WEBVTT 1 00:00:06.600 --> 00:00:08.580 So like I said, my name is Wendy Carravaille. 2 00:00:08.640 --> 00:00:12.000 I'm one of the stroke program managers at Corewell Health William Beaumont 3 00:00:12.080 --> 00:00:16.031 University Hospital. We're going to be talking about stroke education. 4 00:00:16.320 --> 00:00:19.610 If you have any questions, please raise your hand during the presentation, or go 5 00:00:19.660 --> 00:00:22.400 ahead and wait until the end of the presentation and ask your questions, okay? 6 00:00:23.820 --> 00:00:26.370 Our objectives today, because we like to have objectives, 7 00:00:27.600 --> 00:00:29.130 are: what is a stroke, 8 00:00:30.620 --> 00:00:34.440 discussion of stroke types, treatment of stroke, signs and 9 00:00:34.520 --> 00:00:37.820 symptoms of stroke, and of course, stroke prevention. 10 00:00:40.240 --> 00:00:41.120 Here's our Corewell 11 00:00:42.020 --> 00:00:45.620 Health East Side hospitals. As you see, 12 00:00:46.120 --> 00:00:49.980 we have several different hospitals that are considered a primary 13 00:00:50.540 --> 00:00:51.280 stroke center. 14 00:00:52.360 --> 00:00:56.080 Us at William Beaumont University Hospital is a comprehensive 15 00:00:56.220 --> 00:00:59.720 stroke center, but all the hospitals you will see 16 00:00:59.820 --> 00:01:03.680 here listed, including the ER sites that are 17 00:01:03.740 --> 00:01:04.880 on the right-hand side, 18 00:01:06.020 --> 00:01:09.180 all have what we call a stroke process. 19 00:01:09.700 --> 00:01:13.380 So basically, we have ways that we treat 20 00:01:13.480 --> 00:01:17.330 stroke, and you would need to go to only William 21 00:01:17.380 --> 00:01:21.120 Beaumont University Hospital or Dearborn if you need to have a clot 22 00:01:21.160 --> 00:01:24.870 removed. All right, so talking about stroke centers and 23 00:01:24.940 --> 00:01:26.600 stroke center certifications. 24 00:01:28.020 --> 00:01:31.760 William Beaumont University Hospital in Royal Oak was the first Joint Commission 25 00:01:32.260 --> 00:01:35.960 certified comprehensive stroke center in Southeastern 26 00:01:36.000 --> 00:01:36.480 Michigan. 27 00:01:37.520 --> 00:01:41.280 It was a designated award by the Joint Commission, and the American 28 00:01:41.360 --> 00:01:45.340 Heart and American Stroke Associations to hospitals deemed 29 00:01:45.420 --> 00:01:47.920 capable of managing the most complex stroke 30 00:01:48.000 --> 00:01:50.260 cases. 31 00:01:51.600 --> 00:01:55.260 And we have 24/7 neurological services 32 00:01:55.740 --> 00:01:59.420 and perform a required minimal amount of ischemic and 33 00:01:59.480 --> 00:02:03.180 hemorrhagic treatments, including endovascular 34 00:02:03.260 --> 00:02:06.060 reperfusion and endovascular coiling. 35 00:02:08.581 --> 00:02:12.200 So facts about stroke is approximately every 36 00:02:12.740 --> 00:02:16.100 40 seconds, someone in the United States has a stroke, and 37 00:02:16.160 --> 00:02:19.840 approximately every four minutes, someone in the United States dies from a 38 00:02:19.920 --> 00:02:23.440 stroke. So we know how important education and prevention are. 39 00:02:24.460 --> 00:02:28.120 Because about each year, 795,000 40 00:02:28.180 --> 00:02:30.000 Americans are diagnosed with stroke, 41 00:02:31.000 --> 00:02:34.780 and what's concerning is 600,000 are new, but actually 42 00:02:34.860 --> 00:02:38.340 approximately 195,000 strokes are 43 00:02:38.440 --> 00:02:42.400 recurrent strokes. That means someone had a stroke for the second time and 44 00:02:42.460 --> 00:02:44.140 maybe even subsequent times. 45 00:02:45.240 --> 00:02:48.940 Stroke is the fifth leading cause of death in the United States but is the 46 00:02:49.000 --> 00:02:52.740 single leading cause of long-term disability, 47 00:02:53.460 --> 00:02:57.260 with nearly seven million survivors among adults 48 00:02:57.380 --> 00:03:00.600 ages 20 and older. So significant 49 00:03:01.800 --> 00:03:05.520 direct and indirect cost, not only in cost of 50 00:03:06.900 --> 00:03:10.690 living and how people are doing and caring for themselves, but 51 00:03:10.780 --> 00:03:14.670 also billions and billions of dollars for the 52 00:03:14.700 --> 00:03:15.080 cost. 53 00:03:16.470 --> 00:03:19.020 So what we're talking about today are stroke basics. 