Community Medical School presents: “In Stroke, Every Minute Counts: When Time = Brain”

welcome to the last in the spring series
of community medical school my name is David Schneider I’m a cardiologist over
at the Medical Center and another role that I play is the director of the
Cardiovascular Research Institute I’ve been here a long time actually I came
here straight out of training and I won’t tell you how long I’ve been here
but it’s more than 20 years and the I’ve been the director of the CRVI now for
five years and the CVRI made a request of community medical school to
participate actively in this process and we’re very pleased they that they’ve
allowed us to do some thematic lectures so for those of you who joined
us in February was Heart Month and we did a heart talk during that month May
is actually a stroke month and so today you’ll hear a bit about stroke and if
you come back in the fall in October we’ll talk a bit about Claudine such as
DVT that kind of thing so those are thematically cardiovascular areas the
cardiovascular Research Institute has a pretty simple mission our goal really is
to foster cardiovascular research inside the University of Vermont and what we’re
really about is improving care of patients in the community and what we’re
trying to highlight is some of the work that we’re doing through these talks and
what you’ll see today and through most of our talks is a somatic connection
between basic science work that’s being done in at the bench in a laboratory and
how that can apply to taking better care of patients so that in the future we’re
doing better and better care and there’s remarkable things going on in
cardiovascular research within the University of Vermont and so this is a
little bit of a way for us to take the bushel basket off our lantern and let
you guys see some of the great work that’s going on here and so today we’re
really fortunate to have a couple of individuals who work in the area of
stroke Dr. Evadne Marcolini is an interesting collection of skills
she’s an emergency room doctor and she’s also a neuro critical care specialist so
she takes care of strokes as they present in the emergency department and
also in the early phases when they’re critically ill and so she brings a very
strong clinical emphasis to what she does Dr. Marilyn Cipolla is a PhD
researcher who’s done incredible research at understanding how the brain
and particularly the blood vessels in the brain respond to the injury and what
the early phases and hearth and the translational thrust of that how does
that apply to doing better is she’s looking at ways to help people recover
more effectively after a stroke and her work is actually moving I would say
fairly rapidly towards clinical use and and it can it’s very exciting in terms
of what it can bring us so as much as I’d like to continue talking I think my
time is up and I’ll turn it over to the two of these guys well thank you very
much for that introduction and and let me speak on behalf of Dr. Cipolla
and myself we were both just thrilled to be here we’re standing here and talking
about how exciting it is to be able to talk to you guys and we were told that
half of you actually come back for many of these talks you’re not just you’re
not just here to see us but I think that’s really really
exciting and and I love being a part of it so thank you for coming and spending
the time with us tonight this is Sidney Sidney and his wife woke up one morning
about 7:30 she went downstairs to make breakfast and about 8:30 she said where
is he couldn’t find him went back upstairs and found him down on the
ground and he couldn’t move one whole side okay and his speech was slurred how
many of you in this room know somebody who has had a stroke
all right that’s that’s a lot how many of you are concerned that you might have
a stroke all of us are those of you who aren’t raising your hands are lying
we’re all worried about this and what dr. Cipolla and I want to do tonight is
go over everything from soup to nuts from how do you think about stroke and
when you see somebody who’s doing something that doesn’t seem quite right
should you pull that call bell and should you call 9-1-1 or is it something
else right I’m here to tell you the simple answer to that is you should
always call irrespective now I’m the person in the emergency department who
the patients come to and half of the patients who come into the emergency
department that are stroke alerts that’s what we call a patient who comes in
who’s a stroke alert are not strokes and we are very happy about that
we want there to be an over call so hear this message if you think somebody might
be having a stroke pick up the phone and call 911
all the time every time because that’s what we want we would rather have an
over call and have a lot of people coming in and then we figure out that
they’re not having a stroke then to miss a stroke so that’s a really really
important message and probably you know the most important message here but
we’re going to talk about everything from what do you do when you think it’s
going on what do we do when the patient comes into the emergency department and
then how do we treat those patients when they’re in the hospital and what’s going
on in the research to help move our science forward so hopefully we’ll give
you everything you need and we’re going to have questions at the end so take
notes don’t forget your questions because we
really want to get to those so good evening everybody I’m Marilyn Cipolla
and I also want to welcome everybody and say what a privilege it really is to be
here a privilege to do this with with every doctor mark Bellini so let’s start
with talking about the impact of stroke everybody here pretty much raised their
hand whenever you asked about knowing somebody who had a stroke or in fear of
having a stroke well stroke is actually quite prevalent in our population
there’s 750,000 new strokes that are diagnosed each year every 45 seconds
someone suffers a stroke every three minutes someone dies from a stroke
stroke is the second leading cause of death worldwide and so leading cause a
long-term disability about there’s about four million stroke survivors in the US
and it costs about an estimated thirty four billion dollars a year each year
you may not know this about 40,000 more women than men haven’t have a stroke and
more women than men died from a stroke each year so everyone’s going to take
over again and talk about strokes what is a stroke and then I’m going to get a
look at talk about the research that we’re doing that dr. Schneider was
talking about so we’re trying not to stand too close to each other because we
don’t want our mics to have interface so what is a stroke the blood vessels
that carry blood into the brain can get blocked they can get blocked or they can
rupture and bleed and that means Bloods not getting to the brain that’s what a
stroke is the very basic we’re going to talk about different types of stroke
different locations of stroke but the basic knowledge is that blood is not
getting to a certain area of the brain now if you look up here this is a
thrombus an ischemic stroke means that there’s a clot it’s either a thrombus or
an embolus and we’ll go to the next slide a
thrombus means that a clot forms in the place where it affects the brain an
embolus is a clot that forms somewhere else and travels to a place in the brain
and lodges there and get stuck either way wherever that clot gets stuck in the
artery everything beyond it that usually gets supplied with blood is not getting
supplied with blood so that part of the brain dies that’s what we call an
ischemic stroke a hemorrhagic stroke is a bleed it’s a blood vessel that
ruptures so I’m gonna go back here sorry the let’s go back to the ischemic let’s
stick with the clots if that clot gets stuck in a large vessel
we call that an LV O or a large vessel occlusion that’s gonna have a big effect
on the patient’s ability to function so somebody who loses the function of their
whole right side can’t move their leg can’t move their arm that’s probably a
large vessel occlusion it’s blocking a big artery that’s controlling the whole
half of the body of the motor function the other type of clot can be a small
vessel of one of the tiny vessels that goes
deep into the brain that either gets stuck with a clot or it bleeds and those
are not those are the type of strokes that maybe will cause you to have some
slurred speech or maybe vision isn’t so good it all depends on where it is but
the reason that there’s a big difference between the large vessel occlusion and
the small vessel problems is we have a way to fix the large vessel occlusion
and we’ll talk about that but those are two types large vessels and small
vessels when we’re thinking about clots but there’s also bleeds strokes that are
caused by a hemorrhage or the blood vessel rupturing here we have a picture
of an aneurysm some of you have probably heard of an aneurysm you may know people
who have had an aneurysm and actually two percent of us in this room have an
aneurysm in our brain it’s not a big deal most of them don’t rupture but it’s
