Hear a Patient Power interview with Dr. Wade Smith, a neurologist. When a stroke occurs, a blood vessel in the brain becomes blocked or bursts, sometimes causing permanent brain damage or even death. Prompt treatment and follow-up care are critical.
What are the warning signs of a stroke, a potentially life-threatening or disabling condition, and how do you get the speediest, best, most-advanced care? We'll tell you next on Patient Power.
Hello. This is Andrew Schorr once again with Patient Power, and we are talking about stroke. Now stroke is a pretty scary event and it can be life-threatening. Certainly is a huge cause, the biggest cause really of disability, and we're going to talk about the symptoms of stroke and how it's so important to call 911 and get emergency care, but what happens when you get that care? What's available either in the emergency room or right after that in the hospital? What drugs could be helpful, and what other approaches are helpful as well?
With us to help us understand that is Dr. Wade Smith. Dr. Smith is the director of the UCSF Neurovascular Disease and Stroke Center. He's also the director of the UCSF Neurological Intensive Care Unit. So not only is he a neurologist, he's also an intensive care specialist for people with neurologic issues. Dr. Smith, thank you so much for being with us on Patient Power.
Thank you for having me Andrew.
Dr. Smith, so let's talk about stroke first of all. It is a huge healthcare issue. What are the signs of stroke that people need to be mindful of?
There are several Andrew. The cardinal feature of stroke though is that it is a sudden onset of neurologic problem. Patients might first notice that half of their body becomes weak, like the left arm or the left leg for example, or they might notice that half of their body has gone to sleep where there's no sensation on that side. They might notice that they can't walk and don't have a particularly good explanation for it but realize they just simply can't walk.
Two of the others to be concerned about would be a sudden change in the ability to speak — either you can't say the words right or you can't think of the word to say.
Lastly, a change in vision where you lose vision in one eye or half of your vision disappears suddenly.
Now why is speed in getting care so important?
It's important because stroke, that's the subset of stroke caused by a reduction in blood flow to the brain, like a clot, comes from your heart and shoots up into one of the brain blood vessels and cuts down flow to the brain. That results in death of brain tissue every minute that that blood clots in its place. One estimate I saw from a colleague of mine is that over a million nerve cells dies per minute until that blood clot is id from the blood vessel.
I've always heard the term that you all use is "Time is Brain." So every second cells are dying, and you don't get them back right?
You don't get them back. That's correct. The brain doesn't regenerate like the liver, so our treatments really have to be directed at very quickly restoring blood flow to that part of the brain that's starved of blood flow.
Over the last many years now, you've had medications. I know one of them is called "TPA" that's injected, a "clot buster" if you will, and that works for many people if it's done quick enough, right?
That's right. In fact, there is very new exciting research that was presented in Europe two months ago where the drug is found to be effective even up to 4-1/2 hours after the onset of symptoms. The previous study that was published in 1995 said it worked up to 3 hours, so by having a little larger window of opportunity we think that will allow us to treat a larger percentage of patients.
What if it's longer than that or what if the patient for whatever reason isn't responding to that drug therapy?
That's a great question. A number of investigators said, "Well maybe what we could do is just take a mechanical device and go up inside the artery and grab a clot and take it back out of the body." That's a procedure called thrombectomy, where you're taking a thrombus and removing it from the body.
An innovative scientist at UCLA invented a device to do that, and that was tested in two clinical trials in which I was privileged to be the principal investigator for nationally. Those trials showed that you can open up blood vessels more than half the time just by placing this catheter into a leg artery bringing it up all the way into the brain and very delicately pulling back on the clot much like taking a wine cork right out of the wine bottle neck. The clot can be removed right out of the body and blood flow restored quite quickly.
Now at UCSF you do this of course. You're an advanced stroke center. What does that mean?
We're what you call a comprehensive stroke center, and that means that we respond 24/7 for any patient with signs and symptoms of stroke to our emergency room and can either administer TPA, which is given by an IV infusion into the arm, or if needed go into the arteries with a catheter and take them out in an angiocatheter lab.
And that's what you were describing. Now that is not available everywhere.