54 00:03:19.220 --> 00:03:21.829 Stroke, or central venous system infarction, 55 00:03:22.920 --> 00:03:24.420 is defined by brain, 56 00:03:25.460 --> 00:03:29.200 spinal cord, or retinal cell death 57 00:03:29.260 --> 00:03:31.480 attributed to ischemia based on 58 00:03:31.580 --> 00:03:34.700 neuropathological, neuroimaging, 59 00:03:34.920 --> 00:03:38.080 and/or clinical evidence of permanent injury. 60 00:03:39.300 --> 00:03:41.620 There are three different types of stroke. 61 00:03:42.560 --> 00:03:44.800 The first one, of course, is ischemic stroke. 62 00:03:45.880 --> 00:03:46.620 That is when 63 00:03:47.620 --> 00:03:49.920 you have a thrombus or there's 64 00:03:51.020 --> 00:03:51.620 emboli 65 00:03:53.160 --> 00:03:56.860 that cause a clot in the vascular system, 66 00:03:57.360 --> 00:03:59.700 when you have ischemic stroke symptoms. 67 00:04:00.760 --> 00:04:04.370 Hemorrhagic strokes is approximately 13% of all strokes. 68 00:04:04.820 --> 00:04:08.780 That is when there's blood within the brain that doesn't belong there, 69 00:04:10.980 --> 00:04:14.580 and that is intracranial hemorrhage and subarachnoid hemorrhages. 70 00:04:15.420 --> 00:04:15.960 The third 71 00:04:17.940 --> 00:04:21.280 is transient ischemic attacks, or TIAs. 72 00:04:23.840 --> 00:04:26.959 Signs and symptoms of stroke, as you see, very 73 00:04:27.900 --> 00:04:31.220 prominent there, sudden and usually maximal on 74 00:04:31.320 --> 00:04:31.940 onset. 75 00:04:32.760 --> 00:04:36.380 It is weakness or numbness of the face, arm or leg, 76 00:04:36.560 --> 00:04:39.760 especially if it's unilateral. Changes in speech, 77 00:04:40.340 --> 00:04:42.400 dysarthria, aphasia, 78 00:04:43.440 --> 00:04:44.500 sudden confusion 79 00:04:45.700 --> 00:04:47.180 or understanding commands. 80 00:04:48.210 --> 00:04:51.810 Sudden vision changes, including double vision and 81 00:04:51.880 --> 00:04:52.740 development of 82 00:04:53.760 --> 00:04:55.640 visual field deficits. 83 00:04:56.960 --> 00:05:00.700 Sudden trouble walking or dizziness, loss of balance or 84 00:05:00.820 --> 00:05:01.580 coordination, 85 00:05:02.500 --> 00:05:06.000 and sudden severe headache with no known cause, especially those 86 00:05:06.040 --> 00:05:08.080 associated with nausea and vomiting. 87 00:05:10.480 --> 00:05:12.600 This is the mnemonic that we use 88 00:05:13.720 --> 00:05:15.960 at Corewell Health. It is BE FAST. 89 00:05:16.820 --> 00:05:20.660 In signs and symptoms of stroke, BE FAST, to determine if someone might be 90 00:05:20.700 --> 00:05:23.710 experiencing the symptoms of a stroke, remember the following: 91 00:05:24.680 --> 00:05:26.000 B is for balance, 92 00:05:26.860 --> 00:05:30.720 E is for eyes, F is for face, A is for 93 00:05:30.840 --> 00:05:33.920 arms, S is for speech, and T is for time. 94 00:05:35.100 --> 00:05:38.960 So basically what it is, is balance, having trouble balance or 95 00:05:39.040 --> 00:05:42.240 walking difficulties. E, eyes, visual 96 00:05:42.320 --> 00:05:44.460 disturbances or visual field loss. 97 00:05:45.600 --> 00:05:49.540 Face, is your smile uneven? If you're having any 98 00:05:49.640 --> 00:05:50.740 numbness or tingling. 99 00:05:51.640 --> 00:05:55.600 A is arms. Does one arm drift down when holding both arms up? 100 00:05:56.380 --> 00:05:59.380 Is there any new or sudden weakness or numbness? 101 00:06:00.660 --> 00:06:04.640 S is speech. Does their speech sound strange or slurred, or 102 00:06:04.680 --> 00:06:08.452 are they having difficulty forming words?And sometimes the 103 00:06:08.492 --> 00:06:11.842 confusion that they're looking at you like they don't understand what you're saying 104 00:06:11.892 --> 00:06:13.612 is what we called receptive aphasia, 105 00:06:14.972 --> 00:06:17.212 understanding what is being said to them. 106 00:06:18.532 --> 00:06:22.452 T is time. Of course, time to call 911, but T could 107 00:06:22.552 --> 00:06:25.752 also mean terrible headache. So those headaches that 108 00:06:26.112 --> 00:06:29.772 patients have or people have when they're having a 109 00:06:29.812 --> 00:06:30.832 hemorrhagic stroke. 