Prakash Chandran: Time is of the essence if you or a loved one has a stroke. But what should you do in the event that one happens and are there ways to prevent them from happening in the first place?

My name is Prakash Chandran. And in this episode of Be Well with Skagit Regional Health, we'll be talking about strokes. Here with us to discuss are Dr. Jay Biessel, an Emergency Department stroke champion, and Dr. Patti Brettell, the Stroke Medical Director, both at Skagit Regional Health. Dr. Biessel and Dr. Brettell, thank you so much for joining us today. I really appreciate your time. Dr. Bretell, I'd love to start with you with just a simple question. How common are strokes?

Patti Brettell, MD: Hi, Prakash, and thanks for having us here today. Both Jay and I have a lot of heart for stroke and have spent a lot of time helping the community know more about it. Strokes are very common. There are over 800,000 strokes in the United States. In addition to that, there is another 250,000 things called TIAs or transient ischemic attacks. Sometimes people call them mini-strokes.

Most strokes are ischemic strokes, meaning there's been something interfering with blood flow to the brain. Usually, that's a clot that's formed in the brain. Eighty-seven percent of all strokes are ischemic. Another 10% of strokes are hemorrhagic, meaning there's been a vessel that's ruptured. And of the strokes that occur, almost a third of them are recurrent strokes. So yes, it's an extremely common problem.

Prakash Chandran: So understanding how common they are, Dr. Biessel, could you tell us a little bit about the signs and symptoms of a stroke?

Jay Biessel, DO: Thank you for having us. So as far as the signs and symptoms of a stroke, the brain is very complex, so it can present in many different ways. But we essentially advise the public with a little acronym called FAST, which stands for face, so does the person have any facial droop? Arm, does the person have weakness in one or both arms? S is for speech. Is the person having any trouble speaking or does a speech sound strange? And then T is for time, which just means time is of the essence. So if you recognize these symptoms, you have to call or text 911 and get yourself to the emergency department. For some facilities, we've also added BE FAST with a B-E preceding that fast. And the B is for balance. And then, the E is for, are there any vision changes?

Prakash Chandran: And Dr. Biessel, just expanding on those symptoms a little bit, what should you do if someone you know is experiencing some of the symptoms that you just mentioned?

Jay Biessel, DO: So most importantly, if someone that you know or yourself are experiencing any of these symptoms, I think the most important thing is to get on your phone and call or text 911 and get an ambulance to the house to get you to someone like myself in the emergency department to further assess and see what's going on.

Prakash Chandran: Yeah. I'm so glad that you mentioned calling or texting 911 is important, because I feel like if someone were to notice one of these symptoms, they would think, "Well, let me get you in my car and drive to the hospital as fast as possible," just to save time. Dr. Biessel, can you speak broadly to why calling or texting 911 is so important rather than getting someone in a car and driving to the emergency room?

Jay Biessel, DO: Absolutely. So the symptoms are obviously concerning. And I think that the best thing to do is to have a 911 and EMS dispatch come to the house. There's a lot of things that they actually do pre-arrival to the emergency department that really help my assessment and management that you could not do yourself in a private vehicle heading to the emergency department, such as checking sugar, seeing what your blood pressure is, assessing and documenting your symptoms at the time of onset. Those are all very helpful.

Prakash Chandran: Yeah, that makes a lot of sense. There's almost some pre-triage that's done that just cannot be done if you have someone in the car and drive to the emergency room yourself. So very important to call 911. Dr. Brettell, we just talked about what happens if you're noticing symptoms of a stroke, but is there a way to just prevent strokes from happening in the first place? I guess, broadly speaking, are strokes preventable?

Patti Brettell, MD: So the most striking statistic I can give you on that is that, from the years 1960 to 2009, there has been a reduction in the number of strokes from about 8.7% to 5%. And most of that is based on preventive medicine. One of the reasons for going to the hospital when you've had a stroke, even if you might not get emergent treatment, is to understand why that occurred and what factors go into causing your stroke so that you can prevent future strokes. There have been a whole bunch of retrospective studies around the world and in the U.S. on preventable causes of stroke and the statistic goes from between 82% to 90% of strokes are preventable. Eighty-two to ninety percent, that's amazing. And they're simple things. Simple, but hard for us to do sometimes. Control of blood pressure, healthy diet, regular exercise, smoking cessation, a really big one. This makes a huge change in your life.