when those aneurysms rupture that it can cause a hemorrhagic stroke so if this
thing ruptures and bleeds all of the brain that’s supplied distal to that
that’s not going to get blood supply and it’s not going to get oxygen and that
part of the brain may die so that’s a hemorrhagic stroke it’s not as common as
the ischemic stroke but it has more mortality more morbidity the other thing
that can happen is some of these these are called the these are the small
vessels that I was talking about right in the deep part of the brain those can
bleed and so they can get they can get clots or they can bleed if they bleed in
the deep part of the brain that’s when you have a stroke that has different
type of functional problems so if you see
somebody that has an inability to move their arm and their leg and they can’t
speak that’s likely a large vessel but somebody who has a small vessel bleed
like this they might not be able to speak while they may have slurred speech
they may have comprehension difficulty they may have some other subtle things
but typically they won’t have a motor problem but it’s not for you guys to
figure out which vessels are blocked remember the most important thing is if
you think somebody’s having a stroke call 9-1-1 get them to the emergency
department so we can use our testing and and figure out what’s going on is it a
ischemic stroke or a hemorrhagic stroke is it a clot or is it a bleed because you
can’t really tell until you get a cat scan you need to get a cat scan to tell
if it’s a clot versus a bleed so who is at risk I know you’re all gonna be
reading these lists and saying oh do I have this do I have that am I at risk we
all do this and I made this list both of these lists sort of over here are the
things that we can’t really control we’re born with this this is our genetic
makeup but on this side some of these things we can control stress unhealthy
diet tobacco all of those things contribute to stroke and there’s one
thing that contributes to stroke that I’d like to say is really important that
we can do something about and I see people all the time who come in and they
have high blood pressure they have chronic high blood pressure and I say
they come into the emergency department I say do you take any medication and
they say well I don’t really take it because I don’t like to take medications
I say okay fair enough I don’t like to take
medications either but what I think they don’t see is if blood pressure is not
controlled and we have great medications to control blood pressure if we control
the blood pressure we decrease the risk of stroke and I think that if those
people who don’t like to take the medications could see the alternative to
see what might happen because blood pressures too high they might take their
medications and and you know I don’t take blood pressure medication so I
don’t know I’m speaking you know I’m speaking out of turn but if I had one
wish for everybody who I see in the emergency department it’s that they
control blood pressure because there are so many diseases that happen because of
uncontrolled blood pressure and stroke is one of them and and we don’t want to
wait until it’s too late so let’s just go back again and talk about three
different types of stroke I told you two of them already remember we talked about
the ischemic stroke there’s an area where there’s a clot there’s a big clot
and the blood flow is obstructed can’t get by this is a hemorrhagic stroke
where you’ve got a rupture of a vessel now high blood pressure contributes to
this we think because chronic high blood pressure breaks down that in inner wall
of the artery and it makes it very brittle and it makes it such that when
when your arteries dilate and constrict and dilate and constrict somebody who’s
got chronic hypertension and add to that maybe high high cholesterol the inner
lining of this blood vessel doesn’t do so well and it gets kind of brittle and
we think our our best science right now says that chronic high blood pressure is
associated with ruptured vessel so here’s the hemorrhagic we’ve talked
about those I want to talk about a third type and that’s a dissection has anyone
heard of dissection yeah yeah it’s out there what happens is this remember we
have the three layers of the blood vessels and the bloods heading this way
for some reason that inner layer ruptures okay you still have the outer
two layers so maybe that doesn’t bleed like this one but it makes a little
dissection and so now you’ve got a separation of the inner layer and the
middle layer and that separation can sort of separate externally and it can
eventually bleed or it can just separate like this and what forms in here is a
clot now if you look at this blood is still going past there but not for long
because when you form a clot in a blood vessel like this one that attracts more
platelets and the clot gets bigger and when their clot gets bigger this gets
bigger and eventually you close off this lumen
that’s a dissection now the other thing that can happen is if you form a clot
here and it gets bigger little bits of that clot can break off and head further
deep into the brain so this is why with stroke you can have one big stroke or
you can have showering you can have multiple little strokes and when people
have symptoms for stroke it’s not just one symptom it’s multiple different
things and the dissection is unique because it can happen in young people we
are seeing a lot of young people have dissection of vertebral arteries the two
arteries in the back of your neck can have a dissection in the carotid
arteries – that’s more common in older folks but the dissection it’s kind of
tricky because if you have a dissection in a vertebral artery it’s probably not
going to affect the movement of your arm or leg it’s
gonna make you dizzy or nauseous or vomiting and when somebody’s got nausea
and vomiting what do you think is the most common thing for people to say it’s
causing it what’s that flu flu is a big one what else
stomach stuff right food poisoning it’s always food poisoning what did I
eat right but what we have to start recognizing is if this dizziness started
all of a sudden probably not food poisoning it’s probably not the flu it
might be a stroke and it’s harder to figure out again not your job that’s my
job so the dissection is an important thing
and we talked about dissection of the carotid artery or the vertebral artery
where it happens will cause different symptoms so let’s talk a little bit
about stroke location what you have in your anatomy is four main arteries that
feed the brain you have two carotid in the front of the neck and two vertebral
x’ in the back and that’s a good thing because if you lose one carotid you
still have three other large vessels to feed the brain when God designed us she
designed it that way so depending on which of these arteries
has a clot that travels up the artery into the brain that depends on where
that clots gonna land if you look at it from the side here here’s the carotid
arteries and here’s the vertebral and it goes through the the spine for a bit and
then it comes here the carotid artery distribution feeds what we call the
anterior part of the brain and if somebody has an anterior stroke they’re
more likely to have those motor function problems can’t move my arm can’t move my
leg can’t speak if somebody has a posterior from a vertebral artery
problem they’re affecting the cerebellum and the cerebellum is responsible for
balance and dizziness weakness nausea vomiting this kind of thing so those are
the two general distributions of stroke however there are connections so it’s
not all as clean as that so we think of the anterior as the motor type stuff and
we think of the posterior as the weakened Dizzy’s that’s very broad and
very general the important thing to remember about posterior is it’s not as
obvious right it’s just not as obvious and we have to be thinking of it so
Sydney what kind of a stroke does he have I’m hearing large large vessel occlusion
yes and I’m also hearing anterior yes absolutely he’s having a large vessel
occlusion anterior stroke what about this guy this guy’s golfing it’s about
4:00 in the afternoon he bent over to pick up a golf ball and when he stood
back up he was dizzy and he said Oh must be the flu just kidding no he said he
said oh I must be dehydrated so he goes to the clubhouse and he has a lemonade
and he sits down for a while he still doesn’t feel better he’s still dizzy
kind of like this the room spinning right and he says oh I’m just tired I
just traveled I took care of this patient I just traveled I came back from
Morocco where I was visiting my daughter in college and I’m tired and I was
dehydrated I just need to go home and have a meal so he goes home and he has a
meal and that doesn’t help he said I must need to sleep I must be really
sleep-deprived so he goes to sleep and wakes up later
and he’s still dizzy and the next morning his wife says what’s wrong with
you and he said well I’m just a little bit dizzy she said you’re going to the
emergency department and sure enough he had a posterior vertebral artery
dissection and the dissection caused the clot to go to his brain and cause him
