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Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And today we're discussing stroke awareness. Joining me is Dr. Saad Mir. He's an Associate Medical Director of New York Presbyterian Mobile Stroke Treatment Unit and Site Chief and Stroke Director at New York Presbyterian Lower Manhattan Hospital. Dr. Mir, it's a pleasure to have you join us today and what a great topic this is. So, as we get into this and explain to listeners a little bit about stroke and why it's so important that they know the symptoms, tell us the prevalence of stroke, and there are different types. Tell us about those.

Saad Mir, M.D. (Guest): Well, Melanie, it's a great question. A stroke is basically when the blood flow to the brain is compromised for some reason. So, if you think about arteries throughout the body being the pipes that carry clean blood to the different organs, the brain has these arteries or pipes that is taking blood flow to them, and providing oxygen to the brain so it can function normally.

So, if the pipe develops a blockage or a clot, that causes one type of stroke or if the pipe bursts and bleeds, that's a different type of stroke. So, we really think about stroke in two different ways, either a clot or a bleed. The clot is far more common. And it's about 85% of the time people have clots and 15% of the time they have bleeds.

But regardless of the type of stroke, it's a huge problem. Approximately 800,000 people in the United States per year have a stroke and it's the leading cause of medical disability in the United States and it's approximately $46 billion per year in health care related costs and lost productivity. So, stroke is a huge problem. And increasing awareness is a prime objective for the American Heart and Stroke Association.

Host: That was an excellent explanation Dr. Mir, clot versus bleed. That was really, really great and very easy to understand. Now speak about risk because really who is at risk. There are some uncontrollable risk factors, and then there are some modifiable ones. Explain a little bit about those.

Dr. Mir: As I mentioned, the pipes that are throughout the entire body, they are not very different. So, the arteries in the brain, the arteries in the heart, the arteries in the body; they are all prone to the same diseases. So, when you think about someone having a heart attack, the risk factors for a heart attack are high blood pressure, diabetes, high cholesterol, smoking, inactivity. Those are all the same risk factors that increase your chances of having a stroke.

One exception is, heart conditions such as heart failure and low ejection fraction of the heart, as well as irregular heart rhythms; those increase your risk of having a stroke because the brain is the first organ that the heart sends its blood to aside from the coronaries, of course. But these heart conditions very commonly will send blood clots up to the brain. And so we also include heart conditions as a risk factor for stroke.

Host: So, there are really quite a few of these things. And now let's talk about symptoms and I think this is one of the main messages we'd like to get out today. There's an acronym. BE FAST. Can you tell us what that is and why time is brain? Why it's so important that we call 9-1-1 and get EMS involved and get help right away if we notice any of these symptoms in ourselves or in a loved one.

Dr. Mir: Absolutely. Stroke is a syndrome, it's is a clinical syndrome. Any bystander could look at someone and just know that they may be having a stroke because of what a stroke really is, is when blood flow is disrupted to the brain, then that part of the brain doesn't work. And it usually starts within seconds to minutes of the blood flow being compromised.

If you think about what the brain does, controls the vision, controls speech, controls strength, controls balance. If you have the acute onset or immediate onset of symptoms that affect those systems, then that could very well be a stroke. The BE FAST acronym is a very popular one.

And one that we use in public awareness for stroke, as well as the EMS systems, the ambulance systems also use it. And it basically helps people remember some of the main categories of symptoms from stroke. So, B stands for balance. So, if someone immediately loses their balance and is falling to one side, the E stands for eyes. So, loss of vision. Half of the vision, blurry vision can be symptoms of a stroke. The F stands for face. So, people are very familiar with this one. When someone develops a facial droop, the A stands for arm. So, if your arm suddenly becomes paralyzed or stops working. S stands for speech. So, speech can be thought of in two ways.

One is you could just have slurred speech, a garbled speech, like a googoogo blah blah, and the other type of speech is that production or understanding of speech. So, if someone can't get words out, that's one type of stroke and the other one is they can't understand what's being told to them. And the T stands for time, and this is the most critical part of the acronym.

When someone has stroke symptoms that start then the blood clot is blocking blood flow, then the downstream brain tissue is losing oxygen and is becoming injured. And we can offer a medication that can break up blood clots and to salvage brain tissue; but that has to be given within a certain amount of time. And that timeframe is within four and a half hours of when the symptoms started. So, in the BE FAST acronym, T is the most critical thing. And I'm sure we'll talk a little bit more about what that treatment is.

Host: We will. And thank you for that explanation there. So, when I mentioned time is brain and calling EMS, and you mentioned briefly EMS. Why is it important to tell them that you suspect that you or a loved one is having a stroke. They can do some stuff, right. They can call ahead and get things started so that you can do those treatments and then speak a little bit about what happens at the ER and what TPA really is.

Dr. Mir: In high density cities, such as New York City or any metropolitan area, the temptation with patients or people is to get to the hospital themselves, call a cab, call an Uber, whatever it may be. But that has some downside. Sure, it might shave a minute or two off here or there, but what the ambulance can do and provide, is sort of multifactorial. When the paramedics arrive, they're able to provide acute treatment such as if a patient's sugars really low, if their blood pressure is super high, they're able to provide that first assessment and treatment if necessary. And the other things is that they can triage patients appropriately to the right hospital. So, if a patient is found to have a very large stroke syndrome, the ambulance can bypass certain smaller hospitals and go to a higher level tertiary care hospital that can treat the patient. And as you mentioned, the other thing the paramedics can do is they are looped in with all the different hospital systems so they can provide pre-notification to the hospital that we're bringing a patient in with suspected stroke. And so that allows all the resources at the hospital to be readily available at the door, to meet the patient and to evaluate them. And the last thing I'll say is I'll make a plug for our Mobile Stroke Treatment Unit Program, which is a program at New York Presbyterian Hospital.

