[Music] good evening and welcome to doctors on call i'm dr mary owen faculty member from the department of family medicine and biobehavioral health at the university of minnesota medical school duluth campus and director of the center of american indian and minority health at the university of minnesota medical school i'm also a family physician for the fond du lac band of lake superior chippewa and i'm your host for your program tonight our program tonight on stroke and other neurologic problem problems the success of this problem program is very dependent on you the viewer so please call in your questions or email them to ask wdse.org the telephone numbers can be found at the bottom of your screen our panel this evening this evening include dr vikram jadav a neurologist with essentia health and dr john wood a family medicine physician with essentia health and director of the duluth family medicine residency program our medical students answering the phones tonight are elizabeth baker of chippewa falls with wisconsin morgan burns from pipestone minnesota and melinda cassandra lopez of truman minnesota and now on to tonight's program on stroke and other neurologic problems well thank you both for being here we had a lot of questions right off the bat people um sent us questions even before the show so i'll go ahead and start with some of those but i have to ask my question first the one i'm very curious about is um and i'll start start with you dr wood is um what have you seen as far as neurologic symptoms from uh kovid so far well in our clinic or with my in our experience in our clinic has basically been more of the cognitive slowing long-term kind of effects not so many not so many of the immediate sequelae i mean you could say that loss of smell and taste certainly those are onset and very common symptoms in cobalt but many of those are going to resolve over time but obviously the more serious things marry or dr owen or the are the long haul kind of the cognitive slowing that is really hard to predict who will get that and the treatment of course is more mainly supportive at this point and it's very uh devastating for those who get that and very unpredictable as well so that's been the main thing we've had to deal with dr vic anything to add on the long-term sequelae that you've seen sure i mean we have seen some and i'm a stroke neurologist so i tend to see patients who have strokes after covet because these are probably the patients who have had a bigger affliction of covered infection dr wood probably sees the patients who are coming to the clinic and more stable so covid as we know has a huge spectrum and some patients can be even asymptomatic after getting the infection whereas some patients could be on the knocking on the doors of death unfortunately it could be really bad situation what we have seen is kovit does increase your risk for stroke in certain cases because the covalent inflamma infection it causes more inflammation and causes what we call a hypercoagula coagulable state so that kind of like thickening of the blood so this promotes more clot formation and these clots can form in any organ it can form the clots can form in your lungs they can form in your kidneys and more importantly if those clots form in the blood vessels of the head or the neck then you're going to be left with very devastating strokes that must be really difficult because a lot of patients while being treated in the icu are probably developing some of these symptoms exactly and so limited on care what we can do for people so let's just turn right to neurological diseases what should bystanders recognize as stroke symptoms and how should they act to help and i'll go to you dr wood well you probably heard of that fast mnemonic for those of you who hadn't it would be um facial asymmetry like all of a sudden you got a droopy face so there's different kinds of stroke but we're talking about an ischemic stroke where you kind of lose blood to a certain part of your brain and dr vick may talk about that in more detail it's usually pretty darn sudden you're fine and then all of a sudden you're not and then it's really bad right away and so what that would be is the fast things think about facial asymmetry arm drooping i can't hold my arm up and then my speech is kind of slurred and then the t part is time because what we're talking about is time and that's probably something we're going to focus on today but so the first part is you recognize there's something going on with this bystander you may have not even met this person but you've got to act fast and then the next thing is to try to recognize that and then get 911 the emergency system involved because then you could kind of take over and end up where you need to be to kind of get the uh this problem taken care of with more definitive treatment so that's where i'd start with that is those kind of symptoms sometimes they can be more subtle obviously you can have some cognitive issues or you can be confused or you can be you you're you're not walking properly you know there's many there's it's a spectrum of things but the thing i'm really talking about at least for the a lot of bystanders be easier to recognize would be that those those three symptoms thank you dr vic anything to add and also can you extrapolate on the time piece sure yeah i will and uh thanks dr uh would summarize it very well the new acronym has been expanded a little bit to and to encourage people to even identify some of the rarer stroke symptoms and that would be b fast so