Selected Podcast
Primary and Secondary Stroke Prevention
Primary and Secondary Stroke Prevention - what the best ways are to evaluate if someone is having a stroke, what can we do to prevent them, and how do we treat them?
Featured Speaker:
Robert Jackson, MD, MS
Dr. Robert J. Jackson is board certified in Neurology and Vascular Neurology living in Temecula, California and is the stroke medical director at Temecula Valley Hospital. He received his medical degree from Eastern Virginia Medical School, did his residency at Barrow Neurological Institute, and completed a stroke fellowship at Cedars Sinai Hospital. He has been in clinical practice for 8 years. He specializes as a neuro-hospitalist/vascular neurologist and is experienced in stroke. Transcription:
Prakash Chandran: Time is always important when you or a loved one is having a stroke. You must act fast. But what do we need to know about preventing strokes from happening in the first place? And if one's already occurred, how do we ensure that they don't happen again?
Compassion, trust, courage, innovation, the values of Temecula Valley Hospital. We proudly present TVH Health Chat.
Prakash Chandran: Welcome to TVH Health Chat with Temecula Valley Hospital. My name is Prakash Chandran. Today, we're discussing primary and secondary stroke prevention. Joining me is Dr. Robert Jackson. He's a stroke medical director and neuro-hospitalist at Temecula Valley Hospital. Dr. Jackson, thank you so much for joining us today. I really appreciate your time. Let's get started with the basics. What exactly is a stroke?
Dr Robert Jackson: Hi, Prakash. Thank you so much for having me on. A stroke is a clinical syndrome, which basically means that we are concerned that there is an issue with blood flow to the brain. That could be one of two different things, either something's plugging up an artery or something causing an artery to burst, causing blood to develop a clot into the head. And those give you focal neurological symptoms.
Prakash Chandran: Okay. And are there different types of strokes that people should be aware of?
Dr Robert Jackson: Indeed. So that kind of brings us to the question of what is the initial cause of the stroke. It could be due to an artery being plugged up, which is known as an ischemic stroke, which can come in different flavors, either being a small vessel or a lacunar stroke, which means only a teeny, teeny, tiny world artery of the brain being affected. Or it could be due to a large vessel stroke or a big artery in the brain and certainly a very large area is being affected. The same thing with hemorrhagic strokes, where an artery has burst. That depends on where in the brain that artery has burst and what the cause is that can give you a lot of different symptoms.
Prakash Chandran: Okay. And between those two different types of strokes that you mentioned, is one more common than the other?
Dr Robert Jackson: Correct. The ischemic stroke is about 80% of the time what is occurring. Only 20% of the time, it'd be the bleeding type of stroke.
Prakash Chandran: Okay. So let's talk about the symptoms. How does one know when someone is having a stroke?
Dr Robert Jackson: Yeah, that's a great question. So there is a public campaign that we are trying to help spearhead, which is awareness of major stroke symptoms. And we use an acronym to help people try and remember those symptoms. And that acronym is BE FAST, trying to be fast in recognizing your stroke symptoms. So each letter stands for something.
B in BE FAST stands for acute balance loss, so acute balance difficulties, like inability to walk and inability to hit a target with your hands or severe vertigo. E is eye, so acute vision loss within one eye or within one part of the world with both eyes. F means face, So acute onset of facial drooping, especially in the lower part of the face. A being arms, or acute onset of arm weakness or leg weakness. S is speech, so acute onset of speech difficulty like unable to understand speech, unable to speak entirely or severe slurring of your speech. And actually, the most important of all is T, which is time. So the faster we recognize these symptoms, the faster we can get someone to a hospital or possibly we can treat and hopefully help reverse these symptoms.
Prakash Chandran: Okay. So let me say it back to just so I can be clear. So you're saying that mnemonic is BE FAST. That's B-E-F-A-S-T. B stands for that loss of balance. E is eye or vision loss. F is the facial droop. A is arms. S is speech. And T is because time is of the essence. Is that correct?
Dr Robert Jackson: That's correct.
Prakash Chandran: So let's focus on that last letter, T. Why is it so important to act quickly?
Dr Robert Jackson: Absolutely. So in each of these types of strokes, time is of the essence. If it is a bleeding type of stroke, the issue is that the bleeding can continue to get worse. So what we really want to do is we want to be sure to try and control that bleeding as fast as we can, and especially try to minimize the blood pressure, so that way the blood does not continue to keep pouring into the head, which results in the bleed. If it is on the schemic stroke or something has plugged up an artery, we have two major treatments that we can use to try and help open up the artery and hopefully restore normal blood flow and hopefully completely eradicate the symptoms. One of them is a medication called tPA or tissue plasminogen activator. What that basically is for a layman is it's Draino for the artery to try and help bust up the clot and restore normal blood flow. We can only give that medication though within a very short timeframe, that being within three to possibly four and a half hours from the onset of symptoms.
