Transcription:
CVA / Stroke Education

Alyne Ellis (Host):  What exactly is happening when someone is having a stroke? And if medical intervention is obtained soon enough, can some damage be averted? Here to tell us more is Dr. Neel Khanna, an Interventional Cardiologist at Montefiore St. Louis Cornwall. I'm Alyne Ellis. Welcome to Doc Talk presented by Montefiore St. Luke's Cornwall. It's a pleasure to have you here.

Neel Khanna, MD (Guest): Hi, how are you?

Host: I'm fine. Thanks. So, what is happening to us when we have a stroke?

Dr. Khanna: So, basically a stroke is twofold. It can either be because there's a lack of blood flow because of a blockage in one of the arteries that go to the brain, or because there's a bleed in the brain that's putting pressure on the brain. One of those two things are both called strokes.

Host: And is there a difference in the types of strokes that we can have?

Dr. Khanna: Yes, they basically have differing symptoms and obviously different causes. Number one, people who suffer from a brain bleed, which is either an intracerebral hemorrhage where it bleeds within the brain or on the outside covering of the brain, which is called a subarachnoid hemorrhage; those people usually present, unfortunately with pretty severe sudden symptoms, that slowly, if at all, get better. They're actually managed much differently also because we want to limit the amount of bleeding. So, blood pressure control becomes extremely important because obviously the higher the blood pressure is, the more bleeding that could be inside the brain. So, we pay special attention to that. Patients who have this type of stroke with bleeding, are monitored very closely in an intensive care unit. You do not want to give these patients any type of blood thinners or anything that within their blood at all cause it could make the problem even worse. Oftentimes, if we're concerned that there could still be more bleeding, sometimes patients require a specialized procedure where a doctor who's an interventionalist can send catheters up and look at where the bleeding is coming from and possibly stop it with special material like coils.

On the contrary, I think the type of stroke that most people are familiar with is an ischemic or thrombotic stroke, where either through the carotid arteries that go to the brain or some of the smaller vessels that go to the brain become blocked up. And this can happen because of plaque deposition. It can happen because of a blood clot that forms somewhere in the heart or in other vasculature of the body and finds its way to the brain and clogs up one of the arteries.

This is a troublesome stroke, because we want to try to restore flow in this case. So, in certain cases, blood thinners become very important as opposed to the other type of stroke. Often in patients who present quickly with their symptoms, we give medication that can help break through this kind of a clot or plaque so that there can be a restoration of flow so that people can regain a lot of the functions that they were having previously.

Host: Is there a window of time when a medical intervention can make a difference to the outcome Doctor?

Dr. Khanna: Yes, I think this is probably the most important message for strokes for the general population. The sooner that you can come and seek medical attention, the better when you're having a stroke or having symptoms that you're concerned about. Deficits, trouble speaking, problem with motor function that is sudden. The sooner that you're able to come in, the better your recovery can be long-term. Obviously the more time that passes, the more damage is done to the brain, and the more lasting some of these deficits could be. So, generally speaking, we treat patients with some of these strongest medications to try to break through some of these clots in the first four and a half hours after the onset of their symptoms. We go totally based on patient symptoms. And we start at time zero from when they feel that the symptoms first started. So, obviously that needs a lot of awareness or someone who's with the patient who noticed it. Four and a half hours is the general time period we give, we really would like for patients to come in the first three hours of symptoms. Optimally, we would like them as soon as they feel the deficit to make their way to an emergency room so that they could be evaluated by physicians who can potentially treat this. Time is brain material. So, the less time it is, the more brain that we can save in the end.

Host: And how successful can immediate intervention?

Dr. Khanna: With time, we're realizing that they're actually extremely successful. Obviously giving something like Alteplase, which is a strong lytic medication, which will break through clots can often have very good results for patients with more than 50% of patients having pretty significant recovery very quickly. Obviously these medications are very strong, so the patients have to be monitored very closely. You know, now, in this day and age, even with ischemic strokes where there's lack of blood flow to the brain, even in the first 24 hours after the onset of symptoms, patients can go to certain hospitals and be transferred to certain hospitals where they have specialized interventionalists who can go in and actually suck out some of the clot that is there.

So, that has also shown extremely beneficial results for the patients who are suffering from this. So, in the end, in this day and age, most hospitals, including this hospital, Montefiore St. Luke's has teams that are specialized, that are on call for stroke codes. So, when an emergency room physician sees a patient that they are concerned about and it's in the first couple of hours after the onset of symptoms, up to four and a half hours, or sometimes even 24 hours, because like I said, we can do those procedures in the first 24 hours; they call a special code for these specialized neurologists to come and evaluate the patient immediately so that they can get immediate attention. These teams have been created because of such successful results that they've seen with some of these medications and procedures. So, most hospitals in this day and age have these specialized teams and they should really be taken advantage of.

