[Music] foreign [Music] thank you for taking time from your busy day to watch this special presentation from the El Paso County Medical Society I'm Dr Joel Hendricks president of the El Paso County Medical Society and it is my hope that you will find our program of great interest educational and informative about the medical care provided by some of our best physicians in our country right here in the Borderland from all of us at the El Paso County Medical Society please enjoy tonight's program [Music] thank you this is stroke awareness month and do you know the signs of somebody having a stroke how can you tell and if someone is having a stroke what do you do timing is the most important thing and we're going to talk about this tonight there's actually a phrase that's used in the medical field when it comes to stroke time is brain during the next hour we have experts talking about all kinds of people that have strokes not just those who are at high risk and strategies and treatments to not only help at the time of treatment but also some prevention managers that we can talk about this program is underwritten by tenet the hospitals of Providence and also the El Paso County Medical Society has been bringing the show to you for over 26 years I'm Catherine Berg thanks for tuning in this is the El Paso physician thank you [Music] thank you again for joining us we are talking about strokes this evening and we have two doctors with us of different disciplines but really know everything about the world of Strokes a little bit about neurology a little bit about internal medicine and also nursing so we have Dr Kenneth baruman here who is emergency medicine but he's also the chief of staff at Sierra Medical Center and not until just about five minutes ago did I realize that he started off as a nurse and graduated from the UTEP School of Nursing so thank you so much for being here that's going to be a lot of fun talking with you this evening and then we also have Dr vikas Gupta who is in the world of Neurology and also did some Internal Medicine along the way some preventive preventative Cardiology so it's going to be a really interesting program and Dr bruman I'd like to start with you you're an emergency medicine you said you've been in ER doc since you've become a doctor describe your day if you can uh you are also Chief of Staff right and so we're going to leave that at the table for a little while but your day in the ER and again we have so many TV shows that we see about the ER room is it like that really and the year is actually the probably the most exciting job I can ever think of it's you never know what's coming through the door uh you have a variety of populations anywhere from children to 104 year old people uh you just don't know what's coming in oftentimes the patients don't know what's happening to them so they're trying to explain to you what's going on and you're trying to decipher that from their clinical stuff from what they're telling you what the family's telling you and uh it's kind of a great puzzle and it's a great way to to work your life I I think it's very exciting to be in the emergency department high stress and it was interesting as I asked if you were on call when you walked in we asked Dr Gupta Dr Gupta is on call and you said well I'm an ER dots I feel like I'm always on call um Dr Gupta let's take things to you to neurology and the study of what you were doing now and you've been in El Paso for a whopping three years we were talking about the great food we have in El Paso but you've been all over the country and studied different things in your area of Neurology and strokes of what we're speaking about tonight what is it that you do all day every day thank you very much for having me today and uh it's great pleasure to meet Dr Perryman as well what I do day-to-day practices best described as Interventional neurology something very similar like an international cardiologist so what I do is Interventional treatment of stroke both ischemic stroke caused by your blood clot in the brain and also minimally invasive treatment of bleeding kind of Strokes such as ruptured brain aneurysm or bleeding cause in the brain from a brain not true against malformation or a fistula in the brain or for example the treatment of carotids disease by placement of a stent or doing angioplasty so our work is very similar just like the cardiologists do heart angiogram we do what we call the brain angiogram the same principle same philosophy we put in a small catheter in the restaurant usually these days or through the artery in the leg and a small cancer the size of a spaghetti goes from the wrist artery all the way up inside the brain where the blood clot in the brain is and we retrieve the blood clot to get the patients suffering from Majors through get better and be on their life yeah and then it will talk about the two different types of stroke or at least the two main different types of Strokes because I know that there is I like doing this particular program because there are two very different treatments depending on what type of the stroke it is so what I'd like to do is kind of back up a little bit and talk about just in general terms Dr bruman what is happening when someone's having a stroke and then we'll go into the different types of stroke so stroke essentially means there's not blood flow getting to one part of the brain whether that be a delivery problem like the arteries blocked or whether that be a clot which is then distally mean meaning the blood can't get past that clot or whether there's some other foreign object in there the strangest one I saw was a paint gun in the neck and then it was a paint clot into the brain so anything that stops the blood flow to the brain that's normal is going to cause a stroke and it can be a variety of things that cause us I'm just going to ask you about that later because you can't just say something like a paint gun and then a paint block that's going to be a conversation that we're going to have to have sure um so if I could talk about ischemic and I know you mentioned it and then hemorrhagic and then at least those two are the as I understand the two main types of Strokes right and as an ER doctor the diagnosis of those um so first let's talk about the two differences and then we'll talk about ambulances and who do you call what do you do exactly but what is an ischemic stroke ischemic stroke means there's not blood flowing through there it's usually from a clot or some kind of blockage to that artery that prevents the blood normal blood flow distally meaning beyond that area so that part of the brain is not getting its blood flow it's not getting its glucose and time is really the essential component of all of this you do not want to sit around and saying hey something's not right my faces doesn't feel right my arm doesn't feel right that's the time where you initiate 9-1-1 immediately I I think 9-1-1 is the key to all these processes so ischemic means there's something blocking it hemorrhagic means the lack of blood flow so you think about your your garden hose and when you're delivering it to your garden and it's working fine but now you got to puncture in that in that hose and now the the water's seeping out to the side not the same amount of water is getting to your garden as it is leaking out so now we have a disruption in the normal blood flow and that's what the other component of most Strokes are okay so here in Dr Gupta if I'm if I'm jumping because I