110 00:06:32.632 --> 00:06:34.832 This is the brain anatomy review, 111 00:06:35.652 --> 00:06:36.172 basically 112 00:06:37.652 --> 00:06:41.592 showing exactly frontal lobe, you see all the way on the 113 00:06:41.852 --> 00:06:45.772 left hand there on the top. Frontal lobe is difficulty 114 00:06:45.792 --> 00:06:48.692 in judgment, foresight, or voluntary movement. 115 00:06:50.612 --> 00:06:54.202 Above that is motor cortex, or problems with movement. 116 00:06:55.152 --> 00:06:59.032 Going all the way over to the right, probably right around 1:00 on the 117 00:06:59.592 --> 00:07:03.372 clock dial, we have sensory cortex, pain, 118 00:07:03.492 --> 00:07:06.932 heat, or other sensations. Then we have parietal lobe, 119 00:07:07.052 --> 00:07:10.152 comprehension of language. So that's that understanding. 120 00:07:10.212 --> 00:07:11.812 We talked about receptive aphasia. 121 00:07:12.972 --> 00:07:15.352 Temporal lobe, the middle of the 122 00:07:17.492 --> 00:07:19.552 picture you see there, is hearing. 123 00:07:19.952 --> 00:07:23.512 Occipital lobe is in the back of the brain, is primary a visual 124 00:07:23.712 --> 00:07:27.572 area, so could have to do with some problems with visual field 125 00:07:27.592 --> 00:07:28.872 loss or vision loss. 126 00:07:29.752 --> 00:07:32.352 Wernicke area is speech comprehension. 127 00:07:32.512 --> 00:07:35.892 Again, more of the problem with 128 00:07:36.272 --> 00:07:37.552 understanding speech. 129 00:07:39.612 --> 00:07:43.512 And then cerebellum, right about the 5:00 area 130 00:07:43.592 --> 00:07:45.292 there on the brain. 131 00:07:46.132 --> 00:07:47.132 And then brain stem, 132 00:07:48.532 --> 00:07:52.282 swallowing, breathing, or heartbeat issues, wakefulness 133 00:07:52.332 --> 00:07:55.182 center, or other voluntary functions. 134 00:07:56.172 --> 00:08:00.002 And then coming around to temporal lobe, intellectual and emotional 135 00:08:00.112 --> 00:08:00.642 function. 136 00:08:01.512 --> 00:08:03.712 And then the frontal lobe is smell. 137 00:08:03.752 --> 00:08:07.072 Broca areas is speech, so problem with expression, 138 00:08:07.992 --> 00:08:09.872 forming words, speaking. 139 00:08:11.932 --> 00:08:15.911 Time is brain, so compare with the normal rate of neuron loss 140 00:08:15.952 --> 00:08:19.572 in a brain that is aging. The ischemic brain 141 00:08:19.632 --> 00:08:22.812 ages 3.6 years for each hour without treatment. 142 00:08:22.852 --> 00:08:26.732 So what we say, time is brain. Very important that you get 143 00:08:26.752 --> 00:08:30.732 help as soon as possible. That's why we encourage for everyone to 144 00:08:30.792 --> 00:08:31.872 call 911. 145 00:08:34.072 --> 00:08:35.992 We're going to break down the types of strokes. 146 00:08:36.372 --> 00:08:40.312 So ischemic stroke is caused by decreased or absent blood 147 00:08:40.372 --> 00:08:43.992 flow to a portion of the brain, depriving the 148 00:08:44.052 --> 00:08:48.012 neurons in the brain of oxygen and glucose, which they 149 00:08:48.092 --> 00:08:51.792 need, and if they don't receive it, it results in cell 150 00:08:51.872 --> 00:08:52.772 damage and death. 151 00:08:53.872 --> 00:08:57.112 The degree of damage is dependent, of course, on the length of ischemia 152 00:08:57.792 --> 00:08:59.732 and the degree of collateral flow. 153 00:09:00.772 --> 00:09:04.652 The symptoms usually develop, again, sudden and maximal on 154 00:09:04.712 --> 00:09:08.692 onset. They can be preceded by warning signs that may 155 00:09:08.732 --> 00:09:12.272 include loss of strength or sensation on one side of the body. 156 00:09:12.442 --> 00:09:15.752 Any of those signs and symptoms that we already reviewed. 