[music playing] Male Voice: Carle combines clinical care,
health insurance, and research in a way that solves problems today, with an eye toward
the future.
Supported by a deep philanthropic spirit, and dedicated to making life better, for as
many as possible.
Rameen: Meeting the ever changing in healthcare needs
of our communities.
Paris Community Hospital/Family Medical Center is now Horizon Health, with the same ownership,
management, providers and employees.
Horizon Health provides patient care and promotes wellness to the communities of East Central
Illinois.
Jeff: At HSHS St. Anthony's Memorial Hospital we
are at work transforming heart care, rebuilding knees and hips, delivering new generations,
and focused on providing healthcare to you.
We are HSHS St. Anthony's Memorial Hospital.
Lori: Sarah Bush Lincoln Health System supporting
healthy lifestyles, eating heart-healthy diet, staying active, managing stress, and regular
checkups are ways of reducing your health risks.
Proper health is important to all at Sarah Bush Lincoln Health System.
Ke'an: Hi.
Thank you so much for joining us on this episode of Being Well.
I'm your host, Ke'an Armstrong.
And today, we are going to be talking about stroke awareness and the latest treatment
options with stroke.
Ke'an: And joining me today are two physicians.
I have Dr. Amrendra Miranpuri, from Carle.
And I have Dr. Joseph Burton, with Sarah Bush.
So, thank you so much, both of you, for joining me today.
Joseph: Thanks for having us.
Ke'an: Yeah.
Amrendra: Thanks for having us, yeah.
Ke'an: So, this is an amazing topic to talk about.
I think a lot of people are interested in this, and learning about stroke, and know
when and how to take a loved one, or what to do if they're suffering themselves.
So, let's just start off with some basics here, like: what is a stroke?
How do we explain it to folks?
Amrendra: Most strokes come in as a blockage in a blood vessel.
So, you'll have a patient come in where they may have a drooping of their face, they may
not be able to get words out.
They might have a weak arm.
And generally, when you see somebody who comes in with an acute, abrupt onset of something
like that, stroke kind of makes it to the top of the list, because if that's not identified
and treated, if possible, patients can have long-term complications from that.
Amrendra: And so, 80% of the strokes that we see present like that, where it's a blockage
of a blood vessel.
A part of the brain is not getting blood flow to it, and so they'll have these types of
manifestations, the facial droop, arm weakness, speech difficulties, problems with their vision
potentially.
Amrendra: The other 20% are bleeding strokes.
So, it's a blood vessel that may have bled into the brain itself.
And those patients will oftentimes present with headaches, nausea, vomiting.
Because of the bleed, they're having some elevated pressure in the brain, and so those
patients require a different treatment course.
Ke'an: So, you're a neurosurgeon with Carle, and you are the medical director of acute
care medicine at Sarah Bush.
So you both work hand-in-hand when it comes to dealing with patients with stroke.
So, we're going to have you talking a little bit more about that portion, what causes a
stroke, what is a stroke.
And then, I want you to talk a little bit about who is at risk, and is it only older
people?
Joseph: Usually, it is.
And it's patients that have underlying comorbidities, or risk factors, such as hypertension, diabetes.
And depending on how well-controlled those disease entities are, that's sometimes what
puts people at higher risk for having strokes.
Joseph: People who have underlying coronary artery disease, or heart disease, are also
at increased risk, because you can have a stroke by a ruptured vessel, or a vessel that
has compromised blood flow.
Or you can have what we call "global hypoperfusion."
So, if your heart doesn't work well, and if you have low blood pressure, or if you go
into shock because of blood loss, or because of an infection, or a heart attack that's
massive, those things can also put you at risk to have a stroke, because of just generalized
decreased blood flow to your brain.
Joseph: And depending upon what part of the brain is affected, that's what determines
how severe the stroke is.
And it also, in determining which vessels are injured, that's what drives the treatment
therapies that we look at in the emergency department, or in any acute setting.
Ke'an: And what's the typical thing that you see?
Does someone bring themselves to the doctor, curious about this and what's happening to
them?
A loved one maybe calls?
What takes place, so the people who are watching this will know maybe what to look for, or
how to notice if something is happening with themselves?
