Prevention and Treatment of Stroke

Dr. Demaerschalk discusses stroke and how prompt treatment is crucial. Early action can minimize brain damage and improve outcomes. The good news is that strokes can be treated and prevented.

Dr. Demaerschalk has specialized in stroke, emergency neurology, and telemedicine for over a decade. His research focuses on thrombolysis, regional stroke systems of care, health economics, meta-analysis, evidence based medicine, and telemedicine. He has co-authored American Heart Association and American Stroke Association guidelines for the management of acute ischemic stroke and the American Academy of Neurology guidelines for telemedicine in neurology. He has designed and conducted pivotal clinical trials demonstrating reliability, validity, safety, and efficacy of telemedicine for stroke and the first US cost effectiveness analysis of telestroke.

Transcript

Neal Howard: Hello and welcome to the program. I feel glad that you could join us today. More women than men have strokes every year. Partly because women live longer. That’s just one of the stroke facts that we’re going to discuss today with a doctor from the Mayo Clinic, Dr. Bart Demaerschalk. He’s here to talk about how strokes can be prevented and treated. Welcome to the program, Dr. Demaerschalk.

Dr. Bart Demaerschalk: Good morning, Neal. My pleasure.

N: Give us just a bit of background about yourself. I know that you are with the Mayo Clinic. Talk about some of your patients. What is a normal day for you?

B: Every day is different. In stroke, I spend part of my time managing stroke at the hospital. So it’s an acute care environment. I’m part of a stroke team, a multidisciplinary stroke team of neurologists, neurosurgeons, emergency physicians, neuroradiologist, nurses, paramedics. We greet patients as they arrive at an emergency department, acquire the necessary information, examine them, image their brain and blood vessels, make a determination if the stroke is because of a blocked artery or because of a hemorrhage and then organize the emergency management appropriate to that particular patient in their particular stroke. That’s part of a day. Other parts of the day or other days are spent in our cerebral vascular or stroke prevention clinics. So these are clinics designed to accommodate patients that have previously had a stroke or a warning stroke, a transient ischemic attack and the focus there is on understanding their risk factors – high blood pressure, high cholesterol, smoking, sedentary lifestyle, previous cardiovascular disease, heart attacks, an abnormal heart rhythm, atrial fibrillation, cigarette smoking, all of these things, understanding the …, understanding how one can prevent stroke, manage those risk factors, treat them, follow them and really all with the objective of preventing a recurrence, disabling stroke from occurring. So those are two facets of my day. Another really exciting part of the world of stroke is connected care, its virtual care. Our audience might understand that stroke is a brain emergency and time is of the essence. And it’s not always realistic for a patient exhibiting symptoms and signs of stroke to be evaluated in a stroke center and traditionally patients that present in remote rural hospitals with symptoms and signs of stroke are transported sometimes hundreds of miles away over hours by ground or air ambulance. Instead, we bring the stroke expertise to the patients with live synchronous audio-video consultations rather than transport them.

N: Now, you mentioned two different types, I believe, of stroke – an ischemic type stroke or are there others?

B: Approximately 75 to 80% of all stroke is ischemic. So that’s what we refer to as a blocked artery in the brain depriving a part of the brain of its usual blood supply oxygen and nutrients. The less common type of stroke 20 to 25% of all stroke is hemorrhagic – that’s bleeding. Bleeding in the brain by a variety of causes. It could be an aneurysm that ruptures. It might be what we call a subdural hematoma. It could be a bleed right into the brain substance of the brain or the ventricles of the brain which are the fluid-filled chambers of the brain. So two distinct types of stroke – ischemic and hemorrhagic.

N: Now, I know time is of the essence but it sounds as if the latter is more severe even though less common than the former.

B: No question about that hemorrhagic stroke leads to a higher death and disability than ischemic stroke. It’s less common but it’s more dangerous, more deadly.

N: Now, I mentioned that the outset that more women than men have strokes every year in part because women live longer. What are some of the other facts about stroke that our listeners may not be familiar?

B: The principal reason is the one you’ve already mentioned and it has to do with life expectancy. Other reasons why there is a modestly higher risk of stroke in women has to do with endocrine factors. So for example, vascular disease of all type whether it’s cardiovascular disease, heart or cerebral vascular disease brain, it can be influenced by hormones. And there’s an association, a slightly higher risk for example of vascular disease during pregnancy around pregnancy, higher risk of both ischemic and hemorrhagic strokes so that’s one important factor, a distinct difference between men and women and then an association between the use of external hormones in the form of either oral contraceptive medication, hormone replacement therapy also play a role particularly when women who for example smoke, have all contraceptive medication and may have also migraine or migraine with aura. That particular constellation raises just modestly the overall risk of stroke in a young otherwise healthy woman compared to their peers or to men of the same age.

N: So how do you tell you’re young otherwise healthy? How do you tell that you’re having a stroke and when is the time to see a doctor?

B: Right. Well, let’s speak first about recognizing the warning symptoms and signs of stroke because that constitutes a medical emergency. So what’s important for everyone to recognize is these are symptoms that come on abruptly not gradually but the abrupt and unanticipated development of weakness on one side of the body, weakness, heaviness, clumsiness on one side of the body – face, arm or leg, one side of the body that becomes numb, loss of sensation, tingling, again abrupt …, loss of speech, so the loss of the ability to understand, the loss of the ability to articulate, speak fluently, slurred speech, finally vision. They could be the abrupt onset of complete loss of vision, loss of half a vision or double vision and then the sudden unanticipated onset of a severe headache. These are the cardinal features of the heart possibility of an acute stroke syndrome and the only response one should have to that is to dial 911 or the family member, the witness, the friend should be dialing 911. Now, these things constitute a medical emergency.

N: Now, in wrapping up, Doctor, briefly describe how a stroke can be prevented obviously avoiding certain things. What’s the next step for the best outcome?

B: Yes. So one of the first things that patients with their caregivers will do … to try to understand the mechanism by which the stroke occurred. Three most common causes for stroke are large artery, atherosclerosis, hardening of the arteries, plaque in the arteries. Another main cause of stroke is from the heart what we call cardioembolism, clot from the heart because of a prior heart attack or because of a heart rhythm disturbance, atrial fibrillation or a mechanical or prosthetic valve and finally small vessel disease of the brain. These are tiny little penetrating arteries in the brain, the walls become thickened with protein-laden and then the lumen where the blood flows becomes narrowed. The way to prevent these strokes are a multitude of things but importantly management of blood pressure, management of cholesterol, smoking cessation, management of cardiovascular disease, the use of medications called antiplatelet medications, aspirin clopidogrel are examples, blood thinning, the use of blood thinners, warfarin and some of the novel anticoagulants when the cause of stroke is cardioembolic. In addition to good lifestyle management, weight loss, exercise, diet, management of diabetes, these are the cardinal ways in which stroke risk factors are treated and stroke is prevented.

N: Doctor, thank you so much for talking with us today and I’m hoping to talk with you again.

B: You’re very welcome. My pleasure. Have a great day.

N: You’ve been listening to Health Professional Radio. I’m your host, Neal Howard. Transcripts and audio of this program are available at hpr.fm and healthprofessionalradio.com.au.

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