157 00:09:18.172 --> 00:09:22.092 The type of strokes of ischemic stroke are thrombotic stroke 158 00:09:22.812 --> 00:09:26.712 occurs when an acute clot that occludes an artery is superimposed upon 159 00:09:26.792 --> 00:09:30.472 chronic arterial narrowing, acutely altering the 160 00:09:30.512 --> 00:09:31.602 endothelial lining, 161 00:09:32.712 --> 00:09:36.492 which could be caused by plaque rupture or both. 162 00:09:37.832 --> 00:09:40.952 And what a large vessel thrombosis is an 163 00:09:41.112 --> 00:09:44.792 LVO. Large vessel thrombosis or 164 00:09:44.912 --> 00:09:47.992 large vessel occlusion, LVO, 165 00:09:48.712 --> 00:09:48.962 is 166 00:09:49.892 --> 00:09:53.472 what we try to treat when we try to remove the clot. 167 00:09:54.682 --> 00:09:57.792 The most common and best understood type of thrombotic stroke, 168 00:09:58.452 --> 00:10:02.192 mainly caused by the combination of that long-term atherosclerosis, 169 00:10:02.872 --> 00:10:05.382 followed by a rapid blood clot formation. 170 00:10:06.512 --> 00:10:10.412 Small vessel disease or lacunar infarcts occurs when blood flow is blocked to the 171 00:10:10.452 --> 00:10:14.032 very small arterial vessels, closely linked to 172 00:10:14.052 --> 00:10:14.992 hypertension, 173 00:10:15.812 --> 00:10:18.772 and we give medical management for those patients. 174 00:10:21.512 --> 00:10:25.352 Embolic strokes occurs when an intravascular material, typically blood 175 00:10:25.372 --> 00:10:28.972 clot or obviously clots, separates from the 176 00:10:28.992 --> 00:10:32.612 proximal source and flows through the artery until it causes 177 00:10:32.672 --> 00:10:35.412 occlusion of one of the arteries in the brain. 178 00:10:36.652 --> 00:10:40.332 The most common origin of cardioembolic typically due to 179 00:10:40.372 --> 00:10:44.192 atrial fibrillation, so you're at a high risk if you have atrial fibrillation. 180 00:10:44.792 --> 00:10:48.412 Also could be secondary to a patent foramen 181 00:10:48.452 --> 00:10:52.052 ovale, valvular disease, acute myocardial 182 00:10:52.072 --> 00:10:53.572 infarction or heart attack, 183 00:10:54.572 --> 00:10:58.532 or endocarditis, so infection of the heart 184 00:10:58.572 --> 00:10:58.952 lining. 185 00:11:00.392 --> 00:11:04.292 Cryptogenic strokes are ischemic strokes 186 00:11:04.332 --> 00:11:07.832 without a readily identifiable etiology or cause. 187 00:11:09.072 --> 00:11:12.652 Transient ischemic attacks, or TIAs, is a transient 188 00:11:12.712 --> 00:11:16.232 episode of neurological dysfunction caused by focal brain, 189 00:11:16.692 --> 00:11:20.532 spinal cord, or retinal ischemia without the evidence of acute 190 00:11:20.632 --> 00:11:21.132 infarct. 191 00:11:21.972 --> 00:11:25.932 So what that means is you're having all the stroke symptoms 192 00:11:25.952 --> 00:11:29.872 that we discussed, especially when it comes to BE FAST and all 193 00:11:29.912 --> 00:11:31.841 those face, arms, 194 00:11:32.972 --> 00:11:36.032 stability, walking, balance, all of that, speech, 195 00:11:36.492 --> 00:11:37.031 eyes. 196 00:11:38.332 --> 00:11:42.272 But what happens is the clot doesn't stay, and there 197 00:11:42.312 --> 00:11:45.502 isn't permanent damage. So what the great thing is, is that, 198 00:11:46.592 --> 00:11:50.052 yes, there's no permanent damage. You did have the symptoms. 199 00:11:50.132 --> 00:11:54.052 The MRI is negative for stroke, but you're at a higher risk for having a stroke 200 00:11:54.072 --> 00:11:57.252 in the near future. So definitely take those 201 00:11:57.892 --> 00:12:01.022 transient ischemic attacks or TIAs very seriously. 202 00:12:03.892 --> 00:12:07.292 Retinal artery occlusions or CRAOs are a 203 00:12:07.352 --> 00:12:10.532 stroke in the eye. So if you want to think about sudden 204 00:12:10.572 --> 00:12:14.468 painless vision loss that persistsCaused 205 00:12:14.508 --> 00:12:18.388 by a thrombus or embolus lodging in the lumen of the retinal artery. 206 00:12:19.488 --> 00:12:23.408 And what the doctor sees, the ophthalmologist usually sees this 207 00:12:23.448 --> 00:12:26.168 little cherry red spot when they look in your eye. 208 00:12:28.068 --> 00:12:31.728 Cerebral venous sinus thrombosis results when a clot 209 00:12:31.788 --> 00:12:35.748 forms within the venous sinuses and impairs drainage of the blood from 210 00:12:35.788 --> 00:12:38.948 the brain. So it's a little bit different cause. 