Play PodcastPlay Download PodcastDownload

Transcription:

Scott Webb: Many strokes are preventable and reversible if we see our doctors regularly, treat our high blood pressure and call 911 at the first signs of a stroke. And joining me today to emphasize these points and tell us about the stroke team at SVMH is Dr. Rene Colorado. He's the Medical Director of the Stroke Center at the Salinas Valley memorial Healthcare System.

This is Ask The Experts, a podcast from Salinas Valley Memorial Healthcare System. I'm Scott Webb. So doctor, it's such a pleasure to be on with you. We're talking about stroke today and, you know, signs, symptoms, treatment, and so on. But just as a base level here, what is a stroke exactly and when does it occur?

Dr. Rene Colorado: Well, thanks for having me. It's a great pleasure being here. So a stroke occurs when the blood supply to a part of the brain is interrupted. So this prevents the tissue from getting oxygen, nutrients and, eventually, brain cells die from this. The brain is actually very, very sensitive to lack of blood supply. And so stroke is a medical emergency.

Scott Webb: It definitely is. And we're going to discuss today the importance of calling 911 at the first signs and what are those signs exactly. Before we get there though, are there different types of stroke?

Dr. Rene Colorado: Yes, actually, there are. We classify stroke into two main categories. So one of them is what we call ischemic or sometimes we call it a dry stroke. These occurs when a blood vessel in the brain gets blocked. So blockage of a blood vessel leads to interruption of the blood flow like we were discussing earlier. So the blood supply doesn't get to the brain and brain cells die from that. This is the main type of stroke in most patients. It's about 70% of all the strokes we see.

The other type we call it a hemorrhagic or wet. It means there is bleeding inside the brain. Most of the time, these happens from a weakened blood vessel. So the blood vessel ruptures and the patients get bleeding inside the brain. These also causes decrease of blood supply to the brain, and so the brain cells die from that.

There are a few other categories within the hemorrhagic stroke. The very main cause of that is high blood pressure. So when someone has high blood pressure and is uncontrolled, that buildup of pressure can lead to rupture of a blood vessel.

There are other causes such as malformation of the blood vessels in the brain. Another common one is aneurysms. These are little outpouching in a blood vessel and that can rupture. And some patients are born with malformations of the blood vessels, those sometimes can rupture. But by far, high blood pressure is the main cause of these other types of hemorrhagic stroke. This one is about 30% of all the strokes.

Scott Webb: And you mentioned there about high blood pressure. And I think one of the tricky things with blood pressure is that most of us don't know when we have high blood pressure and it really emphasizes the importance of getting yearly physicals, those, you know, checkups and screenings, and really seeing our doctors at least once a year, right?

Dr. Rene Colorado: Absolutely, Scott. That is an excellent, excellent point you made. Uncontrolled high blood pressure is a very, very powerful risk factor for stroke, and is absolutely of importance to have regular checkups. You know, many people tend to think that they feel when they have high blood pressure, but we know that's very rare. Most of us don't know that we have high blood pressure. And the only way we can know is actually by measuring the blood pressure and then doing regular checkups with a physician, so absolutely very important.

Scott Webb: Yeah. It's so important we see our PCPs. And I think back to, you know, TV shows and movies and people will say things like, "Oh, my blood pressure is so high today." And you know, "You doctors, I don't have to tell you," like we know that's not how it works, right?

Dr. Rene Colorado: Exactly. Exactly. I don't think we can emphasize that point more. Undetected high blood pressure is so common and, you know, many times it just leads over time to problems with kidneys, with our eyes. But definitely one of the worst, probably the worst complication is a rupture of one of the blood vessels in the brain. And, you know, in my practice, I have noticed that we are starting to get more patients who are younger having stroke. You know, sometimes we get patients who are in their 40s or 50s, and unfortunately, they didn't know they have high blood pressure and that led to bleeding in the brain, one of these strokes. So absolutely very important.

Scott Webb: And when we talk about people having strokes, regardless of age, what are some of the warning signs that we can be on the lookout for?

Dr. Rene Colorado: Yeah. So there are many warning signs, but I think having a big picture concept of the signs of stroke is the most important. Number one is sudden. So stroke is always sudden because interruption from a blockage or from bleeding in the brain happens in a very sudden way. So the sudden onset of any neurological symptom, any malfunction of the brain can be a sign of stroke.

But giving concrete and specific signs, you know, the best way to remember it, and those are weakness or numbness particularly of one side of the body. Some patients can develop also speech difficulty or confusion. Some patients may develop visual problems in one or both eyes. Some patients may develop sudden onset of dizziness with difficulty walking. And then some patients may have headache.

