Cheryl Martin (Host): Stroke. No one wants one, but every 40 seconds here in the United States, someone has a stroke. An estimated 800,000 people a year. Here to tell us how to recognize a stroke and what to do is Neurologist Dr. Chandni Kalaria. She's a Medical Stroke Director for WakeMed. This is WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina.

I'm Cheryl Martin. Dr. Kalaria, thanks for being on to discuss this critical topic for all of us.

Chandni Kalaria, MD: Thank you for having me.

Host: Let's begin with the basics. What is a stroke?

Chandni Kalaria, MD: A stroke quite simply is when part of your brain is not getting enough blood. And so that either happens by a pipe in your brain, one of the arteries getting blocked, or if the pipe bursts, that's when you have what's called a hemorrhagic stroke, a bleeding type stroke. And so a stroke is when the proper blood is not getting where it needs to go.

Host: What is the most common type of stroke?

Chandni Kalaria, MD: About 85% of strokes will be what we call ischemic strokes. And that means the blocked pipe. So the clot goes or something happens to your pipe and it gets blocked, and that's why the blood is not getting to the brain where it needs to go. That's the most common type of stroke.

Host: What are the signs of stroke?

Chandni Kalaria, MD: If you're worried that you're having a stroke, you should think of the acronym BE FAST. And so, what that means is each letter stands for a symptom you could be having. So B is for balance. If all of a sudden you can't walk, you're off balance, it happens all of a sudden. That could be the sign of a stroke to the back part of your brain or another part of your brain that involves you walking and balancing. If you all of a sudden can't see, your vision's off, your eyes look funny to your family and not moving in the right way. That's another sign of a stroke. The other thing people think about more commonly is the face. So face drooping. So one part of your face going lower than the other part of your face. Even if you're smiling, trying to talk, that's another sign of a stroke.

Then you also want to think about your arms or even your legs, but holding up both arms and seeing if one arm is drifting. If one arm is stronger than the other, that could be a sign of a stroke. Then speech, having trouble understanding or speaking, could in fact be a stroke to part of your language center or even another part of your brain that's making it so that you can't understand speech, can't get your words out, slurred words. Those are all signs that your brain is not functioning as it should be. And the T is very important. That stands for time. So when we think about BE FAST, the T at the end is a reminder that time is of the essence. Every second counts, every minute counts, and getting to the hospital as soon as possible is very important.

Host: Also time is brain.

Chandni Kalaria, MD: That's right. That's a phrase that is often used as another reminder that, every second is important. So time is brain. Every minute that you don't have enough blood to your brain, about 2 million brain cells will die. So it's very important to get to the hospital as soon as possible.

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Host: And I'm glad we're having this conversation because if you are with another person that has these symptoms, it's important for us to know them as well so we can assist. We know what's going on.

Chandni Kalaria, MD: That's exactly right. And one thing to point out here, since we're talking about it, if you think that you're having a stroke or your loved one's having a stroke, you want to call 9-1-1. That's the best way to get to the hospital in time. The EMS responders are excellent at recognizing signs of stroke, calling in different information that's important to the ED providers to get ready for when you come in or your loved one comes in.

 So that's what we recommend, is that if you feel like you or your loved one's having a stroke is to call 9-1-1.

Host: Any other immediate actions to take during a stroke?

Chandni Kalaria, MD: I think those are the most important things. It's nothing that specifically recommends that you sit in a certain position or lie down. You always want to be in a safe place. And so if you can't walk, not trying to walk, those kinds of things are certainly just reasonable common sense things. But other than calling 9-1-1 and using the recommendations that they give you over the phone, that's the most important thing.

Host: What are the risk factors of stroke?

Chandni Kalaria, MD: The most common risk factor, both in the US and worldwide is really high blood pressure. So hypertension and a lot of people sort of dismiss high blood pressure, I've found, because it doesn't hurt, until it does. Having high blood pressure doesn't trouble someone symptomatically until it causes significant damage.

And so high blood pressure is the number 1, 2, 3 cause of stroke and risk of stroke. And so if you have to choose one thing to just focus on, it's definitely making sure that you don't ignore the signs of high blood pressure, that you go to your doctor regularly, and stay on top of your blood pressure. So that's one of the main risk factors for stroke.

