You may think only older people need to worry about having a stroke, but it can happen to anyone, anywhere, at any time. Stroke is the fifth leading cause of death in the U.S. and the number-one cause of long-term disability.
Stroke deaths are preventable. The most important factor is time.
Stroke Prevention Awareness Month in May brought a panel of experts to the podcast, hosted by Jonathan Fialkow, M.D., chief population health office at Baptist Health South Florida. Their discussion ranged from stroke symptoms and risk factors to what to do if you see someone who is experiencing a stroke.
Panel guests were:
You may think only older people need to worry about having a stroke, but it can happen to anyone, anywhere, at any time. Stroke is the fifth leading cause of death in the U.S. and the number-one cause of long-term disability.
Stroke deaths are preventable. The most important factor is time.
Stroke Prevention Awareness Month in May brought a panel of experts to the podcast, hosted by Jonathan Fialkow, M.D., chief population health office at Baptist Health South Florida. Their discussion ranged from stroke symptoms and risk factors to what to do if you see someone who is experiencing a stroke.
Panel guests were:
Baptist HealthTalk Podcast Transcript – Stroke Awareness Month
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Dr. Fialkow:
Welcome back, Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Baptist Health's Miami Cardiac and Vascular Institute, where I'm also chief of cardiology at Baptist Hospital and the chief population health officer at Baptist Health.
You may think strokes are something only older people need to worry about, but a stroke can happen to anyone, anywhere, at any time. Stoke is the 5th leading cause of death in the U.S.
But stroke deaths are preventable. The most important factor in successfully treating a stroke victim is time, as we’ll hear today from a panel of experts who recently joined me for an episode of Baptist Health’s Resource Live program.
My guests were:
Dr. Leo Huynh, Chief of Emergency Medicine at Baptist Hospital,
Dr. Felipe De Los Rios, Director of the Stroke Program at Baptist Health’s Miami Neuroscience Institute,
And Dr. Brian Snelling, Chief of Cerebrovascular and Endovascular Neurosurgery and the Director of the Stroke program at Marcus Neuroscience Institute.
Let’s hear what they had to say….
Dr. Fialkow: So let's get started with the dialogue and I'll turn it over to Brian first. Brian, big question. Tell us what is a stroke and maybe get into a little bit of the different kinds of strokes.
Dr. Snelling:
Yeah, exactly. Quite simply a stroke is a disruption of blood flow to the brain and that disruption of blood flow deprives the brain cells themselves of oxygen. Which can lead to the death of the cells over time. And with regards to the different types of stroke, there are really two main types of stroke. There's ischemic stroke, where there's a blockage of blood vessels that deliver blood to the brain. And then the other side of that, there's what we call hemorrhagic stroke. And those are bleeds that can occur in and around the brain.
Dr. Fialkow: Is one more common than the other, between the ischemic, the block of blood flow, and then the hemorrhagic, the bleeding kind of stroke?
Dr. Snelling:
Yeah, ischemic stroke is overwhelmingly more common. It makes up around five out of six types of strokes. So out of six people that come to the hospital with a stroke, about five of them will have what's called an ischemic stroke.
Dr. Fialkow: So the treatments are different obviously and the approach is different based on the kind of stroke. It's important for us as practitioners especially if we're going to prevent strokes to know what causes a stroke. But if someone has a stroke is there a differentiation in the way the stroke affects them whether it's a hemorrhagic or an ischemic stroke?
Dr. Snelling:
Yes, there's certainly is. Ischemic strokes can certainly have some specific symptoms that we'll touch on in a little more detail I think later on. And hemorrhagic strokes can have a couple of different kinds and they can present a little bit differently. So there is some neurons there. The most important thing is that we'll touch on the signs and symptoms to be aware of. Know how to prevent them but if you do recognize that you or a loved one or a friend is having symptoms of a stroke, what to look out for and then how to get the best care as quickly as possible.
Dr. Fialkow: So I appreciate that and we will be getting into a little, quite a bit about the symptoms and signs of a stroke. And what to do if your loved one expresses those kinds of concerns. Let's switch gears a little bit to Felipe. We know that we want to minimize the damage of a stroke but going back to the overarching prevention. What are the risk factors or things that may make someone more likely to be at risk for stroke? And more importantly, what can we do to decrease the risk for stroke as a population?