to be dizzy so this is what happens but can you see how it could be really easy
to think oh it’s dizziness oh I’m dehydrated Oh food poisoning something
like that very easy so back to the first thing that we said if you think
somebody’s having a stroke just bring them in and let us figure it out this is one of the sort of public ads
that’s out there that helps people to understand what a stroke is and you
think about facial weakness so if you ask somebody to smile and they can smile
with both sides of their face that’s good but if they’re smiling and there’s
one side that’s drooping that that may be a stroke arm weakness just ask them
to lift up their arms can you lift both arms and if one arm doesn’t lift very
well that could be a stroke same thing with legs but arms is easy
speech difficulties today is a sunny day in Burlington if they can’t say that and
repeat after you or if you know that their speech is slurred because you know
what they sound like every day that could be a stroke and time call 9-1-1 so
this any one of these can be a stroke but the other thing that’s really really
really important is time and that’s in many different ways so first of all if
something happens all of a sudden right and when people say well I’ve got nausea
and vomiting dizziness and I say what were you doing when it first started
they say well I don’t know it’s been going on for a few days they can’t
remember what they were doing or where they were when it first started it’s
probably not sudden onset alright but if they say I was standing in the bathroom
brushing my teeth at 9 o’clock in the morning getting ready to go around
stairs and all of a sudden something hit me like a ton of bricks and I was on the
ground okay that’s a sudden onset would you agree yeah so just what what were
they doing when it first started if it’s a sudden onset you have to think well it
might be one of those clots that traveled through and got stuck and right
when it got stuck that’s when they started with the symptoms or there was a
bleed a rupture of an artery and when that happened that’s when they got
symptoms so if you think you think sudden onset some of these
things going on it might be a stroke don’t try to guess just bring him in
call 9-1-1 this is the most important thing to do how many of you know
somebody I’m not saying you did this but how many of you know somebody who
something happened maybe somebody was having a heart attack or chest pain or
headache or stroke and they called their relative who lives six states over right
we all do it we all do it that’s not who we want you to call we want you to call
9-1-1 and here’s why and we’ll talk more about this but the sooner we get to that
patient who’s having a stroke the better chance we have of saving neurons the
better chance we have it’s all about time the faster we get to them the
better chance we have so timing is really everything and and one of the
things that you can think about is when was the last time I saw this person at
their baseline or normal because if the last time they were normal was 1 o’clock
in the afternoon that’s when we set the clock and we have certain therapies that
we can use and do but they’re based on how long has this been going on and
we’ll talk more about that great Effie that was amazing
did everybody just learn a ton about stroke right yes me too so we talked in the stroke field we
talked about time is brain the title of this really as time is brain that’s
because with the stroke time lost his brain loss about two million neurons are
lost every minute of a large vessel occlusion LVO that Evie was just talking
about the question that we have is why does anybody know why the brain is so
sensitive to loss of blood flow sure but but more than that it’s the neurons the
most major cell type in the brain is is called a neuron this is just a diagram
of neuron this isn’t a real neuron it’s a diagram of a neuron and notice how
they’re all interconnected so they were they function in networks and they’re
highly metabolic so they have very high metabolism because they’re so important
and they’re doing so many things all at the same time they also have a very
limited capacity to store energy unlike muscle muscle stores energy very well
you can get up and walk very readily without having to do much it stores
energy the neurons don’t do this and again everybody a lot of people said
oxygen right so when the oxygen supply to those neurons is lost from an
occlusion or a rupture it’s the only blood supply that these neurons have and
it’s lost and so these neurons die very rapidly now not all tissue in the brain
is the same in terms of blood in terms of loss of function we talk about two
different regions in the brain the core infarction here which is the dead tissue
and this is from a large vessel occlusion this is that what’s called the
core and these neurons have died and they’re not coming back okay
um then there’s this region outside of the of the core infarction this dead
tissue called the penumbra and this is a region where the blood supply isn’t so
low that it’s killing the neurons but it stuns the neurons so they can’t
really function very well but they’re not dead yet and I’m going to talk a
little bit later about salvaging this penumbra region what we can do to
salvage this for numbre we can’t do a lot to salvage this dead tissue but what
happens over time if we don’t do anything to salvage this penumbra this
core infarction this dead tissue expands and it encompasses this entire penumbra
so a lot of us in the stroke field are working on how we salvage the penumbra
and keep this dead tissue from expanding and I’m gonna talk about that a little
bit later but every is gonna come back she’s gonna talk a little bit about
treatments and then I’m going to talk about the research we’re doing to to
work on the penumbra so the first thing we do when this patient comes by
ambulance to the emergency department is we get a cat scan this is this is not
the cat scan that we get but we get a plain cat scan and what we’re looking
for is does this patient have a bleed or not okay if they have a bleed if if they
have a brain bleed then we go down a certain pathway to take care of that
patient if they don’t then we think they have a clot because they have signs of
stroke and there’s no bleed and so we figure oh there must be a clot in there
and we do a CT with contrast to look at the vessels and when we look at the
vessels and again this is not a CT with contrast but kind of looks like this
when we see the vessels you can see this is the right side this is actually an
angiogram so this is going into the angio suite and putting a catheter in
the femoral artery going up and shooting contrast into the brain all right so
that we can look at the right side of the brain now you see a lot of blood
vessels here but nothing’s going on here and that’s because there’s a clot so
this is how we find where the clot is and the best thing to do is to get that
clot out now until 2015 we didn’t have a great way to get the clot out but in
2015 we had three big studies actually five big studies that showed us that you
can go in with something called a stent Retriever and actually grab the clot and
pull it out and if you can imagine the sooner we do that this the more of that
penumbra we’re going to save because that penumbra that Marilyn said is not
dead yet it can die but if we reaper fuse it if we get oxygen going back to
it it won’t die that’s our goal we’re not saving that core we’re not
saving the dead tissue we’re saving the penumbra so how do we do that this is a
stent Retriever so remember I said you go into the femoral artery and you put
this catheter up this is the catheter and then it gets to the clot this is the
clot and this is a very micro wire stent this is the latest technology and that
stent goes through the clot and then when they deploy that stent just expands
and it kind of grabs the clot and when it grabs the clot it’s pulling it away
from the walls of the artery and right then and there you now have blood flow
so it’s a really wonderful technique and you’re pulling that then then it’s it’s
like chicken wire and it’s it’s kind of like a little bit like the stents that
that are used in in the cardiac world – but now you grab this clot and this
balloon is blown up during this process to stop the flow of blood so it’s not
getting in the way then you deflate the balloon you pull that out and now the
clot is out and you have an open artery and the blood is
and your perfusing that penumbra this is endovascular therapy or some people call
it mechanical thrombectomy thrombectomy meaning you’re taking the thrombus and
you’re you’re getting it out and this is a good technology for those large vessel
occlusions we can’t use it for the small vessels they’re too small you can’t get
in there and you can’t really pull clot out of small vessels but if somebody has
a large vessel occlusion those are the people we can get this out now the other
thing is a little more old-fashioned it’s been around since the mid 90s is
TPA and I know you’ve heard of TPA it’s
