thank you good evening and welcome to doctors on call I'm Dr Mary Owen associate dean of Native American Health and director of the center for 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 today for our program tonight on or tonight on stroke and other neurologic problems the success of this 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 panelists this evening include Dr Vikram jadav a neurologist with Essentia Health and Dr Dylan Wyatt an emergency medicine physician with St Luke's Hospital our medical students answering the phones tonight are Katie Benson from Staples Minnesota Claire Buntrock of Rochester Minnesota and Abby Rader from Glencoe Minnesota and now on tonight's program on stroke and other neurologic problems thank you both for being here thanks for having us thanks for having us so let's just get started with the question that's always at the top of these shows these days is how has covid affected your work well and around Neurology in this instance have you seen more Strokes because of kovid seen less go ahead definitely I mean we have seen an uptick in the number of Strokes which can be exclusively attributed to covid because now with sufficient research that has gone into covet it is known that uh whenever somebody has covered infection the blood can thicken up a little bit and this can predispose the patients or the individual to having Strokes because of the thickened blood which can form clots so we are seeing sometimes patients as young as even 30 or 40 year old who are having Strokes because they have covered infection of course it was much more initially but now as more and more people have getting have gotten their vaccines and are immunized against the against the infection then we are seeing less and less numbers but definitely covet is an independent risk factor for increased Strokes not only in older people but younger patients also and what is the time lapse between having covid or is there a is there a given time lapse or is it variable on between when people get coveted and when they might have the stroke it could be variable but usually the the risk is front loaded so in the initial stages in the acute phase of the infection you can definitely have a higher risk of stroke and that can keep on weaning off as you are more and more away from the as you as you improve and recover from the infection okay Dr Wyatt anything to add on that one from our perspective in kind of trying to identify Strokes in the emergency room it's sort of lowers our threshold with which we consider Strokes in a patient and kind of broadens the way we think about it in even younger patients whereas before we may have had a higher thought for something more like a complex migraine to mimic a stroke or something else now we'd be have a lot higher on our thought process you know did this person have covid maybe that means that they're they're having a stroke despite them being younger than what we would traditionally think being a risky age so as doctors we call that having a differential all the different things we think about when a patient comes in and you're saying covet has really broadened our differential to include something we wouldn't include before so definitely for every patient we suspect of having a stroke or we get called for we do order a covet test okay let's go back to some Basics Dr Wyatt tell tell me what the difference is between a TIA for instance what is a TIA first of all between a TIA and a stroke and how are they treated differently so a TIA is a transient ischemic attack and it's basically just fancy medical terminology for a short period where blood flow is not reaching a part of the brain in essence that that's what a stroke is it's blood flow not reaching a portion of the brain the effects we see on the body the things that that are classically sort of brought throughout to everybody to know the facial drooping the weakness that is from a lack of blood flow to a part of the brain when that stops spontaneously after a period of time it's a transient change and therefore is a transient ischemic attack it differs from a stroke whereas a stroke is a bit longer lasting now there is some blurring there because occasionally there can be spontaneous Improvement in strokes and it's not exactly a black or white but generally speaking the the stroke is a longer persistent symptom whereas a transient ischemic attack self-resolves when do you call Dr zadaff when do you call the neurologist when you're seeing people in the emergency department for this for me a lot of it depends on number one the complexity of the case sometimes this is a it's a slam dunk sort of the symptoms started at this time it is entirely in a distribution of the body that is consistent with part of the brain and therefore highly suggestive we do a CT Imaging study which would potentially show the area of concern then oftentimes we talk to a neurologist potentially on one hand to help us if it's not showing what we would have expected in regards to the CT kind of broaden the way that we're thinking and just say hey kind of lend me your ear here let's put our brains together the other thing would be hey we've identified this problem do we need to do a clot busting medication to try and get rid of that clot or is it big enough and close enough that we can have someone do what's called neural Intervention which is sort of like when people put stents into in the heart to get to the clots out there and I think you'd have a lot better uh explanation about that process yeah I agree I mean we work closely with our ER colleagues