Dr. De Los Rios:
Yeah, no that's, prevention is key, I think, repairing the brain is not easy. And many times we're able to help but you want to prevent it in the first place as much as possible. And the good news is that stroke in general is 80%, has been found to be about 80% preventable. So there's a lot of things that we can do to prevent a stroke. The other 20% there's some genetics involved, environmental factors. There's things that we, they're out of our control but most of it we can help ourselves reduce our own risk of having stroke. And some of these things are are common to coronary or cardiac disease. Things like high blood pressure, high cholesterol, lack of exercise, having a healthy weight, checking for and treating diabetes, avoiding tobacco, vaping or otherwise, alcohol, recreational drugs. All those things can help us reduce our risk of having another one.
Dr. Fialkow: So I think that's well said. The same factors that might be in play for cardiac outcomes are the same for cerebrovascular stroke outcomes. And in fact it's important I think for the listeners to know if you have these risk factors you may have a stroke or a heart attack. You can't say you're going to have one or the other. So it's the same prevention type of strategies to to decrease the occurrence of this.
Dr. De Los Rios:
Yeah, and especially in midlife, nothing, you know because many, many, especially young adults feel like everything's going for them. You know, there, there are no risk or feel like they have no risk themselves at that point in time of having diseases like these. But the truth is if you care for your arteries in midlife, starting a new life then you're going to be well set for older age without complications. So it's good to start early. And going to get your routine checks for your primary and making sure you don't have this risk factors. And if you do then you consult with them.
Dr. Fialkow: I, I often tell my patients, you know when you're in your 20s and 30s you're going to live forever. In the 40s you start paying attention in your 50s. You say, well why didn't I do that when I was in my 30s and 40s? So, so start early and you can actually lay a good foundation for better health as you get older. Leo going back to now the 800 pound gorilla what would be warning signs of a stroke? Because we do want to get it to the concept of getting people treated recognized and treated as quickly as possible. And then what would be the more definitive signs of a stroke?
Dr. Leo Huynh:
Yeah. So we see stroke presenting in the old very very often and early detection is key, obviously. So sometimes the symptoms are very obvious. It's either numbness or weakness on one side of the body. It could be visual loss, either one eye or both eyes is important. Speech problems, trouble speaking or slurred speech. And also could be more, more vague symptoms. Something like dizziness or sudden onset of confusion, trouble walking things as such. And those, those both for both the ischemic and hemorrhagic stroke that Brian alluded to earlier. The slight difference in hemorrhagic stroke many times it's accompanied by headache. So a lot of times they were preceding headaches and then neurological deficits and headache during the onset of symptoms. So it's a wide wide range of symptoms. I think the key is a sudden change. If you see a sudden change I think we all have to pay attention.
Dr. Fialkow: Felipe at one of our previous resource sessions had mentioned that especially with a stroke in particular, you lose something, you lose a function, you lose the ability to move or sense something like that. In the interest of not scaring people in the sense, most headaches are not hemorrhagic strokes. Most little weakness you might feel could be a numbness and a nervous, something like that. But on the other hand we don't want people to ignore these symptoms. Can you give any guidance about when you should activate a more serious evaluation for these symptoms? Is there any, any perception that you can give to people that might say, Hey, you know, this is serious. Call 911 or can you explain it with something else? It's kind of a loaded question but I want to make sure we don't make everyone think every time they have a symptom, it's a stroke.
Dr. De Los Rios:
Jonathan, are you are asking that for me or for Leo?
Dr. Fialkow: It was for Leo. My bad guys.
Dr. De Los Rios:
That's okay.That's okay.
Dr. Leo Huynh:
Oh, for me. Well, to me, to me, I think, I think the early evaluation is critical because I think the mistake is, is trying to see if it goes away and you know, sometimes you do that and you lose time and losing time you're losing essentially neurons. So I think the early thing is getting an early evaluation if you're unsure. So the common mistake is let's see if it goes away and then they come in several hours later, and time is less.
Dr. Fialkow: Fair. Fair enough,
Dr. De Los Rios:
I'd like just to think that Jonathan, if I could, to what Leo had said, one of them is headache plus something else. So you have headache plus weakness, numbness you know, something else. That's, that's a very, you know, concerning red flag. And then the other one is what we call 'worst headache of life.' So if, if it's a headache that is the worst headache you can possibly imagine almost unbearable then you have to go to the emergency room right away.