So in 2016, we launched this program where we have ambulances that are equipped with CT scanners, all the stroke treatment on them. We have cameras inside of them that allow vascular neurologistit to evaluate patients in the ambulance. So, we have these ambulances that are going to patients' homes when they're having stroke symptoms, we take the patients out from their home. We evaluate them at home in the ambulance and provide stroke treatment. And we have found that on average, we're shaving off treatment times about 30 minutes with this new program. So, the benefits of calling 9-1-1 and having an ambulance, either a typical ambulance or a mobile stroke unit program pick you up, is incredible.

Host: I'm so glad you told us about that. So, tell us a little bit about what happens, treatments that are available and why time is so important for these treatments to be effective.

Dr. Mir: So, a typical situation, either in the ER or in the Mobile Stroke Unit, what happens is the patients are immediately assessed and we perform a neurologic assessment to see what the stroke symptoms might be. And once the stroke assessment is done, we then perform a CT scan, which takes less than a minute to do. And that CT scan will tell us if this is a blood clot type of stroke or a bleeding type of stroke. If it's a bleeding type of stroke, then obviously we have to just control the bleed. And there's a variety of things that we do for that. But if there's no bleed and the patient doesn't have any contraindications to getting treatment, the acute stroke treatment that we can offer is called a tissue plasminogen activator or TPA. And that's a medication that basically activates the blood thinning in our system to break down blood clots. So, if the CT scan is negative, we presume that there's a blood clot in the brain. We can give this medication that breaks down that blood clot. And it should be noted that this medication is actually used in heart attacks and clots and other parts of the body.

So, it's used for a lot of different things, but for stroke we have to give that medication usually within four and a half hours of when the symptoms started. Because that's the time in which there's actually brain that can be saved by breaking down the blood clot. If we do it past four and a half hours, it can be a little bit more risky or because the brain may have some injury that predisposes it to bleeding.

Host: So, any other treatments that you're excited about that you'd like to mention, and while you're telling us about that, why don't you speak about life after stroke? Just briefly tell us stroke rehab. What have you been seeing with patients as far as what their life is like?

Dr. Mir: Sure. And I also should mention that if someone has a large stroke syndrome, meaning we suspect that there's a big blood clot that's causing symptoms we can do a specialized scan called a CT of the arteries, and we can look at the arteries from the, all the way from the heart up into the brain. And if there's a big blood clot, that's blocking blood flow, our interventional neurosurgeons or interventional radiologists could actually go up and remove that blood clot surgically through the arteries. So, that's a really exciting advance in stroke care that's happened over the past few years. And we can do that procedure up to 24 hours or even longer. It just depends on what the specialized scan shows and how much brain tissue we can save. So, that's really exciting.

As far as what recovery is like, there's a huge spectrum of stroke recovery. Some patients come in with strokes and in the hospital they're completely normal and they have no residual symptoms and they can just go home. Some patients have very minimal deficits, like mild weakness of the face or arm. And so they can go home and do outpatient physical therapy to recover some of that strength back. And then some patients who have significant deficits, such as, you know paralyzed arm or a paralyzed leg or trouble speaking; those patients will tend to go to acute rehab where they get intense physical, occupational, and speech therapy that can allow them to recover more and more of those things. So, the spectrum of stroke recovery is pretty broad.

Host: Now as we wrap up, I'd like you to speak about prevention, whether it's diet or lifestyle, what you would like the listeners to take away from this message today. We know we heard BE FAST and that's so, so important. You can reiterate that, but also prevention and what you'd like us to know about some lifestyles and working with our physician to really get it so that maybe we don't have to worry about this at all.

Dr. Mir: I think the easiest thing to saym the 30,000 foot view for preventing strokes is to be healthy, listen to your primary care doctors. And that entails making sure your blood pressure is adequately controlled, you're not sort of ignoring your blood pressure and letting it run high for a really long time. Making sure that you don't have diabetes or elevated sugars, keeping your cholesterol under control. Exercising four to five times per week. We say moderate intensity, so you're sort of breathing hard. You're sweating a little bit. Take your medicines as prescribed by your physicians is also really important, not skipping doses and, you know, eating a healthy diet.

And this is something a lot of patients ask me and other physicians, like what is the ideal diet? We don't have a perfect answer to that. We've previously have said Mediterranean diet is probably the best template to follow. And that's basically a diet that's low in saturated fat, low in sodium, a lot of fruits and vegetables, fiber rich whole grains, some fish here and there, a lot of nuts, a lot of legumes like lentils and then lower fat dairy products. So, all in all, see your primary care doctors very frequently. Make sure you're listening to their advice. Keeping your blood pressure, sugar, cholesterol, all under control, exercising, eating good healthy diet. And I think it goes without saying not to smoke, and not to drink too much.

Host: Great information, Dr. Mir. Thank you so much for joining us today. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to thank our listeners and invite our audience to download, subscribe, rate, and review Back to Health on Apple podcasts, Spotify and Google podcast. For more health tips, you can always visit weillcornell.org and search podcasts. We have some great ones in our library and parents don't forget to check out our Kids Healthcast. I'm Melanie Cole.

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