Search for tag: "stroke signs"

Interviewer: We all know that a stroke is a serious and potentially life-threatening situation, but it might surprise you that it impacts women more than men. According to the CDC, stroke is the fifth leading cause of death for women in the U.S., and as many as one in five women between the ages of 55 and 75 will have a stroke.

To help us better understand why women face an increased risk of stroke, were joined by Dr. Jana Wold, an associate professor of neurology and a stroke specialist at University of Utah Health.

Dr. Wold, let's start out with why are women at more risk of stroke than men?

Dr. Wold: So the best way to understand it is because women live longer than men and because stroke risk increases with age. So because we have a larger proportion of the population in this older age group, the greater-than-85-years-old age group that are women, and also that's when your stroke risk really ramps up, overall more women have strokes than men.

Interviewer: So I'm hearing that more older women might have strokes than men. What about younger women?

Dr. Wold: Unfortunately, there is a risk of stroke in pregnancy. So, at a younger age, there also is a brief period of time when women are of childbearing age that their stroke risk could be higher than some men.

Interviewer: Yeah. And that is very unique, childbearing, to women obviously. What are some other risk factors that are very unique to women versus men?

Dr. Wold: Yeah. So women take oral contraceptives. Not all women, but some women do. And those medications, unfortunately, do carry a small risk of stroke. So in the wide scheme of things, it's a very small risk.

And women who take oral contraceptives tend to be women younger than the age of 50, so their overall risk of stroke is low, but if you are taking oral contraceptives, that can double your stroke risk. And if you are smoking while you are taking your oral contraceptives, that can dramatically increase your stroke risk.

Also, in speaking of oral contraceptives, oral contraceptives should not be given to women who have migraine with aura because that also increases your stroke risk, because migraine with aura independently increases your stroke risk.

Hormone replacement therapy. So if you are taking hormone replacement therapy for a long period of time, this also can increase your risk of stroke. There was a time many years ago when we thought maybe taking hormone replacement could actually decrease your risk of stroke, and that is not true.

The other important thing that I haven't mentioned yet — atrial fibrillation. So atrial fibrillation carries a high risk of stroke. It is uncommon in the younger population, but as you age, your risk for atrial fibrillation increases. And it's actually riskier for women to have atrial fibrillation than it is for men when you consider their stroke risk. So atrial fibrillation, you can be screened for this in your doctor's office when you are above the age of 75.

Interviewer: So if a woman's listening and she recognized some of these increased risk factors, does that mean that perhaps hormone therapy is not a great idea, birth control is not a great idea? How can a woman weigh the risk versus the benefits of those things?

Dr. Wold: Yes, absolutely. So this is where your primary care doctor comes into play. Everyone should have a primary care doctor whether or not you're a woman or a man, and you need to discuss this with your primary care doctor.

So, for example, if you are a young woman and you're considering going on oral contraceptives, you need to make sure that your physician is aware if you suffer from migraine with aura or if you are a current smoker or if you have high blood pressure. So you need to be in good communication with your primary care physician to make sure that they are also considering your overall risk of stroke.

When it comes to hormone replacement therapy, again, I would have a conversation with your primary care physician or whichever physician would be prescribing this treatment for you. And you would just need to understand the risks and the benefits, because it's going to be different for different women.

Interviewer: And I understand that women sometimes don't experience the standard stroke symptoms. What are those standard symptoms?

Dr. Wold: Yeah. So the standard stroke symptoms, the way we like to remember them is an acronym known as FAST. This stands for face, arm, speech, time.

Face is for that facial asymmetry that you were speaking of before. So if your face is droopy on one side, that can be a symptom of stroke.

Also, if you have one arm that is weak, that can be a symptom of stroke.

And then if you have a change in your speech, that can be a symptom of stroke as well.

The T is for time, because if you notice any of those symptoms, you need to immediately call 911 and go to the emergency room to be evaluated.