211 00:12:39.948 --> 00:12:43.468 And the symptoms are a little bit different, including headache, blurred 212 00:12:43.548 --> 00:12:47.518 vision, fainting, loss of consciousness, loss of control over 213 00:12:47.648 --> 00:12:51.388 part of the body, seizures, coma. Pretty serious, right? 214 00:12:52.128 --> 00:12:55.488 Definitely want to get immediate help and call 911. 215 00:12:56.428 --> 00:13:00.328 Management includes anticoagulations to prevent propagation of the clot 216 00:13:00.388 --> 00:13:01.448 and workup for 217 00:13:02.488 --> 00:13:03.208 the cause. 218 00:13:05.928 --> 00:13:09.108 We talked a little bit already about ischemic stroke treatments. 219 00:13:09.568 --> 00:13:12.348 They are aimed of saving that still viable brain tissue. 220 00:13:12.488 --> 00:13:13.568 It's called penumbra. 221 00:13:14.408 --> 00:13:18.368 And if you look at that picture on the bottom there, all 222 00:13:18.408 --> 00:13:22.068 the way to the left, the green section there is the penumbra. 223 00:13:22.768 --> 00:13:26.588 The red section is the acute infarct, or what we call the 224 00:13:26.608 --> 00:13:27.568 core infarct. 225 00:13:28.628 --> 00:13:31.608 If we can get treatment, which include 226 00:13:32.908 --> 00:13:33.828 tenecteplase, 227 00:13:34.688 --> 00:13:37.708 it's a medication, it's only one of the 228 00:13:38.468 --> 00:13:38.708 two 229 00:13:39.788 --> 00:13:41.988 FDA-approved medications for stroke. 230 00:13:42.928 --> 00:13:44.588 And if necessary, 231 00:13:45.968 --> 00:13:48.628 we remove that occlusion, we remove the clot. 232 00:13:49.488 --> 00:13:53.368 We won't see progression of the stroke all the way to the right, where 233 00:13:53.448 --> 00:13:57.308 we have all red. That means all the area that you see 234 00:13:57.388 --> 00:14:01.108 there is now a stroke. So that 235 00:14:01.188 --> 00:14:03.048 green area is penumbra, 236 00:14:03.868 --> 00:14:04.588 decreased 237 00:14:07.788 --> 00:14:11.628 blood flow. But with the treatment, that's we're 238 00:14:11.728 --> 00:14:15.388 hoping prevent something that occurs all the way to the 239 00:14:15.468 --> 00:14:15.868 right. 240 00:14:16.888 --> 00:14:19.488 The one on the right is the- 241 00:14:20.868 --> 00:14:21.168 So 242 00:14:21.988 --> 00:14:23.088 if you see here, 243 00:14:24.228 --> 00:14:26.748 this one here, the core infarct is in red. 244 00:14:27.388 --> 00:14:31.008 So that's where the stroke is. The penumbra, that is the area 245 00:14:31.568 --> 00:14:34.908 of the brain that has decreased perfusion, 246 00:14:35.388 --> 00:14:38.588 meaning decreased blood flow because the clot is still there. 247 00:14:39.348 --> 00:14:42.408 So unfortunately, if we're not able to remove the clot, 248 00:14:43.138 --> 00:14:46.768 unfortunately what happens is that penumbra, because the 249 00:14:46.828 --> 00:14:50.048 decreased perfusion or the decreased blood flow, 250 00:14:50.128 --> 00:14:53.948 eventually it can actually be affected and be part of the 251 00:14:54.008 --> 00:14:54.808 infarct. 252 00:14:58.048 --> 00:14:59.188 So number one is the one that's . Number one is what? 253 00:15:00.688 --> 00:15:04.508 Normal? No, that's not normal. That red area there, that's a 254 00:15:04.548 --> 00:15:06.148 core infarct or the core stroke. 255 00:15:07.748 --> 00:15:09.378 So the normal one is the one, all red one? 256 00:15:10.428 --> 00:15:12.848 The normal one wouldn't have any red. 257 00:15:14.548 --> 00:15:18.108 The red part is the stroke. The green part is the 258 00:15:18.128 --> 00:15:20.848 penumbra or decreased blood flow area. 259 00:15:21.848 --> 00:15:25.808 So what we want to do is we want to treat this patient, remove the clot if 260 00:15:25.868 --> 00:15:29.678 possible, give them tenecteplase if possible, and 261 00:15:29.708 --> 00:15:32.268 prevent the all red area. 262 00:15:34.028 --> 00:15:36.018 As soon as possible. As soon as possible, you need the treatment. 263 00:15:36.148 --> 00:15:39.018 That's why it's so important that you call 911 to get help. 264 00:15:39.868 --> 00:15:43.648 So tenecteplase, it does say for eligible patients up to four and a half 265 00:15:43.748 --> 00:15:44.348 hours. 266 00:15:45.728 --> 00:15:49.348 We are able to possibly, in the near 267 00:15:49.468 --> 00:15:53.168 future, extend that window for a very small criteria 268 00:15:53.268 --> 00:15:57.008 of patients, so up to nine hours. 