because we always consider our ER colleagues as like the first line of defense and they are the first ones to tackle patients who are coming in with stroke-like symptoms and as Dr quite rightly mentioned you get the CT Imaging which is a quick Imaging to make sure whether this is a bleeding kind of a stroke or an ischemic kind of a stroke and ischemic kind of a stroke is one where you actually have a clot blocking a blood vessel which is preventing blood flowing into a particular part of the brain and not getting enough oxygen so if the patient has blockage in an important blood vessel which is affecting that particular part of the brain we can actually put a catheter through the groin or the arm and go all the way through the blood vessels into the neck and that part of the blood vessel which is occluded put in a stent retriever which is just like a stent but attached to a wire capture the clot and pull it out and that way we restore the blood flow to that part of the brain and preserve the brain function so this is called an immersion thrombectomy and all of this is very fast because anybody who comes in into the ER suspicious for a TI or even a stroke symptoms the brain attack or a stroke code or a stroke alert these are the codes that get activated and it's almost like a chain reaction that the patient gets rushed into the CT scanner the neurologist gets called and this even happens even in the small years where you do not have a neurologist on call and you can set up a video monitoring so we can sit remotely in Duluth and can evaluate patients all over Northland so you're saying that I've worked in some clinics up by Bemidji if I'm up there and as long as they have that monitor system and it could be a basic screen it could be just a basic screen with zoom or some kind of a software doctor this is what I'm seeing on my patient can you take a look as well and make sure that you agree with this plan and then where would we go from here yes okay I agree and then if the patient is a candidate for getting the cloud Buster like the IV thrombolytic medications they get that and then they are shipped over to the main Center where we where the team is already ready for the patients like they are shipped to the angio Suite which is like the cath lab equivalent for the brain and then we we go in and do our catheter business over there so Dr Wyatt anytime a person student or patient presents to you right in the emergency department the time starts from the minute they open they walk through the door and there's a protocol that you're following it sounds like absolutely it's very protocolized for a good reason time is brain is the phrase We love to use with Strokes because it's true the every moment that that part of the brain is not receiving blood flow damage is being done damage that can be permanent so we are very regimented in the way we go about doing that because there's not any time to sort of faff about worrying about oh wait we have to do this or maybe this no it needs to be protocolized and very simple in a way you want to remove some of the thinking about the process and allow the thinking to be about the presentation and the patient and it's interesting because this has come about this whole protocol is coming out because doctors and nurses and the Whole Health Team have worked together to find the barriers to this to getting people treatment so it's a nice result of that collaboration between providers absolutely I think so um Dr Wyatt what should you do if you suspect someone's having a stroke if you suspect you or a loved one is having the stroke the most important thing to do is to call 9-1-1 right away again time is brain and if you are unable to communicate trying to get in touch with someone who can help you who might know some key pieces of information that we we need to know when's the last time you were completely at your normal you know when is there anything like new medications that may not be on our list of medications that could prevent us from doing certain treatments but the most important thing is is calling 9-1-1 to be brought into the emergency room because the alternative is giving more time for injury to occur within the brain anything else to add Dr John I agree uh totally I mean time is brain and recognition of symptoms is very important see uh in the in the common world like we know heart attacks there is very good recognition chest pain people are always worried am I having a heart attack but the same thing is not true for a stroke because sometimes you have weakness or some numbness on the arm and people think ah you know what I just slept on the wrong side and this will go away let me just shrug it off Shake it off I have had carpal tunnel something like that so that importance of recognition of the symptoms in coming in is very important so there is a very good abbreviation or a record mnemonic that can be used it's called be fast so the b stands for balance so if somebody is having lack of balance and cannot walk in a straight line unsteady almost like you're drunk but without having a drink and E in that B5 stands for eyes so if you're having loss of vision or you cannot see from one side of the field cut F is for facial group so if you are having facial group drooling of saliva from one side A is for arm and leg so if you're having arm and leg weakness on one side s is for slurred speed so if you're having slurred speech and T is for time so if you have any of these above symptoms time is of your sense call 9-1-1 and come to the nearest year okay excellent thank you sometimes though