The other thing you can sometimes do is, if it's a very large clot, we can go in and mechanically remove it by a mechanical thrombectomy, which is like a Roto-Rooter procedure where you're able to go and snake up the pipe, pull up the clot and restore normal blood flow. That procedure, luckily we have sometimes a little bit more time where we could possibly do it all the way up to possibly 24 hours past when the stroke symptoms have started if people are able to meet certain criteria
Prakash Chandran: So, first of all, I appreciate all the plumbing references. I don't think I've had it explained to me in that way, so thank you for that. You mentioned that tPA or even this thrombectomy procedure, time is of the essence, right? Sometimes within three to four and a half hours of the initial onset of symptoms. So people, when someone recognizes these BE FAST symptoms, they might think to just get the person in the car and drive straight to the hospital. I've heard that that is not the right thing to do. So could you talk about what someone should do if they recognize the symptoms of a stroke in themselves or a loved one?
Dr Robert Jackson: Absolutely. So if you're ever concerned about yourself or somebody else that you're with having an acute ischemic stroke, it's of vital importance to call 911 to try and help assess what's going on and bring the patient to the hospital quickly and efficiently and safely. Especially, don't worry about driving yourself to the hospital while you're having a stroke, because stroke symptoms can progress and you can get worse while you're in the middle of having a stroke. So that's why it's a vital importance to have somebody else be able to safely get you to the hospital. And then also, it's also helpful that a patient be able to be evaluated by emergency services to check a blood pressure, check glucose, to see if something else that's emergently going on that could explain some of the symptoms. And the nice thing about EMS is they will give the hospital a heads up that, "Hey, we are bringing over the patient that we are concerned is having an acute stroke," so we're able to mobilize the team and get everyone ready as quickly as possible.
Prakash Chandran: Yeah, I feel like so many people don't realize the process of getting to the hospital, getting checked in and everything like that, how much time that eats up. So when you have 911 come, and like you said, EMS kind of pre-triages you and contacts the hospital directly, you're saving all of that time and you're being treated in the best way possible, leading up to actually getting to the hospital, right?
Dr Robert Jackson: Correct. Yeah. The fastest tPA times that we are normally able to achieve from somebody coming into the hospital to getting the medication is almost universally when EMS lets us know, "Hey, we're coming in and we're concerned that the patient is having a stroke." So the neurologist, myself and my colleagues, are normally able to get to the emergency department and meet the patient as soon as they hit the door.
Prakash Chandran: So let's talk a little bit about prevention. We're talking about all these circumstances around if someone has a stroke, but how can someone reduce the risk of getting one in the first place?
Dr Robert Jackson: Yeah, very important question. So there are certain risk factors that we know that can lead to both isschemic, the plugging up of an artery, as well as the hemorrhagic or causing an artery to burst, those being high blood pressure, high cholesterol, diabetes and smoking and irregular heart rhythms like atrial fibrillation or flutter. So the best primary prevention, which means trying to help prevent a stroke from happening in the first, place is to be sure that our blood pressure is well-controlled, our cholesterol is well-controlled, our diabetes is well controlled or at least try to help solve the diabetes if it's type 2. For atrial fibrillation or flutter, there are certain people that have to be put on a blood thinning medication like Coumadin, Xarelto, Eliquis, Pradaxa, something that really helps thin the blood to prevent a clot from forming. And then stopping smoking is of vital importance. It decreases not only the risk of heart attacks but stroke as well.
Prakash Chandran: What about age? Does that play a factor in someone being more susceptible to having a stroke again?
Dr Robert Jackson: Unfortunately, yes. As we get older into our 60s, 70s, 80s, 90s, and occasionally into the 100s, that is an increased risk factor for stroke because more plaque develops within arteries, there's more damage that occurred over time. So as we get older, there is a slightly increased risk of having a stroke, that being said, I've seen people in their teenage years, in their 20s, 30s, 40s, 50s, all comers have had a stroke, depending on what the possible cause is.
Prakash Chandran: So another question that I know is asked a lot is once someone has a stroke, are they somehow more susceptible to getting a stroke again?