Now, with headache, it is very important to remember the sudden part. Patients who are having a stroke can develop a sudden headache. And the great majority of the time, it's a very severe headache and many times is associated with other neurological symptoms such as the ones I mentioned earlier, weakness, difficulty thinking or speech disturbances.

Scott Webb: It's the suddenness, right?

Dr. Rene Colorado: Exactly.

Scott Webb: Yeah. It's not something that comes on over time. So if something changes in you suddenly, like you have the worst headache of your life suddenly, that's when we call 911, right?

Dr. Rene Colorado: Exactly. That's really the best way of putting it. We do have, you know, and we'll discuss a little bit later, I believe, some ways of remembering what the sign and symptoms are, but you know, many times I counsel the patient, it doesn't matter that you don't remember exactly whether it was one side of their body, whether it was a leg that should be weak or speech. I think remembering that a sudden problem with your brain or with thinking or with the function of your neurological system, it should be definitely a warning sign of stroke.

Scott Webb: Yeah. It definitely is. And when we talk about who's most at risk, what are the factors? Men, women hereditary, you know, is it a family history, genetics lifestyle, all the above?

Dr. Rene Colorado: Yeah. In fact, Scott, all of the above. I would like to go into a little bit more detail. And so we think of them in different ways. The way I like to put it many times to patients is there are some that we can control, which are the ones that we emphasize. And there are some that we cannot control. And, you know, those are mainly just for knowing one's risk of stroke. But the ones that we can control, the most powerful one, it's high blood pressure like we talked earlier. So I think we would discuss a little bit about that.

The other important risk factor is heart disease. So there are multiple problems that can happen with the heart that makes someone susceptible or likely to have a stroke. The biggest ones are heart rhythm problems. So patients who have irregular heart rhythm, one particular one called atrial fibrillation is the most powerful risk factor for stroke. And then patients that have cardiac problems with the structure of the heart, such as their heart is not contracting normally, patients who have had a heart attack before, the old can have increased risk of stroke.

And then there are other conditions that not only increase risk of stroke, but also heart attack, including diabetes, high cholesterol. When someone has high cholesterol, they can develop buildup of plaque in the blood vessels, the ones in the brain and outside of the brain. And sometimes the buildup gets so severe that it interrupts with the flow. You know, the easiest way to think about it is it’s like a pipe, like a plumbing pipe. The plaque accumulates with calcium, cholesterol and that can interrupt the blood flow. And sometimes that plaque can also break off and go to the brain and cause a blockage somewhere else.

Smoking is another powerful one. It can almost double one's risk of stroke. And then a few of the other ones are important as well, lack of exercise or obesity, excessive alcohol use. So those are the ones that we can control.

Now, uncontrollable factors include age. So we know that the risk of stroke increases significantly after someone is 55, is the age that we think. Anyone above their 50s is higher risk of stroke. Gender, it's a little bit more complex. Men tend to have a higher incidence of stroke when younger, but then things switch a little bit when patients are older and women start having more strokes in older years. And then having a history of prior stroke and also history of a stroke in the family also increases someone's risk for stroke.

We also know race plays a role, and that's also a very complex relationship. But we know that, in general, African Americans and those of Hispanic ethnicity also can have increased risk of stroke compared to other groups.

Scott Webb: Yeah. And so obviously, there are modifiable things. And I know that time is brain. That's what they usually say when it comes to stroke. So I want to have you go through the FAST acronym and explain to listeners what that means.

Dr. Rene Colorado: Absolutely. So FAST is an acronym that we use in the stroke world to help patients and communities remember what the signs of stroke are and what they need to do. It's a very helpful acronym. So F stands for facial drooping, A stands for arm weakness, and S stands for speech disturbances. So those are three big symptoms of stroke. Again, like we were discussing earlier, I don't want patients or communities to think that's the only symptom. Those capture the great majority of strokes. So face drooping, arm weakness, and speech disturbances.

And then the time, we have it there to remind patients and communities that time is extremely important. Time is of the essence, as you said earlier. Because when someone is having a stroke, many times, there are things that we can do to interrupt a stroke or to lessen the consequences of this stroke. So remembering the signs and then the time is important. And so the acronym is FAST, again, F-A-S-T.

Scott Webb: Time is of the essence, because if people get to the hospital quickly enough, the symptoms or the lasting effects of a stroke can be reversed, right?

Dr. Rene Colorado: In some cases, they can. Yes. And you know, the biggest effort we are doing now in the community of stroke is really that, trying to get the patients to the hospital as soon as we can. You wouldn't believe the numbers that we see in terms of when people present to the hospital. We have medications that we can give to patients, you know, in the case of ischemic stroke, like we were discussing earlier, that blockage of a blood vessel. We have a medication that we can give and we end up using the medication, depending on the area, probably a good number will be anywhere from 5% to 10% of the time. Ninety percent of patients go without getting the medication that could reverse things. And the main factor is time. Many patients, a great majority of patients, present to the hospital too late for treatment.