Amrendra: It's variable.
Sometimes, there are witnesses to this happening.
And so, the key with stroke is that it's abrupt.
It's not something that gradually takes time for it to manifest.
So, you might be sitting there at dinner with someone, and all of a sudden, they can't talk,
or they have a facial droop.
And so, that is a red flag that somebody could be having a stroke.
Amrendra: The other situation is where it's unwitnessed, and those are terrifying because
you don't know how long that patient's been sitting on the floor.
Ke'an: Yeah, scary.
Amrendra: Maybe they had a weak leg, weak arm, and they fall to the ground.
And somebody comes upon them, maybe a family member, several hours, or in some cases where
we've seen, a day or two later.
You show up to the apartment, and you see somebody lying there.
So, those patients are obviously much different than the patient where you see it happen before
you.
Ke'an: When they come into the emergency department, time is of the essence, because someone has
really taken heart to seeing, "Hey, something is very wrong here, this may be a stroke."
So, you would be one of the first people who would see that patient coming in?
Joseph: To Dr. Miranpuri's point, there's a group of strokes that occur while people
are sleeping.
Ke'an: Oh, okay.
Joseph: And so, they go to bed, they're normal, they're acting normal, they're talking normal.
And then they wake up and then they have these deficits, and they can't speak, or they can't,
sometimes, get out of bed, or they're having difficulties.
And so, the sentinel indicator is that a family member either finds them still in bed, or
hears them fall in the morning.
Numerous times, we have patients' husbands or wives say, "I got up first, I was fixing
breakfast, and then I heard a thud."
Joseph: And so, currently, and we can talk in more detail about some of this, is that
these patients typically, when they woke up with those symptoms, we considered them out
of the treatment window for certain options in terms of how we treat stroke.
We now have studies that are letting us know that we perhaps have more time than that,
now, and we can actually potentially treat some of these patients that have had these
types of strokes.
Ke'an: Oh, that's good to know.
Joseph: And so, that's probably one of the best pieces of news that we've had in terms
of treatment of stroke.
And those studies have been around for a while longer, but the two studies that came out
at the beginning of, January, February, of this year, are the ones that have brought
more attention to all of this.
Joseph: Dr. Miranpuri has known for quite some time that this treatment option was likely
going to work, but these studies, which he can speak to, are the exciting part of the
treatment.
Ke'an: Oh, okay.
Do you want to expand on that?
Amrendra: Yeah.
So, one of the things that people probably know about a loved one or a friend in the
community is the clot-busting drug TPA.
So, this is a drug that, when patients come into an emergency room, we have in some patients
up to three hours from when they were last known normal, and then in other patients,
up to four and a half hours.
But four and a half hours is the max.
Amrendra: So, if somebody woke up with a stroke, and they went to bed at 11:00 at night, and
it's 7:00 in the morning, they show up to an emergency department.
They are likely not going to be eligible for that clot-busting drug, unless they woke up
in the middle of the night and the family member said, "Yeah, he woke up at 3:00 in
the morning, and they went back to sleep.
And when I saw them at 3:00 in the morning, they were perfectly normal.
But then they went back to bed, and now at 5:00, I saw them not normal."
Amrendra: So, that history is the key to stroke care.
We rely on the witness, because oftentimes the patient can't tell us reliably what's
going on.
And this medication, if you give it outside the time window, you're putting the patient
at risk of having bleeding in the brain.
And it's a clot-busting drug, so it's basically given through an IV, and it finds its way
up to the level of where that blockage is in the blood vessel, and it lyses the clot.
Not in all patients, but in enough to know that that is the standard of care.
So, patients who can get that, it's a wonderful option.
Amrendra: The other patients that, as a neurosurgeon, I get involved with, are the patients that
come in with very severe strokes.
These are the patients who are basically paralyzed on one side, they have a ... They can't speak,
they're looking off to one side.
And these patients, when we study their blood vessels through a scan that we obtain in the
emergency department, we will see that there's a blockage in the largest blood vessel that
supplies the whole half of brain.
And what we know is that that clot-busting drug, because you're giving it through an
IV, it doesn't work as effectively in lysing that clot.
