 Hello and welcome. I'm Kushboo and you're watching Health Mantra. Today we are here with two very special doctors. Today's episode aims at helping you diagnose the early signs of a stroke. Stroke that is something that takes maximum lives in India or at least it leaves you disabled. Here when we have these doctors, we get to learn more, maybe we'll be able to help someone around us while they are experiencing some signs of this. So let's get to know the doctors first. To help us understand better here today, we have Dr. Saffal Shetty. Dr. Saffal Shetty is a consultant in neurology and Dr. Charodha Sambhaji. Dr. Charodha is a consultant in interventional neuroradiology. First of all, doctor, as we speak of a stroke, what exactly is a stroke and how can one identify or diagnose it? Stroke is, first of all, a medical emergency. Stroke is a condition where a person doesn't get enough blood supply to the brain. So blood supply gets completely cut off either because there is a block in the blood vessel which is going towards the brain from the heart or there is a rupture of the blood vessel which is going towards the heart. So we divide the stroke into two different types. One is ischemic where there is clot in the blood vessel which blocks the blood supply and blood doesn't go into that particular aspect of the brain and causes symptoms. Other one is hemorrhagic where the blood vessel ruptures causing bleeding in the brain. Hence, the blood in the brain can cause some amount of mass effect on the brain and cause symptoms. Right now over here we will discuss mainly about the ischemic aspect where there is clot in the blood vessel and the blood supply is not happening to the particular aspect of the brain and causing the symptoms. So whenever someone has stroke or whenever someone is having an impending stroke, we find some classical symptoms. So symptoms have to be sudden in onset. That is the most important part. So it has to be sudden. That means patient was seen absolutely okay few hours back and he's developed a symptom. So what are the symptoms? Some of the common symptoms which we see in patients and we go by a mnemonic called B-fast. So B is for loss of balance if there is sudden loss of balance. E is for loss of vision if there is a sudden loss of vision in any one of the eyes. F is facial weakness if there is drooping of one side of the face or there is angle of deviation of mouth to one side. Next is A, arm weakness. Next is S which is speech, loss of speech or slurring of speech. And last one is T. So B-fast, T is time. So someone who has had any one of these symptoms has to come to the medical attention within 4 and a half hours. That's how it is important. We will speak further on why it is important to come within those 4 and a half hours. But the symptoms are these, loss of balance, loss of vision, facial weakness, arm weakness and loss of speech or slurring of speech. And Dr. Chhara will be able to tell more about the diagnosis aspect. So as Dr. Safful has discussed about what a stroke is, you can have sometimes a stroke-looking event which may not be a stroke or the stroke could be because of bleed in the brain or it could be because of lack of blood supply. So lack of blood supply is because of a block in the artery which could be called a stroll accumulation or sometimes a clot coming from the heart or anywhere in line or in path from anywhere, from any of the pipes or the vessels which supply blood to the brain. A clot can go from anywhere from there to the brain and this causes a stroke. So basically to identify the anatomy of the stroke on whether this patient really has a stroke, we need to do an imaging. So imaging can be CT scan or an MRI and whichever is available to you at the earliest, you should get a CT or an MRI done. So at our place, we do a MRI for patients who can cooperate. Many times these patients can be restless. So an MRI needs the patients to be a little more still and allow us to do the scan which takes around 10 to 15 minutes. Whereas in CT scan, it would take hardly a minute or so to do the scan. And the main reason why do we do imaging is that we want to know whether it's really a stroke and whether it's a bleed or it's a blocked artery. So because the treatment, the further treatment depends on what is the diagnosis, whether it's a bleed like stroke or it is an ischemic stroke where you have a blocked blood vessel. So the anatomy of this problem is better delineated by CT or MRI. And MRI scores a little better when it comes to delineating all these problems together. Along with that, we do something called as vessel imaging also. The blood vessels which are supplying the brain are also imaged on the CT scan or the MRI. And we call that angiography, so MR angiography or CT angiography. So along with the scan to find out whether this patient really has a stroke, we would further go ahead and do something called as MR angiography which we can do without injecting dye when you do it with an MRI. CT scan would always require dye to be injected through the veins to delineate the arteries. So once this anatomy of the problem is known whether this patient really has a stroke, that is what is the first thing to be known or it was just a mimic stroke. Mimic stroke, mimics could be anything like tumors or some conditions like demyelination scan also present like stroke. So once we isolate these conditions and then zero down to a diagnosis of ischemic stroke which is commonly treated, the hemorrhagic stroke usually is conserved unless it has lot of compression effect on the brain, we take them for decompressive surgeries. So most of the times it is an ischemic stroke where we have to deal with or give medications. So once we identify this patient to be having an ischemic stroke and then we can actually motivate or mobilize the rest of the team to further treat this patient with either medicines or some other therapies which we will discuss further. And doctor what exactly causes a stroke? So there are various risk factors for stroke. So there are some there is something called as modifiable risk factor that is basically uncontrolled diabetes, uncontrolled hypertension, smoking okay and there are