In our community, we've seen this shift into healthier lifestyles on the west coast. There are parts of the United States where we don't really see that happening nearly as much. And there are factors that go into causing your stroke that may not be part of those, but most of those can be detectable during hospitalization and a short hospitalization. It's not a prolonged hospitalization like it used to be. Cardiac monitoring for looking for atrial fibrillation which would require a different treatment. Other cardiac problems that might be present can be determined and adjustments in medications to prevent strokes in the future.

Prakash Chandran: Dr. Biessel, I know that there are two different types of strokes that were mentioned up at the top, the ischemic and the hemorrhagic. Can you talk to us about the different types of treatments that are available for both?

Jay Biessel, DO: Yeah, of course. So, maybe I'll broaden that to what to expect when they arrive at their emergency department and what can we do. And as we hinted at earlier, there's certain things that are actually done in transport via EMS that really help my assessment and treatment plan prior to coming in. So, is this a stroke is the first question regarding treatment. And so there is a lot of stroke mimics out there that aren't necessarily a stroke that needs to be dealt with in a different manner, including, low blood sugars, low blood pressure and very high blood pressure.

So one of the first things that we do in the emergency department is a quick neurologic assessment, a set of vitals, a blood sugar and we go to the imaging department to get a CT of their brain to differentiate what Dr. Brettell spoke about earlier, as to whether this is a bleeding stroke or a non-bleeding stroke because the treatment and management plan is different for each.

So, we'll start with the bleeding strokes, which again are a minority of the cases, roughly 15%. And for those individuals, a lot of it is supportive care at our shop. The blood pressure has to be strictly controlled. And we do treatments such as elevate the head of the bed. And honestly, I get on the phone with a neurosurgeon and a neurosurgical-capable facility for discussion as to the amount of bleed, where the bleed is and potential surgical interventions.

Now, the large volume of patients that we deal with is ischemic strokes. And those people will have a normal head CT or normal in the sense that they don't have a bleed. In this case, we have medications that we can offer to a certain subset of patients. And they have to fall within a strict set of guidelines to be eligible for this medication. One of which is a time window. So the patients need to be within four and a half hours, three hours for some depending on their age. Otherwise, they're not even a candidate for this medication. And the medication I'm discussing is tPA. Some may refer to it as a clot-busting medication and there's another medication out there, Tenecteplase, which is very similar. But this medication needs to be administered within a certain time window and, again, a certain patient subset. So I need to ask a series of questions regarding their medications and their surgical history. I need to know what their blood pressure is to even be eligible for this medication. And then, if we determine that the patient is eligible, we give this in the most rapid and time-sensitive window possible.

And I can further elaborate on that as well. What the medicine is, it's a fibrinolytic medicine, which really essentially breaks down clots that formed. So if there's a thrombus that is formed in one of your vessels and the vessel is blocked, this medicine will eat away at that blood clot and break it apart in hopes to restore perfusion.

Patti Brettell, MD: I'd like to add a little more about Tenecteplase and Alteplase, tPA and clot-busting drugs. It's very important to get to the hospital as soon as you can, because these drugs work best and open the vessel without complications if they're done very close to the onset of symptoms. The faster you can get there, the better these drugs are going to work.

The risk we run into, and the reason there's a limit on how many hours is the risk of bleeding. If the stroke is gone on for a period of time, that's over four and a half hours, and sometimes it can without a large stroke, we can still do these clot busters, but we don't know. And opening up the vessel in a safe manner is what we want to do.

We also have the opportunity with our stroke affiliate, Swedish Providence in Seattle, to open the vessel up endovascularly in their facility. The faster you're in our facility, the faster we can arrange for you to be transferred if you do have a large vessel occlusion that would be amenable to this. The use of Tenecteplase is becoming more common. Swedish uses that in their facility. We're looking at it for our facility. It opens up the vessel faster and it seems to have less disability associated with it long term. So we're looking forward to seeing that used in our facility. And Jay and I are actively involved in the committees to determine when to do so.

Jay Biessel, DO: Absolutely. And Patti, I'm just going to add, just to stress that point, I don't want anyone to feel that just because their symptoms are outside of that four-and-a-half-hour time window, that there's nothing that we can do, because at times that intervention window for the actual clot retrieval at a hospital like Swedish can be 24 hours. Isn't that right?

