Scott Webb (Host): Time is of the essence when you or a friend or a loved one is having a stroke. And my guest today is here to explain the different types of strokes, treatment options, and why it's imperative that we not ignore the signs and symptoms of stroke. And I'm joined today by Dr. Asif Khan. He's a cardiologist with Montefiore St. Luke's Cornwall.

 This is Doc Talk presented by Montefiore St. Luke's Cornwall. I'm Scott Webb. Dr. Khan, it's nice to have you here today. We're going to talk stroke awareness, and what does that mean? Like, I know time is brain, time is of the essence. I know a little bit about strokes, but you're the expert. So, let's start there. Like, what are the most common early warning signs of stroke, and how can patients and families recognize them quickly?

Dr. Asif Khan: Strokes, basically, it's called BE FAST, B-E-F-A-S-T. So, the acronym is used to recognize, like, warning signs of a stroke. So, the B stands for balance issues. The E stands for eye issues, vision. F is for facial issues. You know, things like drooping of the eyelid, that there is drooping of the face, the lips, the lower lips. Arm issues where patients may complain of weakness in the arm, the arm may drift. If you ask them to put your hands up, they might fall slowly or drift down. There's issues with the speech. And then, very important is also time. We have to know when did the symptoms start and when you show up to the ER.

Host: Yeah. As I mentioned there before we really got rolling here, time is of the essence, time is brain. And I know, Doctor, there's different types of strokes, right? So, maybe explain to us, like, how the different types of stroke differ in terms of the symptoms and treatment.

Dr. Asif Khan: So, basically, there are two types of stroke. So, majority, 70%, is something called ischemic stroke. So, what that means is the brain itself is divided into different segments, and each segment is supplied by a blood vessel. Now, if there is any restriction of blood flow to that segment, that segment will suffer. And this is known as ischemic stroke, and that is 70% of the cases. And then, 30% of the cases, it is called hemorrhagic stroke, which basically means that there was a rupture of blood vessel, or there was a bleed inside the brain. And the bleeding itself, it pushes the brain against the skull, and that causes the signs and symptoms of stroke.

Host: And then, Doctor, would the treatment be different, right? Depending on which type of stroke a patient was having, it sounds like treatment would be different. And so, it's important, as you say, to know when did the symptoms start, what symptoms a patient is having, right? So, give us a sense then of the difference in treatment options.

Dr. Asif Khan: Oh, yeah. Treatment completely varies. So, for ischemic stroke, I mean, you have to first find out what's causing the stroke, what causes ischemia, right? And usually, if you look at the big factors, it's usually a thrombus or a plaque. So, these are small blood clots, which may block the blood vessel and prevent blood from flowing distally into the brain. So, for those kind of issues, what you do is you give a medication like Alteplase, what it does is it breaks down the clot.

Host: Okay.

Dr. Asif Khan: And for hemorrhagic stroke, because there's a bleed inside your head, the fastest thing to do is to evacuate the blood so that the pressure on the brain does not build up.

Host: I think I've heard this, Doctor, but this is anecdotal at best, but is there like a golden window, if you will, for stroke treatment in terms of, like, getting patients to the hospital and treating them, and maybe what advances have been made to extend that treatment timeline I feel like I've heard from other experts that there's more time. Time is still of the essence, but that there's more time than there used to be.

Dr. Asif Khan: That is correct. So, initially, we had only three-hour window. So, if the patient presents to the hospital with stroke-like symptoms within a three-hour window, and they're having ischemic stroke, then we would treat them with this medication called Alteplase, clot busters to break down the clot.

Now, what they have done is they have extended that time period from three hours to 4.5 hours. So, now, patients have more time to come in to get the medications. And also, patients who are outside the window, say, who comes in for more than 4.5 hours, four and a half hours later, there are other interventions that we can do. Like, we can go inside those blood vessel and extract that thrombus.

Host: Okay. Yeah. So, the golden window, if you will, is that four and a half hours, which is certainly significantly longer than it used to be. And time is of the essence, and we don't want folks ignoring the symptoms or assuming the symptoms may just sort of, you know, write themselves or go away. And you mentioned Alteplase a couple of times. I wanted to get a little better sense, these thrombolytic drugs, if you will, like, how do they work? They're clotbusters, but how does that work?

Dr. Asif Khan: So, basically, these medications, there is Alteplase, there is tenectaplase. So, these medications, they go in and they bind to the clots itself. Inside the clot, there is a substance which is known as fibrin, and it goes and it binds with the fibrin. And what it does is, once it binds, it starts breaking them down.

Host: Okay.