Dr Robert Jackson: Unfortunately, yes. Just statistically, once you've had a stroke, you are more inclined to have another one in the future. But the idea is once you've had a stroke, if we try to figure it out what the underlying cause is, if we're able to figure out where this came from in the first place, then ideally we're able to do the right treatment medication-wise or possibly surgery to try and help prevent another stroke from happening.
Prakash Chandran: And also those risk factors that you spoke about earlier, right? Like if you have a stroke and you still maintain high cholesterol and you continue to smoke, the likelihood of you getting one again obviously goes up, right?
Dr Robert Jackson: Unfortunately, that is true.
Prakash Chandran: So one question that I always like to ask before we close is given all of your experience in dealing with patients who have had strokes or have had multiple strokes, what is one thing that you just know to be true that you wish more patients knew?
Dr Robert Jackson: The biggest things are the stuff that we just discussed. And the most important thing is try to be fast in recognizing stroke symptoms, getting to the hospital as quickly as possible and not sitting on it. What we really don't want to do is have somebody think, "Oh, I'm having some symptoms. I'll wait 15, 20 minutes to see if they'll go away," and then not worry about it. For an ischemic stroke, with somebody who's having a clot that's blocking an artery, for every minute the stroke is occurring, we lose up to 2 million neurons every minute. So that's why it's so important to try and recognize the symptoms and get to the hospital as quickly as we can to try and help salvage all of those brain cells.
Prakash Chandran: Yes. That totally makes sense to me. Any final words of wisdom before we close here today, Dr. Jackson?
Dr Robert Jackson: So the biggest thing for stroke prevention, especially in primary, where you've never had a stroke, is follow up with your primary care doctor and be sure that the blood pressure, cholesterol, diabetes is well-controlled as best as we can. Definitely stop smoking. And then for secondary prevention, which means that you've had a stroke in the past, we're now trying to prevent another one, is to be sure that we follow up with a neurologist, give you the recommendations, do the work to try and figure out what the underlying cause is, so hopefully another stroke never happens.
Prakash Chandran: Well, I think that is wonderful advice, Dr. Jackson, and a perfect place to end. Thank you so much for your time today.
Dr Robert Jackson: All right. Thank you so much for having me on.
Prakash Chandran: That was Dr. Robert Jackson, a stroke medical director and neuro-hospitalist at Temecula Valley Hospital. You're listening to TVH Health Chat. For more information, please visit temeculavalleyhospital.com/stroke. Please remember to subscribe, rate and review this podcast and all other Temecula Valley Hospital podcasts.
Physicians are independent practitioners who are not employees or agents of Temecula valley hospital. The hospital shall not be liable for actions or treatments provided by a physician. My name is Prakash Chandran . Thank you again for listening, and we'll talk next time.
Prakash Chandran: Time is always important when you or a loved one is having a stroke. You must act fast. But what do we need to know about preventing strokes from happening in the first place? And if one's already occurred, how do we ensure that they don't happen again?
Compassion, trust, courage, innovation, the values of Temecula Valley Hospital. We proudly present TVH Health Chat.
Prakash Chandran: Welcome to TVH Health Chat with Temecula Valley Hospital. My name is Prakash Chandran. Today, we're discussing primary and secondary stroke prevention. Joining me is Dr. Robert Jackson. He's a stroke medical director and neuro-hospitalist at Temecula Valley Hospital. Dr. Jackson, thank you so much for joining us today. I really appreciate your time. Let's get started with the basics. What exactly is a stroke?
Dr Robert Jackson: Hi, Prakash. Thank you so much for having me on. A stroke is a clinical syndrome, which basically means that we are concerned that there is an issue with blood flow to the brain. That could be one of two different things, either something's plugging up an artery or something causing an artery to burst, causing blood to develop a clot into the head. And those give you focal neurological symptoms.
Prakash Chandran: Okay. And are there different types of strokes that people should be aware of?
Dr Robert Jackson: Indeed. So that kind of brings us to the question of what is the initial cause of the stroke. It could be due to an artery being plugged up, which is known as an ischemic stroke, which can come in different flavors, either being a small vessel or a lacunar stroke, which means only a teeny, teeny, tiny world artery of the brain being affected. Or it could be due to a large vessel stroke or a big artery in the brain and certainly a very large area is being affected. The same thing with hemorrhagic strokes, where an artery has burst. That depends on where in the brain that artery has burst and what the cause is that can give you a lot of different symptoms.
Prakash Chandran: Okay. And between those two different types of strokes that you mentioned, is one more common than the other?
Dr Robert Jackson: Correct. The ischemic stroke is about 80% of the time what is occurring. Only 20% of the time, it'd be the bleeding type of stroke.