Interviewer: And those standard symptoms, those aren't necessarily always the way women experience stroke symptoms. Can you expand on that?

Dr. Wold: Not necessarily. There are some studies showing that women are more likely to have atypical symptoms of stroke, but it's not clearly defined what those would be. So, overall, I would say when you experience any sort of acute change in your vision or your speech or your strength or your walking, that's when you need to consider stroke.

Interviewer: And are there other risk factors that women would want to keep in mind?

Dr. Wold: I would just consider changes in those areas. And a lot of women, also men, like to call their neighbor, call their son, call their daughter. I would encourage you to call 911 when you notice those symptoms.

Interviewer: Right. Because the tricky thing about stroke is it can kind of trick you, can't it?

Dr. Wold: It can. And the medications that we can provide in the emergency room, there's one medication and it's time sensitive, so you need to get to the emergency room very quickly.

Interviewer: Dr. Wold, in your experience, what are some of the misconceptions that you find that people have when it comes to women and stroke?

Dr. Wold: I think a misconception can be that there's nothing that you can do about your risk for stroke, and because the risk of stroke increases as you age, that it sort of is just inevitable, and that once you have a stroke, then you need to try to prevent the second one. But we as stroke physicians would certainly like people to be interested in preventing that first stroke, which you certainly can do.

Interviewer: If there's a woman listening and she might be worried now about her risk of stroke, what takeaway message would you give to them?

Dr. Wold: The takeaway message would be to know what your independent risk is for stroke, and so to consider if you have high blood pressure. If you have high blood pressure, you need to be under the care of a physician. You need to have it properly treated. And if you are a smoker, you should consider stopping smoking.

The other thing that you can do as far as lifestyle measures are concerned is to exercise regularly, and we mean cardiovascular exercise, and also keep a healthy diet that is high in fruits and vegetables.

Amy: This is Amy Steinbrech talking with Dr. Steven Edgley, the director of stroke rehabilitation at the University of Utah Health Care.

Dr. Edgley, thank you for joining me so much in studio for a podcast on stroke recovery.

Dr. Edgley: My pleasure.

Amy: Every year, more than 795,000 people in the United States suffer a stroke. Strokes are becoming more common among young adults in the prime of their life. I'm wondering if you could tell me a little bit about stroke recovery process in the young stroke survivor.

Dr. Edgley: It's true that about 10% of stroke patients are under the age of 50. This population represents a special population in terms of the unique challenges they face that are generally in the crux of their career and raising families, and this life event is very hard for most people. I find that all stroke patients who have a loss of function, they go through certain stages of mourning or loss.
We talk about the Kubler-Ross stages of mourning, which entails denial, bargaining, things like anger, and, ultimately, acceptance. I find that especially in the young stroke patient, meaning younger than, say, 50, these patients need to be guided towards things that will improve their chances for recovery before they reach the level of acceptance. Oftentimes stroke patients don't fully realize their own potential.

Amy: So this is somewhat pushing the stroke patient to their potential and making them realize their potential?

Dr. Edgley: Exactly. It takes a lot of guidance and someone actually, a whole team of people to guide them through the barriers that they encounter, medical, physical, emotional, everything.

Amy: Right. So I guess one way to look at a stroke is it's a process from beginning to end. Stroke recovery is truly a process.

Dr. Edgley: That's exactly right. A process that takes a lot of support. For many people that are young, they have the potential to get back to high level things like driving, or returning to work. They just need a little guidance and the resources and a team of people to help them along.

Amy: Young adults are often faced with this different set of circumstances than elderly stroke patients. They have a long life expectancy in front of them.

Dr. Edgley: I think it's critical to set the patient on the right course for their next future decades. And getting them set up with the things that will truly provide quality of life, like being able to access the community, like being able to recreate and like being able to form meaningful relationships with friends and family. And for some people, like being able to return to their former employment, or at least do some service, activities, which is helpful to their overall quality of life.