non-modifiable. So age is a non-modifiable risk factor so obviously we cannot reverse aging. So a person who is elderly has higher chance of having stroke than a person who is younger. Not that we do not see patients with stroke in younger age but literally we see patients who are elderly or who have crossed 60 whom we see in our routine clinical practice. So these are the risk factors as person who has these risk factors has higher chance of getting a stroke and as Dr. Charu told already though one of the thing is that if a person has a clot in the heart that clot can go up to the brain also through the blood vessels which go from the heart to the brain. So that is one or if there is excessive cholesterol deposition because of excessive cholesterol in the blood itself or diabetes also can cause some cholesterol changes in the body and can deposit in the blood vessel. If the cholesterol deposition is higher then the blood vessel gets clot and a person can have stroke. So these are some of the common ways of how a stroke can occur but there are risk factors which we have already discussed. I would like to add one point what Dr. Charu mentioned about stroke mimics. A person who has had a seizure or a fit can very well mimic stroke. If a person has had a seizure or a fit and it was one sided and no one has seen it. When the fit has gone a person can have that side weak and it can get confused with stroke. So that is why it becomes important to take the history from the patient who has unable to speak if we have to take the history from the relatives. So it becomes important for us to know who was with the patient when the patient was seen. So that is something I would like to add on. So these are some of the common causes of stroke how the stroke can be seen. So in usually in stroke you have an immediate cause which is as we described earlier is usually a clot or a vessel that is blocked or narrowed. And these conditions are usually slowly building up because of the conditions that Dr. Safal has already mentioned like diabetes, hypertension. Many a times you have heart conditions which can give rise to a stroke where your heart has become weakened because of your previous heart attacks where the heart is weaker and that part of the heart is not moving well. When something does not move well or the part of the heart does not move well you have chance of clot building up there. So something to remain fluidic you need it to be constantly moving like your buttermilk they keep moving it and then so if you have the blood starts clotting when it is not moving. So if your heart is weakened or has an area in the heart which is weak that part of the heart can generate clots and those can migrate to the brain and give rise to a stroke. So this all we would analyze when a patient with stroke comes to us. But more importantly we will be looking at what is the immediate cause whether it is the vessel that is blocked whether the vessel has got some separated layers which we call dissection. Many a times you have trauma to the neck or some normal movement of the neck or a sudden movement of the neck where one of your vessel has separated there are layers in the vessel which can separate out and if they separate out we call it dissection. These patients also will present with stroke. And they are usually younger. Those are usually younger. So the cause of stroke would be again a clot or dissection or a vessel which has narrowed and then suddenly got blocked because the narrowed segment again the flow becomes slow and the vessel can get thrombosed or get clotted because the flow is slow. So these are the immediate causes of stroke which we identify because we need to start something a treatment that is immediate. And the associated conditions like diabetes, hypertension and all we would treat them to prevent strokes or a second attack or stroke and keep them in control to prevent further strokes. And doctor previously both of you mentioned that a patient needs to hurry up physically time. So what is the importance of time in this? Why is it necessary that you have to hurry as soon as possible? So time as I told that as the blood supply is getting reduced to the particular aspect to the particular part of the brain the nerves or the brain cells starts getting you know decreased oxygen. So they start dying and there is a particular time after which we cannot salvage those dying blood cells they are already dead. So that means to say that the disability which the patient is going to have is going to be permanent or it is going to be definitely not how he as how he was. So that is why the time which has been told is has to be less than four and a half hours. Okay anyone who is suspected to have stroke should come to the medical attention should seek medical attention within four and a half hours. Okay and not wait thinking that you know I have not had food that is why probably my one side of one side of the one arm is weak or I am not able to speak properly. So they should not wait moment they feel that you know something is wrong or they are not able to speak they are not able to lift up their hand they are not able to see properly from one eye they should seek medical attention. Unlike the patient for the heart attack there is no pain here. So that is the differentiating point. So people who have heart attack they will have pain and they are aware that there is an impending doom happening. So they seek medical attention quickly but over here there is no pain. So patients most of the patients tend to ignore it thinking that it is going to be okay. So let me just get go to sleep or let me have some food I will be alright. Fortunately some of the symptoms may resolve fortunately but some of them might not resolve also and it becomes severe and severe and some of them might have gone to sleep and they wake up with the much more devastating weakness on one side of the body. At that point of time we do not have that window or the time period of four and half hours is already lost. So we cannot give a definite treatment to reverse the whole process. So with advent of new medications and technology we are able to reverse these symptoms also with help the help of an injection