Prakash Chandran: Okay. So let's talk about the symptoms. How does one know when someone is having a stroke?
Dr Robert Jackson: Yeah, that's a great question. So there is a public campaign that we are trying to help spearhead, which is awareness of major stroke symptoms. And we use an acronym to help people try and remember those symptoms. And that acronym is BE FAST, trying to be fast in recognizing your stroke symptoms. So each letter stands for something.
B in BE FAST stands for acute balance loss, so acute balance difficulties, like inability to walk and inability to hit a target with your hands or severe vertigo. E is eye, so acute vision loss within one eye or within one part of the world with both eyes. F means face, So acute onset of facial drooping, especially in the lower part of the face. A being arms, or acute onset of arm weakness or leg weakness. S is speech, so acute onset of speech difficulty like unable to understand speech, unable to speak entirely or severe slurring of your speech. And actually, the most important of all is T, which is time. So the faster we recognize these symptoms, the faster we can get someone to a hospital or possibly we can treat and hopefully help reverse these symptoms.
Prakash Chandran: Okay. So let me say it back to just so I can be clear. So you're saying that mnemonic is BE FAST. That's B-E-F-A-S-T. B stands for that loss of balance. E is eye or vision loss. F is the facial droop. A is arms. S is speech. And T is because time is of the essence. Is that correct?
Dr Robert Jackson: That's correct.
Prakash Chandran: So let's focus on that last letter, T. Why is it so important to act quickly?
Dr Robert Jackson: Absolutely. So in each of these types of strokes, time is of the essence. If it is a bleeding type of stroke, the issue is that the bleeding can continue to get worse. So what we really want to do is we want to be sure to try and control that bleeding as fast as we can, and especially try to minimize the blood pressure, so that way the blood does not continue to keep pouring into the head, which results in the bleed. If it is on the schemic stroke or something has plugged up an artery, we have two major treatments that we can use to try and help open up the artery and hopefully restore normal blood flow and hopefully completely eradicate the symptoms. One of them is a medication called tPA or tissue plasminogen activator. What that basically is for a layman is it's Draino for the artery to try and help bust up the clot and restore normal blood flow. We can only give that medication though within a very short timeframe, that being within three to possibly four and a half hours from the onset of symptoms.
The other thing you can sometimes do is, if it's a very large clot, we can go in and mechanically remove it by a mechanical thrombectomy, which is like a Roto-Rooter procedure where you're able to go and snake up the pipe, pull up the clot and restore normal blood flow. That procedure, luckily we have sometimes a little bit more time where we could possibly do it all the way up to possibly 24 hours past when the stroke symptoms have started if people are able to meet certain criteria
Prakash Chandran: So, first of all, I appreciate all the plumbing references. I don't think I've had it explained to me in that way, so thank you for that. You mentioned that tPA or even this thrombectomy procedure, time is of the essence, right? Sometimes within three to four and a half hours of the initial onset of symptoms. So people, when someone recognizes these BE FAST symptoms, they might think to just get the person in the car and drive straight to the hospital. I've heard that that is not the right thing to do. So could you talk about what someone should do if they recognize the symptoms of a stroke in themselves or a loved one?
Dr Robert Jackson: Absolutely. So if you're ever concerned about yourself or somebody else that you're with having an acute ischemic stroke, it's of vital importance to call 911 to try and help assess what's going on and bring the patient to the hospital quickly and efficiently and safely. Especially, don't worry about driving yourself to the hospital while you're having a stroke, because stroke symptoms can progress and you can get worse while you're in the middle of having a stroke. So that's why it's a vital importance to have somebody else be able to safely get you to the hospital. And then also, it's also helpful that a patient be able to be evaluated by emergency services to check a blood pressure, check glucose, to see if something else that's emergently going on that could explain some of the symptoms. And the nice thing about EMS is they will give the hospital a heads up that, "Hey, we are bringing over the patient that we are concerned is having an acute stroke," so we're able to mobilize the team and get everyone ready as quickly as possible.
Prakash Chandran: Yeah, I feel like so many people don't realize the process of getting to the hospital, getting checked in and everything like that, how much time that eats up. So when you have 911 come, and like you said, EMS kind of pre-triages you and contacts the hospital directly, you're saving all of that time and you're being treated in the best way possible, leading up to actually getting to the hospital, right?
Dr Robert Jackson: Correct. Yeah. The fastest tPA times that we are normally able to achieve from somebody coming into the hospital to getting the medication is almost universally when EMS lets us know, "Hey, we're coming in and we're concerned that the patient is having a stroke." So the neurologist, myself and my colleagues, are normally able to get to the emergency department and meet the patient as soon as they hit the door.