Amy: Remaining engaged with community and family I'm sure is a big part of that.

Dr. Edgley: Yes. Yes.

Amy: How do young patients sell themselves short oftentimes?

Dr. Edgley: You know, when patients have a stroke, it's a really traumatic life event. They probably don't see their friends and family going through and succeeding without the process of recovery. They don't know what to expect. They don't know how to get themselves out of this black pit. I think many patients come to a certain level of comfort and realize that things will be okay in their life in terms of their basic needs, but don't really have an idea what to reach for. Many times the limits of people are limits that they put on themselves.

Amy: Self imposed. Yeah.

Dr. Edgley: Now, that's not to say that every stroke patient has the potential to get that back to 100%, the way their life was in the past. Certainly reaching and striving to get as much quality of life, and be as independent in the community is really important.

Amy: Recognizing your potential.

Dr. Edgley: Yes.

Amy: Have you experienced other people putting limits on stroke patients?

Dr. Edgley: I do see occasionally some people around the stroke patient who, based on misinformation, have some assumptions what the stroke patient's potential is. We commonly deal with this in therapy. For example, the patient's family member tries to do everything for the patient without giving them the chance to learn how to do the activities themselves. That's a common occurrence, and a simple matter of just educating the family members to let's try to promote as much independence as possible. And the way to do that is you learn by doing.

Amy: Right. Most often finding that balance, that perfect balance between independence and dependence.

Dr. Edgley: Yes.

Amy: What are some of the barriers, Dr. Edgley, do young stroke patients face in recognizing their potential?

Dr. Edgley: I would say, again, a stroke is a major life event and it requires a major life adjustment. Some people are able to adjust better than others on their own.

Amy: Right.

Dr. Edgley: Most people are able to adjust more effectively with a broad network of support, including family, friends, and rehab specialists. With time we like to promote higher level goals, like return to work if possible. For that to occur, you have generally got to have a supportive employer who is willing to take a chance. Stroke patients have the potential to be superb employees.

Amy: Dr. Edgley, what advice or tips do you have for the young stroke patient?

Dr. Edgley: Accept yourself and where you are. But don't accept the limitations that you perceive or that other people put on you.

updated: April 7, 2021
originally published: December 10, 2014

Dr. Miller: How to get your strut back after a stroke. That's next on Scope Radio.

Hi, I'm here today with Dr. Stephen Edgley. He is an associate professor in the department of physical medicine and rehabilitation in the University of Utah. Steve, a patient has had a stroke and is having difficulty walking. What do they need to do, to be able to get back on their feet again and get around?

Dr. Edgley: This is an extremely critical point that so many patients, months in, actually years in, after struggling with a stroke. The typical stroke patients are by and large...

Dr. Miller: Now, we are talking about a stroke patient where one side of the body, one leg is affected. Am I right about thinking that?

Dr. Edgley: Usually.

Dr. Miller: Usually, Okay. It's not usually both, it's in one side.

Dr. Edgley: So usually one side is weak. I'm going to stress how the importance of being as active as possible and this carries huge health consequences. We know that the insistence of heart disease, diabetes, major risk factors can actually lead to death is much greater when you're inactive.

Dr. Miller: Getting back on your feet is important for more than one reason.

Dr. Edgley: Yes, also the quality of life reasons being able to [inaudible 00:01:46] the community is also an important factor. We have a lot of research that clearly shows that if a stroke patient is able to achieve a good speed, walking speed of just 1.8 miles per hour, they will most likely an predictably be able to ask us the community, walking in the community rather than just walking and hobbling around the home.

Dr. Miller: So the need to do the physical therapy is one thing but these patients also have not just weakness sometimes but pain, spasticity of the affected side. Is that right Steve?

Dr. Edgley: Yes, That's another critical point. These patients typically need an intervention by a specialist in rehab to overcome the barriers to achieve better walking speed. Those barriers are typically things like spasticity of muscle tying their leg up, inhibiting fast walking. Things like pain and low endurance.

