Joey Wahler (Host): Stroke is among the top five causes of death in the United States. So on this episode of Curating Care, we're discussing stroke awareness. Our guests from St. Clair Health, Dr. Maxim Hammer, he's Chief of Neurology, to address stroke symptoms and what to do if you or a loved one is having a stroke; and Dr. Jason Biggs, he's Emergency Medicine Chair, to explain how St. Clair Hospital serves as a certified primary stroke center.

This is Curating Care, a podcast from St. Clair Health, expert care from people who care. Thanks for listening. I'm Joey Wahler. Well, hi there, doctors. Thanks for joining us.

Maxim Hammer, MD: Thank you.

Jason Biggs, MD: Thanks for having us

Host: So first for you, Dr. Hammer, May is Stroke Awareness Month. Now, one in four people worldwide will have a stroke and it's one of the top five causes of death in the US as we mentioned earlier. So, can you explain, for those unaware, what is a stroke simply put?

Maxim Hammer, MD: Thank you very much for having me. I think that it's very important to understand what a stroke is, because that will lead to a better recognition of stroke symptoms out in the community. I want to point out very briefly, however, that even though stroke is the fifth leading cause of death in the United States, it's actually the second leading cause of death worldwide. And there's an interesting difference there. So if you look at the planet as a whole, it's actually a much more prominent cause of death than here in the United States in general.

The word stroke refers to a syndrome, which is a collection of symptoms that occurs all of a sudden. Here is a good functional definition of a stroke. It's a sudden neurological deficit caused by a vascular problem. So, there's three components to that definition. Sudden refers to something that happens from one moment to the next. Not something that develops over several days or several weeks, but rather one minute to the next, typically, is what I mean by sudden. So, the first characteristic of a stroke is that it's sudden.

The second characteristic of a stroke is that there's some neurological deficit. What does that mean? Well, it means some loss of function. The most common symptoms that people might have are weakness, numbness, and tingling, especially if it affects just one side of the body, so either the right side or the left side. It can affect the face or the arm or the leg, typically on one side of the body or it can affect all three, face, arm and leg weakness, numbness and tingling. Another common deficit that can occur is all of a sudden losing vision. Loss of vision or part of the visual field is another very typical symptom of a stroke. Another very common symptom is trouble talking, which can manifest itself as slurred speech, for example. But it can also be an inability to come up with the right word or sometimes even an inability to understand other people. So, weakness, numbness, tingling, loss of vision, trouble talking, trouble communicating and trouble understanding others. And then finally, sudden loss of coordination including falling down.

Those are all the typical symptoms of stroke. So, a stroke is a sudden neurological deficit, and I just gave you a long list of the common deficits that can occur. And then, the last component of this definition is that it's a vascular problem, and that refers to the circulation. There's two types of stroke. If the vascular problem is a blocked artery, then this is called an ischemic stroke. Ischemic refers to lack of blood supply. This is the most common type of stroke. If the vascular problem is a ruptured artery, a broken artery and there's bleeding in the brain, that's referred to as a hemorrhagic stroke, and that is less common.

So again, a stroke is a sudden, meaning one minute to the next; neurological deficit, and we talked about various symptoms, weakness, numbness, tingling, loss of vision, double vision, slurred speech, difficulty communicating, understanding, or sudden incoordination or falls; caused by a vascular problem or blocked artery or sometimes a ruptured artery. So, that's what a stroke is. I know that that was a very long-winded description, but I think it's much easier to understand stroke if you begin with a good definition.

Host: Absolutely. And so having said that, for you, Dr. Biggs, because time is of the essence when dealing with a stroke patient, can you tell us why that is and explain what happens when a patient arrives in your emergency room with those stroke symptoms?

Jason Biggs, MD: Oh, that's a question. That was a great definition from Dr. Hammer to overview the pathophysiology or the why a stroke happens. But there's a saying in stroke that time is brain, so every minute counts. So, one plug I'd like to start with is if you as a bystander or a family member or you yourself think you're having a stroke, call 911. That summons EMS who will arrive and assess you. And the most important thing there is they can start to proceed with diagnostics and help alert us in the emergency department that you may be coming in with a stroke. That allows us to prepare and get things ready to work as quickly as we can. So, we have patients who arrive via ems or they may arrive as a walk-in patient with family. And those patients when identified, we term that as stroke alert. And that mobilizes our team to get working on this patient as quickly as possible.

So, what happens when a patient arrives is our stroke team assesses a patient that includes at our hospital an emergency physician, emergency nurses, emergency techs, our unit secretary. We begin with a quick assessment of this patient. Typically, as the EMS unit arrives, we hear from them what their assessment of the situation is, and then we begin our work while the nursing staff is obtaining vital signs and placing IV access and drawing blood. The physician starts to evaluate that patient, getting a detailed history. One of the most important questions we ask is "What is the patient's last known well?" So when was this first and last normal and when did these symptoms start? As Dr. Hammer alluded to, this is a sudden change and we need to know when that started because that helps determine which treatment options we have available for the patient.