thrombolysis meaning we’re breaking up the clot with a chemical and this is
just used in the IV we inject a bolus of TPA it goes to the clot where it is and
it starts breaking it down we’ve been using this since the mid 90s now there’s
a little bit of controversy around TPA because if you think about it if I’m
going to inject something in the vessel that can break up clot it can also cause
bleeding elsewhere right so it might cause bleeding in the brain it might
cause bleeding somewhere else so people are a little bit worried about that I
will tell you that it’s only about 3% of the patients who get TPA that eventually
have a bleed the rest of them it either helps by dissolving the clot or it
doesn’t really have an effect at all now when you have a large vessel occlusion
think of it kind of like liquid plumr all right how much liquid plumr do you
need for a big old you know clog yeah you kind of need a lot and sometimes it
doesn’t help and you’ve got to get the plunger right right it’s kind of how I
think of it so TPA has been around forever we still
use TPA somebody comes in today with a large vessel occlusion and they they
meet the criteria they will have TPA they will get TPA they will be offered
TPA now you can always decline you can always say I don’t want TPA but
this is the standard of care this is what we do and then we’re trying to
figure out is this a large vessel occlusion or not and we send them for
another CT with contrast or CTA sometimes we’ll even get an MRI or a
different CT to look at well how long has this been going on and we’ll make a
decision on whether or not to take them to get thrombectomy this is a nice
picture of a juicy clot that was pulled out of somebody’s brain with a stent
retriever okay so so we give TPA and maybe that works maybe it doesn’t and
how do we know it works well we’re doing an exam we’re asking you smile lift your
arms up and if you can’t lift your arms up and you know this one doesn’t go up
and then we give you the TPA and all of a sudden now you’re lifting your arms up
again well gosh the TPA probably worked and then we’re going to continue to
watch but there’s a lot of different things that can happen with stroke the
major thing we do though is the TPA and plus or minus the thrombectomy now in
order to get TPA we have to get to the patient within four and a half hours so
remember we talked about the last time the patient was seen normal seen at
their baseline if that was at one o’clock in the afternoon I’ve got to get
that TPA on board by 5:30 because at 6 o’clock we don’t give it at 6 o’clock
the risk is too high for a bleed and we want to be safe
and the other thing is every 15 minutes that we wait longer to give the TPA it’s
not as effective it’s more effective if you give it right away
so that’s why it’s always really helpful to know when was the last time that
patient was seen normal well what if you went to bed at 8 o’clock and you woke up
in the morning with signs of stroke when was the last time seeing normal 8 hours
ago depending on how long you sleep right so that’s not somebody that we can
give TPA to very easily we do have some advanced imaging techniques that can
help us get to how old is the stroke and we know when did it happen but in
general four and a half hours is our cutoff but thrombectomy is much longer
we can do thrombectomy on patients up to 24 hours ok so this is really very cool
thing all right it’s a wonderful technique and it’s absolutely I have
seen people young people who have had stroke large vessel occlusion and who
would otherwise have been neurologically devastated and had thrombectomy and and
they walked out of the hospital with nothing but a facial droop a slight
facial droop it’s really amazing but the first step is we got to get these
patients to us so how do we do that well I told you call 9-1-1 call the ambulance
and you’re thinking well i don’t know i could probably drive to the hospital
faster than calling the ambulance waiting for them to get to me etc but
that there’s more to it than that when the ambulance gets there they are
trained and skilled at determining if a patient has signs of stroke all right
they’re gonna do a finger stick blood glucose because if somebody has a really
low blood sugar they can look like they’re having a stroke
for sure and they’re going to be able to to use this app that we’re piloting now
called fast Edie they put the exam into this app and depending on where you are
this app will tell you where is the closest hospital and it’ll give you a
map a GPS on how to get there because you know Vermont’s a big state there are
a lot of rural areas and not every hospital has the capability to do
endovascular thrombectomy and if you have a large vessel occlusion you want
to go to the place that can do thrombectomy if you have a smaller
stroke you want to go to the closest place to maybe get TPA so this app is
it’s a pilot project right now and we’re trying to figure out wherever you are in
the state where is the best hospital for you to go to now if you want to have
endovascular thrombectomy you come here because we we provide that but smaller
hospitals don’t have that capability it takes a specially trained person to do
this as either a neurologist or a neurosurgeon or radiologists who
specially trained in doing that procedure so you can’t have them
everywhere right that’s why if you’re having a large vessel occlusion we don’t
want you to go to the closest hospital we want you to come here we’re still
working the kinks out this is this is a pilot project but this is how the
science is advancing even with EMS but right now what they do when they get the
patient in the ambulance and they do the the simple test to say this patient is
having a stroke or has signs of strokes they call me I’m here in the emergency
department and they call me and they say coming in with a patient who has a
stroke and so I say okay we’re alerting everybody radiology the Registrar myself
nursing neurology the stroke team we all meet you at the door and we go to work
fast we go to work very fast because time is brain so that’s why
it’s so important to call the ambulance and not call your cousin in California I
say that jokingly but people do because they’re like I don’t know
am I having a stroke maybe I want my cousin to tell me I’m not having a
stroke right and so call the ambulance and get to it
and I repeat it I want you to come here if you’re not having a stroke I want to
tell you you’re not having a stroke I would much rather you come instead of
not coming and you were having a stroke so when was the patient last seen normal
that’s that’s a question that EMS is going to ask you me thank you so we’re
gonna switch gears a little bit and talk about some science so I’m a vascular
biologist what that means is I study the blood vessels in the brain and Stroke is
a vascular disease we have you talked about the blood vessels that are blocked
there or there hemorrhaged or they they burst I study those blood vessels and
one of the things we’re doing now is trying to understand or trying to use
and take advantage of what’s already there in terms of reperfusion therapies
so the endovascular therapy and the the TPA therapy
those are reperfusion therapies okay so we’re focused on reperfusion therapies
because we know those work okay they are the most effective so we’re trying to
take advantage of what’s already there and this is a very simple diagram of the
blood vessels in the brain these are the big blood vessels of the carotid artery
these gray ones are the materials in the back and these circles represent where
there are connections between these large artery perfused territories so
this is the middle cerebral artery territory and the anterior cerebral
artery territory and why they’re so important these connections is because
if you have a blockage a large vessel occlusion in the middle cerebral artery
there can be retrograde flow from the other territory the anterior cerebral
artery territory to sustain the blood flow
and limit the damage and salvage that tissue in the penumbra I was talking
about so these little connections they’re called collaterals or we call
them peel collaterals because they lie on top of the brain are really important
for stroke and Stroke outcome so this is one of these CT imaging that every
showed and I want to show you the importance of this this is the same
patient that had a large vessel occlusion and again they’ve been
injected with a dye so you can see the blood vessels and you can see this is
taken over time and so you can see where there’s an occlusion here because
there’s the a region in the brain that’s devoid of blood vessels or dye in those
blood vessels so you can’t see them because of this large vessel occlusion
but notice over time you start seeing some of these blood vessels but that
occlusion is still there so how did those blood vessels get the
dye in them well they came from the other vascular territory that’s at
retrograde flow and it’s really important we know now that the
collaterals is what we call collateral status or how open those collaterals are
it’s the strongest predictor for outcome of stroke patients with these good
