Prakash Chandran (Host): A stroke occurs when the flow of blood to the brain is suddenly interrupted or reduced. Just like a field of flowers struck by a drought; brain cells without blood supply will start to wither and die very quickly. That is why it's so important to act fast if you see someone showing symptoms of a stroke.

Here to discuss is Dr.Fahed Saada. He's a Neuro hospitalist and the Stroke Program Director at St. Joseph's Health. Welcome to St. Joseph's Health Med Cast, a podcast by St. Joseph's Health. I'm your host, Prakash Chandran. So Dr. Saada, thank you so much for joining us today. I really appreciate your time. I wanted to get started by asking what exactly are the typical and atypical signs and symptoms of a stroke?

Fahed Saada, MD: Thank you for having me here today. Stroke can vary in presentation. There are both common and atypical symptoms associated with this condition. Some of the most common stroke symptoms that we see include a sudden onset of neurological problems. These could include numbness or weakness, especially if they're affecting one side of the body. It could affect the face, arm, or leg. Sudden onset of confusion. Trouble speaking. Trouble creating sentences or difficulty understanding someone else speaking. Other symptoms such as sudden trouble with vision, blurred vision or double vision, severe headaches with no known cause or no specific history of headaches or other rare causes or rare symptoms such as dizziness, loss of balance or coordination difficulties. The atypical symptoms though manifest differently and usually are difficult to pick up. These are unexplained behavioral changes, altered consciousness, sudden onset nausea, vomiting. That is, again, very sudden and not typically consistent with someone that's having a stomach bug.

Those can be missed or can look like something else rather than a stroke. Other patients can have sudden hiccups, swallowing difficulty, or feeling a stuck sensation in their throat. It is important to remember that any of these symptoms can vary, depending on the area of the brain that is affected but very important to seek immediate medical attention when these symptoms occur suddenly.

Host: Now I definitely want to get into the urgency piece of it, but I want to stick with the signs and symptoms a little bit longer. I've heard of this acronym FAST before. Is that something you can explain for us?

Fahed Saada, MD: Yeah, FAST is used to educate everyone in the community. You know, I, was sitting once having dinner with my kids and my 10 year old would actually broke down FAST for me. Cause it's being taught in school as well. Which is a very important acronym, acronym to consider. If we break this down to the letter F for instance, F for face. When you see someone who's having an asymmetrical smile. You check to see their smile and see if they're one of their side one of the smile or one of their face droops or appears uneven. The A is used for arms. Evaluate the person's arms by asking them to raise both arms up and see one of the arm drifts down or is weaker than the other.

The S, evaluate the person's speech. Ask the person to repeat simple phrases. Look for slurred speech, difficulty creating sentences, or the inability to speak coherently. Then is a T is for time, and if any of these signs are picked up or seen, then time is up the essence. You have to, it's really crucial, critical to act quickly and call emergency services and seek medical attention.

Host: Yeah, so you've emphasized this a couple times now. Why is it so urgent to reach out for help immediately?

Fahed Saada, MD: It's important because we are, I want to say, limited on the treatment for stroke, but at the same time, if we can have patients present immediately after the sudden onset in stroke symptoms, the outcome with treatment is really extensively, significantly better than the patients that present a day or two later.

Furthermore, the treatment is really restricted to a narrow window for patients can only receive treatment within the first four and a half hours of their last known well time. And this is important. Not really when the symptoms started, it's when they were seen last normally up to sometimes four hours.

But outside that window it's really hard to provide any treatment because it can cause harm to the brain if treatment is provided outside the 24-hour window.

Host: Okay, so speaking of treatments, what are the types of treatments that are available for strokes?

Fahed Saada, MD: That's right. So the treatment options for stroke depend on whether the stroke is an ischemic stroke, which is caused by a blockage in the blood vessel, or it's a hemorrhagic stroke, which is caused by a bleeding in the brain. Ischemic stroke tends to be more prevalent, presenting in about 85% of strokes while hemorrhagic strokes, are less common and presenting in about 10 to 15% of strokes. So the goal of treatment is to restore the blood flow to the brain. We want to minimize brain damage and prevent future strokes. So if we break down into ischemic and hemorrhagic, ischemic stroke treatment includes what we call thrombolytics or clot buster medication.

We administer these medications through an IV to hopefully achieve a clot dissolving effect with these medications within a few hours so we can restore the blood flow to that part of the brain. The more advanced intervention now, if there is a big artery in the brain that has a clot causing lack of blood flow to that part of the brain, we could actually do a procedure called mechanical thrombectomy.

This is done by specialized neurosurgeons that go in, in a catheter just like a cardiac catheterization, but instead of going to the heart, they go to the brain and remove the blood clot that's causing the lack of the blood flow or the stroke. This is again typically performed on large artery blockage and has to be done within 24 hours. Outside that window of 24 hours becomes risky to perform that procedure.

