Ask Us Anything About… Stroke

A stroke happens when blood flow to the brain is blocked. But did you know that approximately 80 percent of strokes are preventable? Join us for a conversation about stroke symptoms, risk factors and treatments.

Our guests are Dr. Ray Reichwein, neurologist and Dr. Kevin Cockroft, neurosurgeon, co-directors of the Penn State Comprehensive Stroke Center.

May 5, 2017 Penn State Health News
View full transcript of video

Transcript

Description – The video begins inside a room with three males standing in front of a bookshelf. The three standing from left to right include neurologist, Dr. Ray Reichwein, neurosurgeon, Dr. Kevin Cockroft and Scott Gilbert.

Scott Gilbert – At Hershey Medical Center, this is Ask Us Anything About Stroke. I’m Scott Gilbert. What you may not realize is that stroke is the leading cause of serious long-term disability. It’s also the fifth leading cause of death. You may not also realize that experts say 80 percent, or maybe even 90 percent, of strokes are actually preventable. We’ll be talking about these issues today with two of our physicians, the co-directors of the Penn State Stroke Center. They are Dr. Ray Reichwein — he’s a neurologist — and Dr. Kevin Cockroft, a neurosurgeon. Thanks for being here today, guys. We appreciate it.

Dr. Kevin Cockroft – Thank you, Scott.

Scott Gilbert – Let’s start by talking about what a stroke is. What goes on in the brain when a stroke happens?

Dr. Kevin Cockroft – So a stroke basically is when a blood vessel to the brain becomes disrupted in some fashion. And there are two major types: An ischemic stroke is when the blood vessel becomes blocked; and a hemorrhagic stroke, or bleeding stroke, is when the blood vessel bursts, and you get blood around or in the brain itself.

Scott Gilbert – Okay. Which type is more common?

Dr. Ray Reichwein – The ischemic stroke, or the clot blocking up a blood vessel, is most common; and it accounts for about 85 percent of all strokes.

Scott Gilbert – Let’s talk a bit about the risk factors. I’m curious to see whether the causes of each of these strokes — and the risk factors differ depending on the types — but what are some of the most common risk factors?

Dr. Ray Reichwein – So there’s a acronym out in society — and we can hold up the cup that walks through it — but the common symptoms fit into an acronym called BE FAST. And the B stands for a balance problem. The E stands for an eye problem, either visual offs, or double vision. The F stands for facial droop and/or numbness. The A stands for arm — arm weakness or numbness. The S stands for a speech problem; so just slurred speech, problems getting your words out or even understanding what’s going on. And then the T emphasizes the importance of time — time is brain — that calling 9-1-1 and getting the EMS system to bring you in provides the best likelihood of acute stroke care.

Scott Gilbert – You’re watching Ask Us Anything About Stroke from Penn State Health. I’m Scott Gilbert along with Dr. Reichwein, Dr. Cockroft. We all welcome your questions and your comments on this Facebook post. Whether you’re watching it live or even on playback, we can get some answers to your questions if, again, you would just post them in the comment field. And also, of course, we encourage you to share this post. We’re talking a bit about the symptoms, the possible signs that someone is suffering a stroke; and the BE in BE FAST is new — balance, eyesight. Why were those added?

Dr. Kevin Cockroft – Well, it turned out that the original FAST acronym was missing a couple of important areas; and so the idea was to add those in and try and cover now about 95 percent of those symptoms that people will have when they’re experiencing a stroke.

Scott Gilbert – And the T stands for time, and I know I’ve heard you say many times, both of you, “time is brain.”

Dr. Ray Reichwein – Correct. The earlier the treatment, generally the better the outcome; and there is clear, established literature that supports that there is a commonly available clot-buster called tPA; and the quicker you get it, particularly under 90 minutes from symptom onset, the better the outcome, and the lower the risk. And there’s some endovascular treatments that Dr. Cockroft can talk about that, again, also emphasize earlier treatment is associated with better outcomes.

Scott Gilbert – So if you delay that care, that could prevent you from receiving a clot-busting drug.

Dr. Ray Reichwein – And it turns out that only about 30 percent of people receive the I.V. clot-buster medication, and the main reason they don’t receive it is because there’s a time delay. They often get to the emergency department beyond the treatment window, unfortunately.

Scott Gilbert – All right. Again, you’re watching Ask Us Anything About Stroke from Penn State Health. Feel free to add your questions and comments in the field below. Feel free. We will definitely pass those along here to Dr. Ray Reichwein and Dr. Kevin Cockroft. Dr. Cockroft, we’re talking about the tPA as one intervention. As a surgeon, can you tell us about any of the other options out there for breaking up those clots?