Dr. Miller: How often would pain occur in someone with a stroke?

Dr. Edgley: Well it depends, pain syndromes are typically exacerbated by the hemiparetic gait. So the gait mechanics being a little all off counter leads patients be more susceptible to common things like joint arthritis. There are some specific pain syndromes that occur as a result of stroke sometimes.

Dr. Miller: I would guess that the post-stroke patient who has suffered weakness to the leg is not getting this team approach that the physiatrist supplies, that their recovery is going to be delayed or really impaired.

Dr. Edgley: I see patients that have gone on for years being restricted to the home environment with little intervention and attention to these barriers can often achieve great results even to the extent of a much greater quality of life.

Dr. Miller: So what are the barriers to maybe walking faster than the 1.8 miles an hour. Can they eventually build up to a pace that is faster than that?

Dr. Edgley: Well, it depends on a lot of variables. We approach it like this, first try to break down as many barriers to walking speed as possible. And then get them into an aggressive physical therapy program. And then reevaluate the situation.

Typically if the patient can walk a limited distance at home, we can influence the situation to enable the patient to be somewhat effective at walking in the community by breaking down these barriers in a more specialized and team-oriented therapy approach.

Dr. Miller: So a patient with this stroke problem where they can't walk, once they get into therapy are we actually teaching another part of the brain to help take over?

Dr. Edgley: Often we are, the brain has significant potential to do, adapt, and change, even years after a stroke. What we are really doing in therapy, especially months and years after, a stroke is trying to capitalize on the brain's ability to be plastic and adapt. Teaching them the [inaudible 00:06:23] strategies for faster walking and more functional movement.

Dr. Miller: So, it's not just the walking? What you pointed out, is that patients after a stroke, who walk, are able to get going. As opposed to those who don't, do better in the long run, live better, and live healthier. It seems like such a simple thing, yet it has remarkable consequences.

Dr. Edgley: Indeed, it is an extremely critical and some people we now consider walking speed to be the fifth vital sign. It's something we measure in our clinic as an objective measure of how they're doing overall and how they're doing physically.

updated: July 15, 2020
originally published: August 5, 2014

Dr. Miller: Atrial fibrillation and stroke, are they related and can it be treated? Today on Scope radio, this is Dr. Tom Miller.

Narrator: Medical news and research from University Utah physicians and specials you can use for a happier, healthier life. You are listening to the Scope.

Dr. Miller: I am here today with Dr. Dana DeWitt. She is a professor in neurology and a stroke specialist in the University of Utah, the department of Neurology. Dana, tell us a little bit but atrial fibrillation, what is it and does it lead to stroke? Can it cause stroke?

Dr. DeWitt: Atrial fibrillation is an irregular heartbeat. It causes a portion of the heart, called atrium to contract in a very irregular manner and when that happens, clot can form in that portion of the heart and break off and go up to the brain and cause a stroke. It is clearly a major risk factor for stroke.

Dr. Miller: Atrial fibrillation, in my experience, is more common in older patients and older people, and sometimes goes unnoticed. Many times its picked up on a routine physical and sometimes in E.K.G. or patients who complain of palpitations which when you look into it, turns out to be atrial fibrillation. The issue that I have is, in telling the patient, well it's not just this irregular heart rhythm but you might have a stroke down the road if we don't take care of this. In your experience, how many of these strokes that you see, when they come in through the emergency room due to atrial fibrillation.

Dr. DeWitt: It's a fairly large proportion, probably a quarter at least. The hard part is that in many cases, patients will come in and having had a stroke, not have atrial fibrillation at the time so the atrial fibrillation can be intermittent and can sometimes be difficult to detect.

Dr. Miller: How do we detect for atrial fibrillation nowadays? What's the best way?