we just added the b e to the fast and the b stands for balance so sometimes patients may these are patients who are having stroke in the back of their head and they might just have lack of balance their coordination is all over the place they might experience some nausea vomiting so that b's for balance is for eyes so you might have loss of vision in just one eye or you may not be able to see on one side of your visual field and then the remaining acronym remains the same fast so face arm leg slurred speech and t's for time so the most important thing if you identify any of these be fast symptoms time is of time is very essential and you should call 911 or go to the nearest er because if you can get to the nearest er then you are eligible to get the clot busting medication and this is a life-saving medication because if you can get to the ear within the first four and a half hours in some instances up to three hours then you are eligible to get the clot busting medication because after four and a half hours the according to the clinical trials the efficacy is probably not as much of course once you go to the er then there is a quick sequence of events which actually gets expedited by alerting what we call a stroke code a stroke alert or in different parts of the country it's called a brain attack or a brain code and the patient is rushed to the ct scanner immediately to make sure that we are dealing with the more common ischemic variety of stroke where in the clot might be blocking one of the blood vessels or the patient is not getting enough oxygen to the brain via the blood supply and not the hemorrhagic stroke or the bleeding stroke and once we identify that the ct scan doesn't show any bleed and the patient is eligible to get the clot busting medication we give the medication quickly and what would be the next step if that didn't work or if you wanted if that were a bigger clot excellent yeah and that is uh very dear to my heart actually because that's what i specialize in it's the role of the interventional neurologist so what we do is if there is a bigger clot we actually don't even wait to see whether the clot busting medication has actually acted because every minute you are delaying treatment you're losing essentially two million brain cells and so what we do is immediately we take the patient to the angiospeed so this is a specialized or suite or like kind of a room where you have a biplane ngo suite wherein you can take x-rays of the head fluoroscopy on two different planes like laterally and from anterior posteriorly so you are able to put a catheter all the way from the groin or from the arm of the patient without making any big incisions and go all the way into the neck blood vessels and the brain blood vessel and deploy a device like a stent to capture the clot and pull it out and many times we have some really good results with patients as soon as the clot comes out the blood flow is restored to the brain and the patients who are previously not able to talk or they had complete paralysis on one side of their body are able to move and do a lot of things i mean these are the best possible results but we see a lot of good results with this kind of treatment thank you for that that's very insightful and and helpful to for family members to know what their families are going through their family members are going through when they go in the hospital and they're very fearful of what's going to happen exactly yeah so could i have one thing mary yes please like it's amazing because i'm old enough you can maybe tell by my hair that in the past you couldn't really do anything like working in a little er seeing people have a stroke essentially almost right in front of you i've seen that happen and really have no treatment at all except for you know perhaps heparin or some something that really wasn't very effective and and now it's just life-saving revolutionary treatment and that's all been within the past 30 years you know it's it's incredible what's here now that wasn't here earlier and this our part of the state our country of course has a really good system to get these people where they need to be yeah and even in duluth the increased availability of of treatment between here in the twin cities dr uh dr woods what are the risk factors for strokes in middle-aged men i'd say hypertension high blood pressure uh elevated cholesterol diabetes would be you know the biggest three there's certain in in those three and so if you're thinking about trying to modify risk factors i really think about those three those three things if you have those or if you haven't been to a physician you should really get those things checked out to make sure you don't have those things because obviously you can have hypertension and not be aware of it you can have diabetes and not be aware you're going to have high blood pressure not be aware of it and if those those three things if they don't cause the devastating stroke that dr vick is involved with they can sometimes cause smaller strokes like multi-infarct dement that can lead to dementia because you get a lot of little strokes that you're not even aware you're having but have a cumulative effect after a few years that can lead to memory loss and dementia can present similar to dementia and then it's kind of like you're falling off a cliff when you reach a certain point and then can kind of keep going and then the treatment is it's you really can't do much except modify those risk factors and then if you come into the game too late it's really