The Health Curve

Stroke: When Every Second Counts - with Dr. Jaspal Gill, Cardiologist and Clinical Research Fellow at the University of London (Heart Health Series)

• Dr. Jason Arora • Season 1 • Episode 14

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Strokes are one of the leading causes of long-term disability worldwide. Yet most people don’t know the difference between a mini-stroke and a major one—or how to spot the signs in time. 

In this episode, we explain what a stroke is, why it happens, and how you can act fast to minimize damage and save a life. From clots to bleeds, from BE FAST to full recovery—we’ll cover what you need to know and why your brain can’t afford to wait.

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In this special 4-part series on cardiovascular diseases, we're going to give you something that's getting harder and harder to come by: time with a cardiologist. 

Access to medical care is a growing challenge—especially when it comes to specialists. In the U.S. today, a single cardiologist may be responsible for thousands of patients, and nearly half of all U.S. counties don’t even have one. 

We’re joined by Dr. Jaspal Gill, Cardiologist and Clinical Research Fellow at the University of London, to break down the fundamentals of the most common—and most critical—heart conditions: high blood pressure, heart attacks, stroke, and arrhythmia.


SPEAKER_01:

Hello and welcome to The Health Curve. I'm your host, Jason Arora. In this special four-part series on cardiovascular health, we're going to give you something that's getting harder and harder to come by. Time with a cardiologist. This episode is on stroke. Stroke is a leading cause of serious long-term disability worldwide, with over 140 million healthy years of life lost each year. Around one in four people will experience a stroke at some point in their lifetime. And it's also a leading cause of death. So we're back with Dr. Jaspal Gill, who's going to tell us more. Thanks again for joining us, Jaspal. So we've already talked a lot about what's happening in the blood vessels around the body with high blood pressure, with heart attacks. Is a stroke basically a heart attack of the brain?

SPEAKER_00:

A stroke is very much like a heart attack of the brain. When they occur, that part of the brain is not getting the blood supply that it needs. The main difference between what's happening is that there can be two ways that people can have a stroke. And it can either be ischemic stroke, which is essentially where that part of the brain is not getting the blood supply because the blood vessel is blocked. In a very similar mechanism to what we described in a heart attack, that fatty bit of the blood vessel ruptures and there's clot that forms, which stops the blood flow. But you can also have something called a hemorrhagic stroke, which is actually when there's bleeding in the brain that prevents that part of the brain from receiving its blood supply. And so the first thing when people have a stroke that we clinicians try and do is try and identify whether this is bleeding or whether this is a blockage, because they've obviously got two completely different treatment pathways. And obviously, if you give someone who's got bleeding a blood thinner because you think it's a blockage, it's going to make everything a lot worse. So that's one of the key things when it comes to a stroke.

SPEAKER_01:

Right. And how can you tell the difference between the two with a patient?

SPEAKER_00:

So with the patient that's in front of you, it's incredibly difficult just from clinical signs or symptoms for us to be able to identify whether it's either an ischemic stroke or a hemorrhagic stroke. To do that, we really need to have brain imaging, and that's a CT of the brain. That's the type of scan. which is basically a 3D x-ray, which is looking at the brain from all different angles to try and reconstruct what's going on and identify whether there is bleeding there or whether there is blockage.

SPEAKER_01:

And the causes are the same, right, as what we've already discussed? That's exactly right, yeah.

SPEAKER_00:

So the causes are incredibly similar because of the nature of stroke, because it has that hemorrhagic aspect to it as well. There are some other things that we need to take into account. people who have problems with the blood itself, whether it's conditions like hemophilia, which means the blood is more likely to be thinner and less likely to clot, gives people a higher risk of bleeding, they would have a higher risk of that. But also because people who are already on blood thinning medications for whichever other reason that they might be on them, they will have a higher risk of having a hemorrhagic stroke as well.

SPEAKER_01:

So that's a stroke. What do people mean when they talk about a mini-stroke? So a

SPEAKER_00:

mini-stroke is actually... only possible when you have a blockage type of stroke problem going on. So it's never going to be a problem with bleeding if you're talking about a mini stroke. Now, a mini stroke is occurring when there is a blood vessel which is either just about to block and it's just kind of stuttering like that. So you're getting occasional symptoms of a stroke, but then they actually are recovering because there is a bit of blockage, but then the blood starts to manage to get its way back through and then that bit of the brain gets its blood flow back. So you can sometimes have the symptoms of a stroke. You can have those transiently, but then they will get better. And that's actually what the medical name of a mini stroke is, is a transient ischemic attack, which is what they call it, or a TIA. It can also sometimes be, if, for example, you have clots that are flying around within the bloodstream, and that can happen for many other reasons. If you've got these tiny little micro clots, which are going into a small blood vessel, blocking it off momentarily, but then actually after a few minutes or so, then the blood blood flow starts getting through and that clot kind of dissolves away, that can also give you something called PIAs or mini strokes as well.