want to go in an order of diagnosing this um and if you need to throw things again and this is we were talking about this if I'm asking one doc one thing and you want to throw it the other one feel free to do that but if uh someone when people are having a stroke usually the person that is with that other individual is a person that says okay you you're just not acting right um and I'd like for you to take it from a neurologist point if how do you know if yourself is having a stroke it's easier to tell if somebody else is and maybe describe some of those symptoms that are happening sure that's an excellent point the the point that you brought about that stroke is most often noticed by the family or the friends around the person that is experiencing this truth because sometimes the person who's experiencing this stroke may not be able to speak so his ability or her ability to communicate that I'm having weakness on one side about your numbness is impaired by her inability or his inability to speak and communicate but more often than not the the classic symptoms that the person experiences is sudden onset of weakness or paralysis of one side of the body arm or leg or set an onset of numbness or certain onset of lack of vision in one eyes or both or certain onset of spinning sensation vertiginous sensation it obviously that includes also the inability to speak Etc and facial droop so it's very important for the family members and friends around them they're often the ones that notice that oh the face is droopy or the person is not walking right but from an individual perspective the the common things that is that are noticeable is that suddenly my arm feels numb or heavy or weak or I cannot control it so loss of coordination and then the symptoms progress and is there pain involved that's that's a very important point and that's the reason why this stroke gets neglected is unlike a heart attack which gets everybody's attention immediately these Strokes are painless so people often it if it happens while they're sleeping or people tend to think that oh my arm is numb because I slept in a wrong position so the there is a delay in seeking immediate medical care because of the fact that it's not causing pain and we're going to talk and I just thought about it as you were saying it uh there's something that people call Old I just had a mini stroke and maybe there's like four or five mini strokes but we'll I do want to get to that in a little while um Dr baruman I would like to ask you when an ambulance is called like somebody's noticing something's wrong an ambulance is called and I know several shows back we had a firefighter on Chief firefighter on he was talking about the Different Stroke units there's a stroke unit that we have in El Paso but this in general too if the stroke unit isn't by you in general what is what are the ambulances equipped with to start some kind of treatment because like you said timing is it um before I ask that question because it goes what you were talking earlier before the show Fast the word fast the acronym and it's looking for the face if the face is drooping arm is not feeling right it's feeling heavy and or not functioning speech is off and then time so that's something we'll talk about a couple of times to help educate the audience just think of the acronym fast face arm speech and time what is it that the um ambulances the emergency vehicles have that might be able to help with diagnosis so most of El Paso Fire is equipped with medications with blood pressure evaluation and the key is the paramedics and their evaluation so they do what's called a lap score a lamb score they're going to take a an assessment of the patient and see if they really look like it's a real stroke they'll call in immediately and then they'll transport the key is the timing to get to a facility where either we're going to take the clot out or we're going to give you something to break up this clot now there is one ambulance in town that UMC has that has a cat scanner on it so we actually have a cat scanner that runs around the city it's separated in different parts of the city throughout the town and there'll be a dispatch to Strokes they have an eight slice CT scan for the doctors we know that that's a small thing but we don't need a huge scanner in these ambulances all we need to know if there's a bleed or not and these eight slides CT on on an ambulance will give us a great amount of information whether this is a bleeding stroke or more likely a clot stroke and that really helps us decide what we're going to do with this patient once they arrive to the department and are the symptoms any different from a bleed Stroke versus a clot stroke the symptoms are basically the same as again there's not blood getting to the right area exactly I mean there there can be some differences but for the most part it's essentially it's a lack of ability to do something because of lack of blood flow whether it's been diverted by a a bleed or whether it's been diverted because of a clot okay so I'm going to keep it with you for a moment so now we have someone that is getting to the ER and um immediately yes definitely the symptoms of a stroke now they get into the ER and where do they go to figure out what it which kind of a stroke it is like okay so uh what we do is when when the ambulance calls us and say they think they have a stroke we meet them at the ambulance store okay we get you know the registration people get their stuff but we go straight to the cat scanner right so we're going to find out if it's the first place you go correct okay we'll put all the stuff in the patient we'll get the vital signs in the cat scanner so again the key is time so we're gonna get them to the cat scanner as soon as we can we want to find out if this is possibly a clot stroke or a bleeding stroke because that really helps us determine which path we're going to take okay and I do want to talk later about uh blood thinners because that is something if it is a clot stroke then that that begins your whole life on on different things um Dr Gupta and it's just so I can kind of ping pong back and forth but the beginning of the show a lot of it's like the ER stuff but once they get to the ER um and let's say it is a clot stroke what kind of medications are then administered right then and there because I understand that there's some that that almost immediately not immediately but kind of can uh get the clot to break down is that done intravenously is that done through the head and I know you were talking a little bit earlier about getting into the brain so that's a great question uh Catherine again though for the last 25 years or so the only FDA approved medical standard of care for treatment of acute scheming stroke is the ibtpa which is given within four and a half hours of patient symptom onset for acute issuing stroke so once my colleague this is Dr Berryman looks at a CT scan and there is no evidence of hemorrhage and we have a working diagnosis of a streaming stroke caused by a blood clotting the brain so the the focus is to administer the IV clot busting medication called the TPA now we have a second optional connective place which is similar except it's more potent than TPA and it's given through the IV so it's given again this is a medical standard of care in order to dissolve the clot and is given within four and a half hours or some demands it so you call it a clot busting medication either TPA or tnk okay and going back to what you were