269 00:15:58.148 --> 00:16:02.068 And then mechanical thrombectomy, up to 24 hours after symptom onset, 270 00:16:02.168 --> 00:16:04.288 if you're a candidate for that treatment. 271 00:16:07.428 --> 00:16:11.088 Transient ischemic attacks, I think I already mentioned this, but it's a brief 272 00:16:11.168 --> 00:16:14.938 episode of focal neurological deficit lasting less than 15 273 00:16:14.968 --> 00:16:15.358 minutes, 274 00:16:17.008 --> 00:16:20.588 with no evidence of stroke on imaging. 275 00:16:21.337 --> 00:16:25.188 The 90-day stroke risk after a TIA increases 276 00:16:25.248 --> 00:16:28.828 up to 17%, with practically half 277 00:16:28.888 --> 00:16:31.808 occurring within the first seven days after a TIA. 278 00:16:33.288 --> 00:16:35.037 According to the American Heart 279 00:16:35.087 --> 00:16:38.238 Association/American Stroke 280 00:16:38.288 --> 00:16:42.068 Association, approximately 15% of strokes are herald 281 00:16:42.148 --> 00:16:44.958 by a TIA. Between 7% and 282 00:16:45.168 --> 00:16:48.688 40% of patients treated with ischemic stroke 283 00:16:48.768 --> 00:16:51.608 reported experiencing a TIA first. 284 00:16:53.128 --> 00:16:56.908 Approximately a third of patients who have a TIA will go on to have a stroke 285 00:16:56.948 --> 00:17:00.268 within a year. So definitely considered 286 00:17:01.188 --> 00:17:04.969 TIAs not benign, but rather a precursor to ischemic stroke, 287 00:17:05.868 --> 00:17:09.229 because we know 80% of stroke are preventable. 288 00:17:10.689 --> 00:17:14.168 But before we go on to how to prevent stroke, we need to talk about the other 289 00:17:14.248 --> 00:17:14.658 stroke 290 00:17:16.189 --> 00:17:19.568 type, which is hemorrhagic stroke. 291 00:17:19.588 --> 00:17:23.408 Intracerebral hemorrhage is a ruptured blood vessel deep in 292 00:17:23.449 --> 00:17:26.908 the brain tissue. High blood pressure is the most common 293 00:17:26.949 --> 00:17:30.788 cause. Subarachnoid hemorrhage, or SAH, is 294 00:17:31.268 --> 00:17:35.218 blood vessel ruptures near the surface of the brain and blood pours into 295 00:17:35.228 --> 00:17:38.108 the area between the brain and the skull. 296 00:17:38.188 --> 00:17:41.728 This type has many possible causes but is usually the result of a 297 00:17:41.788 --> 00:17:43.888 ruptured aneurysm. 298 00:17:45.768 --> 00:17:47.848 How do hemorrhages happen? 299 00:17:48.848 --> 00:17:52.568 Of course, subarachnoid hemorrhage is that aneurysm 300 00:17:52.608 --> 00:17:55.768 rupture we talked about, or a condition called 301 00:17:55.848 --> 00:17:58.418 arteriovenous malformation rupture. 302 00:17:59.988 --> 00:18:03.977 IPH is the common cause by spontaneous rupture of 303 00:18:04.068 --> 00:18:06.808 vessels damaged by long-term hypertension, 304 00:18:07.888 --> 00:18:11.588 uncontrolled hypertension, amyloid angiopathy, 305 00:18:13.088 --> 00:18:15.968 anticoagulation and coagulopathy issues, 306 00:18:16.628 --> 00:18:18.728 hemorrhagic transformation of ischemic 307 00:18:18.748 --> 00:18:22.644 stroke.An intraventricular hemorrhage is 308 00:18:22.664 --> 00:18:25.984 not primary, but actually is when the blood seeps 309 00:18:26.584 --> 00:18:29.664 from one of the primary bleeds, which would be 310 00:18:30.364 --> 00:18:31.544 SAH or ICH, 311 00:18:32.444 --> 00:18:32.764 and 312 00:18:33.824 --> 00:18:35.804 extends to the ventricles of the brain. 313 00:18:37.564 --> 00:18:40.524 So here are our risk factors for hemorrhagic stroke. 314 00:18:41.864 --> 00:18:42.804 High blood pressure, 315 00:18:43.724 --> 00:18:47.624 heavy alcohol use, diabetes, tobacco use, poor 316 00:18:47.684 --> 00:18:51.664 diet, physical inactivity, obesity, substance 317 00:18:51.784 --> 00:18:53.964 use, high caffeine intake, 318 00:18:54.904 --> 00:18:57.084 family history, age over 40, 319 00:18:58.324 --> 00:19:02.224 sex, women have an increased incidence of aneurysm compared 320 00:19:02.244 --> 00:19:06.064 to men, AV malformation, and other diseases such 321 00:19:06.104 --> 00:19:07.984 as polycystic diseases, 322 00:19:09.704 --> 00:19:11.964 kidneys, connective tissue disorder, 323 00:19:12.724 --> 00:19:15.244 neurofibromatosis, and other diseases. 