hard to do anything that's very effective and so that would be that's a re that's something to really think about that's why you want to think about these diseases these these things to treat because they can actually if you don't treat them they can have devastating consequences and how about cigarette use same thing yeah smoking is smoking is kind of like the burning ember so to speak that claims all these conditions thanks for mentioning that and kind of amplifies everything you know so and that's certainly a very modifiable risk factor and something we're aware that we're doing and so when your physician talks to you about smoking or your advanced care provider talks about smoking they're doing it out of concern for you i know it may seem like it's annoying and they might feel like you're badgering them but trust me it stopping smoking is probably the best thing you can do for your health anything to add dr vic and those risk factors for middle aged men or women yeah that's right i mean you did cover that the big factors are the high blood pressure bad cholesterol diabetes smoking sometimes you can have non-modifiable factors something that you're born with so sometimes depending on the age of the patient and their presentation we also look for some genetic factors that patients may be having and then we order the blood test to find out those kind of strokes we also advise patients to make sure there is no recreational drug use because sometimes that can be across the board regardless of the age that can cause strokes as well yeah i think people aren't always aware of that you mentioned the genetic um i think that not everybody realizes that the cholesterol can be a genetic factor exactly cholesterol could be a genetic factor too and uh so you have increased cholesterol that it's going to clog up your arteries and definitely it's going to cause a lot of stroke like events speaking of the dementia that you mentioned can be a sequelae of the strokes what are your thoughts dr vick on i'm not going to say this right add but i'll just go to the brand name add your helm to treat alzheimer's does that sound familiar it must be one of the medications for alzheimer's yeah the newer one one of the newer ones there are a couple of classes of uh medications for alzheimer's and they are like the nmda receptor antagonists and then there is like the acid alkaline receptor is inhibitors and uh again the most important thing is the medications that we do have they have gone through some clinical trials to show that there is efficacy and with alzheimer's patients or any dementia patients most important thing we try to convey to the families is early recognition because there is always a reticence about uh something going wrong with yourself you're never you're never going to accept it and it's only when the patients come and we put them through some barrage of tests and i try to make sure that the family members are around to see this and it's only then they start realizing oh wow you cannot even remember two words that we have been asking you to remember and now it becomes very obvious many times alzheimer's doesn't even come to recognition by family as well as the patient themselves till they enter till they have a big event like they may crash their car or they may do something wrong in the house so and then then it becomes very obvious that they are not even able to cope with like some simple tasks that they used to be able to do easily five ten years ago in my experience as a family doctor though sometimes family members are the first ones to notice something's a little different about their their loved one and they bring them in and feel a little bit frustrated because we're not always able to pinpoint exactly you know that form of that dementia we're not always able to pick it up on our test because they're not always as sensitive i agree and family members are a very good resource many times i have seen that family members who live with the patient may not be as in tune rather than family members who have seen the patient after six months or so because then they can appreciate the difference so i usually feel oh after thanksgiving after christmas then we get a few calls nana is just not the same anymore there is something different about her that's really interesting and thought about that the post post holiday calls should stroke survivors i'm going to ask you this dr woods i think you know this one should stroke survivors not that you wouldn't know everything but should stroke survivors take the covet vaccine i would say most definitely yes yeah yeah anything different ad or anything else you want to add about the benefit of the vaccine with patients with neurological diseases totally i totally support that stroke stroke survivors stroke victims should take the vaccine because as we know that coved does increase your risk for stroke forming clots so i support that completely and the booster as well yeah if you're eligible for that okay and you can get it uh what is your favorite treatment for dementia psychological treatment sociological treatment or medication treatment i think it is uh has to be like a multi-faceted treatment and you adopt non-pharmacological as well as pharmacological methods what i mean by that is you start off non-medication measures there's a lot of behavioral therapy and then therapies and acceptance of that you have having dementia and just getting to know that fact and coping up with that and then you start them on medications also as necessary when you know