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Bill Klaproth (Host): When it comes to stroke, how common is stroke recurrence? And what are the strategies for preventing secondary strokes? Here to talk with us about this is Dr. Ilkcan Cokgor, a Neurologist and a member of the medical staff at MarinHealth. This is The Healing Podcast brought to you by MarinHealth. I'm Bill Klaproth. Dr. Cokgor, thank you so much for your time. We really appreciate this. So how common is stroke recurrence?

Ilkcan Cokgor, MD (Guest): It is unfortunately more common than we hoped because we were giving so many different treatments and making advances. The rate of stroke recurrence, at five years reduced from 18% to 12% in 2000 and, afterwards. However since 2005, unfortunately it hasn't gone down. So the first year, usually it is between 12 to 15% and in five years it can range from 26% from country to country, from ethnicity to ethnicity, all the way to 18%.

Host: Okay. So we got it down from 18% to 5% here in the United States on average?

Dr. Cokgor: So in United States, actually it is around 10% within five years time.

Host: Okay. So can you tell us what is an A, B, C, D score?

Dr. Cokgor: An ABCD score is used to look for the risk factors of a stroke. A stands for the age. And it is, score one if a patient is over 60 years of age and then B stands for blood pressure. We worry if it is over 140 over 90 and we give another point to that. Third C is clinical features. How bad is the stroke symptoms? Speech, one-sided weakness, is it arm and the leg together, and it increases the points. D is the duration of the stroke or the transient ischemic events, like a stroke like symptoms. However, recovers for example, if a patient recovers within an hour's time, they get less points rather than recovering more than 60 minutes.

These are actually used for stroke symptoms that recovered within 24 hours. In other words, it is called transient ischemic attack and we score these transient ischemic attack patients for the probability of stroke in near future.

Host: Okay. So that's very interesting. You said age, blood pressure, clinical duration of stroke, A B, C, D, then there's another one, A, B, C, D 2.

Dr. Cokgor: So the two second D is D squared because they added another D diabetes. Diabetes is actually a very major risk factor for stroke, like cholesterol, blood pressure and age. And that's why they gave another point to diabetes and made it ABCD square your score. When the score is less than four, it is a minimal stroke risk factor when you have full points from everything it is the most stroke risk factor for a transient ischemic attack patient.

Host: So then when you look at the A, B, C, D 2 or D squared, as you called it, how do you use that then?

Dr. Cokgor: So we do use it to if a patient in nine points, which means that if they have everything. They are elderly, high blood pressure, multiple neurological symptoms, longer duration of transient ischemic attack, and they have diabetes. This patient has the highest recurrence rate, which I gave a big range between I said 18 or 12% to 26%.

These patients have the 26% of recurrence rate in five years. If they have four points or less than they have the least. We treat every symptom. Of course, we cannot treat the age. However, we look at all the stroke risk factors and pay attention to treat them aggressively, to prevent another stroke looking at these points.

Host: Okay. So if you have a higher point total, that's not good. And you were just talking about strategies for preventing secondary stroke. What are those, how do you counsel people? What are the strategies for preventing secondary stroke?

Dr. Cokgor: Most of the time in a private primary care doctor's office or in the hospital, if a patient already showed up with a transient ischemic attack, which means the stroke symptoms less than 24 hours, we start looking at the risk factors. The most common risk factors are high blood pressure, high cholesterol, which is called hyperlipidaemia and diabetes. We start with these three and then are they smokers, because smoking is a very big risk factor. And then we look for cardiovacular risk factors, like heart attacks in the past, atrial fibrillation, which is an arrythmia. And then we ask them about habits like alcoholism. And then we look into social economical status. Low income means are they accessible to a doctor? Are they accessible to medication or a hospital? And then we look at the ethnicity because different races have different predispositions to stroke. African-Americans have a higher incidence of stroke than Caucasians for example. That's how we group the risk factors.

Host: And then, what are the signs of a secondary stroke?

Dr. Cokgor: Secondary stroke signs are unfortunately exactly the same as primary stroke risk factors. The patient may develop suddenly slurred speech, one-sided weakness, one-sided numbness, double vision, speech difficulty with slurring or inability to speak, they may look altered. They may look awake, alert, but they cannot speak, which is called aphasia.