 Some of the other risk factors for stroke include high blood sugar. So diabetes, having high blood sugar can clog up those pipes and arteries in our brain and over time build up until we have a stroke.

Same thing for cholesterol. Having high cholesterol, is a risk factor for stroke. Of course smoking. If you're smoking, getting all the help you can to quit smoking is so, so important. And then other things to think about would be heart disease, particularly atrial fibrillation. It's a funny heart rhythm, that may be silent as well and picked up in your doctor's office.

But, we know that that funny heart rhythm called atrial fibrillation causes blood clots to form in the heart that then can go to the brain. So those are some of the main risk factors for stroke that you want to keep in mind.

Host: It's my understanding that women have more strokes than men. If so, why?

Chandni Kalaria, MD: That's true actually. About 55,000 more women than men will have a stroke in a given year. Some of the risk factors that are unique to women, including taking the estrogen based contraception, will slightly increase your risk of stroke.

Nowadays they do have lower doses, but nonetheless, it does increase your risk of stroke. And then during pregnancy, women have a higher risk of getting elevated blood pressure, having a condition called preeclampsia. They also can have gestational diabetes so their blood sugar gets elevated during that time.

And then even in the after delivery phase, what we call the postpartum phase, for several weeks afterwards, your blood is thicker than normal and anytime your blood is thicker than normal, you have a risk of forming clots. And so pregnancy is a unique time period where, you may be young and have a stroke.

So those are some of the main risk factors for women that are different from men, that cause more women to have strokes in a given year than men.

Host: You touched on, we are seeing stroke present more in younger populations. Any other reasons why that is?

Chandni Kalaria, MD: That's something that neurologists are not entirely sure why we feel like we're seeing strokes in younger patients nowadays compared to before. Part of the reason, of course is more education, more detection, and people coming to the hospital, which is great. But there's also a question of our diet, our lifestyle and our health in general, that if younger children are more obese and becoming unhealthier, could that just start their risk earlier in life of having strokes? And so it's not entirely clear, but it does show that at a young age, being cognizant of your health and doing healthy activities such as exercising, eating healthy, those kinds of things, they're important not just when we get older, but from a younger age to prevent stroke.

Host: Is there a general age population that's the highest for getting a stroke?

Chandni Kalaria, MD: In general, we think of our younger stroke patients as under the age of about 50 or 60. And so it's more common in older ages of over the age of 60 to have stroke. Part of that is a lot of the reasons we discussed before in terms of risk factors. As we get older, we're more at risk of developing high blood pressure, atrial fibrillation is a more common disease in older patients. And so those kinds of things are what make it more common in older populations. But like you said, we are seeing it more and more in younger populations now.

Host: Please go into more detail of what we can do to lower our risk of stroke.

Chandni Kalaria, MD: I really like the American Heart Association's breakdown of what they call the Essential Eight. And I know eight sounds like a lot, but if you think about it, if, you try and fix eight factors in your life to reduce your risk of stroke, the American Heart Association's Essential Eight would be the ones to focus on.

And so just to go through those briefly, we've talked about some of them. Blood pressure for one, going to a primary care doctor at least once a year, making sure your blood pressure's under control. If you're one of the people who develops high blood pressure, which will be a majority of people, especially over the age of 50, we start developing high blood pressure more.

You want to keep your own diary of your blood pressure at home and really stay on top of it. The other thing is the blood sugar. And the third thing is cholesterol. So some of the things that we already talked about, those can be measured and managed by your doctor quite easily. The harder things are things like exercising.

So, the American Heart Association recommends exercising and to quantify it, they actually say that doing some moderate exercise for about 150 minutes per week, is what you would aim for. And that's quite hard to do every day or four or five days a week. But that's the goal.

And so whatever you can do to try and increase your exercise, is important. The other thing is eating a healthy diet. And so one of the things we found in stroke populations is focusing on a Mediterranean diet is what we would recommend. It sounds fancy, but what it really means is that you want to focus on a lot of vegetables. When you look at your plate, really, one third to one half of it should be vegetables. And then when you're looking at meats, seafoods are good or leaner meats like chicken, without the skin or turkey. Those are the types of meats that you want to go for. And, the other fourth of your plate can be things like whole grains, and, some things like nuts and fruit would be the other thing.