saying earlier sometimes Strokes are easy to ignore because there is no pain and let's say that the four and a half hour time frame is passed let's say that somebody who's having pains wasn't feeling good went to bed slept through the night and tomorrow morning they're like okay I'm still not feeling right so let's say 12 hours has passed and it is a clot type of a stroke talk us through the difference between getting to someone within four and a half hours and getting to someone after 12 hours so again great point a great question and very common scenario more often than not actually stroke happens just like heart attack before the Awakening like around six o'clock in the morning or five o'clock in the morning before the person awakens so technically it can start anywhere between the time that the patient went to bed last night and at the time of Awakening so we are in a situation that we don't know the time of answer of stroke symptoms so the clot busting medication is not indicated so the way to address those patients with stroke is to do a study called a CT and geography which defines the exact location of the clot inside the brain so we confirmed that there is indeed a clot and we assess the clot size and then we put in a small catheter either through the radial artery the wrist artery or through groin artery and then that goes all the way inside the brain where the clot is and we retrieve the clot which is the endovascular or the minimally invasive treatment option for people who are a not eligible for IV thrombolytics or in addition to the iot thrombolytics though I was thrombolytic success rate is maximum for small clots but the effectiveness of IV thrombolytics decreases as the clutch size and the cloud burden increases so much so that you know once you have a clot which is about a centimeter or so in size Studies have shown that the clot busting medication has zero percent efficacy oh wow so in other words the smaller the clot size is the more distal the clot location the higher is efficacy of the IV thrombletic agents but once you get into large clot size large clot burden then the the benefit of endovascular minimally invasive therapy really has made a big difference and it's now proven by large multi-centered International control trials so there are multiple clinical trials so so there is this medical standard of therapy which is the ibtpa and then there is the Interventional standard of stroke therapy where we put the clot out using a suction aspiration catheter or a strength Retriever and especially useful for people who have either had a surgery such as a bypass surgery or a recent abdominal surgery so that they cannot receive the IV medication the blood thinner right and or people who awaken from the stroke so so so the minimal invasive therapy really makes a difference in those cases makes sense to me um so I'm going to take it over now to a different procedure so now we're looking at someone who's having a stroke and it is a brain bleed and from there once you find out that it's not a clogging stroke I'm thinking about the er2 what is the immediate course of action there when it's a bleeding stroke we're still calling our neurointerventionalists to see if they can get in there and find out where this bleeding is now okay that's the issue is is there something that they can do immediately for this or uh you know is this going to be so there's two kinds of bleeds so there's this the the intracranial hemorrhage and then there's a subdural hematoma which is kind of a bruise between the skull and the brain that that also puts pressure on the brain and that it can also affect blood flow so two very different things uh the subdural hematoma is evacuated and that usually reduces everything the bleed itself we're going to call somebody like Dr Gupta and say okay how do we end up doing this is there something we can get in there to to you know find out where the plea inside is so oftentimes if it's a bleeding stroke we're going to refer to our neuro and financials okay and then so here's the question I remember there was a time on one of the stroke programs that there if the bleeding happens inside the skull that there's so much pressure in there that the pressure needs to be relieved and so that would be my next question do you take you know a part of the skull out I mean literally like drill a hole in the skull I remember us talking about that to relieve some of the pressure and let some of the brain get some air and let's talk about that how and it doesn't it seems like how do you do that it literally take some of the skull out put it aside for a while wait till things go back put it back in um but how do you do that so so although the 85 percent of all Strokes are ishkamic as in caused by recording and about 15 or less are the bleeding diverse stroke will a bleeding type of a stroke are the ones with very high mortality probability of dying so as Dr Perryman alluded to one of them is this intracellular Hemorrhage where an immediate craniotomy as in taking the portion of the skull out to allow the brain swelling and the Brain pressure to come down is life-saving so that's one of the few Neurosurgical procedures that that's done emergently as a life-saving measure to save somebody's life in order by reducing the pressure and amount of the pressure caused by the blood in the brain and also the other kind of the bleeding which is from the ruptured aneurysm called the subarachnid Hemorrhage also requires placement of a shunt a small catheter that relieves the pressure inside the brain so once the the key thing is to stabilize the person's blood pressure and the pressure inside the brain either by doing image agency surgical decompression or by placing in a shunt catheter once a patient is stable then then we take the patient to an angiography suite and we do the angiogram to find out what's the cause of bleeding if it's an aneurysm the aneurysm is secured by placement of coils inside the brain or if it's caused by your brain AV fistula or AVM then we treat them accordingly so go backward a little bit when you talk about coils inside the brain if it's an aneurysm let's talk and that's that's a big question too just the word aneurysm um if there's an aneurysm that hasn't burst yet how how does one know that one might have an aneurysm are there always symptoms are there sometimes no symptoms um even though we're talking about Strokes I feel like those are so interchanged often in the world of of this area so when you're talking about aneurysms how does how does someone know that they have an aneurysm great question Catherine in fact most people about 10 the prevalence of aneurysm and unruptured aneurysm is about 10 percent of the population and out of those ten percentage and then out of those uh 10 a very small minority actually go into rupture so most people have brain aneurysm and they're unaware of it because they don't get any symptoms at all it doesn't cost them any symptoms until the point most often in presence with a sudden rupture that causes the worst headache of their lives and so and often loss of consciousness often nausea and vomiting and that's usually a life-threatening event and people present to the ER but most of the time the patients have not had any kind of a head scan either a CT or MRI then there is no way to find that someone has a brain aneurysm because the symptoms are not there sometimes the brain aneurysms can cause weakness of the eye muscles so persons can have pain behind the