So like I said, my name is Wendy Carravaille.
I'm one of the stroke program managers at Corewell Health William Beaumont
University Hospital. We're going to be talking about stroke education.
If you have any questions, please raise your hand during the presentation, or go
ahead and wait until the end of the presentation and ask your questions, okay?
Our objectives today, because we like to have objectives,
are: what is a stroke,
discussion of stroke types, treatment of stroke, signs and
symptoms of stroke, and of course, stroke prevention.
Here's our Corewell
Health East Side hospitals. As you see,
we have several different hospitals that are considered a primary
stroke center.
Us at William Beaumont University Hospital is a comprehensive
stroke center, but all the hospitals you will see
here listed, including the ER sites that are
on the right-hand side,
all have what we call a stroke process.
So basically, we have ways that we treat
stroke, and you would need to go to only William
Beaumont University Hospital or Dearborn if you need to have a clot
removed. All right, so talking about stroke centers and
stroke center certifications.
William Beaumont University Hospital in Royal Oak was the first Joint Commission
certified comprehensive stroke center in Southeastern
Michigan.
It was a designated award by the Joint Commission, and the American
Heart and American Stroke Associations to hospitals deemed
capable of managing the most complex stroke
cases.
And we have 24/7 neurological services
and perform a required minimal amount of ischemic and
hemorrhagic treatments, including endovascular
reperfusion and endovascular coiling.
So facts about stroke is approximately every
40 seconds, someone in the United States has a stroke, and
approximately every four minutes, someone in the United States dies from a
stroke. So we know how important education and prevention are.
Because about each year, 795,000
Americans are diagnosed with stroke,
and what's concerning is 600,000 are new, but actually
approximately 195,000 strokes are
recurrent strokes. That means someone had a stroke for the second time and
maybe even subsequent times.
Stroke is the fifth leading cause of death in the United States but is the
single leading cause of long-term disability,
with nearly seven million survivors among adults
ages 20 and older. So significant
direct and indirect cost, not only in cost of
living and how people are doing and caring for themselves, but
also billions and billions of dollars for the
cost.
So what we're talking about today are stroke basics.
Stroke, or central venous system infarction,
is defined by brain,
spinal cord, or retinal cell death
attributed to ischemia based on
neuropathological, neuroimaging,
and/or clinical evidence of permanent injury.
There are three different types of stroke.
The first one, of course, is ischemic stroke.
That is when
you have a thrombus or there's
emboli
that cause a clot in the vascular system,
when you have ischemic stroke symptoms.
Hemorrhagic strokes is approximately 13% of all strokes.
That is when there's blood within the brain that doesn't belong there,
and that is intracranial hemorrhage and subarachnoid hemorrhages.
The third
is transient ischemic attacks, or TIAs.
Signs and symptoms of stroke, as you see, very
prominent there, sudden and usually maximal on
onset.
It is weakness or numbness of the face, arm or leg,
especially if it's unilateral. Changes in speech,
dysarthria, aphasia,
sudden confusion
or understanding commands.
Sudden vision changes, including double vision and
development of
visual field deficits.
Sudden trouble walking or dizziness, loss of balance or
coordination,
and sudden severe headache with no known cause, especially those
associated with nausea and vomiting.
This is the mnemonic that we use
at Corewell Health. It is BE FAST.
In signs and symptoms of stroke, BE FAST, to determine if someone might be
experiencing the symptoms of a stroke, remember the following:
B is for balance,
E is for eyes, F is for face, A is for
arms, S is for speech, and T is for time.
So basically what it is, is balance, having trouble balance or
walking difficulties. E, eyes, visual
disturbances or visual field loss.
Face, is your smile uneven? If you're having any
numbness or tingling.
A is arms. Does one arm drift down when holding both arms up?
Is there any new or sudden weakness or numbness?
S is speech. Does their speech sound strange or slurred, or
are they having difficulty forming words?And sometimes the
confusion that they're looking at you like they don't understand what you're saying
is what we called receptive aphasia,
understanding what is being said to them.
T is time. Of course, time to call 911, but T could
also mean terrible headache. So those headaches that
patients have or people have when they're having a
hemorrhagic stroke.