that it is going beyond a certain point so we always encourage anybody who feels that they may have dementia we don't even like to put that word in initially we will just call it cognitive decline because it's a big big diagnosis to give to a patient because it's going to stick with them for the rest of their life so we want to make sure that they have some sort of neurological i mean neurobehavioral and neuropsychological testing this is a barrage of tests that will put them through different tests to figure out what are their their capabilities of every part of the brain like some part of the brain is response responsible for executive functioning some part of the brain is responsible for language for memory visual spatial skills so not all dementias are the same vascular dementia may not be the same as alzheimer's as dementia that is seen with parkinson's disease so each of them needs to be identified and treated accordingly so there are different medications like dementia from parkinson's might be treated differently compared to dementia that is coming from alzheimer's or dementia that is coming from excess like increased number of strokes the patient may have had over their lifetime i think that's a really good point i i've found that a lot of my patients don't understand that they're different forms of dementia so thanks for explaining that i i want to go to dr woods before i go back to you on that alzheimer's question is there a link between migraines with aura and stroke boy i actually don't know if there is a true causal link i do know that migraines can mimic stroke and many times and often can be confusing at least in the first when patients do present with stroke-like symptoms that they can't present having a migraine but it can be looking like a stroke but i actually don't know if migraines with aura are leading to or there's a predisposition to stroke i don't have any i don't know that do you know of any of the research on this dr victor yeah i mean there are some like if you have increased amount of migraines there is some association with stroke there are certain situations also some uh clinical entities wherein you may experience more migraines and have stroke there is something called carousel so these are patients who may experience stroke earlier in life and they might have migraines also there is there is some association but definitely probably not as strong as association of stroke with hypertension right or diabetes back to that dementia or alzheimer's in particular where do you see alzheimer's care going in the next 10 years i think it's going to be strong because there are a lot of projects and research projects go in the pipeline for alzheimer's disease and we know that the baby boomers i mean they're they're aging that's a big population and it is recognized now that we are going to have a huge population who may have dementia issues and we may not have those resources but i feel that the care is going to be increased and there is going to be good research for that and as you mentioned like you were just asking me about the medication the new medication that came out so there's going to be more and more research and probably new uh trials clinical trials for alzheimer's patients i mean alzheimer's treating alzheimer's disease yeah i think we are starting to see more of that on tv as they promote those drugs exactly and then worldwide it's a huge issue like incredibly devastating worldwide alzheimer's disease is devastating and lots of resources need to be taken to try to treat this disease or at least support individuals and families that have this disease that's very tragic because if you think that in a country as rich as ours people struggle to support their family members with dementia and what's it going to look like in countries without the resources exactly yeah there has to be good education and acceptance of the fact that okay embrace the disease this is not something that you can shy away from and just learn to live with what you can do and how you can cope up with this as a person with family members who are going through this right now it's interesting to watch the different forms of dementia and how they change a person's personality even yes so it's not just the behaviors or the imbalance or other things that you might think you might see but the actual mood disturbance and the anxieties and other things that come from it so it's devastating for families as well do you see do you ever see strokes in adolescence yeah we do see strokes in young people and they tend to be either something that is genetics that's something that they might have inherited or it could be even related to like as i said like if there is drug use or something and that can be a big component of strokes because these are strokes that can be easily avoided and these strokes also can tend to be uh devastating because some of these are these medica these recreational drugs they can they are they can cause spasming of the vessels they can cause clots to form and they can be easily avoided essentially so are there other risk factors besides uh illicit drug use yeah the genetic factors can be seen in adolescence uh very frequently okay yeah i mean you can have adolescents who for example have sickle cell and sickle cell disease and they can have a higher incidence of stroke as well thank you for that um someone asked about the watchmen procedure does that sound familiar yeah so the watchman procedure it more or less i mean it comes into the realm of cardiology but we do deal