SPEAKER_01:

So is a mini stroke a little bit like angina, but with the brain?

SPEAKER_00:

Yeah, that's one way of looking at it, yeah. Except I would say that angina can be something that's relatively low acuity. People can live with angina for years and it's not a problem. If you think you're having a mini stroke, you need to get to hospital and you need to be seen and sorted out.

SPEAKER_01:

So how are strokes and mini strokes treated?

SPEAKER_00:

So as we mentioned, with the different types of stroke, that's actually key to figuring out what the treatment is. If we've got a blockage, then we're either thinking about blood thinning or clot-blusting medicine. And if it's a bleed, then we need to try and give you medicines to try and help the blood clot so that we reduce the size of the bleed. So they're kind of two ends of the spectrum in terms of what we can give to try and sort it out.

SPEAKER_01:

Okay. And then that needs to happen pretty quickly once it's been recognized, right?

SPEAKER_00:

That's right. Just like with the heart, the quicker that you get into hospital, the quicker that we can start these medications to try and do it. And the more brain that you're going to save and the better your chance of having a good outcome, especially in terms of function that you can have there. And the treatment for a stroke can sometimes be geographically dictated. So depending on where you are, some hospitals sometimes offer something called a thrombectomy, which is similar or analogous So what we do with the heart in terms of our balloons and stents trying to open up vessels. But actually what they're doing in a stroke is they're trying to remove the clot from the blood vessels in the brain. And so that involves a procedure where they can try and remove that blood vessel if they think that that will help. Often it's related to the timing, just like as it does with a heart attack. The problem that arises within health systems is that this is often not something that enough hospitals offer to be able to have a kind of nationwide network in order to make sure that if this happens to anybody, that there's somewhere that they can go and have this done, which is why geography does play into this. If you happen to be close to one of these centers when it occurs, then you might be able to receive that treatment. But unfortunately, if you're not near one of those centers, it will just be a medical treatment that you could be offered.

SPEAKER_01:

And is that treatment more definitive? Is it better? So there is evidence that that treatment

SPEAKER_00:

is better. The treatment effect is not quite as astounding as it were compared to what we do in people's hearts with stents and with angioplasty with balloons. And that just probably is representing the fact that the blood vessels in the vein are much more difficult to maneuver, much more difficult to work in. You can't use devices like stents as easily. They don't work as well for various reasons. And that means that the procedure is just not quite as effective in the context of the brain as it is for the heart.

SPEAKER_01:

And it's not more available because of a lack of specialists or equipment or something else? It's a little bit of

SPEAKER_00:

everything, actually. Part of the reason is that because the procedures for this have developed relatively recently compared to the procedure that we use for heart attack. That means that in its infancy, there are fewer people who are doing it. There are fewer centers that have the setup to do it, who can be able to staff, to be able to have enough emergency people around in order to be able to provide this. procedure. And also because the treatment effect is not quite as good as it is for heart attacks, that means that the motivation for healthcare systems to be able to then put these systems into place is a little bit less as well. So it's a combination of all these different

SPEAKER_01:

things. Right. And for people who've been treated for a stroke, what happens long term after that? The blockage may be removed by what we call a thrombectomy or the patient takes a medication to clear the clot essentially. What happens after that? What's the aftercare?

SPEAKER_00:

So There's a huge spectrum in stroke of what can happen. Some people can have an amazing recovery. They'll regain their entire functional status and have no long terms to be lied about. Even then, they'll probably be in hospital for a few days, perhaps a week or two even, whilst they're recovering from the stroke. It can take quite a long time for people to recover that function. Sometimes some people will get it back within a couple of days. Sometimes people can take a year for it to come back. And in a significant number of people, they will have a permanent reduction in function. And that's where aftercare for stroke becomes very, very important. A lot of what the specialization that stroke wards have is that they have specialized physiotherapy and occupational therapy to try and help people recover function for people who have lost a significant amount of function. And that's where These are really, really important things which are not directly related to the medicines that we're giving or anything like that. But it's just trying to retrain the brain, retrain the body to be able to work together to try and overcome that part of the brain that's had that insult.