Dr. DeWitt: When the patient comes in and he has had a stroke, they are usually in a hospital with a cardiac monitor that watches their heart rhythm during that hospitalization. The problem is that the atrial fibrillation may not be detected during that time and so we may recommend, what we call the 30 day event monitor, which is an E.K.G. monitor that they wear for 30 days. There are also things that are called loop recorders which are these very small implantable devices that are M.R.I. compatible and they are put in by the cardiologist just over the heart with a very minor office procedure, and it monitors your heart over time.

Dr. Miller: So potentially, it can pick up intermit atrial fibrillation.

Dr. DeWitt: Exactly, which carries a high risk of stroke.

Dr. Miller: Now, many of our patients and public know that to prevent a stroke, you take an aspirin a day. Does that work to prevent stroke in atrial fibrillation?

Dr. DeWitt: It has not proven to be effective enough in patients with atrial fibrillation. The best treatment are blood thinners, and now blood thinners come in two different forms. There is a drug called Warfarin which is being used for many, many years.

Dr. Miller: That's rat poison. Isn't it?

Dr. DeWitt: It is rat poison and it is the primary treatment for atrial fibrillation to prevent stroke. The problem with warfarin is, that it requires regular blood test monitoring. There are some dietary interactions like green leafy vegetables that have to be regulated.

Dr. Miller: Antibiotics, if you take antibiotics, seizure drugs.

Dr. DeWitt: Antibiotics, drugs for seizure. There are many interactions and you have to blood test regularly to make sure your dosing is correct. If your dosing is too low then it doesn't protect you, if your dosing is too high, it could cause hemorrhage and this actually leads to a lot of fear sometimes, in not treating patients who are either elderly or might be falling.

Dr. Miller: Or who can't get their testing.

Dr. DeWitt: Who can't get their test done?

Dr. Miller: I know a number of physicians who are uncomfortable treating atrial fibrillation with warfarin. Just because of it narrow window of therapy [inaudible 00:04:00]. That's a big deal, that's a problem. If you have a team of experts, and many times those are pharmacists who take on that monitoring, that's a pretty good way to assure that the patient remains within the therapeutic window. We, at the University of Utah, taken that out of the hands of the physicians if they want us to and monitor that through our [inaudible 00:04:21], and that's have been a very effective way to manage warfarin. Warfarin is not expensive but the monitoring is key. Would you say that's true?

Dr. DeWitt: Absolutely. I tell patients who are on warfarin, the important things is really getting their blood test regularly. There are three new oral agents that have been shown to be effective for treating atrial fibrillation.

Dr. Miller: They are pricey, aren't they?

Dr. DeWitt: They are very pricey because they have a standard dosing and you don't need to do blood test. They have been a bit attractive. The problem is that, a lot of times, the patients are not able to be monitored as well if they do have a stroke, so they may not be a candidate for a thrombolytic agent. In many cases, we just don't feel totally comfortable with them as we are with warfarin in many cases.

Dr. Miller: The problem that I have in practice is, either the cost of neural medication is too much for the older person to afford or the fact that they have to be able to come in for testing and monitoring on a regular basis, whether it's by myself or a team. So there are pluses and minuses with each type of treatment.

Dr. DeWitt: I think the important thing though is that we know that atrial fibrillation is a big factor in stroke. In many cases, it's not just the monitoring but the impression, because the patients are getting older or because they are a little unsteady on their feet, that they shouldn't be treated with anti-coagulation and unfortunately, we are the ones who see those patients come into the hospitals with their big strokes.

Dr. Miller: And aspirin is not enough.

Dr. DeWitt: Aspirin is not enough.

Dr. Miller: Dana, final thoughts?

Dr. DeWitt: Well, I think the important thing is that, with strokes of certain types we suspect clot form the heart and even if we don't pick up atrial fibrillation, I think it's important to monitor the heart and keep looking for it and treat it appropriately.

Announcer: We are your daily does of science, conversation, medicine. This is the Scope, University of Utah Health Scientist Radio.