Dr. Fialkow: And I can echo that. I remember I was 11 years old, walking up coming home from a breakfast with my father and he stumbled and had the worst headache of his life and had a cerebral artery aneurysm, which ruptured survived. It was a complicated course, but that's exactly just suddenly this most incredible headache. So certainly pay attention to that and get checked out right away. And then we'll talk about how to do that as well. Brian, switch gears again a little bit for a second. We talked about risk factors and of course what's, you know these are risk factors for cardiovascular disease, stroke, heart attack, cancers, various other things like we talked about, but something that's really coming under a great scrutiny is is stress certainly in the COVID environment and with our current societal stresses. And we know that depression, anxiety, and other behavioral aspects can increase the risk of of stress. Can you talk a little bit about that interaction between stress, depression, anxiety, and stroke, and of course the importance of recognizing and managing those stresses?
Dr. Snelling:
Yes certainly. You know, those are sort of a newer category of things that we, that are not classically associated with with the risk of stroke but there's mounting evidence that stress, and certainly that would be like work-related stress does have some association with with developing stroke in adults. And there's sort of studies that have come out that have shown that association. So while the evidence may not be as strong as it is for other things, other risk factors that were mentioned we're starting to see that association and and know that that's something that if it can be modified that, that it should be modified.
Dr. Fialkow: So, so similar to other risk factors it means, pay attention to these things, recognize it in yourself, and look for resources or ways of mitigating those risk factors increase these risks which is, which is well said. Felipe again, we've we've intersected multiple times over the past year. And let's talk specifically about COVID-19. I mean, COVID-19 remember a year ago, we were seeing cardiovascular concerns, cerebrovascular concerns, strokes. What have we learned over the past year regarding the interaction between COVID 19 illnesses and strokes?
Dr. De Los Rios:
Yes. Now we have more data and there there is different sources. The AHA the American Heart Association has a COVID-19 registry I mean some data was presented in the stroke conference this year. And the good news is that, I mean even though it is associated COVID-19 infection is associated with stroke, the risk is really small. It seems like about 1.4% of patients that have symptomatic COVID-19, would or could experience an acute ischemic stroke. So the vast majority of people don't and we do know from other infections like influenza like illnesses even urinary tract infections, that the risk of stroke has increased in general when your body is is battling an infection, the risk might be larger with COVID-19 it's a little bit uncertain but the overwhelming majority of people do not experience this. And, and what we've seen is that those that do experience a stroke, not only can have ischemic stroke, but they can also have bleeding. So normally, like Brian was saying the ischemic stroke is about 80% or so. When we talk about COVID-19 ischemic stroke is about 50% and hemorrhage is about 34, 40%. So there is, there is a possibility of both events but again, for most people, stroke is not on the radar if there's COVID-19.
Dr. Fialkow: So COVID-19 has been found to affect pretty much every organ in your body and every disease sets in, in in one area one way or another, but stroke has become less of a concern regarding the acute COVID issues over time. Can you speak a little bit about there was one of the vaccines had a slight incidence of reporting of a certain kind of blood clotting and essentially the cerebral venous sinus thrombosis. Can you just elaborate on that a little bit, what that is and is it something that we should really be concerned about when we look at our probabilities of side effects of the vaccines?
Dr. Snelling:
Yeah, I think it's good to put things in perspective and understand the difference of stroke and there's this sinus vein thrombosis. So stroke are clots or blockages on the arterial side, the arterial side. And when we're talking about these veins clots on the veins it's on the drainage part of the brain especially when we talk about sinus, sinus vein thrombosis also on the veins as the blood leaves the brain. And the risk has been has been found to be very, very small. So this has been noticed with the Johnson and Johnson and also the AstraZeneca. It's about one per million and maybe a little bit more than that but extremely relevant. At baseline generally the population, this, this this happens sinus vein thrombosis can happen and the baseline frequency is about one per million. So it's very, very close. We haven't seen that with the Moderna or Pfizer vaccines. So there might be something specifically to the other two. But just, just to put it in perspective, oral contraceptives, for example have been shown to increase the risk of thrombosis as well and sinus vein thrombosis too. And the risk with that it's about the alterations are likely of having a vein thrombosis with oral contraceptives is about eight times your normal ratio. So it might be even the bigger your risk with oral contraceptives than with these vaccines. And we saw obviously recommend those as a contraception method. Additionally, I would say that there's treatment for this condition or there's specific things that you can do to treat sinus vein thrombosis when it happens and the risk of having sinus vein thrombosis from COVID-19 which there's also risks from the infection itself seems to be 10 times higher than the risk of getting thrombosis from the vaccine itself. So you're preventing having this complication from the infection by using the vaccine.