collaterals they have better reperfusion they have smaller infarct and less
hemorrhagic transformation that’s bleeding and patients with poor
collaterals they do poor even even if you do wreak analyze and yury profuse
regardless of the endovascular therapy or the TPA they’ll do poorly even if
they have if they have poor collaterals so we study these collaterals in the lab
we use a rat model and this is actually a photo micrograph from our laboratory
and these are the blood vessels that lie on top of the brain it’s through the
microscope because they’re very small this is a vein this is a branch of the
middle cerebral artery this is a branch of the anterior cerebral artery and in
the middle this is one of these collaterals that i was talking about
that provide that retrograde flow during an occlusion so that if the middle
cerebral artery was occluded what fool can go this way and still profuse
penumbra so we actually we study these we dissect these out of the brain and we
study their structure and their function and this is so this is a blood mess is
one of these peel collaterals it’s been mounted on glass cannulas it’s
pressurized it’s perfused it’s kept alive all day so we can study it we can
study its constrictor properties we can study its structure and just to give you
an idea of the size of this it’s at 50 microns here and that’s about the size
of this blood vessel it’s about the size of my hair about the size of a human
hair just so you know this is these are very small blood vessels but they’re
very functional and they’re very important and so one of the first
studies we did looking at these peel collaterals was we compared the
constriction of these blood vessels from a normal rat normal rat just a normal
rat normal blood pressure normal glucose just a normal person a young healthy
male let’s say okay we also looked at a rat with hypertension chronic
hypertension have you talked about hypertension the the importance of
hypertension and Stroke and how it drives a lot of the stroke risk so we’re
very interested in rats with hypertension and hat and how they their
blood vessels are affected by the hypertension because that’s what drives
stroke it’s a primary cause of stroke it’s hypertension so we looked at these
pele collaterals from these normal rats and these hypertensive rats that I’m
going to show you some data ok couple graphs here so what we do is is we
measure the change in the inner diameter so it’s here this is the diameter and
these again room they’re alive these blood vessels are alive so they actually
constrict okay and they constrict when we increase the pressure okay that may
seem odd to you but actually blood vessels are very responsive to pressure
it’s your blood pressure you know when you stand are you or you sit when you
stand up and you get a little bit dizzy those are your blood vessels who are
that are delayed in dilating a little bit because they’re responding to the
pressure okay so we look at pressure as the stimulus because it’s one of the
things that we look at okay it’s important and you can see that when we
look at the inner diameter when we increase pressure in an animal this is
wkyt’s this is those normal animals okay that the
there’s a little bit of an increase with the increase in pressure but pretty much
diameter doesn’t doesn’t change right so it’s about 40 microns 40 50 microns and
then we also measure the tone in these vessels and by the tone I mean how
constricted are they okay how vaso constricted are they
and for these vessels they are about anywhere from you know 15 to 20 up to 20
percent tone at the most okay so they’re about 20 percent constricted projections
not very much for a brain blood draw something it’s okay when we go through
the blood vessels from a hypertensive rat there’s a big difference so first of
all when we increase pressure vessels are very small right they’re only 20 to
30 microns in diameter and when you increase pressure they actually
constrict to the increased pressure this is actually what’s called the myogenic
response it’s a well known response of brain blood vessels these blood vessels
from the normal rats really kind of don’t have much of that and you don’t
want them to have much of that because they’re collaterals you want them to be
able to bleep redirect blood flow when there’s an occlusion so you want them
open you don’t want them to actually have a lot of tone but the hypertensive
rats actually have a tone or tone over 50% so these are the blood vessels that
are perfusing the penumbra and they’re vaso constricted in the hypertensive
rats so this may not be causing the stroke but it certainly isn’t helping
this job so in fact hypertensive rats don’t have
much of a penumbra and they don’t have whatsapp remember because they’re so via
the Pico ladders or so vaso constricted and this was a actually a real surprise
to the field because a stroke field has always assumed up until this study that
it was all about structure that structurally these blood vessels were
smaller alright and that they weren’t vasoactive what we called vasoactive
that they couldn’t be this constricted but they are so this actually was a good
finding and it’s a good finding because what we’re trying to do is now open
those collaterals so if they were structurally smaller you couldn’t make
them bigger by a pharmacologic agent or some sort of treatment
but we can and so the next question we had was can collateral flow be increased
during stroke to increase in Salvage brain tissue and or by time so that
those visit that those blood vessels from the hypertensive rat surveys are
constricted suggests they can be open and maybe we can salvage some tissue so
we tried this so we use a rat model of a large vessel occlusion okay this is a
rat brain here this is the base of the brain this is what’s called the Circle
of Willis this is this it’s called an anastomotic loop it allows for blood
flow to be be redistributed when you have this occlusion here this is a
filament that’s been surgically implanted into the rat it actually goes
in through the internal carotid artery and it’s advanced until it cludes the
middle cerebral artery which is here this is one of the middle cerebral
arteries this is the other middle cerebral artery so this rat had a large
vessel occlusion of the middle cerebral artery this is a really important model
of stroke it’s very big in the field we a lot of us use it because it
approximates clinical stroke it induces brain lesions that are very similar to
human stroke it allows her reperfusion so we can pull this suture out at other
time points just like endovascular therapy and pull that suture out to
allow for reperfusion so we use this model and so we also use this model to
measure changes in blood flow during the stroke to look at whether or not we can
increased collateral blood flow through those little peel collaterals okay I
notice a little bit busy but this is how we actually determine regions on the
brain and where to place flow probes okay we use something called laser
doppler it’s it’s how we measure changes in blood flow and we use two probes
laser Doppler probes one the first probe is in the middle cerebral artery
territory this is the core infarct dead territory this is the unsalvageable
tissue okay the second probe is placed in the
anterior cerebral artery territory just beyond those peel collaterals or what we
call the LMAs so this is the the penumbra region okay so we want to be
able to measure simultaneously what’s happening in the court and what’s
happening in the penumbra okay and then what we did was we measured the
collateral flow during an occlusion so we occluded the middle cerebral artery
and then we treated with a compound called sanguinate a now sanguinate is a
proprietary compound I’ve been working with the drug company who makes it it’s
a it’s an oxygen carrier actually it delivers oxygen to the to the tissue the
hypoxic tissue okay it also has vasoactive properties so we
hypothesize that the sanguine a would actually be able to open those
collaterals and increase collateral flow so lo and behold this these are the this
is the change in cerebral blood flow in the penumbra territory in the collateral
territory and we use the SHR this is a spontaneously hypertensive rat okay so
this is that hypertensive rat with those vaso constricted collaterals and when we
gave a vehicle which is just a control you can see that the colette when we
gave when during the occlusion there was no change in cerebellum flow really if
anything it went down meaning increased or change in blood
flow in the penumbra didn’t happen but when we gave the sanguine a there was
during the occlusion remember the filmin is still in it’s like you came to the
hospital with that clot in your brain and we gave the sanguine eight and we
could increase collateral flow so we could actually increase we could cause
vasodilation of those pele collaterals to increase the collateral flow we could
also improve reperfusion okay so we talked a little bit about reperfusion
therapies the idea is to get that clot out get oxygenated blood to that
ischemic tissue and to salvage as much as possible and so this is a graph
