Seconds can save brain cells.

Welcome to SBH Bronx Health Talk produced by SBH Health
System and broadcast from the beautiful studios at St. Barnabas
Hospital in the Bronx. Hello I’m Steven Clark
Stroke is the fifth leading cause of death in the United States. It
kills about a 140,000 Americans annually and is the number one
cause of disability. Recognizing the signs and acting fast can
mean the difference between life and death. Quick intervention
can also reduce the risk of long-term disability. With us today is
Dr. Sarah Jamison, an emergency medicine physician at SBH
Health System. Welcome Dr. Jamison.

Thanks Steve.

Now a lot of us have heard the acronym F.A.S.T. or FAST, which
is known for identifying the signs of a stroke. What exactly do
these initials stand for?

So FAST is an acronym for different symptoms that we would
like people to recognize before they come in to be evaluated for
stroke. So the “F” in fast stands for face, so if you have one
side of the face that’s drooping or unable to move that’s the
facial symptom. “A” stands for arms, if you have the inability to
move one or both arms. Speech is another one if you have
delayed speech or slurred speech or just the inability to speak
and then “T” stands for time, basically meaning we want
it to be remembered to call the ambulance immediately, to not
waste any time with getting the person into the hospital.

So I guess part of the problem is that if somebody is having an
episode say they have a droop or they’re not finding the right
words or something they shouldn’t just say ‘Well you know it’s
happened before I’ll get better.’ They should get treatment right
away.

Absolutely. We see very often patients will come in a little bit
later, and I guess we’ll speak about time and treatment, but
patients will come in a little bit too late to receive a certain type
of treatment and so with that it’s very important to come in
early and come in often if you do have symptoms.
Hoping that it goes away is not necessarily the best decision to
make and I guess there are also more subtle signs as well.

What are some of those?

Correct. So some of the more subtle signs would be blurry
vision which could affect people for different reasons at different
times, but persistent and very sudden visual blurred vision is
something that is very concerning. Another symptom that’s
more subtle would be dizziness and not just dizziness where
you feel a little bit lightheaded, but dizziness to the point that
you’re unable to walk straight, where you have to hold on to the
walls to be able to stand up and maybe it even causes you
some sort of nausea or even vomiting that’s very concerning
and not to be mistaken for a stomach virus or something that
could be a sign of stroke which should of course bring you into
the emergency room.

Now there are two different types of strokes, right? Explain
those.

So there are two different types of stroke. One, the more widely
known kind, is called an ischemic stroke. Ischemia or an
ischemic stroke basically just talks about or really means that
there is a loss of blood flow to certain types of or certain tissues
in the brain and so with that blood loss there’s no oxygen for the
tissue. The second type of stroke is a hemorrhagic stroke which
is essentially when a blood vessel bursts in the brain for lack of
a better description and it basically causes bleeding in the brain.
However, it can have the same loss of tissue function that an
ischemic stroke would have.

I guess as an emergency room physician it’s all about time.
Correct, it’s all about time so, as I alluded to a little bit earlier, we
do have a certain treatment for certain types of strokes or rather
for ischemic strokes, but we can only give that medication
within a certain amount of time so within four to six hours is a
recommended amount time spent between the onset of
symptoms and treatment for what would be the amount of time
that we need four to six hours like I said so time is tissue time is
brain which is what we really would like for our patients to know
so even if the symptoms start and you again are waiting for
them to get better that’s actually hurting more than helping it. It
kind of robs us of the ability to give the medication that we need
to help.

OK, so again either you or a loved one or someone on the street
suddenly displays these symptoms, these signs, they may have
a stroke what should they do?

Well, the T in fast stands for time meaning waste no time calling
the ambulance and getting the patient over to a hospital. It’s not
helpful to give aspirin. I know a lot of people will do that outside
of the hospital in an attempt to try to help because that’s
something that’s recommended when you think someone’s
having a heart attack. Unlike heart attacks, with strokes
because you could have a hemorrhagic stroke or a bloody
stroke if you will, aspirin increases your bleeding which would
make it worse so unless we know whether or not this person is
having an ischemic stroke or a hemorrhagic stroke we can’t give
any medication because we don’t want to make the problem
worse. So not giving any medication, avoiding treating
someone on your own, would be the most helpful. Just call the
ambulance and get the patient over to the emergency room.

Is one stroke worse than the other?

Yeah, hemorrhagic strokes are worse from what I hear. They’re
more deadly. They cause a lot more complications than an
ischemic stroke in my opinion because it causes a lot of
increase in the volume of the brain you’re at risk for a lot of
other problems like decreased breathing. So with hemorrhagic
strokes more often I’ll have to intubate or rather put the patient
on life support so that they don’t stop breathing, whereas with
ischemic strokes you can see this you can see the same exact
thing it’s just that hemorrhagic strokes for whatever reason are
just a lot more difficult to recover from. We see a lot more
ischemic strokes, which are the equivalent of a heart attack but
in the brain so a lot of people will I guess intertwine or use the
word stroke and heart attack interchangeably. They occur in two
completely different organs.

Who is the most likely candidate for a stroke?

The most likely candidates for strokes are of course people who
are a little bit older, middle-aged and the elderly, those who have
vascular issues and when I say vascular issues that includes
hypertension that can include diabetes, that can include
peripheral vascular disease because the stroke essentially is a
disease of the vessels but in the brain and so those are patients
who have other issues with their vessels or with their heart and
are more likely to have risk to developing a stroke.
OK, so as an emergency room physician do you get called
ahead that the stroke patient is coming to the hospital?
Yes, more often than not we will get phone calls from EMS
to let us know that a stroke is coming to the emergency room
and then we’re able to prepare.