This is the brain anatomy review,
basically
showing exactly frontal lobe, you see all the way on the
left hand there on the top. Frontal lobe is difficulty
in judgment, foresight, or voluntary movement.
Above that is motor cortex, or problems with movement.
Going all the way over to the right, probably right around 1:00 on the
clock dial, we have sensory cortex, pain,
heat, or other sensations. Then we have parietal lobe,
comprehension of language. So that's that understanding.
We talked about receptive aphasia.
Temporal lobe, the middle of the
picture you see there, is hearing.
Occipital lobe is in the back of the brain, is primary a visual
area, so could have to do with some problems with visual field
loss or vision loss.
Wernicke area is speech comprehension.
Again, more of the problem with
understanding speech.
And then cerebellum, right about the 5:00 area
there on the brain.
And then brain stem,
swallowing, breathing, or heartbeat issues, wakefulness
center, or other voluntary functions.
And then coming around to temporal lobe, intellectual and emotional
function.
And then the frontal lobe is smell.
Broca areas is speech, so problem with expression,
forming words, speaking.
Time is brain, so compare with the normal rate of neuron loss
in a brain that is aging. The ischemic brain
ages 3.6 years for each hour without treatment.
So what we say, time is brain. Very important that you get
help as soon as possible. That's why we encourage for everyone to
call 911.
We're going to break down the types of strokes.
So ischemic stroke is caused by decreased or absent blood
flow to a portion of the brain, depriving the
neurons in the brain of oxygen and glucose, which they
need, and if they don't receive it, it results in cell
damage and death.
The degree of damage is dependent, of course, on the length of ischemia
and the degree of collateral flow.
The symptoms usually develop, again, sudden and maximal on
onset. They can be preceded by warning signs that may
include loss of strength or sensation on one side of the body.
Any of those signs and symptoms that we already reviewed.
The type of strokes of ischemic stroke are thrombotic stroke
occurs when an acute clot that occludes an artery is superimposed upon
chronic arterial narrowing, acutely altering the
endothelial lining,
which could be caused by plaque rupture or both.
And what a large vessel thrombosis is an
LVO. Large vessel thrombosis or
large vessel occlusion, LVO,
is
what we try to treat when we try to remove the clot.
The most common and best understood type of thrombotic stroke,
mainly caused by the combination of that long-term atherosclerosis,
followed by a rapid blood clot formation.
Small vessel disease or lacunar infarcts occurs when blood flow is blocked to the
very small arterial vessels, closely linked to
hypertension,
and we give medical management for those patients.
Embolic strokes occurs when an intravascular material, typically blood
clot or obviously clots, separates from the
proximal source and flows through the artery until it causes
occlusion of one of the arteries in the brain.
The most common origin of cardioembolic typically due to
atrial fibrillation, so you're at a high risk if you have atrial fibrillation.
Also could be secondary to a patent foramen
ovale, valvular disease, acute myocardial
infarction or heart attack,
or endocarditis, so infection of the heart
lining.
Cryptogenic strokes are ischemic strokes
without a readily identifiable etiology or cause.
Transient ischemic attacks, or TIAs, is a transient
episode of neurological dysfunction caused by focal brain,
spinal cord, or retinal ischemia without the evidence of acute
infarct.
So what that means is you're having all the stroke symptoms
that we discussed, especially when it comes to BE FAST and all
those face, arms,
stability, walking, balance, all of that, speech,
eyes.
But what happens is the clot doesn't stay, and there
isn't permanent damage. So what the great thing is, is that,
yes, there's no permanent damage. You did have the symptoms.
The MRI is negative for stroke, but you're at a higher risk for having a stroke
in the near future. So definitely take those
transient ischemic attacks or TIAs very seriously.
Retinal artery occlusions or CRAOs are a
stroke in the eye. So if you want to think about sudden
painless vision loss that persistsCaused
by a thrombus or embolus lodging in the lumen of the retinal artery.
And what the doctor sees, the ophthalmologist usually sees this
little cherry red spot when they look in your eye.
Cerebral venous sinus thrombosis results when a clot
forms within the venous sinuses and impairs drainage of the blood from
the brain. So it's a little bit different cause.
And the symptoms are a little bit different, including headache, blurred
vision, fainting, loss of consciousness, loss of control over
part of the body, seizures, coma. Pretty serious, right?