showing the cir change in cerebral blood flow but this is the mca territory this
is the territory of of the core infarction okay this is where we put the
filament in it drops down to you know over eighty percent drop in cerebral
blood flow we leave the filament in for 90 minutes we pull the filament out to
allow for reperfusion and you can see that the vehicle treated animals it
didn’t Reaper fuse not nearly what it started at and it declined over time
this is what’s called no reflow it’s also an important
concept and Stroke is that even though you reek analyzer you pull that clot out
the distal tissues not not profused and that’s happening here but with the
sanguinate you can see that we actually improve reperfusion and we can keep
reperfusion high what did we salvaged tissue we actually did so this is the
rap ring the white area is the infected tissue okay this is a die this is called
a vital dye the cells that are alive take up the dye metabolize it and turn
the tissue red the cells that are dead can’t take up the dye and so it remains
white and in this way we can actually measure the size of the infarct okay and
you can see when we compared the SHR with the vehicle treated to the sanguinate
a treated we had a significant reduction in this infarction I mean we actually
Salvage tissue so we can open those collaterals and we can salvage tissue
and I’m gonna stop there I can’t do any of this work without the support that I
have from the NIH the National Institutes of Health the NIH and the
Heart Lung and Blood and the cardiovascular Research Institute
this is my lab group they do all the work I don’t know if they’re here or not
but they do all the work I can never keep up with current picture so I make
many Me’s of them but they do a great job they’re wonderful and I think we
want I mean I want to thank you very much and we will take questions hi I have two questions actually one is
do you think there is a correlation between concussion and stroke and two is
in terms of I heard from something different that crawling can help with
develop narrow pathways and I don’t know if that’s the same as what happens
during a stroke but if that might be something that you could do
prophylactically you know just begin developing those neural pathways to so
that you can connect your brain yeah the first one when you ask is concussion
associated with stroke the concussion is when somebody has trauma to the brain
and it results in a stunning or seeing stars or maybe they even pass out you
know there’s a wide range of concussion there’s many different severa T’s of
concussion and if the concussion had an area of bleed so if you got hit hard
enough in the head that you had a traumatic bleed which is a different
bleed from what we’re talking about then that could cause a little bit of stroke
but concussion that doesn’t cause a bleed I don’t know if we have any
science that says that it’s associated with stroke I don’t know if I’m
answering your question or maybe you have a specific Yeah right and there’s a lot of research
as you know about concussion and it’s later effects on on brain in in the
neuro pathways and different different effects but we don’t have as far as I
know any direct connection between concussion and risk of developing stroke
later yeah so your second question about neural networks and can you build neural
networks that will be protective of stroke prophylactically I think that you
can build neural networks you can change your neural networks but that’s probably
not going to help prophylactically if you have a stroke because it’s all about
oxygen getting to those neural networks and it doesn’t matter kind of how many
you have if you have a low enough oxygen level those neurons are going to die so
it kind of doesn’t matter know so that’s what I was talking it was
blood flow going coming around not neural networks blood flow coming
around from one vascular territory to another to supply the neurons yep
I’m curious about the mechanics between the areas you work on and the areas that
Dr. Snyder works on and I mean basically you told us you use liquid plumber or
roto-rooter and and it seems like David does about the same thing but it’s
really we hear more cholesterol causing occlusions I guess in in the heart area
tell me if you could just a little bit of the differences between what you see
and versus what he sees sure in cholesterol high blood pressure
and cholesterol and smoking are probably the three top risk factors for vascular
disease and the vessels can be in the heart they can be the vessels that feed
the heart or they can be in the brain or they could be anywhere really but where
they seem to have the biggest impact is in the heart and the brain I’m sorry in
the brain in the heart because I mean the brain so cholesterol contributes
toward building plaque in those arteries and the one thing that we didn’t really
talk about and I’m glad that you brought this up is if you have something called
atrial fibrillation or an irregular heart rate your regular heartbeat which
many of us have what happens is when the heart doesn’t beat in a regular fashion
and it’s irregular it tends to collect blood near the valves kind of like an
eddy when you’re canoeing down the river those rocks and those outcroppings the
water collects in there and when and when the blood collects near the valve
because it’s not the regularly pushed through the heart it
clots it develops clot and when that clot sticks to the valve eventually it
can break off and when the when the clot breaks off from a valve in the heart the
risk is that it goes to the brain and that’s one of the ways that that they
are interconnected so when somebody develops atrial fibrillation as an
underlying disease we talk about putting them on a blood thinner to prevent those
clots from forming the blood thinners have risks somebody on a blood thinner
who falls and hits their head could end up having a traumatic head bleed so it’s
it’s a risk benefit but to come back you know the the cholesterol the high blood
pressure and and and all these things affect the arteries both in the heart
and the brain no no as a matter of fact we we do recommend that people are both
on an aspirin and a statin a statin is a cholesterol lowering lowering agent that
has been shown to decrease the risk of stroke and I would add to that that TPA
is also a link so tissue plasminogen activator was actually first used for
myocardial infarction and then the neurologist kind of were a little
delayed and getting on board with it and they finally did but they’ve correct me
if I’m wrong but the heart doesn’t bleed like the brain does and so it’s not just
you can’t get the protocols you use for myocardial infarction you can’t just
used for the brain so that there had to be separate protocols separate clinical
trials to work out the TPA for the brain but you’re right it’s very similar heart
myocardial infarction versus brain but because they’re such different organs
you can’t do exactly the same or the mic did I understand you to say
that if I’m with someone I suspect that’s having us stroke that is for me
to call 911 hospital as soon as possible because there’s very little I can do
from the first-aid point of view that would help them at that particular time
and to make sure they’re safe absolutely you you got it right on them
right on the money the the most effective thing you can do is to call
911 you tell the dispatcher what’s going on they will they will ask you other
questions they’ll say how old is the patient does he or she take any
medications and when was their last seen normal time and you’ll have some of that
information for when EMS gets there genetically
does a PFO increase the risk of stroke as we age and if it does does having
surgery help so can you describe what a PFO is please yes a PFO is a patent
foramen ovale when when we’re born you got that OVA
let’s let’s make it simple when we’re born there is there’s an opening between
the atria your heart has four chambers two atria two ventricles and that
opening in between the atria typically closes but in a good percentage of us it
doesn’t close so some of the blood is going from the right side of the heart
to the left side of the heart by the atria why is that important well that’s
important because there’s many places in our bodies that we form clot and one of
the common places that we form clot is in the leg so that’s why if you’re on a
long car trip or a long plane trip we tell you to get up and walk around and
get your muscles moving because when your muscles work in your legs they’re
actually producing TPA that’s circulating and breaking down these
little micro clots that we’re all forming so let’s come back let’s say you
develop a clot in the leg and you don’t know about it and it breaks off and it
comes up to the right side of the heart because that’s where all the blood from
your legs comes back to the right side of the heart if it gets through that
patent foramen ovale in somebody who it’s still open now it’s
on the left side of the heart and when it escapes the left side of the heart it
goes to the brain so yes that can increase that risk if the clot is formed