Scott Webb: Yeah. They do and we've heard, you know, alarming stories during COVID-19 of people delaying care for these emergent things, right? These sudden things, whether it be heart-related, stroke-related, whatever it's been, people have been afraid to go to the hospital. And one of the things we've done through these podcasts is try to encourage people to not be afraid to go to the hospital. That's where the doctors are. That's where the nurses are. Everybody's got the full PPE. Everybody's been vaccinated. If you have a problem, if you have an issue, if you think you're having a stroke or a family member is, please call 911, right?

Dr. Rene Colorado: Absolutely. Absolutely, Scott. Stroke is one of the most important medical emergencies there are. Because unfortunately compared to other situations, it can leave the patients with serious long-term consequences. Many times patients can, you know, suffer difficulties with speech that are permanent, not able to talk again or communicate effectively. Many patients end up not being able to walk again. So the consequences of an untreated stroke are very serious and it changes a patient's life drastically.

Scott Webb: So I want to go through a scenario and have you talk about what happens behind the scenes? So doctor, let's say a person is suffering a stroke, they call 911 or somebody calls for them, what happens next for them? What's happening at the hospital? What's going on behind the scenes in preparation, you know, of a potential stroke patient being on their way?

Dr. Rene Colorado: Yes. I'm glad you asked about that, Scott, because it's very good for patients to know what happens behind the scenes so that they know that, you know, calling 911 doesn't simply mean that an ambulance is going to come and they're going to take them to the hospital. This is something that we've been working very hard in all stroke centers as a nation in improving the way we treat stroke.

So in the past, you will call an ambulance and the ambulance will take you to the hospital. At the hospital and emergency room, they'll tell you, "Oh, this patient is having signs of stroke" and the evaluation will start right there. Now, we don't do that. We actually are extremely proactive. So as soon as the ambulance is called, they arrive to the patient's house or wherever they are. They do a very quick evaluation, whether there are signs of stroke and then we get a pre-arrival notification in our emergency room. Let's say you were going in the ambulance. While you're going in the ambulance, we're already preparing the stroke team.

So the first thing that happens is EMS, emergency medical services, lets us know there is a patient coming with stroke. We alert the whole stroke team, which involves multiple people from different areas. We prepare a CT scanner. The emergency room prepares with a physician waiting for the patient at the door. As soon as the patient arrives at the door, and if it's possible and the patient is medically stable, we take them right away to a scanner to do a CT scan to try to differentiate between a hemorrhagic or ischemic stroke. We do a very quick evaluation, very thorough, but quick. And then if the timing is right, like we were discussing, many times we can give a medication that can break a clot and reverse that blockage of the blood supply. That's when it's an ischemic stroke.

When it's a hemorrhagic stroke, which many times the majority of the cases is, because of high blood pressure, we can give powerful medications to drop their blood pressure and decrease the bleeding and, you know, lead to better outcomes.

In rare cases, but there are some where the bleeding is severe or there are aneurysms or malformations that needs to be corrected surgically, a neurosurgeon will be involved. But there are multiple things that go on from the moment that a patient calls with an alert that they're having a stroke. So a lot goes on and there are many things that we can do, which is very exciting nowadays. In the past, there wasn't very much that we could do for stroke patients. Now, there are many things that we can.

Scott Webb: Yeah, you definitely can. And I think one of the great things about SVMH is that it is a certified stroke center. And I wanted you to talk about that a little bit. What does that mean exactly and how does that benefit patients?

Dr. Rene Colorado: Absolutely. Yeah. We're very proud to be a stroke center here in the area. We're a primary stroke center, which requires a certification. We undergo evaluations on a yearly basis and a more detailed one every two years. And what it means is that we're capable of treating essentially all of the strokes. There are some that require a more specialized stroke center, which is called a comprehensive stroke center. That means a tertiary center that typically is in big cities. But we are able to treat the majority of the strokes here. And then, if a patient requires a higher level of stroke center, we're able to identify that and do an efficient transfer to the higher level of care.

Having a stroke center, we have a dedicated stroke unit with specialized nurses, physical therapists, and a host of other medical providers who are dedicated to stroke patients. We also have a intensive care unit where we transfer the patients that need more detailed care, such as patients with very severe bleeding in the brain. And then as a stroke center, we also have a stroke team that has a neurologist, an emergency doctor, and multiple other providers who are specialized in stroke treatment.