Prakash Chandran: So let's talk a little bit about prevention. We're talking about all these circumstances around if someone has a stroke, but how can someone reduce the risk of getting one in the first place?
Dr Robert Jackson: Yeah, very important question. So there are certain risk factors that we know that can lead to both isschemic, the plugging up of an artery, as well as the hemorrhagic or causing an artery to burst, those being high blood pressure, high cholesterol, diabetes and smoking and irregular heart rhythms like atrial fibrillation or flutter. So the best primary prevention, which means trying to help prevent a stroke from happening in the first, place is to be sure that our blood pressure is well-controlled, our cholesterol is well-controlled, our diabetes is well controlled or at least try to help solve the diabetes if it's type 2. For atrial fibrillation or flutter, there are certain people that have to be put on a blood thinning medication like Coumadin, Xarelto, Eliquis, Pradaxa, something that really helps thin the blood to prevent a clot from forming. And then stopping smoking is of vital importance. It decreases not only the risk of heart attacks but stroke as well.
Prakash Chandran: What about age? Does that play a factor in someone being more susceptible to having a stroke again?
Dr Robert Jackson: Unfortunately, yes. As we get older into our 60s, 70s, 80s, 90s, and occasionally into the 100s, that is an increased risk factor for stroke because more plaque develops within arteries, there's more damage that occurred over time. So as we get older, there is a slightly increased risk of having a stroke, that being said, I've seen people in their teenage years, in their 20s, 30s, 40s, 50s, all comers have had a stroke, depending on what the possible cause is.
Prakash Chandran: So another question that I know is asked a lot is once someone has a stroke, are they somehow more susceptible to getting a stroke again?
Dr Robert Jackson: Unfortunately, yes. Just statistically, once you've had a stroke, you are more inclined to have another one in the future. But the idea is once you've had a stroke, if we try to figure it out what the underlying cause is, if we're able to figure out where this came from in the first place, then ideally we're able to do the right treatment medication-wise or possibly surgery to try and help prevent another stroke from happening.
Prakash Chandran: And also those risk factors that you spoke about earlier, right? Like if you have a stroke and you still maintain high cholesterol and you continue to smoke, the likelihood of you getting one again obviously goes up, right?
Dr Robert Jackson: Unfortunately, that is true.
Prakash Chandran: So one question that I always like to ask before we close is given all of your experience in dealing with patients who have had strokes or have had multiple strokes, what is one thing that you just know to be true that you wish more patients knew?
Dr Robert Jackson: The biggest things are the stuff that we just discussed. And the most important thing is try to be fast in recognizing stroke symptoms, getting to the hospital as quickly as possible and not sitting on it. What we really don't want to do is have somebody think, "Oh, I'm having some symptoms. I'll wait 15, 20 minutes to see if they'll go away," and then not worry about it. For an ischemic stroke, with somebody who's having a clot that's blocking an artery, for every minute the stroke is occurring, we lose up to 2 million neurons every minute. So that's why it's so important to try and recognize the symptoms and get to the hospital as quickly as we can to try and help salvage all of those brain cells.
Prakash Chandran: Yes. That totally makes sense to me. Any final words of wisdom before we close here today, Dr. Jackson?
Dr Robert Jackson: So the biggest thing for stroke prevention, especially in primary, where you've never had a stroke, is follow up with your primary care doctor and be sure that the blood pressure, cholesterol, diabetes is well-controlled as best as we can. Definitely stop smoking. And then for secondary prevention, which means that you've had a stroke in the past, we're now trying to prevent another one, is to be sure that we follow up with a neurologist, give you the recommendations, do the work to try and figure out what the underlying cause is, so hopefully another stroke never happens.
Prakash Chandran: Well, I think that is wonderful advice, Dr. Jackson, and a perfect place to end. Thank you so much for your time today.
Dr Robert Jackson: All right. Thank you so much for having me on.
Prakash Chandran: That was Dr. Robert Jackson, a stroke medical director and neuro-hospitalist at Temecula Valley Hospital. You're listening to TVH Health Chat. For more information, please visit temeculavalleyhospital.com/stroke. Please remember to subscribe, rate and review this podcast and all other Temecula Valley Hospital podcasts.
Physicians are independent practitioners who are not employees or agents of Temecula valley hospital. The hospital shall not be liable for actions or treatments provided by a physician. My name is Prakash Chandran . Thank you again for listening, and we'll talk next time.