Dr. Miller: You have had a stroke. How did that happen and how to prevent that from happening again in the future. I am here today with Dr. Dana DeWitt. She is a professor in neurology and a stroke specialist in the University of Utah, the department of neurology. Tell us a little bit about why people have strokes. You have had a stroke, what causes a stroke?

Dr. DeWitt: There are different causes of stroke and it's important that when you have a stroke, to be evaluated by someone who helps determine why it happened. A stroke can occur from a clot coming from the heart, it can occur from a clot coming from one of the arteries in your neck or it can occur because you either have a blood vessel in brain break, or a small blood vessel in the brain close off.

Dr. Miller: But the results, are many times, the same. Is that right?

Dr. DeWitt: Yes.

Dr. Miller: Debilitating problems.

Dr. DeWitt: Debilitating problems, focal deficits, often they don't recover.

Dr. Miller: So Dana, tell me a little bit about the causes behind those embolic, those pieces of tissues that break off or vessels that bruise. What are the main things that cause that to happen? Lifestyle things that might cause another stroke in a patient?

Dr. DeWitt: So, we well know that smoking is one of the major causes of hardening of the arteries and high blood pressure. It's a major risk factor for stroke. We know that high blood pressure is also a big risk factor for stroke. High blood pressure can cause blood vessels in brain to thicken, it can be one of the causes for [inaudible 00:01:35] and can also cause heart disease. And then we know that cardiac conditions, people who have had heart attacks, whose heart doesn't pump normally and then there is the irregular heart beat called atrial fibrillation which carries a high risk of stroke. And that's when a certain part of the heart called the atrium, actually becomes a little stretched and fibrillates and clog can form in the heart.

Dr. Miller: What about age? Is age related to stroke?

Dr. DeWitt: Well, we know well that as people get older, the risk of stroke is greater. We also do see in young people on occasion, sometimes that can be due to hyper-coagulable or clotting [inaudible 00:02:15] problems or something called dissection in blood vessels or tears in blood vessels, but the major strokes occur in older patients

Dr. Miller: Men and women about the same?

Dr. DeWitt: There is a high risk of stroke in men. Then again cause of stroke in women is a little different except if the women was a smoker and had hyper tension and high cholesterol for years, then her risk is the same.

Dr. Miller: So now I am assuming that if you had a stroke, your risk of having another stroke is higher, higher than the average population risk. Is that true?

Dr. DeWitt: It is. Evaluating those patients is why that's so important. There is also something called a TIA, which is really transient ischemic which is a stroke like event, presumed caused by the same thing that causes a stroke but it clears quickly, and patients then are also at risk for stroke within a short period of time. So it's an important thing for a doctor to evaluate you for your blood pressure. If you are a smoker, you need to stop smoking. You need to know what your cholesterol is and treat your cholesterol, and you need to have your heart evaluated to see if you might have atrial fibrillation or some other cardiac risk?

Dr. Miller: It's true. I think that many people that have atrial fibrillation may not know that.

Dr. DeWitt: That's very true. Atrial fibrillation, we are founding more and more about it but it maybe that atrial fibrillation actually isn't seen at the time that the stroke occurs. It may actually be found later and there are now methods, 30 day monitors or what we call loop recorders, which are implantable recorders that watch over a heart for a long period of time to see if atrial fibrillation occurs. Heart ultrasound, called an echo cardiogram can sometimes tell us if the heart is abnormal in a way that can put patient at risk for atrial fibrillation. It's very important because the treatment is...

Dr. Miller: And those work better to reduce the risk of stroke in the future than aspirins?

Dr. DeWitt: Yes. For atrial fibrillation, absolutely. So it is important to know whether that occurs and whether that needs to be treated in that way.

Dr. Miller: let me ask you a couple of other questions. How about the IBTs, is there a risk of stroke [inaudible 00:04:25] which is diabetes?