eyes or they can have double vision but most of the time mannerisms inside the brain are painless they don't cause symptoms until the point that they cause rupture and bleeding in the brain okay so that leads me to the next question of uh not that there's screening but if someone does have a crazy headache um and I'm thinking about stroke but stroke has all these other symptoms to it but how often is it and maybe not often but maybe you can think of a time or a case study if somebody came into the ER and just had a headache like they could not believe what is the first line there of figuring out what's happening is it the CTC it's going to be the CAT scan okay the worst headache in your life is oftentimes the subarachnoid hemorrhage that's classically how Physicians describe it as the worst headache of your life is a subarachnoid hemorrhage so that's a thing and the other thing is we got to remember is the cranium is a closed Vault I mean there's only so much space that can fit in there so once you have added fluid or added pressure it starts to press on the brain it can actually what's called herniate or push the brain down and stop your breathing so you got to remember that that's why time is so important and volume is so important because there's only so much space within the cranium that we can take added pressure either and that's good to say when you were talking about you know removing that little part of the skull which again freaks me out but here's another question aneurysms Strokes in general I'd like to talk about and I should have done this in the beginning but talk about risk factors who is it that's at risk for stroke and also aneurysm I don't know if there is a risk factor for aneurysm I think that's there's some connective tissue diseases that can make you a little bit more at risk but okay for the most part it's usually it's a weakness in the in the in the wall of the vessel but okay so in general then who is more at risk for stroke because again just watching regular TV um there's afib there's this there's that if you're not you know and I talk about afib too because afib and the risk of stroke because that is something that we hear with different medications um and that could be something that we go into or not are the different medications I know that's a whole Pandora's Box so to speak um but when we're talking about risk factors what would those be specifically for strokes so I think for the clotting ones you got to think of atrial fibrillation where the heart is not beating correctly it can form clots and and send a clot out there's other people that have hypercoagulability issues that can form clots everywhere and then it gets passed the normal systems and it gets up to the brain that's how the clot forms the the other ones are oftentimes due to hypertension uh uncontrolled hypertension is probably number one uh for our bleeding stroke um aneurysms meaning a weakness in the wall and now you have an increased pressure for some reason you're weight lifting and you're doing a lot of stranger stuff it pops that aneurysm now you have a bleed I think in in my opinion those are probably the two big ones okay and when you're sorry I just lost my uh lost my train of thought so we're looking at uh the diagnosis again um and I want to go so risk factors I want to talk about once someone is diagnosed and they're treated and we talked a little bit earlier about having the arm being numb so there are strokes and I don't I feel like it's not so much anymore but I remember when I was much younger I'm 56 now when I was much younger if someone's parent had a stroke that one side of their body just wasn't going to work again and I feel like with time and research and treatments that's not necessarily the case anymore and part of that is that be fast and the other part of it is Rehabilitation and when I say that are there Strokes that are bleeding Strokes more apt and or ischemic Strokes more apt to not being able to rehab well or does One Rehab better than the other or is that even a thing one way or the other so The Strokes are so heterogeneous yeah that every person is affected indifferently depending upon the stroke severity so some people are very lucky and they have a minor stroke also called the Tia in which essentially means that all the symptoms spontaneously reverse and the person is back to normal and it's also called a warning stroke that's a that's a sign or an indication that the person is at risk for having a recurrent stroke that the risk factors needs to be addressed that the person needs to be investigated for what's causing the mini stroke or the tiu symptoms so that's a very important sign not to be ignored but to go to the relevant Physicians and figure it out what's how to reduce the risk factors how to be on the right medication what's the underlying cause of a stroke but that's going to be different in different age groups rights you can have strokes in rare kinds of Strokes in young adults as well as the more common mundane causes or stroke as in high blood pressure and atrial fibrillation and atherosclerotic disease so an investigation for men is stroke leads to the proper treatment right in order to prevent the person from having a bigger badder stroke and then so and so the the disability from the stroke and the recovery from the stroke also depends upon how severe the first stroke was right so in general the bleeding type of The Strokes have very high morbidity and mortality for example as Dr Berryman was relating to the southern hemorrhage just about a few years ago the probability of dying from a first ruptured aneurysm was about 50 percent so half of the time when people presented to the ER with a ruptured brain aneurysm half of them did not even survive because that's how bad the disease was in the rest half of the people who did survive the initial bleeding event those people went on to have further Strokes from the same physiology or the worsening or having stroke in the next two weeks so the outcome from the hemorrhagic under the stroke is usually worse than an ischemy kind of a stroke okay but again a lot of improvement depends on the Intensive Physical Therapy the Improvement in occupational therapy the nursing care that you know we have made over the last decades you know so that has really improved the outcome for patients suffering from ischemic stroke and hemorrhagic stroke how does one know if they've had mini strokes I think the key is you know when something's different you know if your hand's not working it's like hey my hand's numb and then something's not right my speech is not right I can't get find the word so oftentimes it's denial is what I find is people hate to say that something's not right my writing is not correct I can't come up with that word I and it's oftentimes it's a denial issue so Tia's often find as people just because the symptoms can go away it's like oh it was nothing it was a bad migraine or they'll make up some excuse rather than seeking out care so I think it's really important for us to get the education out there for our family members and anybody else if something happens like this that's the time you need to initiate 9-1-1 is we need to get those patients in because I always just blowing it out of the water yeah it's it's denial is is probably the number one case I see with Tia so it's like oh it's nothing it was a bad migraine they'll come up with excuses rather than going out and seeking so I'm listening to and I'm thinking I've had