Definitely want to get immediate help and call 911.
Management includes anticoagulations to prevent propagation of the clot
and workup for
the cause.
We talked a little bit already about ischemic stroke treatments.
They are aimed of saving that still viable brain tissue.
It's called penumbra.
And if you look at that picture on the bottom there, all
the way to the left, the green section there is the penumbra.
The red section is the acute infarct, or what we call the
core infarct.
If we can get treatment, which include
tenecteplase,
it's a medication, it's only one of the
two
FDA-approved medications for stroke.
And if necessary,
we remove that occlusion, we remove the clot.
We won't see progression of the stroke all the way to the right, where
we have all red. That means all the area that you see
there is now a stroke. So that
green area is penumbra,
decreased
blood flow. But with the treatment, that's we're
hoping prevent something that occurs all the way to the
right.
The one on the right is the-
So
if you see here,
this one here, the core infarct is in red.
So that's where the stroke is. The penumbra, that is the area
of the brain that has decreased perfusion,
meaning decreased blood flow because the clot is still there.
So unfortunately, if we're not able to remove the clot,
unfortunately what happens is that penumbra, because the
decreased perfusion or the decreased blood flow,
eventually it can actually be affected and be part of the
infarct.
So number one is the one that's . Number one is what?
Normal? No, that's not normal. That red area there, that's a
core infarct or the core stroke.
So the normal one is the one, all red one?
The normal one wouldn't have any red.
The red part is the stroke. The green part is the
penumbra or decreased blood flow area.
So what we want to do is we want to treat this patient, remove the clot if
possible, give them tenecteplase if possible, and
prevent the all red area.
As soon as possible. As soon as possible, you need the treatment.
That's why it's so important that you call 911 to get help.
So tenecteplase, it does say for eligible patients up to four and a half
hours.
We are able to possibly, in the near
future, extend that window for a very small criteria
of patients, so up to nine hours.
And then mechanical thrombectomy, up to 24 hours after symptom onset,
if you're a candidate for that treatment.
Transient ischemic attacks, I think I already mentioned this, but it's a brief
episode of focal neurological deficit lasting less than 15
minutes,
with no evidence of stroke on imaging.
The 90-day stroke risk after a TIA increases
up to 17%, with practically half
occurring within the first seven days after a TIA.
According to the American Heart
Association/American Stroke
Association, approximately 15% of strokes are herald
by a TIA. Between 7% and
40% of patients treated with ischemic stroke
reported experiencing a TIA first.
Approximately a third of patients who have a TIA will go on to have a stroke
within a year. So definitely considered
TIAs not benign, but rather a precursor to ischemic stroke,
because we know 80% of stroke are preventable.
But before we go on to how to prevent stroke, we need to talk about the other
stroke
type, which is hemorrhagic stroke.
Intracerebral hemorrhage is a ruptured blood vessel deep in
the brain tissue. High blood pressure is the most common
cause. Subarachnoid hemorrhage, or SAH, is
blood vessel ruptures near the surface of the brain and blood pours into
the area between the brain and the skull.
This type has many possible causes but is usually the result of a
ruptured aneurysm.
How do hemorrhages happen?
Of course, subarachnoid hemorrhage is that aneurysm
rupture we talked about, or a condition called
arteriovenous malformation rupture.
IPH is the common cause by spontaneous rupture of
vessels damaged by long-term hypertension,
uncontrolled hypertension, amyloid angiopathy,
anticoagulation and coagulopathy issues,
hemorrhagic transformation of ischemic
stroke.An intraventricular hemorrhage is
not primary, but actually is when the blood seeps
from one of the primary bleeds, which would be
SAH or ICH,
and
extends to the ventricles of the brain.
So here are our risk factors for hemorrhagic stroke.
High blood pressure,
heavy alcohol use, diabetes, tobacco use, poor
diet, physical inactivity, obesity, substance
use, high caffeine intake,
family history, age over 40,
sex, women have an increased incidence of aneurysm compared
to men, AV malformation, and other diseases such
as polycystic diseases,
kidneys, connective tissue disorder,
neurofibromatosis, and other diseases.
This is what a hemorrhagic stroke surgical treatment
looks like.