Amrendra: And so, what we've found is that these patients benefit from an intervention,
a procedure, where we take a small catheter, wires, balloons, stents, and we take it through
an artery in the leg, and we navigate it up through the arteries using X-ray and dye,
and then we actually physically remove the clot.
Because it's such a large clot that the clot-busting drug may not work.
Amrendra: Now, that being said, everybody who is eligible for the clot-busting drug
needs to get the drug.
And anybody who is eligible for the procedure to remove the clot physically, with the mechanical
device, needs to get that procedure done.
Amrendra: And what we don't want patients to do is, we don't want patients to sit at
home, thinking that, "Maybe this thing will get better over time."
If it came on suddenly, it's not something that you've ever had before, you've got to
get medical attention right away.
Because now, we do have data that shows that we can go up with catheters and wires, beyond
the four and a half hours that the clot-busting drug can be used for.
We can go up to 24 hours, "last known normal."
That's a phrase that we use in the stroke world.
Amrendra: But again, we don't want somebody at home, sitting there for 24 hours, getting
the message, "Well, I can wait up to 24 hours, because the doctors say that they have this
new procedure, and they can do it that many hours out."
No, we want you to come in, because the sooner, the better.
Ke'an: The sooner the better.
Time is always of the essence, it sounds like, when it's coming to dealing with a stroke.
So don't wait, that's the biggest thing that you want to get across to people: you need
to get treatment right away.
Joseph: The death rate for strokes in third-world countries is much higher than in the United
States, and part of that reason is linked to the fact that people have not been educated
and made aware that you need to hurry up and get to a definitive place for treatment, for
stroke.
And so, those types of patients typically just either stay at home, or don't go see
anybody.
They don't know what's wrong with them.
And then, unfortunately, in those cases, those patients die.
Joseph: So, we still have an uphill battle to fight, in terms of patient awareness, even
within our communities here, because more often than not, we still have patients that
show up, and they basically ... We say, "When did your symptoms start?"
And they say, "Well, it started sometime day before yesterday."
Or, "It started sometime yesterday, in the morning, but I just put it off."
And then we do an exam, and we find out, "Oh my goodness, you've been having a stroke.
But it's too late, you've passed the window for treatment with TPA."
Joseph: What the new studies have done now is opened up the window for treatment for
certain types of strokes.
It's not for all the strokes, and it's only for a small portion of those types of strokes.
But roughly, the literature I was reading was saying maybe somewhere between 10-20%
of the ischemic strokes, perhaps involve large-vessel strokes, that potentially could be treated
by the endovascular intervention that Dr. Miranpuri does.
Ke'an: Okay.
So, lots of different types of strokes, but just be aware of some of the signs and symptoms
that you've mentioned up to this point.
And don't sit around and wait.
If you're not feeling well, or if someone recognizes this, just go to the doctor, don't
wait.
Ke'an: So, let's talk about how you work together, through the treatment, with Carle and Sarah
Bush.
And the stroke rehabilitation, and how you work together for the patient's care.
Either one of you can- Joseph: Let me start.
Ke'an: Okay.
Joseph: Because, when the studies first came out, in January, February, we were, in the
emergency medicine community, we were very excited because the TPA administration for
the treatment of stroke has been controversial.
There has been a group of ED physicians that felt that the studies initially didn't support
giving TPA for strokes.
Then there was groups of physicians that obviously supported it.
And that has gone back and forth.
It used to be, you were at higher risk from a malpractice standpoint, to be sued if you
gave TPA in the treatment of a patient.
Ke'an: Interesting.
Joseph: Currently, fast-forwarding to within the past two, three years, that trend has
reversed: you are now more apt to be litigated against if you did not give TPA for stroke.
But there's still almost a ... I think the study I read was a 17% chance of you being
sued if you gave the TPA, and there was a bad outcome.
Joseph: And so, it is a sensitive area.
And so, when the emergency medicine community read these papers, and we found out that there
was a treatment for stroke that extended the treatment time window, and that potentially
helped stroke patients, even if they didn't qualify for TPA, that was really good news
for us, and also for the patients, obviously.