that bad migraine day I've had a day where i'm just like have I had mini strokes but you know and I'm joking about it but I but I'm also very serious about it as a person that you think you're fully healthy and you think well just for a day or two you're not you're just not feeling right and you do kind of snap out of it how often does that need to happen for you to realize okay if this is happening more and you said a matter of weeks that which I thought was so interesting Dr groups you said within you know often if you have a stroke and things are okay you you you live through it that within a couple of weeks you'll have another stroke and another's joke how how is that Chain Reaction happening to someone who's already had a stroke and why so that's a great question again because I think it's important to emphasize that a mini stroke or the Tia is a harbinger of a more serious event that's coming down the road unless that patient the person gets a property diagnosis and treatment so the risk of someone having another stroke is very high within the first 24 hours or within the first week after a mini stroke or Tia within the first month of having another stroke at Tia and then within the first six months and then the risk decreases as the time goes on I want to focus on that that's a great point so if you have a stroke chances are and we can look at percentages if you want to but chances are and it's almost like cancer once you get to that five years you're not in the clear but chances are a lot less you're going to have a recurrence so let's use the word recurrence in this a stroke recurrence couple of weeks into a couple of months and then if nothing has happened you know an extra stroke has not happened after six months seven months a year not that you're in the clear but you're less likely is that point is that what you're that is correct so once once about a year goes on or two years goes on then the person sort of returns to the Baseline risk of stroke so so again to reiterate the risk of stroke or risk of recurrence of a stroke is highest within the first week within the first three months within the first six months and then the risk decreases as the time goes on so I'm going to bring that that word rehab back in again so if you're in Rehabilitation for these strokes and I'm just going to throw this out let's say somebody has had two strokes now they've had a stroke and then a month later they had another stroke and let's say that one part of them one side of them is paralyzed is not working well let's talk a little bit about rehab because I think that's so important for people not to give up on their rehab because it really is up to them in the end and Dr Broom and I'll start with you because you're kind of the first line of people who've done that and again you are a trained nurse before you became a doctor is this something that you dealt with and people's attitudes or people's willingness to get better I'd like to talk a little bit about that because sometimes it's tough yeah I think it's really tough and again I think denial is another big component of it it's like oh it was a migraine or oh it's nothing in Hispanic culture there's something that will people will refer to is meaning I was hit by air and I think I have a palsy because of that you'll see this with Bell's policy you see with strokes and it's like no this is a circulatory problem or it's balanced probably one of the two but the issue is that it's it's a denial problem we hate to think that something's wrong and especially if the if the condition is resolved like 15 minutes later oh yeah I can write again oh there's nothing it has been nothing yeah right so I think the denial issue is one thing the Fear Factor is another that we're going to find something but the issue is we are going to find something we're going to be able to fix it or reduce your risk of having worse outcomes so the key is don't be fearful people get active come on in let us evaluate you and reduce your risk of having further uh incidences in the future and I'll throw out there again calling 9-1-1 it's just better and better better to call 9-1-1 do not drive yourself yeah the whole key in fast is the T the time time is brain you lose a million neurons either neurons or glial cells that are helping you a minute so if you're waiting 10 minutes to call the ambulance you've already lost 10 million neurons okay and the transport time and the time to get to the CAT scan you can imagine how many neurons you're losing just in a regular fast stuff you can you can lose a lot of neurons and even if we move very fast so if you're delaying it it causes a much bigger stroke right now that makes sense um so we talked a couple of days ago and we I'd like to bring this up so rapid artificial intelligence this is something that is being used or is newly being used in diagnosis am I understanding that correct let's bring that up a little bit so there's different uh artificial intelligence programs we use at our price something called rapid and what it does is it analyzes the flow it takes the computer analysts analyzes it and really tells you hey there's a high risk of a large vessel occlusion here and is this a device that is like a scan type it takes the scan material and runs it through a computer program oh and it tells you hey I think this is probably going to be a high-risk stroke the advantage we have it's a visual thing also so we can bring it up and say oh man there's no flow right here it's very very fast oh wow it's usually pretty good and it really helps us help uh determine hey do I need something like Dr Gupta right away I have a large vessel occlusion I need to get this done oftentimes before the the CT is even red we'll have the results on that rapid AI so before you describe to me how that works just logistically so you go in you have the CAT scan from there you're taking the readings from the CAT scan putting it into this AI device correct and then from there it's it's translated pops right to our phones and uh so we get it right on our phones and say we can look at it and it also warns you hey a large vessel occlusion which you can also take just take a look at it there's a problem with flow here so it's it's really super fast it's it's faster than our our Radiologists goodness gracious okay um on that note then if we're looking at just different ways of diagnosing and again we talked about aneurysms I'd like to talk a little bit more about afib and just Cardiology because I know you talked about uh before you went into neurology you were an Interventional cardiologist and so there's brain and there's heart everything that has to do the blood flow uh heart attack is you know blood stopping or the heart stopping because blood flows so if we could talk a little bit about Interventional neurology yes but Cardiology too in the area of Strokes it's so um with all due respects I uh did not train in cardiology so um I was never an Interventional cardiologist I trained I started my training in Internal Medicine okay and then for my love of Neurology I switched from from internal medicine to neurology um a I wanted to uh to become an Interventional cardiologist but as fate would have it I become an international neurologist which is not very far in terms of principles and what we do for our patients so uh um so um when it comes to especially the you the the Cardiology neurology overlap when it comes to ishkamic stroke the atrial fibrillation as usual it is a very common risk