Dr. Asif Khan: And once it breaks down, it stays in our system. I think Alteplase is about one hour in total it stays in our system, and it does its job. And the tenactaplace, it's the newer medication that stays in our system for up to two hours. And once you have been treated with these medications for 24 hours after the treatment, we should avoid any blood thinners, because they are still in your system.

Host: Yeah. Wondering, Doctor, the role, if you will, that AFib and maybe other heart conditions play in increasing our stroke risk? And how can these be managed effectively to not only manage those conditions, but also avoid strokes?

Dr. Asif Khan: Correct. So, AFib is a big risk factor for stroke. So, the way the AFib causes stroke is, when you have AFib, there are different pockets inside the heart. And one of these pockets is called left atrial appendage. So, in that pocket, sometimes, the blood actually becomes stagnant. And once it becomes stagnant, it forms a clot.

And these clots can sometimes dislodge. And as the heart is pumping, once they get dislodged, sometimes it may get pumped up into the brain. And once it goes up, that small clot might block one of the blood vessels. And you end up with some kind of ischemic stroke.

Host: Yeah.

Dr. Asif Khan: And it might go on both sides of the brain. So, usually, when we scan the heads of patients, and we find it on both sides, the AFib is high on differential because it's on both sides. So, we think, like, you know, it's just going and showering.

Host: Interesting. Yeah. So, obviously, we don't want AFib to go untreated, or any other heart conditions, not only because of those conditions and the effect they can have on folks, but also because they increase our risk for stroke, right?

Dr. Asif Khan: Correct.

Host: Yeah. Maybe this is a two-part question, Doctor. Folks who have a stroke, have one stroke, are they more likely to have recurrent strokes? And for folks who do have recurrent strokes, are there may be some different, you know, strategies, effective strategies to help prevent subsequent or recurrent strokes?

Dr. Asif Khan: So, first of all, patients who have strokes are at risk of having subsequent strokes. Yes, that's correct, including patients who have TIA, which is like a stroke, but only for 24 hours. Like within 24 hours, the patient's had the signs and symptoms of stroke, and then it reversed, and he's back to his normal baseline.

So, the mechanism is, basically, a patient had a small clot, which blocked the blood vessel. And then, by itself, it dissolved and blood flow was restored. So, it happened very quickly, that's why the patient did not have any residual neurological damage, okay? So, that's TIA. But once you have a stroke, you are at high risk of having recurrent strokes, yes. But what you have to establish is why did the stroke happen. That's the most important part.

There are risk factors for stroke, and I'll give you some of the risk factors. Some of the risk factors includes, like, men more than women are at a higher risk; if you're elderly more than the age of 80; African Americans, Hispanics are at a higher risk in terms of race. If you have a family history of stroke, like, mom, dad, then you're at a higher risk. And then, all the risk factors which are modifiable, things like high blood pressure, diabetes, high cholesterol.

Host: Sure. Smoking,

Dr. Asif Khan: Smoking, correct. Alcohol and then aFib, obviously. So, all these factors, you have to address one-by-one and make sure that if they are not addressed, patient are at risk of having recurrent strokes.

Host: Right. Yeah. So, we need to know our risks, you know, what our risk level is. We need to do address them as best we can, especially the behavior-lifestyle things that we can do.

Good stuff today, Doctor. I feel like we're just kind of scratching the surface. But let's finish up here today, and talk about the long-term complications of strokes. I've known folks who had strokes, and you'd never know they had a stroke. And then, I also know other people who've had strokes, who have trouble with one side of their body or the other, they walk with a cane, there are definitely limitations. So, in terms of those complications, what strategies do you recommend that are, you know, the most effective, I guess, in just sort of living, you know, after you've had a stroke, dealing with the complications of a stroke?

Dr. Asif Khan: For the stroke, it basically depends on which segment of the brain got affected. So, you can have all the way in the spectrum. You can have it in an area which does not have any physical function, and those patients will have stroke, but will not have any symptoms.

However, there'll be other patients who will have some cognitive issue, in terms of thinking, processing. Patients if they have a stroke in their language area, they will not be able to talk, or they will be having something called slurred speech. And for that, you need speech therapy. They may have issues with swallowing. The most common is, like, weakness and balance issues for which you need physical therapy, occupational therapy. And then, there is always a sensory loss,. There's a possibility for which you have to relearn the sensory system. And then, you may also have bowel and bladder incontinence.

Host: Yeah. Well, I definitely appreciate your time and your expertise today, Doctor. I learned a lot. I'm sure listeners agree. Thank you so much.

Dr. Asif Khan: Yeah, thank you. I'm very happy to be on the show. Thank you so much.

Host: And to learn more about the Kaplan Family Center for Cardiovascular Medicine and Interventional Radiology, visit montefioreslc.org.

 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.