Patti Brettell, MD: That's absolutely correct. And we really appreciate having this higher level of care available to our patients in Skagit Valley and at Cascade Valley Hospital, where they can make decisions that we wouldn't ordinarily make in our facility.

Prakash Chandran: So Dr. Brettell, you're already starting to allude to this, but can you just share more information about the stroke program at Skagit Regional Health.

Patti Brettell, MD: Oh, I'd be glad to do so. It's a program that's near and dear to my heart. I've been with the program since we began in 2012. And the hospital actually recruited me as the first neurologist to help them figure out how they could provide better stroke services to the community. At that time, we had a very dedicated staff, but we didn't have an organized way to approach patients.

The American Heart Association and the American Stroke Association have programs and guidelines that, when enacted, deliver superior care. And we have received the gold for Get With The Guidelines from the American Heart Association many times. And I'm very proud of that. Since 2016, we've been certified as a primary stroke center. What that means is that we have facilities beyond the capability of most local facilities to care for patients with specialized attention.

We've also had the privilege of working with telestroke with Swedish Providence. And everyone talks about telemedicine these days and it has to do with Zoom, but this is a much more specialized vehicle that's been around for a lot longer. There's a robot that's present in the emergency room. And Jay can probably tell you a little bit more about how that actually works and how they use it, but they can dial into the vascular neurologist at Swedish who can visualize the patient, do an exam, review all the CT scans and help to make decisions with the emergency room doc and the patient about whether and what procedures to go forward and do.

Our program is really robust. And I can tell you, it just keeps getting better all the time. We have a stroke coordinator who manages both programs, bringing in training for all of our staff at Cascade and Skagit Valley Hospital and helping everyone in the community understand how best to manage stroke patients and reach out to patients so that they will have better access as well.

Prakash Chandran: Yeah, that all sounds truly amazing. And just before we close, there's one question that I always like to ask that I'd like to ask the both of you. Given all of your years and experience in practicing and working with patients with strokes, what is one thing that you know to be true that you wish more patients knew either before they came in with a stroke or just in general?

Patti Brettell, MD: I never met my grandmother. My grandmother died long before I was born from a stroke. My mother had her first stroke at 55. When I got to medical school, I found out that neither one of them needed to die from a stroke. My mother was told cigarettes help lose weight and to take estrogen to stay healthy. Neither one of those things helped her and both of them caused her to have a stroke. It made me realize that women particularly have not been guided well about stroke prevention and what to do about it.

Women don't put themselves first. I believe that we know when something's not right with our body and we need to tell someone about it and do something about it.

Anyone who knows me knows that I'm willing and often will, whether asked or not, give advice about stroke prevention, because even a little stroke, a small stroke, a stroke that has what we call an NIH stroke score of 1, can mean disability. If your speech is off or your right hand doesn't work, you're disabled. So from my standpoint, when I see something that is so preventable yet, we're not doing it, it just makes me want to go out in the community and convert absolutely every person. And also to tell anyone, if you feel like you are having symptoms but you don’t for sure, call or text 911. Don't you decide, we'll decide, and you might save your life.

Prakash Chandran: I think that was perfect. Dr. Biessel, I'll give you the last word.

Jay Biessel, DO: I want to just echo what Dr. Brettell stated. And from the emergency standpoint, what I see time and time again is just people presenting that decided to wait it out at home to see if symptoms will improve with time. But as we stressed here earlier, time is of the essence and we can potentially do something about the stroke and potentially turn it around. Obviously, the medications and the intervention, they're not a golden bullet. They don't work on everybody, but it's something, and there are definitely benefits and a better chance for survival and a return to baseline.

Prakash Chandran: Well, Dr. Biessel and Dr. Brettell, I think that is the perfect place to end. Thank you both so much for educating us today.

Patti Brettell, MD: Thank you, Prakash.

Jay Biessel, DO: Thank you, Prakash, for having us.

Prakash Chandran: That was Dr. Jay Biessell, an emergency department stroke champion and Dr. Patti Brettell, the Stroke Medical Director, both at Skagit Regional Health. You can visit skagitregionalhealth.org. My name's Prakash Chandran. Thank you so much for listening. Be well.