Scott Webb (Host): Strokes are common, and it's important for all of us to know and address our risk factors. And I'm joined today by Dr. Neel Khanna. He's the Medical Director of the Cardiovascular Institute at Montefiore St. Luke's Cornwall, and he's here today tell us more about strokes, how to prevent them, and the importance of seeking medical attention quickly if we believe that we are experiencing a stroke.

 This is Doc Talk presented by Montefiore St. Luke's Cornwall, I'm Scott Webb.

Doctor, it's great to have you on today. We're going to talk about strokes and how prevalent they are, treatment options and so on. So as we get rolling here, what is a stroke and are there different kinds of stroke and really what causes them?

Dr. Neel Khanna: In general, a stroke is a lack of blood flow to the brain, and there's usually two main mechanisms that this happens, either because there's a lack of blood flow to the brain because of a clot that is blocking blood flow or a small vessel that becomes occluded, causing a lack of blood flow.

Or the second type of stroke is a bleeding type of stroke where there's actually bleeding inside of the brain, which will cause a lack of blood flow and put pressure on the brain and cause certain neurologic symptoms.

Host: Yeah. When we think about, uh, plaque in our arteries, how does that form and how does this all sort of tie into strokes?

Dr. Neel Khanna: Well, it's very risk factor based and that's why, you know, doctors often emphasize the risk factors. Plaque is a very complex thing. Generally speaking, it accumulates in all arteries of the body. But, we worry most about the heart arteries and the arteries that go up to the brain. Generally there's damage to the wall, the inner lining of the artery, and that can happen from age, which is a major risk factor.

High blood pressure, which is known to cause what we label as intimal damage or damage to the artery. High cholesterol, diabetes, smoking, which has toxins inside the blood. All of these are risk factors that kind of put pressure on an artery wall and causes you know some damage and inflammation. And on top of that inflammation accumulates plaque or cholesterol.

And on top of that plaque over time, it becomes calcified, it becomes enlarged. And what we worry about in the end is either a clot forming on top of that plaque or a rupture of that plaque, which causes a lack of blood flow. So often what we push our patients to do and ourselves to do is to try to prevent that from happening before, you know, the problem becomes too big. And the way we prevent it is by controlling all of those risk factors, blood pressure, diabetes, cholesterol, smoking, your weight. All of these are strong factors in the progression of plaque and in strokes.

Host: Yeah, they are for sure. And I mentioned in my intro there, we were going to talk about how prevalent stroke is. So you're talking about the risk factors, which sounds like a lot of people I know and maybe even myself. So how prevalent is stroke? And I've heard that younger people used to be like maybe after 50 was more common, but it seems like younger folks are having strokes today.

So maybe you can tackle that, you know, how prevalent is it? And maybe why are younger people experiencing strokes?

Dr. Neel Khanna: It's a big problem inside the United States. Some estimates are that it's the fourth leading cause of morbidity and mortality inside the US. Some models say the fifth, but either way, it's a significant cause of both morbidity and mortality. Strokes are not always deadly. And so a lot of times they just leave patients with deficits, but deficits that make it very difficult for them to carry on the way they were living prior. We are noticing a younger trend towards people having strokes, and often that means a different mechanism. Now, the obesity epidemic and earlier onset of diabetes is definitely contributing to that. And that could be a whole discussion in and of itself in terms of unhealthy eating and drinks that contain a lot of sugar in them that have caused and partially contributed to the obesity epidemic. But all of this causes more premature plaque buildup. And so that can cause both heart attack and stroke risk in people. But also there are some other causes that people may not know as much about, you know, when a younger person, and when I say younger, I'm talking about less than the age of 50, but especially even younger than 40, when they come in with a stroke and it's definitely a significant stroke, we start thinking about other potential causes like blood clots that could have formed in the heart or blood clots that could have formed in the veins of the body and may have traveled up to the heart and got into the brain, through a hole in the heart called the patent foramen ovale, which 22% of the population has. And so it allows these blood clots to travel to the left side of the heart and go to the brain. So you know, the younger the patient is, the more we think about these other types of causes, especially if they don't have a lot of the classic symptoms like high blood pressure and diabetes or smoking.

Host: Yeah, and I know they say that time is brain. So time is heart for the heart. Time is brain when it comes to stroke. So let's talk about what actually happens. What are some of the classic symptoms, signs and symptoms of a stroke?

Dr. Neel Khanna: Yeah, generally speaking, it's a very recognizable deficit, meaning you, you know, the patient or you know the person, it's a loved one, it's a family member, or it's yourself and you notice that there's something wrong. We often push for our patients an acronym FAST, which is often used. And basically you ask the patient to smile. You look at the smile, and you see for any crookedness of the smile that you're not used to, you ask them to raise their arms and you look for any drift of their arms when they're trying to raise it upright. We're looking for unilateral changes in body function, namely one side of the body that's not functioning the way that it was before.

