't realize. So to make it very simple, one, is a plugged pipe. So, a clot that opens up and that blocks a blood vessel and so the brain doesn't get oxygen, or a pipe burst and you have hemorrhage. And so, a hemorrhagic stroke or an ischemic stroke are the two types of strokes we deal with.

Host: What are the first signs and symptoms of a stroke that people should never ignore?

Nirav Patel, MD: Yeah. So, you know, it's very hard because as you realize, the brain controls everything and a stroke in any part of the brain can be-- but the American Heart Association uses a acronym called BEFAST that I think everyone should know. And to make it really simple, it's really a sudden onset of any of these symptoms. And the B is for balance. The E is for the eyes, so like vision loss or double vision. F is for the face if you have a numbness in the face or a facial asymmetry. And then, A is for the arms if you hold your arms up and if one drifts or cannot move it. S for speech, so if your speech is slurred or you cannot get your words out or your words are coming out, you don't make any sense. And the most important part is T, which is really for time, for 911.

Host: Time. And time is brain, and time is life.

Nirav Patel, MD: Absolutely.

Host: So, what steps should be taken if an individual suspects that they or a loved one is experiencing a stroke?

Nirav Patel, MD: The most important thing is if you still think you're having a stroke really is to call 911. Anyone in the United States, in the last 20 years, we have changed our routing. So actually when you call 911, you will go to the nearest stroke center and not to the nearest emergency room. So depending on your county and where you are, it will bypass a local hospital that's not a stroke center.

And probably, the second most important part is that they are in touch with the hospital before you even arrive there. So, the village that descends on you with the neurologist and the stroke team and the CAT scan and all of that stuff is ready and prepped so that we don't waste time.

Host: That is just so much advanced from the days of yore, I mean, well, you remember how it used to be.

Nirav Patel, MD: You know, I was talking, it's almost barbaric that just 25 plus years ago, people would sit in the ER, wait for a CAT scan, wait for a result, and then they would just get admitted to the floor and the neurologist would be called the next day. We are in a much better place. And what's really important with these changes with regionalization and bypassing in the U.S., stroke used to be the third leading cause of death in the United States and now it's a fifth leading cause. So, these changes have improved patient's life and not just survival, but you know, obviously quality of life.

Host: I love the progress. What role do emergency responders and hospitals play in ensuring stroke patients get the care they need quickly?

Nirav Patel, MD: There's a lot of education on the EMS side, right? So, where I'm at, we work with the different counties and talking about how do the EMS know what's a stroke, right? And obviously, nothing's perfect, but they have specific scales that they give. And based on that, they reach out and say, "Where should we go? And they're directed to go to this center or that center. And then, obviously, in the hospital side, if you're a stroke center, there are a lot of resources from nursing, the ER physicians, neurologists, neurosurgeons, neurointerventionalists. There really is a village of people to deal with the different types of strokes and to deal with them emergently. So, they're on call. So, they literally have to respond within five to 10 minutes and help manage that patient. So, I think that's the nuances of having telehealth and having robots and having people physically there and so that we can all give our advice and trying to help the patients.

Host: And they're doing things en route to these stroke centers, correct?

Nirav Patel, MD: Absolutely. Not just the vital signs, but depending on where you live, and this is sort of maybe the future, I live in Los Angeles and UCLA has this MSU, which is a mobile stroke unit and it's a paramedic 911 on steroids with a CAT scan in the field. We give medications in the field. We scan the patient so we actually know stuff well before they even get to the hospital. And that may be the future.

Host: Wow, incredible. So, what are clot-busting drugs and how do they work to stop a stroke in progress?

Nirav Patel, MD: Clot-busting drugs were first approved in 1996 and have become the mainstay. And the thought would be for the type of stroke where there's a clot or an ischemic stroke where there's no bleeding, and that's really important. We are able to give a medication that opens up blood clots that essentially lyses the clot. And traditionally, the original drug was tPA, which is a tissue plasminogen activator. And I think most centers have sort of switched over to a new medication called TNK, which is tenecteplase. But both these medications essentially are given intravenously. And essentially, they break up blood clots. So if you have a clot in the brain, the hope would be if we can dissolve that clot and restore blood flow, the patient's symptoms will get better.