A craniectomy and hematoma evacuation can be used in
severe ICH or cerebral
hemorrhages.
A decompressive craniotomy helps alleviate the increased
pressure in the brain,
and that pressure can cause edema
and hematoma expansion and more
damage.
So clipping helps the treatment
for that aneurysm, but mostly our treatments for
aneurysms are coiling.
They're less invasive and they treat most
all cerebral aneurysms.
So here's stroke recognition and prevention. This is the important part.
Again, BE FAST. So B is for balance, E is for
eyes, F is for face, A is for arm, S is for
speech, T is for time or terrible headache.
So pre-hospital management. The role of EMS is critical in
optimizing stroke care. So that's what we really try to
encourage. Utilization of EMS shortens the
time for
physician,
brain imaging, and increases the
possibility of administration of IV
thrombolysis, that tenecteplase we talked about.
However, the National Hospital Ambulatory Medical
Survey receives
approximately only 53% of patients.
Stroke risk factors, non-modifiable, of course, family history of stroke,
race, ethnicity. We talked about females.
Genetic disorders affecting coagulability or blood
dyscrasias or blood diseases.
Age and gender, and previous stroke or TIA.
Modifiable risk factors are hypertension.
Of course, one of the most important modifiable risk factors for both
ischemic and hemorrhagic stroke is keeping that blood pressure low.
Even if you have hypertension, making sure you're keeping
that blood pressure normal. And if you're taking your
blood pressure every day, that's great. That's what we want to hear.
Make sure you're keeping a record, and if you see your blood pressure climbing
up, you need to call and contact your primary care or your
cardiologist, whoever manages your blood pressure.
If you're currently not taking your blood pressure every day, I highly encourage
you taking your blood pressure every day and keeping a record.
Smoking and tobacco use, and of course, vaping,
is closely linked to atherosclerosis, so we definitely want
to keep that.
Quit if you haven't already quit.
Coronary artery disease, CAD or heart failure doubles the risk for
stroke.
Carotid stenosis,
atrial fibrillation and atrial flutter,
diabetes, hyperlipidemia, and obesity.
Here's the blood pressure. Most common modifiable risk
factor.
Diabetes associated with increased risk of atherosclerosis
results from chronic inflammation and injury
to the blood vessels. People with diabetes are more likely to have high blood
pressure and high cholesterol with 1.8 to six times
increased risk of stroke.
Atrial fibrillation. Non-valvular atrial fibrillation
associated with four to five times increased risk factor of
ischemic stroke.
Tobacco abuse and vaping.
Cigarette smoking is associated with two times risk of ischemic stroke and two to
four times risk of subarachnoid hemorrhage.
Smoking just one cigarette increases your heart rate, your mean blood
pressure, cardiac index, and decrease arterial
disability.
Recommendations, of course, smoking cessation, avoidance of
environmental tobacco smoke. So that's definitely what you'd want to do if you have
someone that you live with that smokes, ask them to smoke outside, right?
Multimodal approach to smoking cessation for them, right?
Including counseling and nicotine replacement can be helpful.
Alcohol abuse. Heavy alcohol consumption is a risk factor for all types of
stroke and can result in hypertension,
hypercoagulability, reduced cerebral blood flow, and
increased risk of atrial fibrillation.
Obesity and physical inactivity.
Of course, if you are obese, your BMI is greater
than 30, we definitely want you to reduce your
weight to decrease blood pressure and risk of stroke.
Physical inactivity is associated with increased total
morbidity,
increased cardiovascular morbidity and mortality,
and increased risk of stroke.
So what we do is recommend physically active men and women
have a 25% to 30% lower risk of stroke
than the least active people. So recommending 30 minutes of
activity five
times a week. It can be divided into smaller intervals.
So we really encourage 10-minute walk
after every one of your meals is the best.
And that means 10 minutes right after your last bite of food, go for a
walk. Don't even clean up your plate, don't clean up the kitchen,
go for a walk.
Dietary recommendations to reduce stroke is
reduce intake of sodium,
increase intake of potassium,
have the DASH or Mediterranean-style diet.
So we're emphasizing in our diet fruit, vegetables, and
low-fat dairy products. And of course,
decreased red meat.