Joseph: The other thing that I would emphasize is that Sarah Bush emergency department at
hospital is, we have always worked very closely with all the specialists and medical staff
up at Carle.
Because they are the trauma tertiary care center, they are now the tertiary stroke center.
And so, the things that they have offered and we have enjoyed for the past multiple
decades, now, has been immense.
And it's been a good thing for the community, it's been a good thing for the hospital.
Joseph: So, Dr. Miranpuri was actually asked to come down and speak with our medical staff.
How many months ago, two?
Amrendra: It's probably three or four, yeah, three months.
Joseph: Three or four months ago.
Joseph: And so, he presented the information to our entire medical staff, to just make
people cognizant of what the treatment options were for this, and how it's developing.
So, it's getting exciting, because as all of this starts to develop, the standard of
care is also going to change to some degree.
Joseph: So, we've actually even begun to prepare, pre-hospital-wise, how we're going to direct
patients.
Because, when you have a limited resource of treatment, which the neuroendovascular
intervention is currently ... Because I think the only, the next closest neuroendovascular
will be Springfield, currently?
Amrendra: Springfield, yeah.
Joseph: So, obviously, we have to be careful of ... We don't want to send too many cases
that may be false positives to these tertiary centers.
At the same time, we want to get patients there as quickly as possible, and what's best
for the patient.
So, we're trying to now figure out what that balance is.
Joseph: And then I can ... I've been taking over.
Amrendra: And Dr. Burton, he calls me in the middle of the night about a potential case,
we have those images that are being produced at Sarah Bush sent over to Carle immediately.
I open up my laptop, I look at the case.
He and I talk about the patient.
And so, we have a conversation.
Because like he said, we don't want somebody coming from here unless they're going to end
up potentially getting something done.
Amrendra: There are some patients, their stroke is so devastating that we may not be able
to reverse the stroke.
That is always our goal.
Ke'an: To reverse the stroke.
Amrendra: To make them look the way they did before they started having these issues.
Ke'an: Okay.
Amrendra: Okay?
Those are the patients that we really get excited about.
Unfortunately, there are some patients who have very devastating strokes, large hemorrhages
in the brain, a blood clot that's been plugging a blood vessel for so long, that we will not
be able to undo that stroke.
Amrendra: And we still have to care for those patients.
We have to have conversations with patients' families, be able to explain to them what
the next several days, weeks, months, will look like.
And we always want to respect those patients' wishes, using the voice of the family.
Amrendra: It's a very tough thing that we have to deal with on a day-to-day basis, because
there's the joys of reversing the stroke, and then there's the sadness of not being
able to reverse it.
But because some patients, knowing their wishes, would like everything done, we want to get
them through that.
And they know they're going to have some deficits.
Amrendra: And then, being able to try to get them to a rehabilitation facility, to get
them as better as they can get, and still being able to interact with their families.
That's always our goal.
And so, if they come to Carle, we really want to get them back to their community as quick
as possible, so they can be close to their loved ones.
Ke'an: Yeah, absolutely.
I think this is great, that we're talking about putting the patient's wellbeing, their
health, above anything else.
And you're working together.
Is this something that is unique, because we're in a rural area?
Or is this just the way things are merging these days?
Joseph: I'd say probably a little bit of both.
But I'd say the fact that we are a rural community medicine scenario, that leads to several challenges
that, if you're in an urban area, you don't have to worry about.
There's more limited resources.
The distance to definitive treatment is longer, and depending on what the weather is like.
We've had snowstorms where we've had critical patients that we couldn't even get out of
Sarah Bush's emergency department sometimes, because of that.
And so, again, you have special circumstances that other places don't face, because they're
not in a rural area.
Joseph: But again, having a good working relationship, and good lines of communication, information.
Now, going to Carle for CT scan results, and things like this.
When I first started at Sarah Bush, if I did a CAT scan at Sarah Bush, that study wasn't
accessible by the Carle docs.
Ke'an: How closely related are heart disease and stroke?