we don't get our patients in they might be fearful of the hospital system for whatever reason so say someone had a stroke they think they might have had a Strokers they think their loved one might have had a stroke a month ago and never went in or is there anything that can still be done of course more importantly there are two phases like the acute phase of the stroke wherein you're trying to contain the size of the stroke and limit the kind of damage that can be done but if that phase is already done and over with and if the stroke is over a few couple of weeks old you can still address the factors that cause the stroke in the very first place so as to prevent future Strokes that's called secondary prevention of strokes and we can still address that so for those things like looking at the heart looking at the blood levels of common things like does the patient have diabetes does the patient have uncontrolled high blood pressure does the patient have a bad lipid like high cholesterol we address all those factors and this can be done in the clinic as well okay and how long does it take if a person has had a stroke before they start to typically correct for the things that have happened for instance speech comes back or motor you know their movement of their limbs comes back is there a given time there's no uh like time set in black and white because each person is different and it depends on how healthy you were or what are the other comorbidities you have as well as your age now granted if you are a younger person who had a stroke you're going to bounce back much faster and better as opposed to somebody who is much older but the most important thing to remember is have very aggressive therapies right at the beginning because if your initial curve of improvement is pretty nice and steep then your final outcome is going to be good so you can start expecting some improvement in your stroke deficits over weeks if not months but if you haven't had any improvements after a few months then the likelihood of having a very good outcome is going to be much lower so it's always good to be aggressive about therapies very front loaded like right at the beginning and we tell our stroke patients don't get frustrated this is expected just plug on through this and you will see the changes day by day like baby step improvements you talked about what would happen if someone had an ischemic stroke or a blockage but what happens if they have a hemorrhagic stroke what's the treatment then that's a very good question there are the hemorrhagic Strokes they do not tend to be as common as the ischemic strokes and there are a couple of different types of hemorrhagic Strokes in one of the hemorrhagic Strokes like you have the blood vessel which has just burst or ruptured and that is bleeding within the brain substance itself and then the other type is like called subarachnoid hemorrhage which is rupture of the blood vessel because of an aneurysm and aneurysm is an out pouching or an abnormal growth in the blood vessel and the vessel just keeps on ballooning up and it will keep on growing till it cannot grow anymore and then it will rupture this type of bleeding is between the layers of the brain both of these bleeds are different types of bleeds are bad they can kill you and the treatment has to be different for if the bleed is large enough that it is compressing part of your brain brain then a neurosurgeon may have to open up your skull take out the blood and relieve the pressure the same thing for subarachnoid hemorrhage as well like the bleeding between the layers of the brain but to treat those kind of Strokes we have to treat the aneurysm which caused the bleed in the first place so the way to treat the aneurysms previously like say 20 25 years ago a lot of these aneurysms you had to open up the skull and you had to clip the aneurysm from outside but now with new inventions and catheter-based procedures we can have the same approach wherein we put the catheter through the arm or through the groin go all the way up to the part of the blood vessel which had that abnormal out pouching and the aneurysm growth and put coils in there and seal up the aneurysm to prevent the bleeding around the coils yep coils and then just pack up the aneurysm so there is no more blood that can go through the aneurysmal growth and now with new invention there are we are even stepping Beyond there are different kinds of stands and web devices which are individually shaped to the aneurysm itself so things are just improving like every six months there is a new device that comes up that helps us to treat and improve patient outcomes some of those also sound time dependent so do you get Dr White do you ever get calls from our rural communities on some of these neurological issues first are you first line there too we often do yes and it's you know it's an honor to be able to be a part of that care to help out because everyone has different capabilities in their institutions and it's just the nature of the institutions themselves and oftentimes we can help direct certain parts of the therapies that can lessen the chances of things getting worse for instance if someone has one of these bleeds very tightly controlling the blood pressure walking folks out there who may not be as closely familiar with that that tight blood pressure control aggressive blood pressure control on how to do that hey do this while you're carefully transporting them and trying to facilitate getting them them to one of our facilities to get them sort of definitively taken care of it's a interesting