Dr. Kevin Cockroft – Sure. So if the tPA does not work; or if it turns out that you actually have a very large blood vessel that’s blocked, causing the stroke, then there’s some other things we can do. And those things are usually devices or procedures that involve using a device to go in and pull out or fish out the clot. And actually, I brought one of these with me today; and this is an example of what this device looks like. And I think you’re stepping on it. [Laughing]

Scott Gilbert – I’m sorry.

Dr. Kevin Cockroft – And so this is what is called a clot-retriever device. This one is called a Solitaire; and you can see as I push it out there, this is kind of like — a “stent on a stick,” we call it — and this is going to go and grab hold of that clot that’s sitting in the blood vessel; and then once it’s got hold of the clot — it takes about a couple of minutes — then we will pull this entire thing out while applying suction on a larger catheter down in the patient’s neck. And that is going to effectively remove the clot and restore blood flow to that area.

Scott Gilbert – Now, what determines whether you will go with an intervention like this versus tPA?

Dr. Kevin Cockroft – So, if a patient has a large blood vessel blocked in the brain; and they are generally within six hours of the stroke onset, then we will contemplate doing this. We do some other advanced imaging studies to look at the brain to see if there is tissue that is salvageable; so sometimes we can go even longer than six hours. But unfortunately, some people even that are within the six-hour window are not going to benefit from this because they’ve already had too much damage. So it’s a bit a complicated process. Just because it can go out to 6 hours, it does not mean you can show up at 5 hours and 55 minutes. It really takes a little bit of assessment beforehand to make a judgment whether this is really going to be useful or not. So I would — as Dr. Reichwein said — encourage you really to show up as soon as possible to give you the best options for treatment and the best chance of making a good recovery.

Scott Gilbert – Again, time is brain; and these are treatments we’re talking about for ischemic strokes — the blockages — 87 percent of all cases. The remaining are those hemorrhagic strokes. Can you talk about interventions to treat those?

Dr. Kevin Cockroft – Yes. So hemorrhagic strokes — these are the things that are caused by brain aneurysms; by weakening of blood vessels that burst, usually in people that chronic high blood pressure or hypertension. It can also be caused by vascular malformations in the brain. A lot of these disorders can actually be prevented, so hypertension — by treating the hypertension and managing your blood pressure well, that can really reduce your risk of those — the most common type of hemorrhagic stroke, which is an intra-cerebral or inter-cerebral hemorrhage. The other ones — aneurysms, blood vessel malformations — if those are found early or incidentally, then many of those can be treated to prevent a rupture — prevent bleeding. And then that’s the best-case scenario in terms of improving outcome for those.

Scott Gilbert – You’re watching Ask Us Anything About Stroke from Penn State Health. I’m Scott Gilbert, along with Dr. Ray Reichwein, Dr. Kevin Cockroft. We welcome your questions in the comment field below this post. Again, whether you’re watching it live or on playback, we’ll make sure we get you some answers. We were talking a bit about the BE FAST acronym — the signs that someone could be suffering a stroke — but there’s one sign that’s not in there. It’s a headache, and we actually got an e-mail from someone who had read our Medical Minute this week at pennstatehealthnews.org. That’s pennstatehealthnews.org. You can check out a Medical Minute on the BE FAST acronym. And she noted that headache is not in there; and she says — her name is Mary [assumed spelling]. She’s from Texas. She says, “One evening after work, I was standing in the kitchen when the sharpest headache I ever had forced me to lean on the counter. The only way I could describe it is a sharp knife stabbed me from my right nostril through my sinuses, through the top of my brain and into my skull. I had no other symptoms.” So how common is a severe headache; or as she says, “The worst headache of your life,” a symptom?

Dr. Ray Reichwein – So it is only probably a few percent of people who have the worst headache of your life or a very severe, atypical headache; and it is classically associated with brain hemorrhages. It can also be associated sometimes with a torn blood vessel — what’s called an arterial dissection. But it’s only a few percent, and that’s why it’s not part of the acronym. The acronym accounts for about 95 percent of the most common symptoms that a patient is going to have. But it’s important to recognize that if it’s very severe, atypical — unusual for that patient — that they do seek attention; and one should focus on those two possibilities as being the most important — again, a brain hemorrhage and/or a torn blood vessel.