Joseph: First off, they're related because of, like I spoke to earlier, if you have a
bad heart attack or if you have poor cardiac function, that can lead to low blood pressure
states, which can then put you at higher risk for strokes just because your perfusion of
your brain is not as good as a normal person, with normal blood pressure.
Joseph: Secondarily, if you have certain types of cardiac dysfunction, such as atrial fibrillation,
that can set you up to form clots in the chambers of your heart.
And if you have those clots, sometimes those clots can break off, and embolize, and cause
embolic strokes.
And so, that's a subset of ischemic stroke.
Joseph: Whenever someone has heart disease, it de increases your chances for stroke.
And so, in terms of preventive medicine, and preventive things, if you eat right, if you
control your blood pressure well, your diabetes well, those things all decreases your chance
for heart disease, and thereby also decreases your chances for stroke.
Ke'an: All right.
Would you like to follow up with that?
Amrendra: There's just a lot of corollaries between heart disease and strokes, like Dr.
Burton highlighted: high blood pressure, cholesterol, diabetes, smoking.
And we see, even patients who have blockages in blood vessels in their legs, and there's
kind of this trifecta, where you have patients who may be at risk for stroke, be at risk
for heart attack, be at risk for having blood clots in their leg arteries, where they're
having pain when they're walking.
So, this is all in a spectrum that's common between these, what we call "vascular diseases."
Ke'an: It is very important to get this education and awareness out.
It's critical to let people know the timeliness of what is important.
And so, to wrap up the program here, we've got a couple of minutes left.
What would you like to let people know, on what's most critical here?
Joseph: I would emphasize the need that, if you think that you're having a stroke, if
you're a family member or if you're the patient -- it's difficult if you're the patient, but
-- you need to get to see a physician as soon as possible.
That would be the number one message that I would deliver.
Ke'an: Okay.
Amrendra: We just had stroke awareness month, and the thing that we were blasting out into
the community was this acronym that a lot of people now know, actually, is FAST.
It's very simple.
FAST is F-A-S-T.
Amrendra: F is for Face: so, if you see somebody, or yourself, having asymmetry in your face
that comes on all of a sudden.
A is Arm: the arm gets weak all of a sudden.
S is Speech: you're not able to get your words out.
And T is Time to get help.
So, if you have those three things, or any one of those three things happening, and that's
not normal for you, you need to get attention.
Amrendra: And that T is, they'll show an ambulance on there.
But the key there is, you're not calling your primary care doctor at 5:00 at night, hoping
they're still there.
You're not ... If you can't move your right side, you're not trying to get through, get
into the car, and try to struggle into the ED.
You want to call 911.
And if you see somebody having these problems, you want to focus on that person, and you
really want to help get them to definitive care, and not second-guess yourself.
Ke'an: So, don't drive them, call 911?
Amrendra: Yep.
Ke'an: All right.
It's been great, listening to all this education, the new updates.
Great information for our viewers out there.
So thank you so much for being a part of Being Well, today.
Joseph: You're welcome.
Amrendra: Thanks for having us.
Ke'an: Thank you.
And thank you so much for watching this episode of Being Well.
We hope you have learned about stroke awareness.
So, don't wait, make that call, and get yourself treatment.
If you need more information about this program, visit our website, WEIU.net, and click on
Being Well.
Thanks for watching.
Lori: Sarah Bush Lincoln Health System supporting
healthy lifestyles, eating heart-healthy diet, staying active, managing stress, and regular
checkups are ways of reducing your health risks.
Proper health is important to all at Sarah Bush Lincoln Health System.
Rameen: Meeting the ever changing in healthcare needs
of our communities.
Paris Community Hospital/Family Medical Center is now Horizon Health, with the same ownership,
management, providers and employees.
Horizon Health provides patient care and promotes wellness to the communities of East Central
Illinois.
Jeff: At HSHS St. Anthony's Memorial Hospital we
are at work transforming heart care, rebuilding knees and hips, delivering new generations,
and focused on providing healthcare to you.
We are HSHS St. Anthony's Memorial Hospital.
Male Voice: Carle combines clinical care, health insurance, and research in a way that
solves problems today, with an eye toward the future.
Supported by a deep philanthropic spirit, and dedicated to making life better, for as
many as possible.
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