factor especially as as we have the Aging population the older we get the higher is a prevalence of someone having this irregular heart rhythm called atrial fibrillation sometimes people can feel it and they call it my heart I'm having palpitations and oftentimes there is silent right so and then the The Strokes caused by this irregular heart rhythm again is is throws up large clot from the heart and it can go any part of the body including the brain so when it goes up into the brain it causes sudden large life-threatening Strokes so it's a very common risk factor but thankfully we have multiple medications now in order to reduce the risk of a person having a stroke from atrial fibrillation so when you're talking about afib 2 because I know for example I'm afib I'm also a syncope and I also have a heart valve that doesn't behave um so I think like oh I'm stroke girl here I am uh so I try to you know everything that you were talking about taking care of yourself so heart valves involved with that so let's talk about afib with again clotting and then a heart valve too doesn't allow the blood flow to be even so throw that in there too because the next question I'm going to ask is medications again we are bombarded with Pharmaceuticals just take this take this and then you've got the disclaimer that's half as long as the commercial and I remember one saying if you've got afib not associated with heart valve problems or whatever why is a heart valve issue an issue sure so great great question again and in olden days if we go back you know 40 50 years ago even even more we used to have a very common thing called the rheumatic heart disease which affected which was essentially a infection which happened in young people while they were young teenagers right and then over period of many years that infection actually affected the heart Wells and it destroyed heart Wells and people ended up having romantic heart disease or affecting their mitral Valves and people had atrial fibrillation and heart failure and unfortunately most of these conditions affected young people in their 20s and 30s and these conditions has kept get worsening so the dramatic valvular disease used to be a big reason for people having stroke because of concomitant atrial fibrillation that fortunately that has been reduced and almost eliminated in modern world but what we still have is young people who are either have the congenital heart diseases and have ischemic stroke or people who have the again just over the period of years they have the non-romatic value of heart diseases and sometimes they are associated with atrial fibrillation sometimes atrial fibrillation is this non-valuable or as in the valves are normal but the patient has irregular heart rhythm atrial fibrillation so patients or people who have valvular heart diseases are at high risk because oftentimes they require mechanical valve or bioprosthetic valve and if you have a mechanical heart valve then that's the highest for clotting plot formation and clot going anywhere in the brain and they need to be on strong blood thinners and people may not have the heart valve disease but they can have atrial fibrillation as an independent risk factor so is there any when we're looking at risk factors too um and I know I'm getting away a little bit from brain in stroke but with risk factors such as heart valve issues and I know you're not a trained cardiologist I totally understand that but fixing these issues is that help then your chances of decreasing your risk for stroke absolutely and that's where medications are coming I know medications I feel like that's so loaded that I almost want to save that till the end but let's talk about fixing some of the valve issues and how that can help decrease your risk so so reducing the risk of having a streaming Stroke by any means whether by quitting smoking aggressively controlling your blood pressure because those are the low hanging fruits right um and believe it or not once the controlling the blood pressure and controlling smoking is one of the most effective and it's a public health measure you know in if we look at the direction in smoking and then concomitant reduction in ischemic heart disease um and then ischemic stroke that's been a huge achievement for the American Heart Association stroke Association so and then you know even along the same lines controlling diabetes controlling obesity um your diet lifestyle and then obviously fixing any any um structural heart disease that all those factors will reduce a person's chance of having an ish coming stroke and taken together obviously our goal is to eliminate as much as possible the risk okay and I'm so here goes sorry I keep popping the microphone but medications now so and I like to not backtrack but when somebody has a stroke and let's say it is an ischemic stroke and now they're on some kind of blood thinners and again their chances are within the next several weeks or next several months that there may be a recurrence in the world of medications because there are so many out there how would you help guide just people who are listening or watching um educate them on medications because I and there's also that Dr Google right you can go to Dr Google and look at all this stuff and they come to you with a piece of paper that has all this stuff on there but you're the doctor so I think that this sometimes is a great platform to talk about don't don't read Dr Google go to Dr baruman or go to Dr Gupta and find out what really to do I think all your concerns need to be sat down and talked to your con your physician because you have legitimate concerns whether they sound way out on left field or not your concerns are very legitimate and if that's going to stop you from taking the medication that's the conversation we need to have whether it's your concerned well you know I don't want to take this because I play Roller Hockey and I'm falling all the time well that's something for us to consider too it puts you at a higher risk but your concern should be our concerns and the only way we're going to be able to address that is for you to bring it to us and for us to talk to us together and decide what's going to happen I did want to bring something up about valvial heart disease that he doesn't see so much what I do is intravenous drug abuse where they'll develop vegetations on their heart and then parts of these vegetations can flip off and give you a stroke that way so that's another thing that is different I just lost you so you injecting yourself and it's not clean needles they have bacteria on it and now the bacteria now starts to form on your valve and it starts to grow and it's what we call a vegetation so either that part of that vegetation can come off or it can cause turbulence around that vegetation now you form a clot and you flip that off so it's we'll see it in intravenous drug abusers and that's the other thing that we'll see with Strokes in young people is from intravenous drugs I have never heard about that before and in the beginning of the program you said something and I'm just curious now this is going down the rabbit hole but you were talking about paintball somebody got hit in the neck is that right it was actually a paint gun and it was a painter when I was at Parkland and the guy had set down his paint gun and it injected it went right into his carotid so then he had paint that went up into his brain and it was very hard to get we didn't get all of it out certainly but it's just one of