Dr. Fialkow: So I think that's a great way to explain probabilities. We tend to be afraid of things that are less likely and not recognize the benefits of what something like the vaccine may be. But the reality is none of us are recommending to avoid a COVID vaccine because of the risk of the central venous sinus thrombosis.
Dr. Snelling:
Exactly.
Dr. Fialkow: I appreciate that. Leo lots of movement and it's been accelerated in the COVID environment towards using technology tools at home monitoring the apps, virtual care. Can you speak a little bit about what your experiences are and where do you think things are going regarding stroke assessment and prevention opportunities and access with using technological tools that we have available now?
Dr. Leo Huynh:
Yes, so, so we use technology from the entire tirade of stroke care. So even from the patient side, the wearables and the watches I've seen several patients that have come in with irregular heartbeat from the Apple watch and it ends up being atrial fibrillation and atrial fibrillation is an irregularity of the of the heart and it's a strong risk factor for stroke. So I think that's important. Additionally, access to care, we talked about the early warning signs that sometimes patients are unsure. So to leverage the technology and use telemedicine which is as, as you know, increase in usage with COVID-19. I do not think it's a, a wrong thing. I think it's a good thing, actually. So as long as the patients have access to care and using the technology is great and all the way to arrive into the hospital and the diagnostic and therapeutic modalities that Felipe and myself and Brian use on a daily basis, it's always, always evolving. And our goal really is to diagnose quickly as well as treat treat quickly as well.
Dr. Fialkow: I mean, down the road, we'll have sensors in people's houses, we'll be able to manage we'll be able to pick up variations in temperature and heart rate and respiratory rate sometimes before people even feel something. So that's kind of interesting to see where that's going but I appreciate that access is important to people 24/7 can get someone on the phone that this care and demands and example the assess their symptoms if they're not sure. The wearables picking up arrhythmias can, can determine people who might be at risk and embolic stroke is a blood clot in the heart that travels to the brain. It's a kind of ischemic stroke, not as common as the blood vessels in the brain closing up but these are all the types of things we can use to impact those stroke numbers that we've seen before. So again, great information. Brian, now let's go back to a couple of more cogent acute types of things for the patients. So ask you a couple of questions regarding whether these things make a difference in one's risk of stroke. Do, is there a difference between men and women, for example is there a gender differential on who's at risk for stroke?
Dr. Snelling:
Yeah. Women are at an increased risk of stroke compared to men and that's both ischemic stroke. And then especially also, when we look at things like subarachnoid hemorrhage or the aneurysm rupture they're at a higher risk as well.
Dr. Fialkow: And then we also noticed birth control pills while not to be avoided the risk is low but they can have a slight increased risk as well. So some of that could be, how about race? Do we see anything different between African-Americans, Asian-American, Asians, Caucasians? Is there any race-related differences that we've been able to identify?
Dr. Snelling:
Yes certain races are at a higher risk for a stroke. Those would be African-Americans Hispanic race, Asian American, Pacific Islanders. Those races would be at a higher risk of developing stroke compared to the others.
Dr. Fialkow: And again, it might be genetic, it might be cultural it might be lifestyle, but we're definitely seeing these trends in the different populations. It, it was mentioned that there are some relatively rare genetic abnormalities that can lead to strokes compared to more Gemma lifestyle, risk factors. But if a family member has a stroke first to be a family member, does it make someone else more likely to have a stroke?
Dr. Snelling:
Generally yes. And then even specifically, again, you know, my my personal biases towards things like brain aneurysms and it's certainly we know if someone has a family history of brain aneurysm or they have two 1st degree relatives that puts them at an increased risk. What I like to tell my patients is that family history is the poor man's genetic test. And there's a lot of multifactorial component to stroke in terms of the multiple gene interactions that may be taking place. And until there's a comprehensive genetic analysis that tells us what that exactly is, the best thing we can do is just take a really accurate family history.
Dr. Fialkow: So if one has a cerebral artery aneurysm whether it's found incidentally it never bled or there is a bleed, what are the general recommendations? I know this is a, again, personally, as I said I know this is a, a little bit of a sensitive area but what do we recommend the family members to do?
Dr. Snelling:
Generally it's two 1st degree relatives. So 1st degree relative is a sister, a brother or mother, father, or a child. And if there's two 1st degree relatives that have a brain aneurysm or have a history of brain aneurysm and that's blood but we call subarachnoid hemorrhage and they're recommended to have a screening study which is usually do that with MRA which is a special type of MRI no contrast, no radiation that looks at the blood vessels of the brain.