They may have vertigo, balance, gait problems, facial droop or losing the vision suddenly rather than double vision. All of these are stroke neurological risk factors. And as soon as the patient feels any o them in combination or isolated, they should definitely check themselves to the nearest emergency room.

Host: Are secondary strokes treated any differently?

Dr. Cokgor: Unfortunately, secondary strokes mostly happen because the patients stopped taking their medications and they think that they are fine now, after a few years from the stroke, they stopped their blood thinners. They stopped their blood pressure medications or cholesterol medications. That's when we get into trouble. The stroke risk factors are treated exactly the same way when there is a second stroke.

And usually these patients are cardio embolic, which means atrial fibrillation patients. Believe it or not one third off atrial fibrillation patients were found to be on no anticoagulation, which means no blood thinners when they present back to the emergency room with the second stroke. So we go through the risk factors again.

We reiterate them with the patients. We put them on their cholesterol medicine, a blood appropriate blood thinners, antiplatelet agent, or anticoagulant. There are many novel anticoagulants, which are much more tolerable, less side effects. However they are more expensive. And that's where the social economical risk factors come because the patient may not be able to afford the medications. And that puts them in the secondary recurrence again, risk factors.

Host: Right. That definitely is a risk factor. And it sounds like the message is if you already have had a stroke, stay on your medication, don't stop taking it. So then what is the recovery and prognosis after multiple strokes?

Dr. Cokgor: Unfortunately, prognosis gets more and more unfavorable. The patients may develop dementia from multiple strokes, especially if they are on both sides of the brain. They may develop balance, gait problems, incontinence. And the reason could be because the stroke could affect brainstem, cortex, cerebellum.

If they are in different parts of the brain they affect the transmission from the cortex to the peripheral nerves. And that is the transmission is through white matter. We call them white matter ischemic changes, which is a very common MRI finding the patients always ask me about, and that if there are white matter ischemic changes, you know, the patients are having some silent strokes. Some silent ischemia to the brain that is harming them slowly. And every time you have a stroke, many times the damage is irreversible and there are long-term consequences.

Host: Yeah. Wow. That's not a great picture at all, but if you understand your risk factors and your ABCD2 score, you can make lifestyle changes to try to prevent another stroke. That seems like that's the message. Is that right Dr. Cokgor?

Dr. Cokgor: That's correct. And we are only talking about ischemic strokes and I want to bring the emphasis, to hemorrhagic strokes, which can happen from a rupture of a blood vessel, and which can be directly related to smoking or high blood pressure. And hemorrhagic strokes are more devastating, poor prognosis, and definitely more disability, less recovery.

So we should keep in mind that strokes. There are even more devastating strokes than ischemic strokes.

Host: Wow. well, that makes sense. And thank you for saying that. So is there anything else that you want to add on this topic, Dr. Cokgor?

Dr. Cokgor: Yes, I strongly want to emphasize that we have to take care of ourselves, our health, especially after 60 years of age. We have to exercise daily, 20 to 30 minutes cardio. At least go out, walk your dog twice a day, have some fresh air. You have to eat healthy. We should try to be more vegetarian, less red meat, more fish, more vegetables, less pasta or candy. And we should try to do hobbies to use the brain. If you get connected with life, if you take care of your diet and you do avoid bad habits like too much drinking, more than one to two per day or smoking or other illicit drugs, that's going to improve our quality of life, our prognosis from a stroke when it happens, because it can happen as we get older. And we definitely may be able to avoid it as much as we can, as much as we live.

Host: And that's what we need to do. And thank you for those tips on how we can live a healthier lifestyle to try to prevent strokes. Dr. Cokgor, thank you so much for your time. This has really been informative. We appreciate it. Thank you again.

Ilkcan Cokgor, MD (Guest): Sure. Thank you. My pleasure.

Bill Klaproth (Host): And once again, that's Dr. Ilkcan Cokgor And for more information, please visit mymarinhealth.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is The Healing Podcast brought to you by MarinHealth. I'm Bill Klaprotth. Thanks for listening.