Scott Webb: Yeah. And what a great team you've assembled and so great for patients, you know, to have that kind of care locally. Let's talk about recovery. Are we talking about weeks, months, years? And if there is such a range there, why does it vary so much?

Dr. Rene Colorado: Yeah. That's a very important and interesting question, Scott. Many patients ask about this and it's always a complex answer. But the variability comes from the fact that strokes in different parts of the brain result in different symptoms. So for example, if you have a stroke in an area of the brain that controls vision, the manifestation of the stroke is going to be mainly with visual problems and patients like that tend to do better than those, for example, that have a stroke in an area of the brain that affects language or in an area of the brain that controls movement. So a lot of the variability has to do with the area where the stroke happened.

But in general, the majority of the patients have the greatest recovery during the first three months. So that's why it's important to have very good rehabilitation, very aggressive physical therapy, occupational therapies, speech therapy. And so the greatest recovery occurs in the first three months, but patients continue to improve over time and particularly speech and language continue to evolve and improve long-term. But certainly, that first initial period is the most important.

Scott Webb: Yeah, it sounds like it. And before we wrap up here, I wanted to ask you, because you mentioned about the age, generally those at risk would be, let's say, after the age of 50 and unless family history and genetics are a big factor, but can young people like kids and babies have strokes?

Dr. Rene Colorado: Yes, absolutely. Stroke can occur at any age, even in utero. So patients who haven't been born can also have a stroke, but the frequency, the incidence of stroke is very low. One particular time is around birth, that tends to be the most common area for children. We call those perinatal or neonatal strokes. After that, it tends to be very low incidence. And then starts picking back up again in 50s. Although, like I was telling you earlier, you know, we do see patients in their 40s, sometimes in their 30s. These tend to be related to an accident like trauma or uncontrolled high blood pressure. Those are the big ones for younger patients.

Scott Webb: Doctor, this has been really great and really educational today. As we wrap up here, anything else you want to add? What would be the takeaways for folks about strokes, signs, symptoms, treatment options, and so on?

Dr. Rene Colorado: Right. Thank you, Scott. So we can't leave without talking about the acronym one more time. So the acronym to remember the signs of stroke and what we have to do about stroke is FAST, F-A-S-T. And that stands for facial drooping, arm weakness, speech disturbances and time, remembering to call 911 right away. That's in terms of remembering the signs of stroke. And then just another big picture information I wanted to provide was that, you know, when the patients come in, the acute treatment when the patients get admitted, that's a big part of stroke treatment, but down the road is really very important as well. Doing the rehabilitation, figuring out why someone had a stroke and then finally prevention.

So many patients think they had a stroke and that's it. Well, there's a lot we can do. And a big part of it is preventing another stroke. So I want to emphasize and close here with reminding patients that continuing to follow up with physicians, making sure they're on track in reducing those vascular risk factors that we discussed to prevent more strokes. That's really a big part of stroke care.

Scott Webb: Yeah. I'm glad you touched on prevention there, and we didn't really get into this, but you mentioned there briefly, that those who have had a stroke are at higher risk to have another stroke, right?

Dr. Rene Colorado: Absolutely. Absolutely. And that's why it's important to continue to follow up closely with the primary care doctor, with a neurologist. Many times a cardiologist is part of the preventing team. So that's absolutely important. And, you know, the incidence of stroke in overall population is relatively high. Through our lifetime, a great majority of people will either experience a stroke or something similar.

There is another entity we didn't talk about. It's called TIA or transient ischemic attack. That is an extremely important entity. And what happens there is a blockage of an artery, but it opens spontaneously. That is just as important as having a stroke because we think of it as a warning sign that someone was going to have a stroke. So it's great that it didn't happened, but that is a signature that that person may have had a stroke and that's the greatest opportunity to prevent one. So that needs equal attention as a stroke. And so patients present to the hospital and then we do the test and then put them on the right therapy to prevent another stroke. That is under the category of schemic stroke, but that's called TIA or transient ischemic attack.

Scott Webb: That's great, doctor. And that's going to be my takeaway today, is, you know, how can we best prevent strokes? What can we do? What are the modifiable? What's the behavior and lifestyle things that we can address? And then when we need care, call 911. Don't drive yourself to the hospital. Call 911, because those ambulances, you know, they are equipped to deal with stroke patients and they're notifying the hospital that a stroke patient is on the way. And at SVMH, the team is assembling and the doctor's waiting there at the door for you. So really amazing stuff. Thank you so much, doctor. And you stay well.

Dr. Rene Colorado: It was my pleasure. Thank you, Scott. Take care.

Scott Webb: For more information about the stroke center at SVMH, go to svmh.com/stroke.

And we hope you found this podcast to be helpful and informative. This is Ask The Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Stay well, and we'll talk again next time.