So as the team mobilizes, we quickly get that patient off to CAT scan. CT scan is our first diagnostic test of choice. And we're doing that to look for potential bleeding in the brain. As Dr. Hammer pointed out, there's hemorrhagic strokes, which are less common, but we do see them, and then ischemic strokes. And so, we need to know upfront which type of stroke this could be. We also often do images of the vessels in CT to look for large blockages because that helps determine one of the potential treatment options. These images are processed and then our radiology team and our telestroke team begin to interpret these images while we're assessing the images and the patient as well. All this happens very quickly because we're trying to make some important decisions.

For patients who present within a certain time window with an ischemic stroke or a lack of blood supply stroke, we're assessing if they're a candidate for what are called thrombolytics or sometimes referred to as clot-busting drugs. These are medications that are given with certain parameters within certain time windows that can have a dramatic impact on patient outcome. And so, we're trying to assess to get that drug into the patient, if at all possible. And we're trying to make a second assessment. Is there a blockage in one of the vessels that would warrant having what's called a thrombectomy or more of a surgical removal of clot with potential catheter type device?

So, those are the two treatment options we have immediately available in the emergency department for patients, and we quickly try to assess those. The national guidelines are we should try to get the thrombolytics, the clot-busting medications, in within 45 minutes of arrival. Our goal is actually faster than that. But getting all of these steps done in a timely fashion to be able to get medication into people as soon as we can is our goal. And it's sometimes challenging to get all those things done in that brief period of time. That's why time is of the essence. And as you pointed out, the sooner that a patient can present to us with a stroke, the better.

Host: And so you just mentioned, Dr. Biggs, the importance of contacting 911. Back to you, Dr. Hammer, if someone or someone they see may be having a stroke, what, if anything, should they do in the meantime while emergency personnel are en route?

Maxim Hammer, MD: Well, I want to answer your question. But before I do, I want to piggyback on something that Dr. Biggs mentioned, which is the importance of getting to the emergency department as quickly as possible. The reason that's so important to get there early is, as Dr. Biggs alluded to, time is brain. And I just wanted to spend one moment explaining that just a little bit further. A neurologist named Jeffrey Saber at UCLA determined many years ago that when there's a large artery that's blocked in the brain causing stroke, brain cells die at a rate of 2 million brain cells per minute. So, every single minute that a stroke is occurring, 2 million brain cells are dying. That's the reason why we want to get patients to the emergency department as quickly as possible to deliver treatment to open up the circulation so that we can minimize the damage that occurs to the brain.

Now to answer your question, you were asking a very interesting and important question, which is, is there anything people can do if they discover that someone around them is having a stroke? Well, step number one, like Dr. Biggs mentioned, is to call 911 and get the patient to the emergency department as quickly as possible, but there are additional things that could be done that might help us help the patient. Those would be collecting information. When was the patient last known to be normal? Was the bystander with the patient at the time the symptoms occurred? And if not, who last saw the patient and exactly what time was it when they last saw the patient. That information about the timing is extremely helpful and sometimes can only be given by people that are bystanders.

Other pieces of information can help us out. What kind of medications does the patient take? What is the medical history of the patient? Those can be additional pieces of information that we can use to treat the patient. If the question is, is there anything that can physically be done to try to treat the stroke before the patient gets to the emergency department? The answer unfortunately is no. There isn't a treatment that you can give at home or in the community while waiting for EMS to arrive. The goal is to simply get the patient to the emergency department as quickly as possible.

Host: And so having said that, back to you, Dr. Biggs, and we mentioned St. Clair is a certified primary stroke center. Can you tell us what that means and what steps St. Clair has to take in order to get that designation?

Jason Biggs, MD: So yeah, we are certified as a primary stroke center. This is a national standard that's regulated by the Joint Commission. To become a primary stroke center, it requires an application process, which is pretty extensive. It requires us to submit data. We have a site visit with the Joint Commission. And once you become certified, then we re-certify every two years with ongoing data submission, ongoing site visits. We have intercycle calls with the Joint Commission to maintain that certification. I find that it's actually a helpful process because the surveyors who come on are able to give us great feedback. They've learned best practices from around the country. So, it's a great opportunity for us to review our stroke process. Thankfully, since we've become accredited, we've maintained a high level of competency and continues very well with our stroke center accreditation.

Host: Now, Dr. Hammer, what people are unfortunately more at risk for a stroke? And what can we do in general to try to prevent one from occurring?