SPEAKER_01:

We'll get back to this conversation in just a moment. But if you're finding this episode helpful... Here's a quick ask. Take a second to follow or subscribe to the Health Curve podcast wherever you're listening. And if someone in your life would benefit from this episode or any of the others you've heard, please send it their way. All right, let's get back to it. So there are also lots of myths and misconceptions about strokes. So one is that strokes only happen in the elderly.

SPEAKER_00:

Absolutely not. Strokes can happen at any age. You can actually have newborns with strokes as well. The way that we manage it is obviously very different, but you can have congenital or neonatal hemorrhage as well, which is a stroke. I personally look after very young people who've had strokes. Luckily for them, they had the thrombectomy treatment, which we mentioned earlier, and they had a fantastic outcome. They didn't have any problems at all. But very, very young patients. We're talking about teenagers and people in their 20s who've had strokes. So don't get me wrong. It's definitely more common as we get older because the risk factors become more common. but it's a disease that can affect people at any age.

SPEAKER_01:

We've talked about the symptoms of a heart attack. It might be a good place here to talk about how you recognize a stroke. What are the symptoms?

SPEAKER_00:

So the main symptoms of a stroke are that you have lost some degree of neurological function within your body. And that usually manifests itself as that you've got either weakness in one of your arms or legs. Sometimes we see facial drooping, and that can manifest itself in different ways. that people wouldn't necessarily expect. It can sometimes mean that you're taking a sip of water and actually find that, oh, I'm drooling out of one side, which is unexpected because that's never a problem that you've had before. And actually it's because there's muscle weakness in those facial muscles. That can be one of the symptoms of a stroke. Can be visual symptoms as well, or difficulty in speech, not being able to actually get your words out because of either problems with either part of the brain that's producing your speech or either the muscles. that are creating the speech in your mouth that are being affected. So those are the main symptoms related to a stroke. And we summarize those as FAST. That's an acronym of F-A-S-T. And that's F for facial droop, A for arm or limb weakness, and S is for speech. And the T is actually just saying that time is critical here. And actually, if you recognize any of those, then time is the most important thing and you've got to get emergency services involved as quickly as you

SPEAKER_01:

can. And there's an updated version of the FAST acronym, BFAST, right? So B being balance, E being the eyes, and then F for facial drooping, A for arm weakness, S for speech impairment, and T for time to call for an ambulance.

SPEAKER_00:

That's right. Unfortunately, here in the UK, I think we're We're still behind the US on that, so that one hasn't caught on over here. But yeah, that's definitely an improvement on us.

SPEAKER_01:

Strokes are painful. This is one thing people say sometimes.

SPEAKER_00:

Yeah, so that's a really interesting one because actually if there's one symptom that makes me as a clinician feel reassured that it's not a stroke, it's pain. Because stroke should not cause pain. It doesn't cause pain in your head. and it doesn't cause pain in this part of your body where you've got symptoms. So pain is not usually a sign of stroke. The only one exception of this is if you've had a really, really catastrophic brain bleed, and then you can have a headache that's going along with this, which bleeding in the brain can cause a stroke, as we've mentioned about hemorrhagic strokes. We don't usually term that as a stroke. We actually directly term that as an intracranial brain bleed, which is a slightly different phenomenon, especially if it occurring in the area where you can perceive pain within the brain. But usually pain does not mean that this is a stroke.

SPEAKER_01:

Another that we've heard a lot of is that you can treat a stroke by taking aspirin.

SPEAKER_00:

So there is some truth in that. If you're having an ischemic stroke, that's completely right. We do treat it with aspirin. But the problem is we can't tell if it's an ischemic stroke or a hemorrhagic stroke. So until we know which one it is, you could actually be causing yourself a significant amount of damage. a hemorrhagic stroke and you take aspirin. Aspirin is a blood thinner. You're making your blood more thin, which is less likely to clot, which means you're going to make any bleeding in your brain worse. So I wouldn't recommend that at all. I just recommend seeking medical attention, being assessed, and having your doctor make that recommendation to take a blood thinner or to help something to make your blood clot.

SPEAKER_01:

Jaspal, thank you so much for joining us and walking us through that. Everyone, please join us for our next and final episode with Dr. Jaspal Gill, where we'll be talking about arrhythmia or abnormal heart rhythms.