in your leg and you don’t have a patent foramen ovale that’s closed off then
it’s going to go to the lungs and form a different type of problem okay so in
your question being if I have a PFO if I have a patent foramen ovale if I close
it off does that decrease my risk for stroke yes it does but closing that off
is a surgical procedure or it’s an endovascular procedure and that has its
its own attendant risks with it so we always have to look at it should I get
this procedure or not some cases it’s worth getting that procedure
in other cases it’s safer to just take a medication to thin your blood and not
have clots hi thank you you touched on lifestyle causes for
blood clots and people with heart arrhythmias and you just talked about
people sitting for long periods can you talk about other reasons that people
that are otherwise healthy might have a blood clot that might go to the brain so
and when you ask that question I think of young people yes we we all think Oh
as we age as we get older we have in more risk for stroke high blood pressure
over time cholesterol over time we’re all building cholesterol and and so that
and then we think the corollary is oh this person’s young they can’t be having
a stroke not true and we talked about the dissection the vertebral artery
dissection now I’ve taken care of some patients some young patients with
vertebral artery dissection and if you have an underlying tissue tissue
disorder like Ahlers Danlos or something like that that makes your tissue a
little bit more friable that is a risk factor but in some of these people that
we’ve seen we asked them what why did you have what have you been up to right
and here’s some of the answers now I’m not saying that this is always the case
but in one one woman that I took care of she had been on a roller coaster a few
days earlier and she did one of these right and another person was doing
Crossfit do you guys know what CrossFit is don’t worry about it okay let me just say CrossFit is this intense
exercise where people get together in groups and they do like 200 squats in
five minutes or something like that I guess makes me tired thinking about it
but but all that stress you know can can be a stress some people say that
chiropractic manipulation can cause dissection and and remember the picture
I showed you where the vertebral artery snakes through the vertebral bones if
you think about somebody if they manipulate you really fast you might
just just you might just you know do something to that artery I’m not saying
that that we know that for sure but some of that kind of trauma is implicated
underlying blood disorders clotting disorders somebody can have a something
called a factor v leiden clotting disorder and that can cause
stroke so when somebody comes in with a stroke we’re doing a full workup we’re
getting an echocardiogram to see if they have any kind of clot on their valve
we’re doing a full blood work workup to see if they have any of these blood
clotting disorders and we’re asking a bunch of questions well you know what do
you been up to what’s so the person who may have had an
injury on a roller coaster or in CrossFit or at a chiropractor’s office
would have suffered an injury that caused a clot an injury that could have
caused a dissection or a claw or a claw yeah yeah I mean because the dissection
she said causes a clot as well so yeah well thank you absolutely there’s some
in the front too I don’t know if they have mics in now please don’t go to the
CrossFit people and tell them that you know
okay I’m gonna get ya can I ask I I have two questions one is if you’ve had one
stroke are you at greater risk for having a second stroke and secondly I’d
like to know when you have a stroke should you have an MRI or cat scan or
both my sister after stroke was told she should have had an MRI okay you take
yeah so yes if you have a stroke you are
about a tenfold increased risk of having a second stroke probably cuz all the
risk factors are there you’ve already had it but yes you can so the question
of cat scan versus MRI is a little complicated the first thing we do is we
get a cat scan it’s a plain non-contract cat scan and all we want to see is is
there blood or not because if it’s an ischemic stroke with a clot we’re going
down the TPA and a vascular pathway if it’s a hemorrhagic stroke or a bleed
we’re doing none of that stuff we’re lowering blood pressure we’re reversing
any kind of coumadin or you know Eliquis or any of the medications that
people take for blood thinners we’re gonna reverse that right away that’s
what we do with the bleeding strokes so if that when we get to the MRI that’s
when we we look at the CT and it doesn’t really show us anything so you could
have a clot that’s not going to show up in the first six hours on the CT or the
first 12 hours and now we want to know it has that stroke happened
so remember when Maryland showed the core and the penumbra right early on the
MRI will be able to see the core and the penumbra cat scan doesn’t see that later
a day later you’re gonna see stroke on the cat scan but now it’s too late
the MRI can show you that early on but the only time we’re really asking that
question is if you’re beyond 6 hours and we’re thinking about should we do
endovascular therapy so that’s that’s the question that’s when
we bring out the MRI and there’s a CT called CT perfusion that can do the same
thing as that MRI so the short answer is no the first thing is the CT that’s what
you need and then you make your decision on TPA and and with timing you make your
decision on endovascular I don’t know if that helps but yeah it is it is more
complicated than you would think no no no if it’s if it’s if it’s closer than
six hours and you’re trying to make a decision should we go in and do
endovascular therapy that’s when an MRI might be helpful yeah correct yeah does
temporal arteritis that if a person has that or has an episode enough episode is
the right way to describe it loss of vision in one eye does that in as a
consequence does that inflammation and as if it’s giant cell does that increase
the risk of stroke I don’t know because that’s in the it’s the blood vessels to
the eye right you can even have clots in the eye the inflammation would probably
make it more prone to clotting because the endothelium becomes activated and
that kind of thing it’s possible but not large vessel occlusion so much we’re
talking about locally within the eye I think yep I have two questions one was prompted by
the person that mentioned baby aspirin and about I don’t know 20 years ago I
heard of a friend’s father who had a stroke and if somebody a passerby
happened to have baby aspirin on them and they stuck it under his tongue while
they were waiting for the ambulance to come and later were told that that was a
good move to do that so that’s my first question that my second is if fatty
deposits are the cause of 80 85 % of all clots then how can we learn how clogged
up we are and I’m thinking of those mailers that come that say for $145 or
$175 you can come to some place in South Burlington and then check you out for
knowledge and you know prevention to know how reliable you are I’m gonna talk
about the baby aspirin you can correct me if I’m wrong I think that’s probably
not a good idea because if it was a hemorrhagic stroke
then you’re just or hemorrhage then you’re just increasing the propensity
for bleeding I think you want to find out first what kind of stroke it is they
got lucky I would say right absolutely because before we get that cat scan we
don’t know if the stroke is caused by a clot or a bleed an aspirin will further
the bleed so the second question and I am so glad you brought this up because I
have strong feelings about it and I’m sure that we all have strong feelings
about it these places where you can go and just get you know cat scan
everything an MRI everything and I’ve seen people come into the hospital with
and they have this list that says we looked at every single organ and you are
at risk for this and this and this and it freaks people
out well if this isn’t this is so not specific because if you it’s as much as
saying you have a heart therefore you are at risk of having a
heart attack no it what happens is you have to look
at when we use testing there’s an acronym that’s out there in the medical
world and we call it’s called vomit VOMIT stands for
victim of modern imaging technology and and this is very very true because if
you get for instance remember we talked about two percent of us in this room
have an aneurysm in our brain okay so if we got a CTA on everybody in this room
we’re gonna find who has aneurysms now how does that help you that’s gonna make
you anxious and nervous to go to sleep at night and it’s gonna make you think
every time you get a headache that you’re gonna have an aneurysm rupture
and it’s not going to be helpful at all because the 1% of those aneurysms will
ever rupture and you’re better off just controlling you’re both pressure and
eating healthy and not smoking etc when you find things now you feel compelled
to do something about them and every procedure and every surgery and