Maxim Hammer, MD: That's an interesting question, and I'd like to take your question and bend it a little. I think that another way of looking at this is what are the causes of stroke? There are 12 or 15 different causes of stroke, although there are three that comprise by far the most common causes and account for almost all strokes. And if we understand what those three causes are, we could potentially identify people who are at risk of stroke prior to a stroke occurring.

The three common causes of stroke are, number one, uncontrolled high blood pressure. High blood pressure, also called hypertension, is known as the silent killer because if you have hypertension, if your blood pressure is not controlled, you feel fine. So, you don't know that there's anything wrong with you. Yet uncontrolled high blood pressure, if it goes on for a long time, can cause heart attacks, stroke, kidney failure, and all kinds of other horrible things. So, high blood pressure is one of the top three causes of stroke.

The second common cause of stroke has to do with atherosclerosis, which is a term that refers to the buildup of cholesterol plaque inside the lining of the arteries. Atherosclerosis can develop in arteries anywhere. For example, we know that atherosclerosis builds up in the arteries of the muscle of the heart called the coronary arteries, and that's what causes almost every heart attack that occurs. But atherosclerosis also builds up in the leg arteries and causes circulation problems for some people, and it can build up in the arteries of the head and neck and lead to stroke. So, atherosclerosis is another, is the second common common cause of stroke. And you can know something about your individual risk of atherosclerosis by looking at your family history. Frequently, people who have atherosclerosis, it runs in the family. So, families that have lots of members who have had heart attacks and strokes might indicate that there's a problem with atherosclerosis in the family.

The third common cause of stroke has to do with the heart rhythm condition called atrial fibrillation. Atrial fibrillation is a heart rhythm irregularity that occurs more and more commonly as people get older and older. Actually, atrial fibrillation is statistically the number one cause of stroke in the older population. And the reason it causes stroke is that it creates a situation where little blood clots form inside the chambers of the heart. And when those blood clots form, they eventually get pumped out of the heart. If the heart is pumping blood out, the blood that is pumped out by the heart goes to the brain and the body, the brain gets most of it. At least 80% of the blood that leaves the heart goes up the brain circulation. So if there's a little blood clot traveling through the chambers of the heart caused by atrial fibrillation, chances are very, very high that blood clot is going to travel up into the brain circulation and block an artery there. So, the people who are at risk of stroke are people with uncontrolled high blood pressure, people who have a lot of atherosclerosis and people with atrial fibrillation.

Host: And so, to the other part of my question, which was what, if anything, can we do ourselves to reduce the risk of stroke?

Maxim Hammer, MD: I think that getting annual checkups and being aware. If you are someone with high blood pressure and if you have high blood pressure, follow doctor's orders and treat it. Lose weight, exercise, stop smoking and, if necessary, start blood pressure medications to get your blood pressure under control.

If you are someone with a strong family history of atherosclerosis, there are screening tests that can be done to determine if you have atherosclerosis. And if that's the case, then controlling your blood pressure, controlling your blood sugars, controlling your cholesterol, avoidance of smoking, reduction of alcohol use and increased physical activity can all promote better health with respect to atherosclerosis and reduce the chance of heart attack and stroke from that. And if you are somebody who we identify has atrial fibrillation, which is something that you can identify again at checkups or if you have palpitations or fluttering in the chest, you should notify your doctor and get checked out. And if you have atrial fibrillation, taking certain blood thinners can dramatically lower your chance of having a stroke.

Host: Gotcha. And finally, back to you, Dr. Biggs, St. Clair also has a telestroke program in place with Mayo Clinic. Can you tell us a little bit about how that works?

Jason Biggs, MD: Sure, yeah. Telestroke gives us 24/7 access to stroke fellowship-trained neurologist at one of institutions in the world, the Mayo Clinic. St. Clair is a part of the Mayo Clinic Care Network, so it's a natural partner for us. In practical terms, what happens is if we have a patient who we're assessing in the emergency department or elsewhere in the hospital and we need a consult with the team, we basically talk with them via phone and then they're able to appear on we call it the stroke robot. But it's basically a series of video monitors. They can assess the patient in real time with us within minutes of activation. And this allows us to tap into their expertise, which is very helpful, because guidelines for stroke continue to evolve and change and having partners that are on call 24 hours a day is very helpful to make sure we're practicing at the highest level of care. So, our team really works well with Mayo collaboratively for continued process improvement for our whole stroke program.

Host: Well, folks, we trust you are now more familiar with stroke awareness and the advanced care provided at St. Clair Hospital. Doctors Maxim Hammer and Jason Biggs, thanks so much again.

Jason Biggs, MD: Thank you very much.

Host: And to learn more, please visit stclair.org/stroke. Again, that's stclair.org/stroke. Now, if you found this podcast helpful, please share it on your social media. And thanks again for listening to Curating Care, a podcast from St. Clair Health. Hoping your health is good health. I'm Joey Wahler.