with we work with cardiologists who do this procedure frequently so the watchmen device is essentially to take care of patients who are on blood thinners for preventing stroke because they have something called atrial fibrillation and atrial fibrillation is like an abnormal heart rhythm in the upper chambers of the heart called the atria and the if if somebody has atrial fibrillation they have a higher propensity to form clots and these clots if they happen to enter into the blood vessel in the neck and thereby go into the brain the patient can have more strokes so the patients are put on blood thinners but if they cannot tolerate the blood thinner maybe they have a stomach ulcer or they have bleeding issues elsewhere then the watchman device can be done to close off one of the appendages in the atrium and try and take them off the blood thinner so that's the advantage of the watchmen device and i think this procedure is done by our cardiologists as well over here in duluth so this procedure can be done in the loop thank you for that um and speaking of on the same subject i have and uh dr wood i think you can answer this one i have atrial fibrillation still having episodes and now on blood thinners will i have to be on the blood thinners for the rest of my life to prevent stroke the simple answer is yes yeah there's a lot been a lot of studies done about this is chad's vast scores and things as a way to identify patients who are at a risk for stroke because like dr vick said when you have atrial fibrillation these upper chambers are beating abnormally and because they're not beating efficiently you can get clots that are forming and then those clots can shower and go to parts of your body that can cause obviously strokes in your brain so the blood thinners yes and the good news is there's many different kinds of blood thinners now and they work a little bit differently and if you're not on warfarin or coumadin you don't have to go in and get the constant monitoring that i think a lot of us are grew up with or are used to so yes but the simple answer is yes for that individual yeah one of our callers was curious about the drug xeraldo can you say anything else about it it's one of those blood thinners so it's one of the newer blood thinners which is not like warfarin but it's kind of like similar mechanism and it is when they compared the trials and did the trials we we call these medications as noaa so novel oral anticoagulants and they can be used instead of warfarin the advantage of these medications like xarelto pradaxa and again i'm just loosely using their trade names also it's not like i'm endorsing the product just to clarify uh xarelto products uh eloquence which is called epic subman so these medications you do not have to do the inr checks so if you're taking the medication regularly as advised be twice a day or once a day you do not have to go to a warfarin clinic to do your inr checks and thereby having to adjust your diet or your lifestyle accordingly to make sure that the drug level remains constant in your body that's the big advantage of doing using the noax over the warfarin medication well incredibly important for family members who are always worried about those falls yeah yeah exactly um one we only have a couple minutes left but i just want you to clarify i think some um viewers are still a little bit uh concerned or question the connection between alzheimer's and dementia so can you clarify that for people that they're different types yeah so alzheimer's is essentially a type of dementia there are different types of dementia and the the commonest one the most popular one as we know is called the alzheimer's dementia and then the other dementias could be vascular dementia so this is a dementia that can happen because of stroke risk factors or heart risk factors and people who have strokes not only because of clots in their blood vessels but these could be very small blood vessels which are smaller than the diameter of your hair cannot even be seen and if these blood vessels over time if high blood pressure bad cholesterol diabetes is not controlled these blood vessels can give out and you can have strokes from these so if you have multiple strokes over or your lifetime then you can have something what we call vascular dementia so that's a different kind of dementia then you have dementia which is related to parkinson's disease so in that case you will have parkinsonian symptoms so you will have some tremors and then you can have some rigidity and bradykinesia so what i mean by that is like slowness of the movement so along with the parkinson's you're going to have some dementia and this dementia tends to manifest in different ways so you can have more of like sometimes emotional outburst and sometimes you can have hallucinations this is called lewy body dementia that is what you see with parkinson's then there is some other dementia called frontotemporal in which case you have more of the executive functioning loss so the most important thing is to go to a neurologist and make sure that you figure out what kind of dementia and cognitive decline you have and address it accordingly thank you dr vick that was excellent i want to thank our panelist dr vikram jadav and dr john wood and our medical student volunteers elizabeth baker morgan burns and melissa cassandra lopez please join dr peter naylan next week for a program on upper gi problems when his panelists will be dr victoria herron and dr john reich thank you for watching and good night [Music] [Music] you