Dr. DeWitt: There is a risk of stroke with diabetes. Diabetes is part on the blood vessels and it can promote more atherosclerosis. It also causes damage to very small blood vessels which can cause small deep strokes. We know that patients with diabetes sometimes get damage to the arteries and their retina, in their eye, and also in their kidneys. So the same process can happen in the brain and cause strokes.

Dr. Miller: How about just obesity in general. People who are not in very good shape, they are overweight, they are not working out much.

Dr. DeWitt: That carries a risk as well. Metabolic syndrome, we know, is kind of a pre diabetic condition but patients who are obese are also more prone to high blood pressure. They are more prone to high cholesterol and those carry risk of stroke.

Dr. Miller: It sounds to me like high blood pressure, diabetes, possible cardiac functions if your heart is pumping well or not and an abnormal rhythm in the heart could all contribute to second stroke. So, what would you say to the person out there that has had a stroke or had a family member with a stroke? Do you think that many of them know their risk factors or they should really be aggressive in trying to find out if those problems we just mentioned are high risk factors?

Dr. DeWitt: I think that's extremely important. We talk about primary stroke prevention versus secondary stroke prevention. One is, to know your risk factors so that the stroke never happens and you treat them aggressively. The other is, once you have a stroke, know why the stroke occurred so that you can prevent another one by again, controlling those risk factors. And again, those risk factors really are high blood pressure, smoking, high cholesterol, diabetes and then obesity and inactivity carry another risk. Mainly because they promote the other problems.

updated: January 15, 2021
originally published: July 15, 2014

Announcer: Medical News and Research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to the Scope.

Interviewer: If a patient has a stroke, the quicker a specialist could see that patient can often times make a huge difference in the outcome afterwards. What do you do if there is not a specialist around? It's called "Telestroke". We're going to learn more about it right now from Dr. David Renner. He's a University of Utah neurologist, also practices at St. Johns Medical Center in Jackson Hole, Wyoming. So the fact that you could actually diagnose a stroke victim by a video phone call leads me to believe that a lot of what you do is a visual diagnosis and not necessarily instruments or other technology.

Dr. David Renner: When we speak to a patient we really are getting a large understanding of what their neurologic examination is like. Just visualizing their movements when I'm speaking to them, tells me almost as much as performing a physical exam on them.

Interviewer: Really?

Dr. David Renner: When you can hear and see the patients, even if you can't touch them, you can almost always arrive at the correct medical decision.

Interviewer: Is it a challenge seeing them on a computer screen versus real life? I mean, is there some kind of loss there?

Dr. David Renner: No, not really. I've been practicing vascular neurology for 13 years now. Pretty quickly you can you can understand exactly what you've got to go to on your neurologic examination to make the decisions you need to.

Interviewer: What specifically are you looking for when you are speaking with them?

Dr. David Renner: First of all, as I'm speaking to the patient, try to understand if the left or the right brain is involved. Then, I try to make an understanding of whether the front of the brain or the back of the brain is involved. At that point, I try to identify which of four major blood vessels would be involved in this patient's neurological syndrome.

Interviewer: Do you have certain questions you ask? This is my left brain question, this is my right brain question. Left Side Stroke

Interviewer: And is that left or right?

Dr. David Renner: That's left brain. That's asking them questions, like, repeat after me say the "Queen lives in England. If she we're here I would go, no if's, and's, or but's about it". That last sentence, "no if's, and's, or but's about it" is a very sensitive sentence that allows one to assess whether or not the left brain has been affected by stroke.

Interviewer: Okay, then what do you do for the right brain?

Dr. David Renner: The right brain is a lot more difficult. This is, actually, a good example of why telemedicine is a wonderful option for the emergency room. It's because a lot of right brain strokes can be missed. Physical examination is absolutely helpful when trying to identify a right brain lesion.

Interviewer: Okay, what about rear and front, since we're talking about this?