those strange things anything that causes a lack of circulation to your brain is going to cause a stroke whether it be a clot whether it be you know lack of blood flow from low blood pressure or in this case a foreign body which is paint so just to follow through that I don't want to take too much time so with this gentleman you didn't get all the paint out was he okay was it did you were you he had residual he was you were able to retrieve some of it but I mean pain is not like a clot where you can fill it up it's very different so he ended up with a pretty significant paralysis but uh it's just one of those freak accidents that can happen you know okay but the key is anything that blocks blood flow is going to cause a stroke okay um I have a question here that I haven't brought up in quite some time so having a stroke and conditions that may follow that and we're not talking about just the rehab that people would go through are there any conditions that may follow having a stroke like we know heart valve issues can lead to a stroke is there anything that is the other way around like you have a stroke which five ten years down the line you are now more apt to get a B and C conditioner is there is there anything like that necessarily Dr Gupta so so great question and there is often an overlap between um cognitive impairment and and as a result of stroke okay so so there's a there is a condition called vascular dementia for which essentially means that if a person has a recurrent ischemic stroke that can damage portions of the brain especially those portions of the brain that control the cognitive abilities our ability to think and logic and reason mathematical abilities and in addition to the motor sensory functions so so imagine a scenario where this goes back to again not underestimating the role of mini stroke or Tia and so a person can have recurrent ischemic stroke sufficiently number of times that can result in cognitive impairment over a period of days and weeks and months if the underlying cause that a stroke is untreated right so this so that sort of cognitive impairment or um is if is a form resulting from recurrent ischemic stroke sometimes Strokes can cause depression you know people often come to our clinics complaining of that their energy levels are not the same as they used to be and sometimes Strokes can cause personality changes right irritability Etc that I'd like to speak about a little bit because I know I've I've heard about that there are actually movies about this so um and you're a neurologist how how does that happen how does it change the personality it's because your brain is the most mysterious organ on planet Earth and it controls not just our bodily functions but it defines who we are right it defines our personality it makes you who you are right and it makes Dr bearman Who is right so all of our personalities are driven by those specific areas of the brain that makes this unique right it controls our dreams our desires or logical thinking or philosophy of life so if so imagine that the personal brain that gets damaged by your stroke or a brain tumor or something inflammation right and then that can certainly lead to personality changes people can become more aggressive or more passive or you know so so it's all possible and we've seen this rare scenarios play out I'm sure Dr betterman has seen in his clinical practice I've seen a few you know people can have weird dreams hallucinations irritabilities psychotic behavior so a lot of things can happen and that Strokes can be one of or a certain change in personality can be a presentation of Islamic stroke it's rare but it's possible right and is it something that continues is it something that after a while goes we use the word Baseline earlier it can go back to a baseline or and I'm sure every different every case is different but in general I think it has a spectrum okay there's there's a matter of you know some people are never going to get any better I mean there is one person who had a big struggle it's a classic book called The Man Who stick his wife for a hat who talks about all these strange little strokes and this one percent had a stroke and he always remembered his house in the same way and he won a big lawsuit because it was some kind of medical problem so he won a big lawsuit and they told the wife do not change the house what did she do she went and bought a new house so now he's take he's going to the restroom in the living room because in his mind that's the bathroom so it really depends on the person it really depends on how much the stroke is affected and some people get somewhat better oftentimes those parts of the brain are never going to improve and they're going to compensate they'll work around compensations but they will never be quite the same and on that note if I remember from shows past there's not a regeneration of neurons in the brain do I remember that correctly because some people would think okay well that's just going to get better once something for the lack of a better word and I hate to use that word but if something dies in the brain it it's that's not going to come back but then there are neural Pathways I'm looking at you because that that's always interesting to me when there's a certain part of the brain that dies the lack of a better word and the neural Pathways elsewhere are created is this part of their personality thing is this part of after a year you're less apt to have a stroke Etc how does that work so brain is amazing in terms of recovering and even though a personal brain may be irreversibly damaged but the the neuroplasticity or ability of the surrounding brain neurons or brain cells to take over and compensate for the loss function is is the key in recovery right so often people make excellent recovery because of the adjoining brain areas we used to think that um there are areas of the brain that are damaged are irreversibly damaged and there is no regenerative potential all that is changing with our understanding especially because now as you know that the stem cell stem cell therapy is is is under active research in an investigation and maybe at some point in future it would it would become a viable option because we are realizing that the brain has tremendous regenerative potential so that goes back to the ability of the brain to heal itself over time or compensate for the other loss functions so I think the way to think about that is those young kids that have strokes you know have you know floss of a limb and then three years later they've regenerated they've more Pathways they're not quite the same but they have increased function so it's a matter of you know the brain does have some flexibility to it and some ways for changing Pathways but I think the younger you are it seems to work better in my in my experience and it because you're young doesn't mean you're not going to have a stroke and that's something that you know people of all walks of life can have a stroke and any aneurysms too you know something could be lying there silent and you just don't know so if somebody is having symptoms and they're 16 years old those are still the stroke symptoms so get them to therapy um stem cell therapy I always like to when we round up the end of the program is what is on the horizon what is new and I know stem cells therapy it is still there's a lot of research there's a lot of stuff going on but what can we look forward to and this is where the disclaimer at the beginning of the show