OK, so what does that mean as far as the preparation goes?

So preparation for a stroke before it comes in basically means
that the treatment team is going to rush to the resuscitation area
where the patient will come in for us to do a very focused history
and a very focused physical exam. It also allows us to make
sure that our cat scan on the suite or the radiology suite is open
and clear so that the patient can within 15 minutes of coming
to the emergency room make it into getting the cat scan. The
cat scan is extremely important because again it lets us know
whether or not we’re dealing with an ischemic versus a
hemorrhagic stroke, which is very important because the
treatment is extremely different and so that’s information that we
need to get much sooner than later.

Let’s talk about the treatment you mentioned earlier that
TPA is not like a wonder drug that everyone gets when they’re
suspected of having a stroke. Right?

Correct. So we do have a medication for strokes it is
called TPA. It’s a medication that is only used for ischemic
strokes, the reason being that TPA is a medication that
essentially eats up any clots that are in the body and namely
any clots that are causing your stroke. So TPA is a good drug in
the fact that it can help people recover from ischemic strokes if
they have very serious symptoms. Because of that the
downside is that the way TPA works is that it essentially causes
bleeding in the body and you can’t control when, where and if it
causes bleeding in the body so it is a drug that has a lot of risks
as well as a lot of benefit. It’s a very effective drug, but also it
can be a very dangerous drug as well.

So if you don’t give TPA, what do you do?

Well with strokes that you are not able to give TPA – and there
are a lot of factors that go into whether or not that patient can
get TPA – the biggest treatment for strokes that are not treated
with TPA is really rehab, physical therapy, occupational
therapy, basically re-teaching that person how to do certain
functions that they may have lost because of this stroke. So
one of the things that has been very well studied and very well
confirmed is that patients who suffer from strokes one of the
determining factors of having a good outcome is really the
nursing care that is associated with that patient during their
hospital stay. So nurses who are very mindful to get the patient
out of bed, to turn them to prevent certain hospital-acquired
infections and basically take very good care of this person while
they don’t necessarily have full function, that care alone has
been proven to really help the outcome and cause a better
outcome for these patients.

What’s a TIA? Why don’t we discuss that?

A TIA stands for a transient ischemic attack and a TIA as I’ve
heard it is called by our patients a mini-stroke. The reason why
it’s I guess considered to be a mini stroke is because it can
mimic the symptoms of stroke but as the word transient
suggests it doesn’t last permanently. It’s something that the
symptoms might come on lasts for about 15 minutes to an hour
or even two and then go away on its own. The reason why TIA’s
are important when you speak about stroke is because TIA’s
are almost warning signals for a potential permanent stroke or a
quote-unquote larger stroke. A TIA is almost your body’s
warning sign saying “Hey you know there might be some issue
with the vessel in the brain and even though it’s not something
that’s permanently affected right now or the vessel may not be
permanently occluded or blocked up, it’s something that could
occur later on and become completely blocked or completely
occluded and actually cause a real stroke.” So for patients who
do have symptoms that they are familiar with as TIA’s, if you
will, it’s very important for even them to come in because it
means that we can catch whatever deficit is going on sooner
than later and prevent them from having a stroke.

How would you prevent it from becoming a stroke at a later
date?

There are certain tests that are done to see what the underlying
issue is. So some people might have, as I mentioned, certain
blockages in their arteries or veins, particularly the carotid
arteries, which are arteries in your neck essentially that supplies
blood flow to the brain. If your carotid arteries have blockages,
whether they be partial or complete, that can cause decreased
flow of blood to the brain and thereby can cause a stroke so
some people have as I mentioned a partial occlusion in this
vein and that can cause TIA’s. If we know that we can or rather
if we test the carotid arteries and see that they have a blockage
before a partial blockage before it becomes a complete
blockage then interventions can be done to prevent it from
becoming a complete blockage and thereby causing a stroke.

For example, what are some of those interventions?

There is something called embolectomy where they basically go
into the vessel and take out whatever would be occluding it.
There is also another condition called atrial fibrillation which is
basically a heart condition where the heart beats very fast and
very very irregularly because of the irregular beating of the heart
it can cause the heart to form blood clots. These blood clots are
then thrown into the circulation by the heart and they can end up
in the brain and that can cause a stroke so patients who
have atrial fibrillation. The treatment for that, or rather the
preventative measure for that, would be to put them on a blood
thinner like coumadin or warfarin. Putting these patients on
blood thinners prevents them from ever developing the clots and
thereby again can prevent stroke. So stroke is not just an acute
event as in yes it might happen one day you know upon
waking up or just all of a sudden, but there have been or there
are usually a lot of events prior to a stroke that can be
intervened on to prevent the stroke from having happen to
begin with.

I guess the bottom line is if you think you may have a problem
don’t wait.

Exactly. A lot of people I think are pretty comfortable with just
quote-unquote waiting for things to go away. Some things do,
but others don’t and you should really work with your doctor to
figure out which symptoms are those that can wait to go
away as opposed to those that need to be acted on.

Thank you Dr. Sarah Jamison. Thank you for joining us in SBH
Bronx Health Talk. For more information on the treatment
and prevention of stroke or other services available at SBH
Health System visit us at http://www.sbhny.org.