The brain works by innervating opposite sides of the body. So the left side of the brain generally controls the right side of the body, and the right side of the brain controls the left side of the body, so we're looking for unilateral changes. Problems in speech. If you're not able to get out the words that you were before, if they're rolling around in your mind, but you just can't verbalize it, these are all worrisome symptoms and the sooner you recognize them or a loved one recognizes them and brings you to attention at a hospital or a medical facility that can treat you with potentially lifesaving medication, the better it is because the longer you wait, the more damage is done to the brain.

Host: Yeah, absolutely. Right. If it, whether it's us or a loved one, call 911. Get to the hospital as quickly as possible. Time is brain. I mentioned to you earlier, I've had some other experts on that maybe don't love the term mini strokes, but whether it's mini strokes or TIAs, you know, that are maybe not these sort of catastrophic type strokes; are the signs and symptoms any different and should we take them any less seriously than a major stroke?

Dr. Neel Khanna: Often not, I mean, obviously our innate tendency is to be more drastic with more drastic symptoms. And often with TIAs or smaller strokes, the symptoms are more subtle, but they're often very easily recognized, especially for the person himself or herself, or for a loved one who sees them all the time.

 Generally speaking, it depends on what type of artery is blocked. If a larger artery like the middle cerebral artery is blocked; often the deficits are extreme and significant. If the clot is smaller or the plaque is smaller and goes up a higher branch, you may have less deficits, but they're still important.

The main reason that we push the term mini stroke or TIA is because often these are sort of warning signs that there may be something bigger coming and often some research shows that almost 20 to 30% of people who have a TIA will have a larger stroke in the next two weeks. So sometimes people don't recognize it or they shrug off the warning signs; which may be as simple as dizziness or, you know, a transient, very short trouble speaking, that resolves pretty quickly and we attribute it to being tired or something. That may be a warning sign that a little piece of a clot or a little piece of plaque went up to the brain and gave a warning sign, and that there's something that is more vulnerable that may be following in the next couple of weeks.

So I push and emphasize to my patients or people that I meet that you know you should recognize all symptoms. And when it comes to a deficit in your ability to function, whether it be speech or walking or talking, you should seek immediate attention to make sure something serious is not going on.

Host: Yeah. Right. If it's not normal for you to be dizzy, then assume the, you know that if you are dizzy, even if it goes away quickly, that there's something else going on. And this may be the warning sign. This may be the one warning you get before a major stroke. So let's talk about the treatment options, whether that's once folks come in, in the ambulance or afterwards if they've had a mini stroke or a TIA and we're trying to prevent the big one. What are the different treatment options?

Dr. Neel Khanna: The main reason that we push people to immediately go to a hospital center preferably, or at least in urgent care, somewhere where they can transfer people with EMS is because when you come into a certain window, you know, three to four hours, within the hospital from the onset of your symptoms, you are eligible for a medication that is alytic.

Basically, it breaks up or busts clot that is there in the brain and allows blood flow to be restored to the brain. These are very powerful medications. They do have bleeding side effects, but the benefit that they have is immediate. You'll notice that right away patients are able to speak better, are able to function better because these medications are able to break up that clot and restore the blood flow to the brain. If you are outside of this window, this time window of recognition, you are no longer eligible for these medications because they can cause more harm than good. The clot may be too solid to break up by that point. So we really emphasize to patients come to the hospital as soon as possible so that you can be within this window and be treated with potentially, you know lifesaving, or at least you know, life improving treatment. If it's past that point or if it's a TIA, often you will get a workup including a CT scan of the brain or an MRI of the brain. We will investigate the blood flow to the brain with ultrasounds and CAT scans to make sure we figure out what the cause of that stroke or TIA could have been, and then there are very important antiplatelet medications, for example, aspirin, clopidogrel, Aggrenox. These are some of the names of medications that work against platelets that will help prevent clotting and will help prevent future events. And then also, like we mentioned at the beginning of our talk, recognition of the risk factors, cholesterol, smoking, all of these are things that can be addressed that can help prevent that bigger stroke from happening down the line.

Host: Yeah, and as you mentioned earlier, you know, prevention is key. It's much, not easier, but it, it's much more effective to address the risk factors before we have a stroke than to end up in an ambulance, in the emergency room and all that that implies. Doctor, thanks so much for your expertise today. This has been great. You stay well.

Dr. Neel Khanna: Thank you. Thank you for having me.

Host: And visit montefiore slc.org for more information about the Cardiovascular Institute.

 And if you found this podcast to be helpful, please be sure to share it on your social channels and be sure to check out all the other Doc Talk episodes. This has been Doc Talk, the podcast from Montefiore St. Luke's Cornwall Hospital. I'm Scott Webb. Stay well.