And so focusing on trying to do a Mediterranean diet is something that is one of the other, Essential Eight. Then you also want to get a good night's sleep, which is something that we don't think about a lot, but the average adult should have about seven to nine hours of sleep to try and rest your body and heal from just the activities of the day.

And, the other two parts of the Essential Eight are working on getting a healthy weight. So understanding what your body mass index is, talking to your doctor about what is a good, healthy weight for you, because it should be individualized. And then of course if you're smoking, you want to quit smoking.

So if you're doing those eight things in life, that will be a very, very good start of preventing stroke and it goes a long way.

Host: Now, you mentioned AFib before, so when you meet with your doctor, let's say once a year, should you ask them to check for that?

Chandni Kalaria, MD: If you have a family history or concerns about it. The primary care doctors have their own protocols of when they will do an EKG, and check for atrial fibrillation. But if it's a concern of yours, it's certainly reasonable to bring up and understand if you need to be checked, if you need to be monitored for longer or not.

Sometimes, they will do an EKG in the office. Sometimes you'll get what's called an echocardiogram, and use other factors to determine are you someone at higher risk of atrial fibrillation? So it's not something that's routinely screened for, but if you have a concern, talking to your doctor and understanding why you might be at lower or higher risk, is certainly important.

Host: Now once you get to the hospital and you have the symptoms of a stroke, how is the stroke diagnosed?

Chandni Kalaria, MD: So what'll happen if you arrive at the hospital and you called 9-1-1 is usually the ER team, the ED team will meet you and, do an assessment. They'll ask you questions about your symptoms and they'll do an exam to see some of those different elements we talked about with BE FAST. They'll be checking your eyes and your arms and your face and, trying to determine if you've had a stroke by the exam.

The other things that happen are you'll get a quick CAT scan of your brain, and that will look to see if this is a bleeding type stroke right off the bat. If not, then a neurologist is involved to decide are you a candidate for something called a clot busting agent? So, a tenecteplase or alteplase, are two clot busting agents that are used in the US and, determine if you're a candidate to have one of those measures.

The other thing that they'll do in the ER is, look at the pipes in your brain and look for the blockage itself. If you have a pretty large pipe blocked, one that a provider can reach, then you might have a neurointerventional physician go in and try and actually get the clot out of your brain.

Beyond those measures, if you come in, to the hospital and are not a candidate for the acute clot busting medicine or what we call the embolectomy, where a provider goes in and actually gets one of the clots out of a larger pipe in your brain; then you'll usually be admitted to watch your blood pressure to get some of the workup for stroke, such as putting you on a monitor to look for atrial fibrillation, getting a picture of your heart. And then of course there'll be another potential picture of your brain with an MRI. And that's usually when we can see the stroke and see the size of the stroke on an MRI.

Host: Anything else you want to share with us just regarding recognizing a stroke and what to do?

Chandni Kalaria, MD: I just hope that everyone listening to this really keeps in mind the signs of a stroke, shares it with family, and educating your whole family on this is lifesaving. And people often will say, I, I'll feel better, I'll get better tomorrow and try and sleep it off.

And unfortunately, it's important to know that these interventions I talked about the clot busting medicine or the embolectomy where someone goes in and actually gets out a large clot; those can only be done within the first several hours after a stroke. And so if the damage is too late and too far gone, you won't be able to get some of those lifesaving treatments and disability saving treatments.

And so I think the most important thing to know is to take your body seriously. Listen to your body and call 9-1-1 if you really think you're having a stroke. I think that's very important. And less than 10% of people arrive in time for those acute therapies I talked about. So, more people understanding how important it is, will be great to, to try and reduce the disability that stroke causes.

Host: Well, you have definitely helped us to understand. So thank you for educating us on how to recognize a stroke and what to do. Dr. Kalaria, thank you.

Chandni Kalaria, MD: Of course. Thank you so much. I really appreciate your time.

Host: Very informative. To learn about WakeMed Stroke Program, please visit wakemed.org. And if you found this podcast helpful, please share it on your social media. You can check out our entire podcast library for other topics of interest to you. Thanks for listening to WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina.