Nolan Alexander (Host): Meaningful Medicine is a Novant Health Podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I am Nolan Alexander. And today, we have Dr. Jafar Hashem, who is a neurocritical care physician with Novant Health. Dr. Hashem, how are you today?

Jafar Hashem, MD: I'm doing very well. Thank you, Nolan. And thank you for having me on this great show.

Host: It's our pleasure. Let's jump into it. What are some signs of a brain emergency, like stroke or aneurysm that people should seek immediate care for?

Jafar Hashem, MD: Yes. One of the most important things for people to understand when thinking about brain emergencies and the signs that are related to that are that they are often sudden and dramatic. But sometimes, they can also be subtle, and that's what can make them dangerous.

So for a stroke, commonly, we use a mnemonic known as the BE FAST. B stands for balance problems or sudden dizziness. E stands for eye, you know, so visual symptoms, sudden vision loss or double vision. F is for face, facial drooping. A is for arm or leg weakness, especially on one side more than the other. S is for speech difficulty, so slurred speech or having trouble finding words. And T is actually the time to call 911 when you feel any of those symptoms.

And beyond that, you know, of course, this is a good-- for all intents and purposes-- a good mnemonic to be aware of. But there are some other things to kind of watch out for that essentially any sudden neurologic change, confusion, inability to understand language, a severe headache that comes out of nowhere unexpected. Sometimes people might describe that as the worst headache of their lives. That can also be a sign of something serious, such as a ruptured aneurysm

Ultimately, what makes this challenging is that symptoms don't always fit to a strict checklist. That's why it's one of the biggest and important takeaways here, is that if something feels abrupt, severe, off, out of character, don't try to wait it out, don't try to explain it. The brain doesn't give many second chances, and that's where calling 911 gets you to the right care faster, and that speed is what directly affects what treatments are available and how well someone ends up recovering. It's always better to be evaluated and told that everything is okay than to miss a real brain emergency where time truly matters.

Host: Let's dive into that just a little bit more. Why is getting fast care so important in these cases?

Jafar Hashem, MD: fast care is very important. As we say in neurology-- we have a famous saying-- that time is brain. That phrase really captures the urgency of those situations. As we said, the brain doesn't really give a whole lot of second chances, so getting fast care is critical. And many of the emergent treatments that we offer really work if we only act early, because what happens after the initial brain injury can also be just as important as the injury itself.

So to go a little bit more into that, the first thing that happens when we have the symptoms happen is the primary brain injury. This is the initial event. So for example, a blood clot that blocks one of the arteries to the brain and causes a stroke or that aneurysm that ruptures and causes the bleeding, the brain cells begin to suffer right away immediately. The longer that goes on, then the more injury that can occur. Once brain tissue is lost, unfortunately, it is really hard to bring that back. And speed is what gives us access to treatments that can directly limit the damage and improve the outcome.

If I were to give a couple of examples that would kind of be quite relatable, is stroke one of the biggest things that we see. There are two major types. The ischemic type where there is a blood clot that limits blood supply to the brain and blood supply is cut off. And that's where our treatments are really limited by time, early on, whereas the most common treatments that we use are clot-dissolving medications known as thrombolytics and mechanical thrombectomy where the clot is typically removed through mechanical means. So, the sooner that blood flow is restored to the brain, that means the more brain tissue we can save. And that really translates into a person's ability to speak better, understand better, move eventually, and get their life back.

Similar for bleeding emergencies such as an aneurysm rupture, where securing that aneurysm early on is of paramount importance so that we don't want to see that bleeding again. And there are other neurosurgical interventions that can help limit the extent of the injury that happens afterwards such as pressure-relieving options, whether that's through drains, drainage, or surgical decompression to allow the brain room to swell safely. All these things can help prevent what is known as secondary brain injury after, that initial event that can cause further worse outcomes. That usually runs on the course of hours to days. But essentially, it all starts from the beginning. If we start right early on and set things up the right way, then hopefully that improves the course to follow.

Host: So in addition to strokes and aneurysms, what are some of the most common reasons a patient may need neurocritical care?

Jafar Hashem, MD: Some of the most common reasons that patients need neurocritical care are variable. believe it or not, most of our patients, they don't plan on coming to the neuro ICU. They don't make appointments ahead of time. These are people who are just living their normal daily lives, you know, just hours earlier before something life-changing like this happens.

The most common reasons that we see ultimately are strokes. So, ischemic strokes is one of the most common things we see as we kind of explained that is blood clot blocking the blood flow of the brain. Other important things are hemorrhagic strokes, which is essentially bleeding into the brain. That could be from various causes. Importantly, ruptured brain aneurysms, traumatic brain injuries, prolonged uncontrolled seizures, brain swelling from other causes, such as infection, lack of oxygen, and a very common that we see is, surgical patients. So, patients who are there for brain surgery, going a little bit more into those, you know, just the severe strokes that we see are often patients that need to be in the ICU. They can't be in any place outside of the ICU. That's where we have close monitoring that we're able to follow them for any expected complications that may happen afterwards.

In the case of severe stroke from ischemic, blood clots, we kind of explain the common treatments that we do, which is essentially clot-busting medications to break up that clot or mechanical thrombectomy where the neurointerventionalists would actually go in through the vessels, work their way up to the brain and actually retrieve that blood clot.

Bleeding in the brain as we kind of talked about, the most common thing we see is related to blood pressure or other risk factors. But one of the most concerning ones that we see is ruptured aneurysms, subarachnoid hemorrhage. these often require very urgent procedures to stop the bleeding and then followed by the close monitoring to prevent complications.

Uncontrolled seizures are also a fairly common thing that we see. So, oftentimes people can have seizures that stop on their own, but there are times when those seizures don't stop and it turns into a medical emergency. Patients can't breathe. And then, a whole host of metabolic issues come after that that can be life-threatening. Those patients need to be in a neurocritical care setting for continuous brain monitoring and carefully titrating those medications to prevent seizures from coming back.

We briefly alluded to major neurosurgical procedures. Those include brain tumors, major spine surgeries that specifically affect the spinal cord and complex vascular conditions such as unruptured brain aneurysms, AVMs, or arteriovenous malformations of the brain. They can require minimally invasive surgeries or endovascular procedures. Traumatic brain injuries are important cause also. And less common things that we see include severe brain infections, such as meningitis, encephalitis; post cardiac arrest, if someone's heart suffers a cardiac arrest, for example, outside of the hospital, that can affect the brain because it's not getting enough blood supply; and neuromuscular conditions, such as myasthenia gravis and Guillain-Barré syndrome, GBS, that can affect the person's ability to breathe because of the weakness.

All in all, the neuro ICU exists because these conditions require more than just routine general ICU care. We're talking about specialized, dedicated neuromonitoring that includes focused nursing care, continuous EEG, intracranial pressure monitoring, a portable head CT, and transcranial Doppler ultrasound. These are the various modalities that are used in the neuro ICU for monitoring the brain function and knowing how to catch something early and to react to it as soon as possible if we see that so that we can improve the outcome and, you know, prevent further damage from happening to the brain. And rapid decision-making and a team that is trained to recognize that is how we prevent long-lasting damage.

Host: Dr. Hashem, I know firsthand some of the situations that would land someone in your unit can be pretty scary for both patients and their loved ones. Brain injuries, depending on the severity, that can have lifelong impacts. How did the care teams guide patients and families through these serious events?

Jafar Hashem, MD: Yes, these events are really frightening. And we never truly lose sight of that. This is one of the most human parts of medicine. Patients and their families often meet us on, you know, one of the worst days of their lives. And they're being asked to absorb a lot of information at a time where emotions are running at an all time high. So, being able to support patients and families during some of their most vulnerable moments is a responsibility that we don't take lightly.

One of the most important things we do is try to slow the experience down for the families, even when medically things are moving very fast. We focus on clear, honest communication, explaining what's going on, what we're worried about, what may happen, what we know, and more importantly, what we don't know and what we're watching out for. So in plain language, without rushing, without sugarcoating, and we expect to repeat ourselves quite often, we're glad to do it because no one is expected to absorb that much of information in a sudden.

Ultimately, our main goal is to make the families, our partners in care. So that means inviting questions, checking that they are understanding regularly, helping them feel grounded in what is happening day to day, rather than feel overwhelmed by the uncertainty of the whole journey. When difficult questions and decisions come up, we take time to understand the patient as a person, their values, their wishes, and what matters most to them.