part of the process and also just to kind of jump off of what you were saying too it can also be very challenging we oftentimes get calls where there's a differentiation between is this bleeding or is this a lack of blood flow the ischemic type and that can can be unless you are looking at the images it can be very challenging to do so for everyone at home the identification is those neurologic changes that be Fast Signs not worrying about one way or the other which one it is just just getting them into us and we'll take care of the rest of that stuff excellent thank you Dr shadab what what is a have you ever heard of this a stroke shower on an MRI so what essentially it is like there are multiple Foci of Strokes all over the MRI and all all parts of the brain so that can happen if the stroke is coming from a clot from the heart so or from a proximal Source instead of just one blood vessel because if it's coming from a more Central Source then that clot might have fragmented and gone into multiple blood vessels so that way it is showing up in different parts of the brain and it might not show up on a CT scan it may not show up on a CT scan the CT scan is an is an equivalent of like let's say a black and white picture compared to an MRI which has more definition and different kinds of slices that exclusively look at different kinds of pathologies like what is this a tumor is this a stroke is this a bleed or is this like a demyelinating lesion so that's the information we get from the MRI whereas a CT scan would be helpful just to rule out is this a bleed or is there something else going on right it's one of the first lots of that protocol yes and then depending on what that that answer is then you go down another line on the protocol and very small Strokes may not be able to be picked up on the CT scan okay okay good discussion um Can a trauma such as twisting or cracking of the neck cause a stroke Dr Wyatt yes it can um especially there have been to my knowledge a slight increase in instances of those recently and oftentimes it's a whether it is from a sports related injury or a treatment related injury and where someone is attempting to crack someone's neck you can actually have tearing of the artery or if someone is older dislodging of some of the vascular disease some of the hardening of the arteries that happens with age that can then as an embolist go up to the brain and stop blood flow so absolutely yes it can Dr job I saw you nodding your head or do you have more to add to this yes definitely like any kind of manipulation which is a bit more excessive and which should not be done like hyper extension of the neck this is similar to what you might have in a whiplash injury if you're having a motor vehicle accident so the same kind of mechanism in which you can have tearing of the blood vessels which is called dissection which can cause a clot to form over there and then cause a stroke so we always tell our patients as we get older do not indulge in any any kind of activities which can cause sudden exaggerated movement of your neck the neck is meant to support the head and that's about it right so as you're aging be careful those upside down yoga moves putting that stress on that head yes we're not saying to stop playing hockey maybe just slow down slow down you know you don't just be smart enough to play like you're 30 anymore yeah be aware right that you're aging and you're human right do individuals who are immunocompromised have a greater risk of Strokes yes they would be having a greater risk of stroke for sure why is that what's the mechanism as we like to say uh well I mean uh basically it's your ability to fight against uh any kind of pathology and sometimes if you are having Affliction of the blood vessels it's ultimately stroke can happen because lack of blood flow to the brain so if your vessels are getting affected for any reason then that's going to result in less blood flow to that part of the brain and you're going to have a stroke from and a lot of people who are immunocompromised have inflammation and we know that any inflammation of the vessels which you at higher risk for heart attack Strokes definitely right anything happening there good can someone have a stroke without knowing it Dr Wyatt absolutely they can um not knowing it or not realizing that what they're having is a stroke oftentimes a challenge for us in the emergency department is when we have people who wake up in the morning having gone to bed at 8 9 10 pm wake up at six seven a.m and suddenly they can't move the left side of their face of their arm we don't know when that occurred it could have been five minutes before they woke up it could have been five minutes after they went to bed or anytime in between furthermore some Strokes are very very subtle it's not uncommon when we do imaging of people who are in their 70s and 80s that will see these small changes of small vascular changes that could indicate very very very small Strokes not big enough to cause a large clinical manifestation but small enough that it's present so absolutely absolutely it can said we have a term for it we call them silent Strokes because they are in a part of the brain that really did not cause so much deficit that was evident for the patient to know and they just probably Shrugged it off and then once you start probing are you sure you didn't never add this yeah maybe like five years ago my arm went limb for a while but then recovered so fast that I didn't really bother to see a doctor at all but then that imprint of the stroke is always left on the