Stroke Types, Treatments and Why Time Is of the Essence (podcast)

There are two major types of strokes. One is called ischemic and that means a lack of blood flow. The other type is a hemorrhagic stroke, meaning there is blood in the brain.

Is one more serious?

It really depends on the size of the stroke and what areas in the brain are affected. Sometimes people can have a small ischemic stroke that is relatively mild or they can have a large ischemic stroke that can be very devastating. It's the same thing with a hemorrhagic stroke. If it's small, it might not cause major symptoms, but if it's large, it can cause some significant devastation.

What is a transient ischemic attack?

A transient ischemic attack means that for a short period of time, there is a lack of blood flow to the brain. Luckily, that blood flow gets restored and so there's no actual damage to the brain. The thing about a transient ischemic attack is that it's a warning sign that you possibly could have a stroke. It's important to get to your doctor and make sure that your risk factors are under control.

If you have signs of a stroke, you should immediately call 911 and go to your nearest emergency room. You need to get medical attention right away. I would not put that off for weeks and weeks. If you can get in to see your doctor that same day, that would be fine. If you can't, then you really need to be evaluated in the emergency department to make sure that there's nothing that can be treated right away to prevent a stroke.

A cryptogenic stroke is just a fancy word for: We don't know exactly what caused the stroke.

When we evaluate a patient for a stroke, we look at the heart to see how the heart is functioning. We also look at the blood vessels that feed the brain. We also look at the blood to see if there is any reason why somebody would have suffered a stroke. We also do more intensive looks at people's hearts to see if the heart is beating normally. Do you have an irregular heartbeat? That can take actually months to figure out. So in a patient who's had a stroke, you do the usual work up trying to figure out why they've had the stroke. Sometimes we need to go a little bit further and do more intensive investigations.

A cryptogenic stroke can happen at any age. Of course as we age, strokes are more common, but a cryptogenic stroke can happen at any age.

The Cryptogenic Stroke Program at Scripps is a place where we look at patients who have a stroke that we can't really figure out the etiology or the reason for the stroke. We do some more in-depth testing.

One of the exciting technologies that we have is a cardiac monitor, which doesn't require major surgery or touching the heart in any way. It's just inserted right under the skin. What happens is that it's constantly picking up your heartbeat all the time.

When you go to bed at night time, there's a bedside monitor where information is downloaded every single night and sent to your cardiologist who looks at it to see if there is any irregular heartbeat. If there is an irregular heartbeat, this can cause a little clot to form in the heart and go from the heart to the brain.

We monitor to look for an irregular rhythm, called atrial fibrillation. In a lot of patients, this is not there all the time, but it comes and goes and it's difficult to catch because as you can imagine, if you go into your doctor's office and have an EKG done, you might not pick it up. We work very closely in this situation. When we have a patient, we frequently send them to cardiology to have this device implanted.

Other things that we do in the Cryptogenic Stroke Program is look for small holes in the heart, especially in younger patients. There is something called a patent foramen ovale, or PFO, which is a small hole in the heart that's relatively common. But we do see that there is an increased risk of stroke in young patients that have this. If we do find this and we do feel it is the cause of the stroke, then the cardiologist can go in and close that hole and prevent stroke.

Time is very critical in diagnosing a stroke because we have treatments to restore the blood flow.

There are two major types of treatments that we have. One is a clot-busting medication, called tPA. That medication can be given within the first four and a half hours of a stroke. That's why it's very important if you have stroke-like symptoms to call 911 and get to your nearest emergency room. There are other types of treatments when patients have what we call large vessel occlusions, meaning one of the larger blood vessels in the brain is closed off. What doctors can do at that point is take a catheter, which is a little tube, and insert it in one of the blood vessels in the leg and have it go to the blood vessel in the brain that's closed off. They grab the clot and pull it outside the body and then blood flow is restored and hopefully there's no damage to the brain.

Should you call 911 for an ambulance or drive yourself to the hospital?

It's very important to call 911 because sometimes even though your symptoms may resolve, they can actually come back while you're driving or while your loved one's driving. You don't want to put your family members or friends in that situation where you start to deteriorate. It's best to call 911 and get to the hospital immediately.

People who are at risk for having a stroke are those who have high blood pressure that's usually not well-controlled. People with diabetes are at increased risk. People who smoke are definitely at increased risk. Also cholesterol can play a role in the development of a stroke.

When a patient comes in acutely, the first thing that we do is a CAT scan. We look at the brain itself to see if there has been any bleeding in the brain, or if there has been any changes in the brain. We also do something called a CT angiogram, which is done at the same time and that outlines the blood vessels that feed the brain, both in the neck and in the brain.

An embolectomy or a thrombectomy is a procedure in which we see that the patient has a very large stroke and one of the major blood vessels in the brain is closed off. Then a doctor will take a catheter and take that up into the blood vessel that's closed off, will grab that clot and then take that clot out and the blood flow will be restored.

F stands for face. If you're with someone you think may be having a stroke, you ask them to smile and you look at how their face moves. Of course your face should be symmetric and there should not be any weakness on one side. If there is, that's concerning.

A is for arm. So, you ask the person to extend their arm. If they can't do it or one arm kind of drifts down, then you know that there's a problem. 

S is for speech. You ask them to say a sentence and if it's slurred or it doesn't come out correctly, then you know that there's a problem. 

T of course is for time. This involves making sure that people understand that you have to get to your nearest emergency room if you have any of these types of symptoms.

That's a very large team. It depends on each individual patient and what their deficit is. We have the physical therapist who works on mobility problems. We have the occupational therapist, who helps us with what we call activities of daily living, just the normal things that we take for granted like learning how to brush your teeth, how to make a sandwich, things that we do on a regular basis. Then we have the speech therapist, extremely important if you have problems with language, problems with swallowing, cognitive problems.

Rehabilitation depends on the patient and the size of the stroke. But people can get better from a stroke for up to a year.

All Scripps hospitals equipped with an emergency room are designated as Primary Stroke Centers. Scripps Memorial Hospital in La Jolla is a Comprehensive Stroke Center.

What's the difference?

A Primary Stroke Center has been certified that they can take care of patients who have an acute stroke, meaning that you come in within the first four and a half hours of your stroke and you need to get that clot-busting medication. All of those hospitals are well equipped to do that. They can get you in to get your CAT scan immediately, have the physicians available immediately to provide that care. That's very important. The Comprehensive Stroke Center is one level higher than that as far as taking care of complex stroke patients.

In the Comprehensive Stroke Center, that is where the embolectomy is performed. And if you have a significant need for long-term monitoring for your stroke or other types of procedures, you would be taken to the comprehensive center.

The American Heart Association and the American Stroke Association have designated Scripps hospitals with a Stroke Gold Plus status.

What does that mean?

The American Heart Association has many different awards and this is the top award for the stroke hospitals. This demonstrates that there are certain metrics, there are certain measurements that we have to abide by in order to take care of our patients well. To achieve that level, you have to take care of your patients, meeting all these metrics, doing it in a quick fashion and in a safe fashion. We have achieved that for all of our hospitals.