okay which we will be discussing a little further and also other modalities of treatment which Dr. Charu will be discussing okay. So that is why the time is important. Brain cells have a particular time duration during which they can survive. So if you do not reverse if you do not open up the clotted blood or if you do not open up this vessel which is blocked then the brain cells die. So once the brain cells die the damage is permanent. So that is why the time is important. So imagine a person who is a painter and he is a breadwinner of the family and his only job is painting and he develops a stroke on the right hand and he does not come into the medical attention early. So we can say that he might not be able to paint again. So that such is a devastating effect of a stroke and it can cause significant impact on the family okay. So that is why we keep saying that it is important you guys should come in at the earliest and we keep building awareness about the whole thing. So that is why the time is important. So actually when you get a stroke it is with the patient as well as the team that is managing to reduce the time for therapy. The reason for that is the brain that represents your hand or leg or your speech area is very small. So when a blood vessel which is supplying that area gets blocked you immediately start having death of cells and millions millions of brain cells will die with passing time. So as we said we have a very narrow window that is around 4.5 hours to 6 hours when your stroke is on the front side of the brain. So we divide the brain into the front side and the back side. So when you are looking at the front side of the brain which represents your voluntary movements that part and speech that area is that area gives you a window of around 4.5 or around 6 hours to maximum around 8 hours to treat. Thereafter if we try to treat or intervene there are chances of having complications. So we avoid or we tailor the treatment based on the age of the patient and see what is the anatomy of the problem by imaging and see if the core of the brain that is already dead whether it is small or big. So as time passes the core of the brain that is dead starts increasing and there is a brain around that core of the brain which is still salvageable. So that brain is hibernating or it is getting supply from the surrounding or the neighboring arteries or the blood vessels which keep this brain intact and that particular concept or that particular reason for that is a collateral supply. So collateral supply comes from the blood vessels which are in the neighboring territory and they keep this area alive for some time till you can re-vascularize or open up the blocked artery. So if you don't intervene in this 4 to 4.5 to 6 hours time then this brain which is at risk also will die. And now when you look at a small representation in the brain which looks at a large area of body to be controlled then you can have a patient who is not going to be independent or not going to have an independent life and life without support if we don't re-vascularize this within that window period. So time is very important here because the therapies can be given only within this window period that is 4.5 hours to 6 hours for the front circulation and the back circulation we still can extend this to round about 12 hours 8 to 12 hours. I hope you have heard all that 4.5 hours we have to be careful any science of it you have to consult a doctor. So doctor as we speak of it how is an acute stroke treated? I had already mentioned about an injection which can be given. So if a patient comes within 4 and half hours we do the necessary brain imaging and then we decide whether the patient is capable or is a candidate to get the injection. Now that every patient should receive it if a patient is a candidate then we go ahead and give it. So injection is given over the period of 1 hour. There is another injection which can be given as a bolus that means to say that it can be given at one shot. So there is a 3 to 6% risk of having a complication because of the injection in the form of bleeding in the brain because of the injection it can occur. So this is with respect to the injection. After giving the injection there is a possibility that the person might not improve if there is a clot in the main vessel. That is where Dr. Charu comes into picture and there are therapies where we can go in and remove the clot from there. That is where Dr. Charu comes in. Actually the window is short. So when you have a patient who is coming to the ER with a stroke or stroke like symptoms there is not much that the ER team has to do. They just pass the IV line and then send the patient for imaging. We diagnose that this patient has a block in the artery and this patient is in the window period. So the first thing that we start or the first therapy that is given to the patient is starting blood lysing agents or blood clot-busting or clot-breaking agents which we call thrombolysis. So this is sent in through a vein in the periphery of the hand or in the arm and this goes to the brain, reaches the brain and then ties the clot. Now this needs some time. So in the meantime that this medicine is taking its effect, still brain cells are dying. There are times where this medicine may not work if the clot burden is high or the vessel that is blocked is too large for this clot, this clot-busting medicine to reach there and break it. In those scenarios it was since 2013 and then more so in 2015 that a new therapy started getting developed or the research started coming in and more and more studies were released or published in 2015 where they started removing the clot directly from the brain and this therapy was called mechanical thrombectomy. So and this was what Dr. Saffold discussed earlier is called chemical thrombolysis. You break the clot by giving medicine and here you actually go inside and you put in something like a fishing net there which we call a stent retriever or we put small catheters or tubes there and connect it to a suction machine with very high suction pressures and just suck out the clot. So either you suck out the clot or you put in a stent retriever which is connected