No it's not. Unfortunately it's expensive to have the radiographic facilities to do that procedure. There are quite few numbers of people trained to actually do that. So throughout America, recent estimates are that most people are within six hours of a comprehensive stroke center, and we hope that number will decrease with time as more people get skilled with the technique.
We're fortunate in the Bay Area that you have UCSF, which is such a center.
A lot of the original research in catheter-based therapies was done here at UCSF with a neurointerventional medical group. They were some of the first to pioneer techniques for treating aneurysms in the brain as well as stroke. So it's fortunate that we have this group here in our midst, and we have taken as much advantage of that as possible to provide this 24/7 service to patients.
Now, when someone has a stroke and they end up in the intensive care, you have this neurological intensive care unit. How unique is that, and what does that mean having that unit?
This is a dedicated intensive care unit that's staffed by neurologists who have been specifically trained in intensive care management. Many neurologists don't practice in an intensive care environment because that has been their focus of training. At UCSF we have 4 neurointensivists and 3 stroke neurologists who are specifically trained in this type of treatment so that we can take care of the patients preoperatively and postoperatively.
Let's talk about what it means to get fast care and more advanced comprehensive care if that's needed in your case and then also have this sort of staff available for recovery. What does it mean for outcomes and somebody, not only a life being saved but then having a quality of life afterwards?
Those are all very important issues Andrew. We advocate for our patients as our primary goal. We want to be sure that we can do everything we can to save their life and make their recovery as good as possible. Unfortunately sometimes we can't do those things, and we keep in mind wishes of patients and especially their cultural beliefs to try to provide the best quality service that we can. I think what we've found internationally is that if you have a dedicated staff that treats stroke as an emergency, the outcomes are remarkably better than they are at hospitals where they don't have a stroke team.
We have 29 ICU beds. We have 18 transitional beds, and a whole ward too where patients once they've graduated from the ICU can go seamlessly into rehab therapy and then getting home. That whole continuum where you start from the moment the stroke happens to the point of getting home from rehab is something that we focus on in detail.
With this kind of speedy and advanced care available, what could be the hope of someone? I know it doesn't always work out this way, but how much of a recovery could someone have if they get quick action and they respond well to the treatment?
It's one of the reasons why we're all here. We have all had several examples where patients have gone from being as sick as you can be from a neurologic perspective to normal.
You may think that stroke only happens to old people, but in fact a large number of strokes happen to people under age 45. For example, we had a young girl, age 16, who had a clot in her basilar artery. That's the artery in the back of the brain that really controls a lot of your basic neurologic functions. If you don't remove a clot in a patient like that, their mortality is over 90 percent. If you live, typically people have a lot of disability from it, and it's quite tragic.
This girl was airlifted here from a Kaiser hospital that treated her initially, knowing what was wrong with her, and came to our center and within 45 minutes the artery was opened. The following day she was almost neurologically normal, and she left two days afterwards.
She's a poster child for what fast intervention can do, and she's been interviewed nationally and internationally in response to how well she did and also to highlight that young people can get strokes too.
Now let's talk about something that people may be familiar with, particularly as they get older, and they wonder well how much should they follow up, and this is something I think called a TIA or transient ischemic attack. People can have these kinds of symptoms that just come and go away. A lot of people don't like to go to the doctor or if they have a sense it could be something serious but they kind of, I don't want to say put their head in the sand, but if it went away maybe it's okay. Any word about TIAs or what they are and that we should pay attention to them?
Good question Andrew. We treat TIA as an emergency here at UCSF in part because we recognize that what can happen following a TIA can be a stroke, and if you are normal right after the TIA by definition, that's the time to intervene. If you get one of the neurologic symptoms I was talking about — loss of strength in half your body, loss of sensation on half of the body, sudden inability to walk, sudden change in your ability to talk or see — any one of those that last for maybe 10 minutes or 15 minutes and goes away, is almost certainly a TIA, a transient ischemic attack. All it is, is a stroke basically that came and went.
A blood clot formed in a vessel, and it dissolved rapidly, blood flow was spontaneously restored to the brain, and the brain works fine.
What we know now is depending upon the symptoms that you have with your TIA your risk of a stroke in the next 24 to 48 hours can be very high, and we have particular therapies that can intervene in a patient like that to prevent that stroke from happening.