Imaging and then we can come to know something happened long time back but you recovered from it if a person has a pacemaker are there any contraindications to treatments of a stroke there should not be but the only big contraindication that we come across is to getting the MRI to look for where the stroke was and what is the size of the stroke but having said that that's not a complete deterrent because clinically we can we can guess like okay where is the stroke and what is the size and what do we need to do so that should not affect us in treating the patient appropriately but usually patients who have pacemakers they may not be able to get an MRI now newer pacemakers there are very MRI compatible as well you just have to ask the cardiologist and then the cardiologists would open and yeah sure we will just be on a watch buy and then we'll see how things are going and they can approve and then get the MRIs done okay thank you Dr Wyatt let's take it back a little bit what happens if you restrict an artery in the neck ah so that could lead to a variety of different things in a healthy very young person if you restrict a single artery in the neck it should be fine there's built-in sort of collateral blood flow multiple different streets you know when 21st Avenue East is closed there are other streets available to go around the same thing is true but as people age those arteries are not not all of them function at 100 capacity and so if your artery that has 89 capacity is the one that's occluded and the others have 30 40 capacity suddenly you can demonstrate symptoms out of a stroke out of nowhere even though it may seem dramatic it's just that it has exposed vulnerability in the other arteries nice explanation and occluded means blocked yes right yes thank you absolutely yeah yeah okay the brain is very very resilient organ and it will keep on scrunching blood flow from different levels till it cannot get any more and then usually at that stage it becomes a crash and burn because then things start falling apart usually we like to explain to patients using this analogy you're driving from the cities to Duluth you're taking the freeway if the freeway is blocked you can still get to Duluth using the smaller County Roads it's just going to take longer so the same way the blood takes longer to get to that part of the brain and at some point the traffic might stop and that's when the blood stops to that part of the pain and you're gonna manifest with some stroke symptoms as an excellent analogy thank you for that I think about a lot of patients who feel like I don't know that disease because I'm not feeling any symptoms and then all of a sudden they're at the danger point because all the implications of the disease have multiplied so our brains and bodies are always in good self-survival mode regardless of what kind of damage we do to our brain voluntarily or involuntarily and that's why people who are older have more Tendencies because culmination of all these things right yes yes thank you let's do an easy one for you do any of those brain exercises you see on TV or the internet actually work uh to ward off uh Dementia or well the one thing that has been proven to delay dementia is actually physical exercise okay so if you are indulging in physical exercise regularly then there is good evidence to show that you can delay dementia so if you're doing those brain activities while you're exercising then that can help like a Sudoku puzzle is not bad to do but it's in a while we're going to see a bunch of people doing Sudoku during Grandma's Marathon next year aren't we have other problems then they're going to be visiting you for having fallen down please don't okay you already talked about we talked about tias a lot of questions about those um it seems like more and more this is a general question seems like more and more people are developing Tremors or their a or people develop Tremors as they age more commonly is that does that mean anything should we always be concerned about a Tremor yeah we should be because it could be like a warning sign for a disease like Parkinson's which is well known uh so you can have different kinds of Tremors now Parkinson and Tremors they can be like resting Tremors when you're just sitting and your arm can be having it's called classically Like a Pill rolling Tremor so that's one of the Tremors you can have trimmers which could be just very benign they may not be associated with any kind of major disease and this those could be just familial and those could be Tremors we call sometimes like action Tremors wherein you are reaching for a cup or some water and then you're having some jerky movements so there's an entire Spectrum but the most important thing is you should not ignore Tremor because it could would be a warning sign of an underlying big disease if caught within time you can delay the progression so you can visit your neurologist and have them evaluate what kind of tremor is it and do we need to do any tests about it have them evaluate that Tremor is one of those things that it's always helpful to evaluate it in person rather than just get some Imaging and think about it point is call your doctor call your doctor don't be shy about it thank you both I want to thank our panelists Dr Vikram jadav and Dr Dylan Wyatt and our medical student volunteers Katie Benson Claire bentrock and Abby Rader please join Dr Ray Christensen next week for a program on upper GI problems when his panelists will be Dr Robert Erickson Dr Victoria Herron and Dr Brad Irwin thank you for watching good night thank you