Dr. David Renner: Front and back, well, the back of the brain holds the high priced real estate in the brain and that's the stuff you can't afford to lose. If I thought that this person was having one of their two vessels in the back of their brain involved, I would immediately dispatch a fixed wing to fly them to Salt Lake City if there was something that we could do endovascularly. So, this brings another really important concept up and that is that stroke treatment does not only involve just clot busting medications, but now we can take little catheters and go up into the brain and we can do angioplasty, which is opening up a narrowing and we can do stinting, which is placing a little metal tube to keep the artery open. We do other, even more complicated vascular procedures, but we make a decision immediately when we see a patient on the Telestroke unit as to whether or not we should fly them in immediately for an intravascular procedure.

Interviewer: What are the back brain questions or what are you looking for there?

Dr. David Renner: Well, those are the things you can usually pick out fairly quickly when a person has eyes that don't move together, when they have subtle facial numbness, when they have subtle facial weakness, slurring speech, unprovoked loss of consciousness where they come back to consciousness right away, spinning vertigo, and subtle signs of weakness on one side of their body with sensory changes on the opposite side of their body. Those are all classic features of back of the brain strokes.

Interviewer: And let's cover the front, what are the questions there?

Dr. David Renner: The front of the brain would be, would usually produce symptoms like weakness of the face and arm more so than the leg or difficulty generating language and not being able to come up with the right word.

Interviewer: Any final thoughts?

Dr. David Renner: The most important thing to remember about stroke is, if you think that you're having acute neurological symptoms of stroke you must get to the emergency room as fast as you can. You should not think about it, you need to call 911 and get there immediately so that way we can start treatment and hopefully open up the artery that might be blocked and give you back all the function that is being taken away from you. Every minute that you wait you lose millions and millions of cells in your brain.

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Interviewer: First he had a heart attack, then he had a stroke.
We're here with Dr. Troy Madsen from the University of Utah Hospital and Emergency Medicine, and the question is, "Is it common after heart failure to then go on to have a stroke like in Randy Travis' case?"

Dr. Troy Madsen: Well, you know with Randy Travis it's hard to know exactly what happened there. Obviously they protect a lot of that health information so they're not going to release a lot of details. But from what I understand he had heart failure, then they did a procedure to try and help his heart out because he was in such serious condition, and then he had a stroke.
So in terms of what happened, he may have had a stroke somehow related to the heart failure or it may have been a complication of the surgery. And both of those are things that we do see, not on a very regular basis, but we do see here and there.

Interviewer: And what exactly is a stroke from a medical standpoint? What's going on there?

Dr. Troy Madsen: Another way to think of a stroke is as a brain attack. We think of heart attacks. We think of a blood clot causing decreased flow to the heart. Same thing happens to the brain, exactly the same thing. You have the arteries that feed the brain, that give the brain the oxygen it needs to work. If something gets lodged in there, either it breaks off from somewhere else in the body, or it just builds up in that artery that feeds the brain, then you have a stroke. You have decreased blood flow to the brain that causes problems.
So in terms of what we can take away from this for ourselves, you have to watch out for strokes in yourself and other people. So the big things to watch for are numbness or weakness generally on one side of the body, difficulty speaking, confusion, difficulty walking. Those are all signs of a stroke and if someone has these symptoms call 911 because if we get to you early enough, if we can get you in the ER and get you the treatment you need, we can oftentimes reverse those symptoms and spare the brain and make sure you're going to be back to normal or at least back to pretty good functioning.

Interviewer: I've heard just recently that literally every minute counts when it comes to a stroke as far as getting that patient seen and some sort of treatment started.

Dr. Troy Madsen: Yes, every minute counts in terms of trying to get people the help they need. There's actually just a study that just came out this last month. It looked exactly at that. It looked at how much time from the patient's symptoms until they got the treatment. They found the sooner they got that treatment the better off they were, the lower the risk of complications.