Scott Gilbert – Sue is asking a question: “Is it advisable to give someone suspected of suffering a stroke aspirin to chew? If so, is that baby or adult aspirin, and how much?”

Dr. Ray Reichwein – A bunch of facilities out there do that; so keep in mind, most strokes are the ischemic strokes, and it would be safe to do so, generally similar to cardiology. Some people recommend taking four chewable aspirins. In reality, when you look at subsequent literature, it really doesn’t add that much benefit; and unfortunately, if you happen to be that 15 percent that could have a brain hemorrhage, it could make you worse. So usually, we have not recommended that routinely, other than emphasizing get promptly — call 9-1-1 — get promptly to an E.D. Get an assessment and a CT scan and then make the decision. And I wish I could say it was more effective on like cardiology, but it adds a little bit; but there’s some risk if you have a brain hemorrhage, so again, it’s probably better recommended not to do so. Get timely help, and then let the experts sort it out.

Scott Gilbert – Now, Mary mentions later in her story, she was later diagnosed with a stroke; but she actually, thinking it was a headache, took medication and went right to bed. It wasn’t until several hours later when she got up, she knew something much worse was going on. How often does that happen?

Dr. Kevin Cockroft – So, well, the description that Mary gave of “the worst headache of her life,” that is an absolutely classic symptom for what is called a subarachnoid hemorrhage, which is a sub-type of a bleeding type of stroke, usually caused by a brain aneurysm rupturing. So that situation, you definitely do not want to take aspirin. So if the headache is a predominant symptom, and you don’t have weakness in your arm, face or trouble with your speech, then that’s something you probably want to avoid the aspirin in. Unfortunately, the description of going to sleep after any of these symptoms is very common, and that’s why we have the problem of not being able to give the clot-busting drug; not being able to use our devices; because people come in too late. They have a vague symptom. They think, “It’ll get better if I just take a nap and take some aspirin,” and so they don’t come to the hospital. And so unfortunately, that’s absolutely the wrong thing to do.

Scott Gilbert – But in many, if not all, cases, early treatment can lead to good things.

Dr. Kevin Cockroft – Absolutely, yes. The sooner we can get there, the more options you have for treatment, and the more likely you are to do better later on.

Scott Gilbert – You’re watching Ask Us Anything About Stroke from Penn State Health. I’m Scott Gilbert, along with Dr. Ray Reichwein, Dr. Kevin Cockroft. We’ve been talking about the treatments for stroke. We’ve been talking about the signs and the symptoms; and I mentioned up top that experts believe that between 80 and 90 percent of strokes may actually be preventable. How could that be the case?

Dr. Ray Reichwein – So there are many common risk factors out there; and very modifiable risk factors if one is aware of them and gets treatment. And those include high blood pressure, diabetes, high cholesterol, as well as behavioral things: smoking and excessive alcohol use. And at least — focused on high blood pressure, diabetes, high cholesterol — these people walk around feeling okay, even though those problems are sitting there. So the importance is, again, to seek medical professionals; and if they do have them, get on the right medications. If you smoke — alcohol — emphasize the importance of that, as to avoiding those bad behaviors. And again, with doing so, the literature is pretty strong, that upwards of 80 to 90 percent of strokes can be prevented; so I would always say, in our world, we can do some very good things acutely to try and undo the damage; but the best cure is, again, not to have the event in the first place. The other thing is, there are some other common risk factors that shouldn’t be ignored that are important in today’s time. In younger people — women with migraine with aura and the use of birth control pills have a higher incidence of stroke. And in older individuals, an irregular heart rhythm — atrial fibrillation — many times is unnoticed other than some heart palpitations, but has a strong correlation to subsequent stroke as one gets older. So if you have heart palpitations and you’re older, you should get screened for this abnormal heart rhythm. And the final thing that’s near and dear to me is mini-strokes. About one in four people are lucky enough to have a mini-stroke, or a transient episode, before they get to the hospital. And this is a great opportunity, so this is the calm before the storm. If they ignore it because they’re back to normal, the same symptoms that we talked about before — within a few days, their highest-risk period — they can have a devastating stroke, and now their world is different. So don’t ignore mini-strokes is my other statement.

Scott Gilbert – Referred to as TIA.