Hemorrhagic stroke treatment includes medication management which is mostly focusing on controlling the bleeding, reducing the blood pressure and stabilizing vital signs. Some of these medications, for instance counteract the effect of blood thinners because a lot of patients that come in with bleeding strokes are on medications that thin their blood. So we would want to reverse those medications. Then in a small group of patients, we have to refer them to outside centers with surgical capabilities such as a neurosurgeon would do surgical intervention that would remove the blood clot, repair damaged blood vessels, or relieve pressure on the brain that's caused by the bleeding.

Lastly, what's important in both of those types of stroke; it's important to have adequate supportive care that include, includes rehabilitation, participating with physical therapy, occupational therapy, speech therapy is really necessary to regain lost function and improve recovery.

Host: Thank you for the comprehensive breakdown of treatment. I definitely have heard that treatments have improved in recent years through medical advancements. Can you speak to this?

Fahed Saada, MD: Yes, yes. So, one medical intervention that has gained attention in recent years for the treatment of ischemic stroke is the use of tenecteplase which is commonly referred to as TNK. Now, TNK used for decades for in, in the cardiology world, but we finally caught up and are using this clot buster medication that's similar to the previous clot buster medication called alteplase, but it has some potential advantages.

And the advantages here are really that TNK is really a genetically engineered protein that works by activating the body's natural clot dissolving system to break down blood clts. So it because it's genetically engineered, we kind of made it to have a longer halflife than the previous medication alteplase, which means it stays active in the body for a longer period of time.

The property allows us to give it in a single large bolus, one time dosing instead of the other medication we were using alteplase, which we needed to give it as a drip for about an hour. So it no longer requires continuous infusion over a specific time period. So that frees up nurse to to do something else rather than watch this medication drip for a whole hour, and it allows us to give treatment immediately without waiting for the whole medication to go in our system that takes about hour or so. So the potential benefit of TNK for the treatment of ischemic stroke again includes the effectiveness of the medication. Really, it's slightly superior to the previous treatment, results in better reperfusion, which means restoring the blood flow to the brain and improves the overall clinical outcome. It's very convenient. Again, it's just a one time five second bolus and it's in our body, and the safety hasn't really shown that it's less safer. It's actually shown to have a similar safety profile to the previous medication alteplase. There's no evidence of significant increased risk of bleeding with this medication. So that's an advantage.

The other interventions that we continue to advance and would be what we call mechanical thrombectomy, where if the patient, approximately a small number of patients actually have what's called a large vessel occlusion, and a whole vessel is blocked as a result of the clot in the brain. And this is where comprehensive stroke centers are actually able to go in the artery and remove that clot. And this has been a breakthrough treatment over the last several years because patients are going from potentially becoming nursing home residents because of the severe disability to going back to work in two weeks. So, it's definitely have been a plus, but again, we come back and emphasize on, you got to present early, you got to present on time, do not wait before seeking medical attention.

Host: I mean, these advancements sound amazing and I do want to just emphasize what you were talking about there at the end, just making sure to get in early when you start to recognize the symptoms. So I want to ask you a practical question. If someone is recognizing those FAST symptoms in themselves or a loved one or even some of the atypical behaviors that you've covered. What should they do immediately? Should they rush off to the hospital? Should they call 911? What is the best thing to do?

Fahed Saada, MD: The best thing to do is call 911. They're better off getting in to the ER because the EMS would pre notified us that they're coming in and we are right there at the door waiting for them, rather than trying to drive themselves, get stuck in traffic and get stuck in the triage desk waiting to get checked in. Now, call 911, get here immediately.

Host: Yeah, and I think that piece is important. There is some pre triage that is done and I've also heard that those operators are trained to kind of identify the type of stroke it is and can route you to the right place. Is that correct?

Fahed Saada, MD: That's right. I'm proud to say that at St. Joseph's Hospital we've been treating stroke patients and we are a primary stroke center certified by the state to treat stroke patients. So our front desk is ready to go train to know if they detect any of these signs and symptoms, even the atypical signs and symptoms. They have the push button where they can call a code stroke and get us involved immediately.

Host: That is amazing. Well, Dr. Saada, I really appreciate your time and just before we sign off, is there anything else that you'd like to share with our audience today?

Fahed Saada, MD: Absolutely. I just want everyone to know that 85% of stroke can be preventable by adopting a healthy lifestyle, including regular exercise, balanced diets, smoking cessation, and managing underlying health conditions such as diabetes or high blood pressure. This can reduce the risk of stroke significantly.

Host: Dr. Saada, thank you so much for your time.

Fahed Saada, MD: Thank you.

Host: That was Dr. Fahed Saada, a neuro hospitalist and the Stroke Program Director at St. Joseph's Health. If you witness someone having a stroke, call 911 immediately and ask paramedics to take them to St. Joseph's Health Hospital. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

Thanks for listening to this episode of St. Joseph's Health Med Cast by St. Joseph's Health. I'm Prakash Chandran. Stay well.