matters because whatever you say here may change in five years but what do you see on the Forefront when it comes to stem cell therapy in Strokes yes but kind of with everything so in stem cells I would leave that to Dr good okay I I don't know enough about stem so I think the the technology and the ability to get to vessels and that kind of stuff would continue to increase our ability to identify Strokes will continue to increase and our ability to intervene will increase as far as stem cells I'm just not well educated and we may not be you know it was brought up and it was just one of those things I was tied and my next question is going to be what's on the Forefront uh coming up but stem cell what do you know and again you're not stuck in anything I know this is not your air of expertise but what do you do you feel good do you feel like there's a lot of stuff that's happening that is going to help not only diagnose but treat Strokes in the future uh absolutely positively yes the future is bright especially as it comes to the stroke both ischium again hemorrhagic stroke um we could not have imagined having on our cell phone an app like Rapid or Vis AI essentially which tells you within minutes of getting within minutes of finishing of the CT scan before anyone else has looked up it's an automatic software it's an app that's on your smartphone so no matter where we are we get an alert the the AI is transforming the way that we treat stroke patients both so the my phone goes gives an alert Bing there is a there is a clot it for seeing so and so stroke patients in so and so location so the message is on my phone with the patient's information with the scans for me to look up but the AI is getting smarter and smarter in detecting the clots in the brain giving us a clot location and also when it comes to ruptured or unruptured aneurysm as in hey we found an incidental aneurysm in this patient we should better monitor this patient or what's the size of the bleeding and and exciting things coming on the loan as in the future is is robotics in Interventional neurology as an ability just like other disciplines you know surgery the ability of a physician to treat a stroke patient remotely remotely as in hundreds of miles away so you could be sitting here at the University or at the Sierra hospital and you could the the technology is available today well the surgeon can be elsewhere the surgeon could be remotely located and still be able to to treat a stroke patient take a blood clot out or treat an aneurysm in the brain using uh remote abilities to with or just over a wireless network because he can he can control the robot present in the cath lab from a remote location so the technology is available obviously is in you know in big centers now but I'm sure that over the next few years is going to filter down to Major other hospitals so that's coming the stem cells are also in clinical research but I'm sure as more promising results come in they would Translate to more patients all of this is amazing so we're at like a four minute point so what I want to do is stop everything and Dr baruman and same thing with you with Dr Gupta in a moment is there anything that we have not covered yet tonight that you want to cover Strokes are so big we can do 50 programs on Strokes there's so many offshoots I don't care how much technology we have which kind of medicine we have the key is recognition and time if you see something get in there quickly because I don't care what technology we have the longer you wait before we intervene the more brain you're going to lose so beyond everything else it's time recognition don't allow your grandma or Grandpa to say ah it's nothing to get them in let's get them evaluated let's get something done better be safe than sorry just call 9-1-1 I know and people think there's a cost to this and that and the other there's nothing more it's going to be a lot costlier yeah and that too and that too and just living just living Dr Gupta how about you anything that we haven't covered yet this evening that you'd like to talk about or something you'd like to cover a little bit more I would read Twist on the same things especially the final take-home message that Dr betterman mentioned is stroke should be treated along the trauma Paradigm just like someone who's having a heart attack when somebody's having a heart attack the whole team the whole team for the trauma person jumps over right because we know the timings of a sense so just because that stroke doesn't hurt it doesn't mean that we have time we have very little time to make a big difference in the patient's outcome so that's the key and then you know we can talk about blood thinners Etc we can go on and on but I think we've hit once some of the very important key take-home messages and the big thing too is you talked about hypertension right which means high blood pressure correct really quickly as an ER doc how can you lower your high blood pressure well dietary changes for sure okay exercise some people it's just it you can do all the other stuff and you're going to need medications so you can try the other stuff but the key is to monitor your blood pressure follow up with your physician and then if you the medication doesn't sit well with you don't just stop it go back and talk to your doctor about what the side effects are that are giving it to you how can we change it can we move you to a different medication and it may take four or five different medications before we find something that works for you the key is not to just stop it because the only person you're hurting is yourself right so have the patience to do that and the wherewithal sometimes to go to go see the doctor and I think that that's that's huge um I want to say thank you again this evening we uh have been talking about Strokes knowing the signs and getting to 9-1-1 making sure that you make that phone call if you are just now tuning into this program or if you want to watch us again because sometimes things go so so fast and for you guys too um there are three different ways that you can watch this program back the first one is pbselpasso.org and just go to watch and just find the El Paso physician the words called the El Paso physician usually you can see the logo on there and then the El Paso County Medical Society website always a good one on there and with all of these by the way you can look up different programs that have been done if you need a knee replacement there's information on there about knee Replacements oncology Etc but EP CMS which El Paso County Medical Society that's.com so epcms.com look for the El Paso physician logo and then also youtube.com so we are streaming now on YouTube and I went on there the other day because somebody was asking me about a shoulder replacement and I said oh I'm sure you can find it on YouTube and then I hung up up and I thought oh can you and so I went on there and sure enough go to youtube.com type in the El Paso physician and from there you've got all the different programs that we've been doing and again we've been doing this for 26 years so there's just about every topic that you can get on there and I want to say a shout out to Diego and his team because about six months ago we started recording these programs and I just feel like the microphones always work the lights are always working so I thank you guys very much I'm Catherine Berg and you've been watching the El Paso physician [Music] thank you [Music] foreign foreign [Music]