Dr. Kevin Cockroft – Sure. And then the other component to this — and not only are there many medical things to do to try and prevent a stroke; but there are also surgical procedures or invasive procedures. And that would include — for the carotid disease, which is a very common cause of stroke, doing procedures — either surgery to clean out that artery, or using a stent and an angioplasty balloon to open up the artery. And then, as we talked about, for the hemorrhagic strokes — aneurysms, blood vessel malformations — doing surgical procedures or procedures with catheters inside the blood vessel to fix those problems so that they do not lead to a stroke later on.

Scott Gilbert – Those carotid arteries, we each have — we all have one on each side, right?

Dr. Kevin Cockroft – Yes.

Scott Gilbert – What are signs that I might have issues there and that I should see a physician about that?

Dr. Kevin Cockroft – Well, sort of the screening test for that is even just listening to the artery; and if you hear an abnormal noise, that can suggest that there’s turbulent blood flow, which suggests a narrowing of the artery. And then the more sophisticated tests will determine how exactly narrowed that artery is. Now, at the moment, it’s controversial — if you’ve not had any stroke symptoms if the artery is narrow, whether you should have just medicine, or whether you should have the artery cleaned out. But certainly, if you’ve had a TIA like Dr. Reichwein mentioned; or you’ve had a small stroke and you have narrowing, then those people we know do better with having the artery cleaned out AND taking medicine, rather than just taking medicine alone.

Scott Gilbert – We welcome your questions for Dr. Ray Reichwein, Dr. Kevin Cockroft, here on Ask Us Anything About Stroke from Penn State Health. Here’s a question from Dina [assumed spelling]: She says, “When having symptoms like chest pain and being short of breath, how rapid can that turn into becoming a permanent damage to the heart?” More of a heart question probably than a stroke question, but any insights to share with her?

Dr. Ray Reichwein – I would only say, again, when people have sudden-onset chest pain, and more so if they have any risk factors, you should presume it’s cardiac in origin until proven otherwise; and not ignore it. Seek medical attention, and people have done the same as to strokes — stayed at home, thinking it’s heartburn or something else — musculoskeletal; and found out they had a significant heart attack that nothing could be done about hours or days later. So rarely, I will tell you it’s part of a stroke. You can have pain syndrome, so you can have arm pain and chest pain, generally not in isolation; but also associated with weakness or some other neurological symptom. But the emphasis point I would have to her is it still could be a vascular event, but of the heart; and time is still the relevant feature there; and early evaluation and early intervention.

Dr. Kevin Cockroft – Yes. Just like we talked about with stroke, there are plenty of interventions that could be done acutely or emergently for a heart attack; and again, to get evaluated as soon as possible. It’s going to give you the best options for treatment.

Scott Gilbert – We’re —

Dr. Ray Reichwein – I was going to say, the only other thing — and there are still people out there that think a stroke is in the heart — so again, we want to emphasize, a stroke is of the brain and neurological symptoms; and again, chest pain is often the heart. But I just recently talked to somebody who still thought a stroke was a problem with the heart and not the brain; so we’re talking brain

Scott Gilbert – I’ve heard it referred to as a brain attack.

Dr. Ray Reichwein – I That’s correct. And that, again, focuses on the concern and hopefully, pursuing aggressive care, just like you would pursue for a heart attack.

Dr. Kevin Cockroft – Yes. As we kind of talked a lot about headache, but headache ends up being — a minority of patients actually have that as a strong symptom; so because strokes are not painful, people don’t treat them as emergently as they would a heart attack, where they have this crushing chest pain; and they know they need medical attention right away. With most stroke symptoms not being painful, as we said, you know, a lot of people will think, “Oh, I’ll just go to sleep. It’ll get better.” And they don’t take it as seriously, and that’s the big problem.

Scott Gilbert – We’re talking a bit about risk factors that affect young people; and in fact, about 200,000 people under the age of 65 have a stroke every year. It’s a big misnomer that it’s just older folks who deal with strokes; but in fact, a lot of younger people do — some people in their 20s do. What are some things to keep in mind for people in that age group? I mean — or I should say — the other question I wanted to ask was, the numbers of strokes in that age group are going up. Do we know why?

Dr. Ray Reichwein – So I think a chunk is related to better awareness; so now that people are more aware of what signs and symptoms are, if they seek medical attention, they get imaging — we find the strokes. Before, they ignored them. They were milder. Many people can recover fairly well, and it’s not uncommon for us to find people that have had strokes and ignored the symptoms. So one is just better awareness, better imaging; and now we’re finding things. The second is, despite lots of advances, people don’t have the greatest of diets. With the computer-savvy world, inactivity is more common, and work-related stressors. There’s data out there on stress that contributes; so again, with that being said, many people develop the standard risk factors — high blood pressure, diabetes, cholesterol issues — and then the subsequent blockages in blood vessels that used to be an older person’s disease; and now we can identify that in teenagers and 20s, as compared to before. The other thing is, again, we’re seeing a higher incidence of migraine with aura; and many women are still on birth-control pills, and there is now a more recent association there, particularly focused on women.