That's a very stark warning for people. Now you're a research center, and as you mentioned some of these approaches were actually developed and perfected at UCSF, so where are you headed now as far as hopefully giving even more refined care for people with stroke going forward?
One of the things that a number of researchers have focused on including our center is to define what patients can be treated at longer and longer times after their stroke. So right now TPA is limited at 4 ½ hours, and that's from the time that your stroke symptoms begin. You've got to get that drug in vein before 4 ½ hours goes by, and clearly the earlier you give it the more effective it is. So that's why we tell people to call 911 if they have symptoms of stroke. Just get to your local emergency room, preferably a stroke center or preferably a comprehensive stroke center like UCSF to get your treatment as fast as possible.
Unfortunately just what you said earlier, some people don't pay attention to the signs and symptoms of stroke and think that I guess because they're not painful perhaps or people tend to diminish the symptoms and don't call for help. The longer they wait, the less chance we have of intervening.
What we're looking at now is for patients who have waited too long to call for help or simply couldn't get help because they were unable to. We're looking at advanced neuroimaging techniques where we can look at the brain and say is there a problem with blood flow? Could we restore it safely even after 8 hours or 12 hours to the patient, or would restoring blood flow actually harmful to them? Trying to figure out who to give it to and who we should avoid those treatments for is really the research question that I think can bring a lot broader care to our community.
Yes, time marches on, and research marches on at UCSF, and that is exciting to hear as you continue to look at that.
A couple of quick things for people. They're saying, "Okay, do I have to worry more if there's a family history of stroke, if I'm getting older? I'm 58-years old. Should I be thinking about it more? If I am a smoker or used to be a smoker or depending upon my race." Any comments on, I know you said it could be any age, but some people who may be more at risk?
Yes. Stroke is not a genetic illness in the most part. There are a couple of rare forms of stroke that you can inherit directly from your parents, but those are few and far between. The more important family history is whether or not your parents smoked, because if they did you're more likely to smoke or have been exposed to second-hand smoke, so we really are conscious about smoking and trying to encourage our patients to quit smoking.
The second one is whether or not your family has a history of high blood pressure or high cholesterol. High cholesterol itself is often inherited, so if a parent died at an early age of a heart attack for example, it's likely that you have a cholesterol disorder, and your cholesterol should be looked at even an earlier age than perhaps it might be. Look at your cholesterol. Make sure that it's within national recommendation standards because we have good data now that if you lower your cholesterol through diet or medications or both that we can prevent a second stroke from happening.
By far the most important is your blood pressure. Regardless of what age you are, your blood pressure should be looked at, and we're now recommending that blood pressures stay about 120/70. Our old recommendations were don't get it any higher than 150/90. That's old news. That's way too high. We know that if you get it around 120/70 long-term that will prevent heart attack and stroke both.
So it's blood pressure, it's cholesterol, it's smoking cessation, and you need to manage your body weight so you don't get diabetes.
Diabetes is a disease primarily impact-full on blood vessels. It causes blood vessels to become diseased and hardened, and so by keeping your weight down you'll prevent your opportunity of getting type-2 diabetes, which is the most common form of diabetes and is an epidemic in the United States because of obesity.
That is just great advice. What I take away from this is a lot of prevention messages, a lot of early warning sign messages, and the importance for quick action, and if you are in the San Francisco Bay area to recognize that UCSF is a leading center that can provide the full range of care should you unfortunately be stricken with a stroke.
Dr. Wade Smith, director of the UCSF Neurovascular Service, thanks for explaining all this to us today on Patient Power.
My pleasure, Andrew. Thank you very much.
Thank you. This is what we do on Patient Power sponsored by UCSF. Thank you for joining us. For more information about the physicians and services at UCSF just call the Physician Referral Service. Here's the number — (888) 689-UCSF or (888) 689-8273.
I'm Andrew Schorr. You've been listening to Patient Power. Remember, knowledge can be the best medicine of all.
Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That's how you'll get care that's most appropriate for you.
Recorded February 2009
Reviewed by health care specialists at UCSF Medical Center.
This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.
Neurovascular Disease and Stroke Center
400 Parnassus Ave., Eighth Floor
San Francisco, CA 94143
Phone: (415) 353-8897
Fax: (415) 353-8705