324 00:19:17.464 --> 00:19:20.884 This is what a hemorrhagic stroke surgical treatment 325 00:19:21.664 --> 00:19:22.244 looks like. 326 00:19:24.084 --> 00:19:28.004 A craniectomy and hematoma evacuation can be used in 327 00:19:28.084 --> 00:19:31.364 severe ICH or cerebral 328 00:19:31.684 --> 00:19:32.424 hemorrhages. 329 00:19:33.324 --> 00:19:36.714 A decompressive craniotomy helps alleviate the increased 330 00:19:36.864 --> 00:19:38.104 pressure in the brain, 331 00:19:38.924 --> 00:19:42.124 and that pressure can cause edema 332 00:19:42.624 --> 00:19:45.624 and hematoma expansion and more 333 00:19:48.284 --> 00:19:48.744 damage. 334 00:19:49.824 --> 00:19:53.664 So clipping helps the treatment 335 00:19:53.704 --> 00:19:57.024 for that aneurysm, but mostly our treatments for 336 00:19:57.084 --> 00:19:59.164 aneurysms are coiling. 337 00:20:00.124 --> 00:20:03.964 They're less invasive and they treat most 338 00:20:04.084 --> 00:20:07.304 all cerebral aneurysms. 339 00:20:09.464 --> 00:20:12.924 So here's stroke recognition and prevention. This is the important part. 340 00:20:13.664 --> 00:20:17.204 Again, BE FAST. So B is for balance, E is for 341 00:20:17.324 --> 00:20:20.944 eyes, F is for face, A is for arm, S is for 342 00:20:21.044 --> 00:20:23.784 speech, T is for time or terrible headache. 343 00:20:25.424 --> 00:20:29.224 So pre-hospital management. The role of EMS is critical in 344 00:20:29.324 --> 00:20:32.584 optimizing stroke care. So that's what we really try to 345 00:20:32.624 --> 00:20:35.444 encourage. Utilization of EMS shortens the 346 00:20:35.504 --> 00:20:38.524 time for 347 00:20:39.804 --> 00:20:40.364 physician, 348 00:20:41.304 --> 00:20:43.204 brain imaging, and increases the 349 00:20:44.144 --> 00:20:46.704 possibility of administration of IV 350 00:20:47.044 --> 00:20:50.404 thrombolysis, that tenecteplase we talked about. 351 00:20:51.324 --> 00:20:54.873 However, the National Hospital Ambulatory Medical 352 00:20:55.004 --> 00:20:57.124 Survey receives 353 00:20:57.964 --> 00:21:01.644 approximately only 53% of patients. 354 00:21:03.524 --> 00:21:07.424 Stroke risk factors, non-modifiable, of course, family history of stroke, 355 00:21:07.664 --> 00:21:11.264 race, ethnicity. We talked about females. 356 00:21:12.324 --> 00:21:15.884 Genetic disorders affecting coagulability or blood 357 00:21:16.384 --> 00:21:18.324 dyscrasias or blood diseases. 358 00:21:19.684 --> 00:21:22.624 Age and gender, and previous stroke or TIA. 359 00:21:23.764 --> 00:21:26.464 Modifiable risk factors are hypertension. 360 00:21:26.944 --> 00:21:30.124 Of course, one of the most important modifiable risk factors for both 361 00:21:31.104 --> 00:21:34.744 ischemic and hemorrhagic stroke is keeping that blood pressure low. 362 00:21:34.924 --> 00:21:38.694 Even if you have hypertension, making sure you're keeping 363 00:21:38.764 --> 00:21:42.684 that blood pressure normal. And if you're taking your 364 00:21:42.724 --> 00:21:46.204 blood pressure every day, that's great. That's what we want to hear. 365 00:21:46.524 --> 00:21:50.384 Make sure you're keeping a record, and if you see your blood pressure climbing 366 00:21:50.464 --> 00:21:53.804 up, you need to call and contact your primary care or your 367 00:21:53.844 --> 00:21:55.994 cardiologist, whoever manages your blood pressure. 368 00:21:56.724 --> 00:22:00.644 If you're currently not taking your blood pressure every day, I highly encourage 369 00:22:00.724 --> 00:22:03.264 you taking your blood pressure every day and keeping a record. 370 00:22:06.024 --> 00:22:08.424 Smoking and tobacco use, and of course, vaping, 371 00:22:09.924 --> 00:22:13.864 is closely linked to atherosclerosis, so we definitely want 372 00:22:13.884 --> 00:22:14.843 to keep that. 373 00:22:16.424 --> 00:22:18.164 Quit if you haven't already quit. 374 00:22:19.524 --> 00:22:23.324 Coronary artery disease, CAD or heart failure doubles the risk for 375 00:22:23.424 --> 00:22:23.844 stroke. 