right up to the with the wire right up to the entry site in the groin. So you enter from the groin, you reach the site of the brain with these small tubes and wires which we call catheters and wires, reach there, place this fishing net like device which is called stent retriever, engage the clot in that and pull the whole assembly out. This is called stent retriever mechanical thrombectomy and if you use a suction device or suction catheters we call suction thrombectomy. So these therapies, these two therapies actually changed the way we started treating stroke since 2013 and 2015. We look at treating these patients in a time frame of around 30 to 45 minutes. So we call it door to needle or door to clot retrieval time should be around 30 to 45 minutes that is what we try to achieve. So when this patient comes in a window period of around 4.5 to 6 hours. So for injections we look at a time frame of 4.5 hours but when you are doing therapies like stent retriever thrombectomy or clot retriever we can extend it to 6 hours. Many a times we have patients whom we cannot give the injection in patients like who have undergone recent surgery. So the surgery site is going to bleed because if you are going to lyse a clot it is going to lyse the clot which is actually holding the surgical site. If patient has had a recent head injury or even a recent stroke, one more stroke earlier to this which was within a time frame of around 3 months you cannot give these chemical agents like the ones which we use for IV thrombolysis. In those scenarios we can still do mechanical thrombectomies and get the clot out because we do not then need an IV thrombolysis because you are pulling out the clot. Okay. So finally doctor is there a way that we can prevent a stroke? Definitely. We have to take care of the risk factors. So if a person has diabetes it has to be kept under check. If it is uncontrolled it has to be brought back to control. Not that if it is controlled patient will not have stroke the chances go down. Okay. Similar aspect with respect to hypertension also or blood pressure. So it has to be brought under control. If a person is smoking then definitely needs to quit. If quitting is becoming difficult then he has to take help, mental health expert needs to be brought in and then it can be stopped. If a patient has an underlying heart condition or there is something called as atrial fibrillation where a person has a irregular heartbeat. So whenever there is irregular heartbeat there is a possibility of causing a clot inside the heart and the clot can go up. So that has to be taken care of. And there are medications which we give to take care of these such kind of conditions. And exercise is another important aspect. It is advised that you have to do moderate exercise for 30 minutes, 5 days a week. And another aspect would be to make sure the cholesterol is under control. So cholesterol check needs to be done and then that has to be taken care of. So this is with respect to preventing a stroke which has not yet occurred. Suppose someone has already got a stroke and we can give medications called blood thinness. Basically they are blood thinness where we can make sure that patient doesn't have any more strokes. So these are the important aspects of preventing the stroke. So when you prevent a stroke you are either trying to prevent a stroke which is not yet happened to this patient and there you look for the risk factors like diabetes and hypertension or high cholesterol levels as Dr. Sophala has discussed. So and then there is secondary prevention. So this individual has got a stroke and he recovered from it completely. Or there is a condition or an event which we call TIA, transient ischemic event. So this is an event which just happens you get some weaknesses in your hand or some numbness and it recovers, immediately recovers. Or sometimes you have this lasting for a day or so and then it recovers. So this is a sign that you have something which is causing this blood supply to that area to reduce which could be a narrowing in the artery which is in the range of around 70 to 90 percent or there could be something coming from the heart. So we need to evaluate these patients for all these things and prevent a stroke. So when you have a narrowing in the blood vessel we do something called as stenting and re-vascularize this when it is critical and prevent a further stroke which you can re-vascularize a vessel in the neck or also you can re-vascularize the vessel directly inside the brain. So that is where you do secondary prevention. So primary prevention again you have to get down your risk factors like stress levels. Walking is a very good exercise, 5 kilometer walk gradually building up to 5 kilometers with the speed ranging from doing 1 kilometer at every 12 minutes and within an hour 45 minutes 15 minutes to 1 hour you finish the walk short step which is called brisk walking can actually get down your requirement of your BP medicines also can keep your cholesterol in check and prevent a stroke whether it is primary or secondary. So if you already have these risk factors still you could prevent getting a stroke or even a heart attack which are almost similar. So any vessels in the body can get blocked and these risk factors are there playing for it. That is what our effort is to make sure we bring out you know we develop the awareness. Awareness about heart is there everyone goes to a doctor if they have some pain anywhere near the chest but there is lack of awareness about stroke. So we want to develop that awareness so that more patients are treated and they get proper treatment before the disability setting. Dr. Charudath, Dr. Saffer thank you so much for your time. Thank you for enlightening us. For those of us experiencing any of these symptoms or anybody around you if you see them experiencing any of these you can always rush them to Manipal hospitals at the emergency department which is open 24-7. Also if anybody wishes to consult Dr. Saffer or Dr. Charudath they are available at Manipal hospitals from Monday to Saturday. See you again next week. Until then eat healthy drink plenty of water watch out for any of these signs and consult a doctor.