Dr. Fialkow: Great. But main point is ask your doctor, get get checked out, which I think is the main point. All right, let's get some final points before we take some questions. And this is perhaps the most important to all of us having to deal with what one should do if they or a loved one has stroke symptoms and why it's so important to act quickly. So Felipe, someone's having a stroke, the symptoms we talked about, the worst headache of their life transient difficulty of speech, weakness of an arm, et cetera. What, what should one do?
Dr. De Los Rios:
Yeah. If there's any suspicion that someone is having a stroke and that person might not be aware so you rely on what others might see. So it's good for everyone to know what the signs or symptoms of stroke are. But if there is a suspicion, you really want to call 911 and not just drive to the closest emergency room because not all emergency rooms are equipped to treat acute ischemic stroke patients. So there's actually certifications and you're the hospital on emergency room can get certified as different degrees of stroke expertise. And if you just go to the closest emergency room you might not be going to the right place. So calling 911 is the way to go. And that pre-alerts the hospital staff of what's happening. And then we're able to give treatment be that a medication that destroys the clots or in the vascular neurosurgery and trying to preserve as much brain as we can. But literally minutes count. The more we delay, the less probability of a great functional recovery.
Dr. Fialkow: So 911, don't get in the car. Do you find most times the person experiencing the stroke is aware of it or there are circumstances where family members may see it or notice it, and the person may not even be aware of it or not thinking it could be a stroke.
Dr. De Los Rios:
Both, both. We see both. I would say probably about equally, I don't know what Brian and Leo's experience has been but there's cases even where neurologists have a stroke and they don't realize that they're having a stroke because it's not that they don't know what the signs or symptoms are, but the area of the brain that's been affected, prevents them from realizing that they're having the, those, those problems. So I see that I see about equally where family members bring and say, "Hey no, something's off. You know, this is not right." And that patient is not really aware that they're speaking slurred or having problems with balance and all those words, the patient themselves pick up the symptoms and they call 911.
Dr. Fialkow: Brian, to that end. Do you ever see patients who were kind of were reluctant to get taken care of call 911 family members this unfortunately helps and saves them?
Dr. Snelling:
Absolutely. You know, calling 911, calling EMS at any, at any of the signs we previously mentioned is of the utmost importance. Only a minority of the types of stroke actually are accompanied with the headache or so most of them are painless. And what I usually try to inform patients is that unlike a heart attack, there's really no impending sense of doom with a stroke. It's like a flip. We say it's a loss of something. It's a loss of function. And a lot of people, whether they don't recognize it or they just try to ignore it and think it'll get better on its own. And just, just to clue people into the to the signs and symptoms of stroke and let them know that most of them are painless to painless loss of function and that they shouldn't try to get to the hospital. They should call 911. And another reason to call 911, I think is a great one is, you know as a health system, we're equipped as hospitals to receive patients that are coming in with stroke symptoms. So if you're picked up in the field by EMS they can call ahead and let us know as opposed to driving in. So when time is critical and time is brain and those minutes count, you're shaving time off of off of your treatment by calling EMS cause they'll let us know and we'll be we'll be able to meet you at the door.
Dr. Fialkow: So again, a great point. And that leads right into a question to Leo from an ER standpoint, not infrequently, you know a person's coming in on their way with a stroke which allows you to be prepared to speak a little bit Leo about this, this final, most important point. We say time is brain. Why that those, those moments those minutes can actually be critical in getting assessed and treated?
Dr. Leo Huynh:
Yeah, absolutely. So, so just the the points that Brian brought up, I think are critical. I mean, the family paying attention to understanding something has changed and reacting is critical because if there's a delay, just to look just a deep dive into the numbers are pretty staggering every minute at 1.9 million neurons die during a stroke. Billions of synopses, which are the connections between neurons are lost and they're lost forever. And lastly, which is an interesting fact that I've learned is for every hour that's delayed it's equivalent to about four years of normal aging of the brain. So the important thing is we've seen it numerous times of a family really saving the life of being on the phone with their loved one and kind of hearing a little subtle difference in their voice and, and reacting in that immediate reaction is critical to, to save to save the patient's life.
Dr. Fialkow: To our listeners, if you have any comments or suggestions for future topics, please email us at baptisthealthtalk@baptisthealth.net that's baptisthealthtalk@baptisthealth.net. We’d love to hear from you.
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