376 00:22:25.284 --> 00:22:26.524 Carotid stenosis, 377 00:22:28.124 --> 00:22:30.444 atrial fibrillation and atrial flutter, 378 00:22:31.804 --> 00:22:35.744 diabetes, hyperlipidemia, and obesity. 379 00:22:37.364 --> 00:22:40.964 Here's the blood pressure. Most common modifiable risk 380 00:22:41.024 --> 00:22:41.504 factor. 381 00:22:42.324 --> 00:22:45.924 Diabetes associated with increased risk of atherosclerosis 382 00:22:46.044 --> 00:22:48.564 results from chronic inflammation and injury 383 00:22:49.464 --> 00:22:53.414 to the blood vessels. People with diabetes are more likely to have high blood 384 00:22:53.464 --> 00:22:57.344 pressure and high cholesterol with 1.8 to six times 385 00:22:57.764 --> 00:22:59.124 increased risk of stroke. 386 00:23:00.884 --> 00:23:04.524 Atrial fibrillation. Non-valvular atrial fibrillation 387 00:23:04.564 --> 00:23:08.264 associated with four to five times increased risk factor of 388 00:23:08.284 --> 00:23:09.144 ischemic stroke. 389 00:23:12.164 --> 00:23:14.644 Tobacco abuse and vaping. 390 00:23:15.804 --> 00:23:19.404 Cigarette smoking is associated with two times risk of ischemic stroke and two to 391 00:23:19.424 --> 00:23:21.824 four times risk of subarachnoid hemorrhage. 392 00:23:22.884 --> 00:23:26.824 Smoking just one cigarette increases your heart rate, your mean blood 393 00:23:26.844 --> 00:23:30.684 pressure, cardiac index, and decrease arterial 394 00:23:32.224 --> 00:23:34.034 disability. 395 00:23:34.904 --> 00:23:38.434 Recommendations, of course, smoking cessation, avoidance of 396 00:23:38.464 --> 00:23:42.174 environmental tobacco smoke. So that's definitely what you'd want to do if you have 397 00:23:42.204 --> 00:23:45.724 someone that you live with that smokes, ask them to smoke outside, right? 398 00:23:48.464 --> 00:23:52.084 Multimodal approach to smoking cessation for them, right? 399 00:23:53.004 --> 00:23:55.824 Including counseling and nicotine replacement can be helpful. 400 00:23:58.544 --> 00:24:02.404 Alcohol abuse. Heavy alcohol consumption is a risk factor for all types of 401 00:24:02.444 --> 00:24:05.034 stroke and can result in hypertension, 402 00:24:05.444 --> 00:24:09.084 hypercoagulability, reduced cerebral blood flow, and 403 00:24:09.144 --> 00:24:11.364 increased risk of atrial fibrillation. 404 00:24:13.864 --> 00:24:15.964 Obesity and physical inactivity. 405 00:24:16.244 --> 00:24:20.144 Of course, if you are obese, your BMI is greater 406 00:24:20.184 --> 00:24:23.904 than 30, we definitely want you to reduce your 407 00:24:23.924 --> 00:24:26.604 weight to decrease blood pressure and risk of stroke. 408 00:24:27.314 --> 00:24:30.754 Physical inactivity is associated with increased total 409 00:24:31.004 --> 00:24:31.694 morbidity, 410 00:24:32.844 --> 00:24:35.854 increased cardiovascular morbidity and mortality, 411 00:24:36.964 --> 00:24:38.304 and increased risk of stroke. 412 00:24:41.564 --> 00:24:45.544 So what we do is recommend physically active men and women 413 00:24:45.684 --> 00:24:49.364 have a 25% to 30% lower risk of stroke 414 00:24:50.644 --> 00:24:54.304 than the least active people. So recommending 30 minutes of 415 00:24:54.324 --> 00:24:55.384 activity five 416 00:24:56.244 --> 00:24:59.764 times a week. It can be divided into smaller intervals. 417 00:25:00.764 --> 00:25:03.764 So we really encourage 10-minute walk 418 00:25:03.864 --> 00:25:07.784 after every one of your meals is the best. 419 00:25:08.204 --> 00:25:11.754 And that means 10 minutes right after your last bite of food, go for a 420 00:25:11.784 --> 00:25:15.164 walk. Don't even clean up your plate, don't clean up the kitchen, 421 00:25:15.884 --> 00:25:16.644 go for a walk. 422 00:25:18.504 --> 00:25:22.484 Dietary recommendations to reduce stroke is 423 00:25:22.584 --> 00:25:24.364 reduce intake of sodium, 424 00:25:25.484 --> 00:25:27.324 increase intake of potassium, 425 00:25:28.284 --> 00:25:31.204 have the DASH or Mediterranean-style diet. 426 00:25:31.804 --> 00:25:35.564 So we're emphasizing in our diet fruit, vegetables, and 427 00:25:35.624 --> 00:25:38.344 low-fat dairy products. And of course, 428 00:25:39.804 --> 00:25:41.344 decreased red meat.