Host: What are the signs of a stroke that we need to recognize at home?

Dr. Khanna: The signs of a stroke can obviously vary, it depends what the functional status of the patient was beforehand, obviously. The most classic symptoms that people feel and see are trouble speaking trouble getting the words out. Obviously, sometimes people also have trouble with their eyesight. A certain part of their visual field can be missing. For example, on the right outside or the left outside they're not able to see. Classically the findings of a stroke, people have weakness and motor deficits, usually on one side of the body. For example, if it's a left sided stroke, often people will feel motor deficits on the right side, the opposite side.

Anytime you have a deficit in one side of the body and not the other, you should really be concerned of whether this is a stroke. Most of the cases that we see, patients have family and loved ones around them. So, often they're able to recognize the signs. They may simply see that one side of the face is drooping, as opposed to how they were the previous day or even a couple of hours before they can often tell little changes in the way the patient is speaking.

And often we see that family members are the first ones who raise concern over what's happening. Generally speaking, though, trouble speaking, trouble with eyesight and visual fields and motor deficits and lack of strength are there primary reasons that people come and seek medical attention.

Host: And what should a person do right away when the signs are recognized?

Dr. Khanna: The first thing to do is to find someone who can help them get to an emergency room. That's the primary goal. So, if they're able to, pick up the phone and call someone and tell them they are concerned, pass that message on. If there's someone in the house to try to get them often, there's limited amount of times that especially if people are having motor deficits, there's limited amounts of things that people who are experiencing the symptoms can do. Obviously, I am not recommending for people to get in a car if they feel that they have deficits, cause that can be dangerous for themselves and others. But the first thing they should do is either find someone close to them who can help them and bring them to an emergency room or if they are unable to, to dial 9-1-1 and get medical attention so that trained medical experts can come pick them up and take them to the hospital. Seeking medical attention is the primary thing that they should do. And so whatever gets them there sooner is what they should do.

Host: Should we take an aspirin when we see the signs of a stroke?

Dr. Khanna: You know, as contrary to let's say heart attacks, we often say to patients who are experiencing chest pain, to take aspirin so that if there is a blood clot, it can slow the progression of that blood clot. Strokes are a little different though. And it depends a lot on some of the history of the patient. Obviously for someone who has new deficits but they are due to a brain bleed, like we talked about, a bleeding stroke rather than an ischemic stroke, taking blood thinners and aspirin can actually be harmful in those cases. So, there is not a general recommendation for people to take aspirin before seeking medical attention. I think when there are stroke symptoms and deficits, like I said, the primary thing to do is to seek medical attention.

In the emergency room, the physicians there will be core trained to recognize the symptoms will get quickly a CT scan, a CAT scan of the brain, which will distinguish on whether this is a bleeding type of a stroke or an ischemic type of a stroke where there's lack of blood flow. That will determine the future management. That CAT scan can be done very quickly in this day and age, as preference are given to patients who have symptoms of a stroke. So I would say, wait until you're able to be evaluated in an emergency setting to make those kinds of decisions.

Host: Is there anything else that you'd like to add Doctor?

Dr. Khanna: The only thing I think I would like to say is that luckily it's time has passed, medical attention and medical treatment has really advanced in this day and age. The way stroke is treated is very different than even 10 or 20 years ago. There are specialized centers where patients who have residual symptoms, even after receiving clot busting medication, that they can be transferred to in potentially the clot can be sucked out with special catheters. Even with patients who haven't gotten it because they're outside of that four and a half hour window, they can also get some of these treatments. I think in this day and age, more than previously, prompt medical attention is so important because there is a lot of patients who have these symptoms of stroke and who get adequately treated very quickly and have minimal deficits, even a couple of months down the line. Obviously, the mainstay of treatment after a stroke, is physical therapy and training the body and the brain to recover after something like this. But our primary goal is physicians is to stress the preventative measures.

Keep an eye on your blood pressure, control your blood pressure as best as possible. Keep an eye on diabetes. And cholesterol levels because all of these risk factors are known to really increase the risk of stroke. Your stroke risk drops dramatically by just doing something as simple as seeing your doctor and having your blood pressure controlled adequately. We would rather not treat anybody for stroke if we could prevent them all. And that's the ultimate goal.

Host: Thank you so much. It was a real pleasure to talk to you.

Dr. Khanna: Thank you too.

Host: Dr. Neel Khanna is an Interventional Cardiologist at Montefiore St. Luke's Cornwall. I'm Alyne Ellis. thank you for listening to this episode of Doc Talk presented by Montefiore St. Luke's Cornwall. Head on over to our website at montefioreslc.org to get connected to one of our providers. And if you found this podcast helpful, please share it on your social channels and be sure to check back in soon for the next podcast. Thank you for listening.