No two people are the same. We often say that. So, our goal is to make sure that the care that is being provided stays aligned with who that person is and not what is just medically possible. So, that is the human side of things. And our teams really try to pay close attention to those small but meaningful details. And that connection helps families feel seen, heard, and it reminds us that we're caring for a person and not just a diagnosis. We can't always control the outcome, but we can make sure that families never feel alone, unheard or rushed through decisions that really matter deeply.

Host: I want to shift the focus on what happens after a patient is stabilized in the neuro ICU. What does recovery look like? For example, could patients need physical rehabilitation or speech or occupational therapy services?

Jafar Hashem, MD: Yes. Great questions. Once a patient is stabilized, recovery is really the next part of their journey. the short answer really is that the recovery can look different for every person. For some patients, stabilization means that they're ready to move out of the ICU fairly quickly. And, you know, sometimes that can be the next day, as soon as the next day or the next, you know, coming few days. Some even do so well as to be able to go home the next day. They are a minority of patients, but these are the real success stories that we thrive on. For example, someone who comes in with an acute stroke and undergoes those clot-retrieving and clot-busting medications that we talked about and they end up doing well early on.

But again, that's not all our patients, and we understand that. And this is part of what we do. Really, what determines a lot of the timeline is how the brain is healing and whether there is ongoing risk for further complications such as swelling, bleeding, or seizures. Those things can be difficult to predict at first. But that's why we have the patient with us under close observation, whether it's a day, a month or more, achieving meaningful recovery at the end of the line is what we really want to see and what we really care about.

Now, recovery overall does involve a team-based rehabilitation approach. So, this does include physical therapy to help regain strength, balance, mobility; occupational therapy helps with regaining the ability to perform daily activities such as dressing, eating; and speech therapy to work on communication, thinking skills, speaking, and swallowing, which is very commonly affected in our neurologic patients. In many cases, you know, the therapy does start really early on and earlier than most people expect, sometimes while patients are even still in the ICU. We like to introduce that as early and as safe as possible to do so, because early rehabilitation can make a meaningful difference on the long-term.

It is also important during that process to set realistic expectations and realistic goals. Brain recovery is rarely linear. And the truth of it is that there can be good days and there can be bad days. And progress may happen in small steps rather than big leaps. This is all part of it. We often educate families that this is to be expected. But also, it is part of the normal process and we embrace time as a commodity so that we can hopefully achieve a better outcome.

Our role is to really to help guide that transition through the process and the unknowns. And many patients really end up recovering far more function than initially we expect. So, we don't give up wherever we see a path forward or any sort of meaningful outcome. We fight hard for it. That's what's most meaningful to us in our practice.

Host: As we prepare to close, I'm curious, I want to ask how neurocritical care became a passion of yours. What drew you to this specialty?

Jafar Hashem, MD: Thank you for asking that. I've always been curious about how complex things work. I've always been fascinated by the workings of the brain. That's what initially drew me into the field of neurology overall. The brain is just incredibly complex. And even after years of training, there's still a lot to learn. There's a lot that still surprises us. And that includes also patients and their outcomes.

But a little bit of more of a background about me starting medicine or going to medical school, I was a classically trained musician, violinist. I've played with the Jordan National Orchestra. That's where I was originally from for many years. And really, that experience helped shape a lot of my perspective on neurocritical care. If I were to draw parallels in an orchestra, there is no single instrument that carries the whole piece. So, everyone has to listen to stay in sync, to adjust to one another. And when it works, it becomes something beautiful, harmonious symphony that is bigger and more powerful than any one part alone.

And the neuro ICU essentially, to me, feels the very much the same. Every patient is at the center of our care. The care teams work together with everyone revolving around them. That includes our nurses, therapists, pharmacists, surgeons, and the physicians. We're each playing a different role, all focused on the same goal eventually. So when everyone is aligned, the care becomes coordinated, thoughtful, and effective. We want to restore hope, provide a path for recovery, and humanize care as best as we can. And that is where I found my true calling in neurocritical care, where urgency, complexity, teamwork, and meaning all come together.

Host: What a renaissance, man. Thank you so much for your time and insight today, Dr. Hashem.

Jafar Hashem, MD: Thank you very much for having me. I really enjoyed this.

Host: That was Dr. Jafar Hashem, who is a neurocritical care physician with Novant Health. To find a physician, visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org.