Scott Gilbert – A lot of us have heard of migraines. When you say, “migraine with aura,” what does that mean?

Dr. Ray Reichwein – So that’s a neurological symptom, with or without a headache, that we conclude is migraine; and it’s classically a visual symptom for many, to where they notice a flickering or flashing light in one part of their vision. They can move around. It’s called a visual aura. It can be any other symptom, so you can have tingling and numbness that moves up an arm or involves your face; and occasionally, some people can be confused or not able to speak. It can very much look just like a stroke. Probably the key component is it has a gradual evolution, so it tends to evolve over minutes, if you will, as compared to a stroke. Strokes are usually sudden onset — boom; negative, and you have a major deficit.

Scott Gilbert – We have a lot of opportunities for you to learn more about stroke, including as I mentioned, the Medical Minute for this week. It’s on those BE FAST symptoms, and you can find that at pennstatehealthnews.org. Also, coming up on May 15th — that’s Monday, May 15th — there will be a program on WHTM TV — ABC 27 out of Harrisburg — Good Day PA! at 12:30 p.m. The entire program will be dedicated to the topic of stroke. I imagine we will be seeing you guys on TV that day, right?

Dr. Kevin Cockroft – I Yes.

Scott Gilbert – Fantastic. Anything else you want folks to know or to keep in mind as we bring this to a close?

Dr. Kevin Cockroft – I think the most important thing is to be aware of these symptoms; take them seriously if you have them; get medical attention as soon as possible; and then to work on things to prevent. Most of the things that we listed: Risk factors for stroke are actually preventable, so the things you can do something about; and it’s important to, you know, take that seriously and work on it.

Dr. Kevin Cockroft – Sure.

Dr. Ray Reichwein – And then I would emphasize that many of the patients will tell you strokes can be quite disabling and change your lives in seconds; so again, the key is prevent it. Give us the best chance to undo the damage if that’s the case, and hopefully, it will lead to better quality of life down the road and many happy years of life.

Scott Gilbert – Penn State Stroke Center is the only comprehensive stroke center in Central Pennsylvania. Why is that important?

Dr. Kevin Cockroft – So comprehensive stroke center means that we really are able to offer the entire spectrum of care for stroke patients; and that includes being able to offer interventions that we described, using those retriever devices to pull out clots; as well as treating the bleeding types of strokes — aneurysms, blood vessel malformations; not to mention giving the clot-busting drug; taking care of patients all the way through their intensive care unit stay to rehabilitation; and hopefully to a good recovery. And being able to offer these different things, that allows patients to get the best options for making a good recovery.

Scott Gilbert – My thanks to both of you for your time.

Scott Gilbert – One more comment, if I can.

Dr. Ray Reichwein – So we have also our line at the TeleHealth program — TeleStroke program — which we provide acute stroke care via specialized neurosurgeons and neurologists to 15 — and soon to be 16 — hospital systems out there. So we’ve now moved out into our community in all four directions to provide acute care, classically in the emergency department, through computer systems and carts and outside E.D. facilities. And that is also treatments, to where we’re now treating many patients at a distance and providing that same high level of care and giving them a better chance at a better outcome.

Scott Gilbert – Then people can stay in their communities for that treatment.

Dr. Kevin Cockroft – Yes.

Dr. Kevin Cockroft – And get an option to get these drugs that they would not have been able to get otherwise.

Scott Gilbert – Good point. Dr. Ray Reichwein, Dr. Kevin Cockroft; both co-directors of the Penn State Stroke Center, the only comprehensive stroke center here in Central Pennsylvania. We have more information about the Stroke Center and its efforts online at pennstatehealth.org/stroke-center. We’ll put that URL in the comment field as well below this post; and we encourage you to add your questions. We can even track down answers to your questions after this program. And this has been one of our longer Ask Us Anything Abouts for sure; but a lot of great information. Thanks to both of you for the time. Thank you very much for watching Ask Us Anything About Stroke from Penn State Health.

Show Full TranscriptCollapse Transcript

If you're having trouble accessing this content, or would like it in another format, please email Penn State Health Marketing & Communications.