everything we do has risk so we balance the risk of the procedure against the
risk of the disease that we’re talking about so it is entirely entirely a
disservice to the public to offer these you know tests everything and and we’ll
tell you what you’re at risk for because it sends them down the pathway of more
testing and more procedures and it’s just not a good idea
am i on getting an imaging test to prove that you have a thirst grossest treat it
control your blood pressure have good cholesterol
exercise keep your weight under control
see your primary care doctor and then if you have extra money they want to throw
away I’d love to go out to dinner I have a question I’m trying to separate fact
fiction from anecdotes and I believe or at least I read that were born with more
neurons than we eventually get they slough off probably from not being used
and then you said that neurons die of a stroke and I’m questioning rehab I saw
once a documentary on TV a few years ago where this gentleman had a stroke and
through extensive rehab physical therapy two years later he was able to regain
use of that arm and was that because of the creation of new neurons or was this
just a great question yeah it’s a great question you know
years ago even just 10 years ago we thought the number of neurons in the
brain was fixed it’s not true we actually do make neurons and in certain
brain regions in certain areas of the brain there is neurogenesis that occurs
we know that so yes there is hope for that and in terms of stroke
rehabilitation so when I talk about the core being dead it fills in with other
cell types it doesn’t mean that you can’t have neurogenesis in fact
neurogenesis does occur with injury because of there’s a repair process that
goes on okay so that’s it’s a great question
that rehabilitation can form neural networks that are very helpful you may
not be able to restore exactly that neural network that lifted your honor
but you can compensate for that there are trials a colleague of mine a
neurosurgeon has done trials that are remarkable where he has injected stem
cells in these are stroke patients that are years out from their shock they’re
not going stroke evolves over the course of of months let’s say in terms of
readability the repair and the rehabilitation of it but you reach a
point where there’s no more repair that’s going to happen that that arm is
not going to lift any more than it has for a time he’s injected stem cells into
the core region and sure enough you know his videos of this woman now lifting her
right you may not be the stem cells you might just be actually the movement of
putting a catheter into the brain that stimulates growth factors to cause some
neurogenesis and some repair so I mean there is some hope we need a lot more
studies before we start puncturing people’s brains with needles and stuff
so so there is hope for neurogenesis there is hope for repair and I think
we’re in a really good good place now where we’re you know this is where
imaging actually really does help and I’m not talking about clinical imaging
I’m talking about cellular imaging where we can see things now that we’ve never
been able to see before and yeah it I think we’re there’s a lot of hope in the
future for for rehabilitation and repair those neurons yeah great question yep the question is what is the watchman
device well yeah the watchman device do you want to answer that so if you have
the atrial fibrillation that upper chamber doesn’t contract normally and
when blood sits in a chamber or conform clause so it already one way to treat
that is to give you a blood thinner some people can’t take blood thinners because
they’re bleeding problems so what they’ve learned is the majority of those
clots actually form in the appendage which is kind of exactly what you think
it’s a little thing that sticks off the side of the atrium and what what we’ve
learned is that you can include that appendage and get roughly the same
effectiveness as if you were taking a blood thinner it’s not the first-line
therapy but it is an effective strategy for people who can’t take blood thinners you want to give it back to MA it’s on it’s on you mentioned how a
young person could have a dissection the vertebrate clot and it causes a sudden
dizziness aren’t there many other things that could cause sudden dizziness I mean
if you’re a young healthy person or not so young healthy person and suddenly
you’re dizzy what’s the chances of that being a stroke versus any number of
other things that’s a very good question yes there are many things that can cause
dizziness sometimes and one of the more common things is benign positional
peripheral vertigo you can have dehydration you can have multiple
different things when a young person comes in or any person comes in with a
sudden onset of dizziness one of the hallmarks is that dizziness doesn’t stop
it persists and if you had dizziness because of let’s say benign positional
peripheral vertigo we can do something to help what that’s caused by is a
little stone in your in your canal and we can do a maneuver to help get that
stone from being stuck in there and get you better and the symptoms go away then
we say oh if the symptoms went away then it’s probably not because of a stroke
because you can’t just make a stroke go away like that and so what we’ll do is
we’ll we’ll bring you in and we’ll look at the whole story right well look at
your risk factors we’ll look at your how did this start when did it start what
are the symptoms and we’ll do a neuro exam a full neuro exam and that includes
everything from can you squeeze my hands give me a smile etc – can you touch
finger to nose can you touch heel to shin can you stand up and do a tandem
gait all right now I don’t need to know who’s done a tandem gait in this
audience but but that’s part of our neuro exam if
you can’t walk straight we’re thinking something something’s wrong and we
gather enough evidence through our exam and our history and we say we think this
might be a stroke so we get an image we get a CT and the CT with contrast to
look at the vessels and that helps us but you’re right most of the time it is
gonna be something more common our presenters are gonna take two more
questions one of our guests up there and then our final question will be asked by
someone in the back here our presenters have agreed to stay just a little bit
after the presentation so you can walk up and ask some questions after two
quick questions the first thing you’ve touched on I think indirectly several
times that you mentioned always call 9-1-1 that 50% aren’t strokes are
wondering what makes up that other 50% again you’ve touched on some of that
briefly and then unrelated my second question are there any risk or side
effects to the sanguinate if I’ve said that correctly this stroke the
first question is what are stroke mimics what else can look like a stroke low
blood sugar low sodium dehydration seizures those are some of the common
ones and many many of those can be happening and we can rule those out with
with other ways so yes come on in so the the sanguinate is actually a
blood product it’s a hemoglobin based oxygen carrier so you can’t be allergic
to bovine okay probably the greatest risk
is a volume that you have to inject and so hypervolemia is a its most stroke
patients can handle that but some won’t be able to so if they have kidney issues
then they would be excluded but it’s a pretty pretty safe comment there it’s
past clinic phase 1 clinical trials for safety so we’re trying to get an
efficacy trial going like yep great question all right my
question is your current state of health in your brain and if you have been
overweight when you’ve had high blood pressure and high cholesterol over time
but you change your diet is there any way of ascertaining exactly how much at
risk you might be for a stroke and if you change your diet and say you go five
years do you have less of a chance of stroke is there any imaging technology
out there or on the horizon that would tell you that and you know as opposed to
it a guess as opposed to scientific and I’m just curious what the state of the
art is in that so the the answer to your first question is absolutely if you
change your diet stop smoking yeah use you medications for blood pressure and
you know for cholesterol you absolutely decrease your risk of stroke how much we
don’t really know now we’ve got studies that look at people who take statins
versus people who don’t and over time you know longitudinal studies that look
at people and we can make a guess but the problem with studies is that you’re
saying well there’s a 75% chance that this could happen well how do I know if
you’re in the 75% or in the 25% I really don’t and and the best thing that you
can do is is just what you said is is decrease your risk by doing all those
things to keep your health and and what dr. Schneider said all the things that
take care of your cardiac health also take care of your stroke health if they
go hand-in-hand because we’re talking about the vascular system the the
arteries well thank you very much

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