Host: You spoke to this. Earlier, but I'd like to dig into it a little further. How critical is the window of time for administering these drugs? And what happens if treatment is delayed?

Nirav Patel, MD: This is something that I wish we would do more. At least, in most academic centers and most stroke centers, unfortunately, maybe 15%, maybe at max 20% of stroke patients get this treatment. And many of the patients don't get it because they just come too late. There's actually a very critical window. As you said, time is brain, so the traditional window is up to four and a half hours. But there's some new windows now where if you come between four and a half and nine hours or you wake up and we don't know when the stroke started. We can use additional imaging with MRI to see if you may be a candidate. But if you don't come in that window, you will not be a candidate because if delayed, unfortunately, the risk of bleeding increases. So as much as we want to help, we don't want to harm. And so, this drug has a very narrow window of when to give it. And even though we say four and a half hours and nine hours, I'd rather give in the first 30 minutes because there's data that shows that for every 15 minutes we give these drugs faster, more patients are independent and more patients have less disability.

Host: Understandable. Are there specific risk factors that make someone more likely to need clot-busting treatment?

Nirav Patel, MD: Yeah. So, you know, there's a whole selection process. So even if you come in there, there are some people who will not get the drug because every patient is different, your blood pressure, what medications you're on, how big is your stroke? And so, we actually have to put it all in perspective. So, it's not just doing the scans, but assessing are we safe to giving it to you? And then, obviously, talking to the patient or the family to discuss risk and benefits before we give it, because the biggest risk is that we can actually cause a ischemic stroke, bleed in the brain, and patients can get worse and or die. So, it's not a completely benign drug. And so, we have to actually make sure that we are treating it as much as we want it fast. We want to make sure it's safe.

Host: Exactly. And how do hospitals determine whether a patient is eligible for clot-busting drugs?

Nirav Patel, MD: So, the first and foremost thing is a CAT scan. Every hospital in the United States has it. We can get a CAT scan within five to 10 minutes. And once we see that, we can actually see if there's any bleeding. And the number one thing on that scan is, is there bleeding that would stop us from giving this medication? Or something else, like if there brain tumor or something else. But if it isn't, that stroke doesn't show up in a CAT scan, so we're not looking for the stroke. We want to make sure there's no reason not to give the blood thinner. Then, we look at the exam and I think those are the two biggest things. Clinical symptoms, imaging to make sure, and then we deal with the blood pressure and the medications. And based on that, discuss with a patient or family and then treat them.

Host: Got it. What actions can people take today to reduce their risk of stroke?

Nirav Patel, MD: I would tell you that, just be aware of your risk factors, right? So, I think we talk about not just in diet and exercise, but you know, if you have diabetes or high blood pressure, follow up with your doctor. Be on the treatment. A hundred percent, diet and exercise will help all of that. Manage your cholesterol. Some people have irregular heart rhythms that increases their risk.

More importantly, be aware that if it happens, what to do. Because unfortunately, there are many patients who say, "Well, I'll just sleep it over and I'll wake up and get better." That just doesn't always happen.

Host: Right. Okay. Anything else you'd like to add?

Nirav Patel, MD: I think the most important part of that strokes can happen at any age. I've seen teenagers have it 20 year. It's not just for the elderly. And stroke is treatable. If nothing else people would get out of there is, there are many treatments of different types, not just the clot-busting drugs. There are other mechanical treatments where we can actually put a catheter up and go fish for that clot. So, it's not just medications, but the point is get to the right place and fast. And I think, as you said, the most important part is time is brain.

Host: Yeah, this is so encouraging. Thank you so much, Dr. Patel, for your time and your expertise today. Loved having you on the podcast,

Nirav Patel, MD: All right. Thanks everyone having me.

Host: And for more info, please visit memorialcare.org/lbstroke. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.