Speaker 1: 0:01

Welcome to the Healthy Matters podcast with Dr. David Hilden , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health healthcare and what matters to you. And now here's our host, Dr. David Hilden.

Speaker 2: 0:19

Hey everybody, it's Dr. David Hilden and welcome to this episode of the Healthy Matters podcast. Today we are gonna talk about strokes. They are ever so common. So we're gonna talk about what causes them and what can be done about them even how to recognize them. To help me out, we have brought neurologist, Dr. Benham Sian . He is a neurologist at Hennepin Healthcare in downtown Minneapolis with a specialty in vascular neurology and brain health. In other words, strokes. He came from Massachusetts General Brigham Hospital, a great hospital on the East coast by way of Northwestern University in Chicago, another great hospital and we are fortunate to have him here in downtown Minneapolis. Benam , welcome to the show.

Speaker 3: 0:58

Thank you so much for having me. It's a pleasure to be here.

Speaker 2: 1:00

Great to have you here on Dr. Sabaan . Now if you could start us off by talking about, before we get into strokes, people often know about a mini stroke or a TIA. Could you tell us what that is?

Speaker 3: 1:12

Absolutely. So TIA stands for transient ischemic attack. Basically this is a medical condition where there is a transient blockage of the blood flow to certain areas in the brain and that will lead to various symptoms. We really take TIAs or transient ischemic as very serious. And the reason is that data shows that about a third of people who experienced TIA, they're going to develop a stroke in coming months and years and specifically weeks and months after having TIA is very critical time to do all the preventive measures that you can do to prevent developing a stroke.

Speaker 2: 1:53

Do we still use the word TIA or mini stroke TIA? Sounds scary. Transient ischemic attack, that sounds pretty bad. <laugh> . <laugh> . Is there really much difference between a TIA and a full blown stroke?

Speaker 3: 2:06

Yes and no. So when we are talking about TIAs or mini stroke , I like to use a term of mini because it shows that we are dealing with type of a stroke. I don't like to use it if we are thinking that this is something minor and and not important. Hmm . So TIAs, when we are having a patient with that condition, we treat that person exactly like person had a stroke. The good news is that that condition did not leave persistent symptoms. And the better news is that that's the opportunity, the golden opportunity for us to start preventive measures to understand why the TIA or mini stroke happened and then we would prevent a more catastrophic or larger damage to the brain.

Speaker 2: 2:50

I like that, that there's actually some good news. You it's you treat it like a stroke but the symptoms didn't last. So let's use this chance to do something about it. So tell us if you would, what are the symptoms of A TAA or a mini stroke ?

Speaker 3: 3:03

So our brain is very complex and fascinating organ and different regions in the brain, they are responsible for different things that we do. One part is responsible for vision, the other part is for our motor activities. The other part is responsible for sensory changes. The other part is responsible for coordination. So if you had this transient blockage of blood flow to any areas of the brain, you can have any of those symptoms. So a person with TIA can present exactly with the symptoms that we would expect with stroke. And maybe some of your listeners will be familiar with this acronym of BFA that you would share with the public. If you experience BA, you have stroke or TIA symptoms,

Speaker 2: 3:46

I wanna get into that right now because we're gonna say it two or three times in the show. Bfat, what does that stand for? Yeah,

Speaker 3: 3:52

BA is a great acronym and we all need to know about that. BFAS stands for B balance. If you have balance issues, if your gait is impaired, E eyes , if you have vision loss or you have double vision, F means that if there's any facial group or any changes or funny sensation in your face, A talks about arms if there's a sensory change or motor changes in your arm. S is about speech and T is time to call 9 1 1 time to call, get to medical attention. And then someone should really evaluate you as soon as possible.

Speaker 2: 4:26

So be fast. We're gonna talk about those later in the show. I'm gonna repeat them because I do want every single listener to know what BFAs stands for. Balance , eyes, face, arms, speech, it's time to call You got it. Did I get it right? Excellent. Okay, good. We're gonna do about, we're gonna talk about that later. So back to tia's mini strokes, how common are they and do they affect men, women, old, young, they

Speaker 3: 4:49

Are actually pretty common. So current data shows that in the United States and whole ward we developed TIA or we have TIA roughly one per thousand percent per year. Let me translate this number to, for example, Minnesota population. We have about more than 5 million population here. That means that every year we have more than 5,000 kids of TIA coming to our

Speaker 2: 5:14

Hospitals. So that's a lot just in Minnesota. Just

Speaker 3: 5:16

In Minnesota. But keep in mind that these are the patients who come to the hospital and we know that and it's unfortunate that actually some people don't show up and we lose these golden opportunity to take care of these patients. So the numbers are huge and I think probably is more of underestimation of the magnitude of the

Speaker 2: 5:33

Situation. That's interesting because why do you think people don't come in? Is it because their symptoms got better and they don't come in and it's Well, I got better? Yeah,

Speaker 3: 5:40

So the symptoms are very short lasting or they are non-specific. For example, a patient might have just dizziness and imbalance lasting for a few minutes and then attributing it to something else. But no , really if you develop those symptoms which are really new to you and you don't have any explanation, you should come to the hospital even if those symptoms are resolved.

Speaker 2: 5:59

What about age or gender?

Speaker 3: 6:02

Uh, both stroke and TIA, again, they are very closely connected. We see that more with advancing age. So older populations are definitely at higher risk of developing both stroke and TIA in terms of gender when it comes to a stroke , uh, which we can get to that in more details. The lifetime risk for a stroke is higher in women. In women. Yeah. And there are reasons for that. But when it comes to TIA numbers are kind of indicating that probably both genders are affected in a similar way or the same frequency.

Speaker 2: 6:35

Okay . Let's move to stroke and before I ask you to tell us about what the difference is, let's keep on the numbers thing. You said in stroke lifetime risk for women is higher. Is that just because women live longer?

Speaker 3: 6:47

Yes and no <laugh> because

Speaker 2: 6:49

They do. Yes

Speaker 3: 6:51

They

Speaker 2: 6:51

Do.

Speaker 3: 6:51

<laugh> . Um , so let me give you some, some general number about the magnet of a stroke in the United States. So our estimate shows that there are about 800,000 kids of a stroke every year in the United States. Nearly

Speaker 2: 7:05

A million, nearly 1,000,800 thousand. And

Speaker 3: 7:08

Current data shows that with the increasing life expectancy and everything in individuals who are 25 years and older, one out of 4% would have a stroke in lifetime. This is a really, really large number and is a really significant situation. Women are at higher risk of developing a stroke when we are talking about life course because certain risk factors that they're exposed to and one of those risk factors are more younger age type of a stroke that can be related to pregnancy or o cpu , uh,

Speaker 2: 7:41

Oral contraceptive

Speaker 3: 7:42

Or contraceptive birth control pills. Yeah, birth control and factors like early menopause. And the other data that we have is that sometimes women are a little bit more vulnerable to conventional uh, vascular risk factors like smoking, diabetes, hypertension and effect of alcohol on, on vascular health.

Speaker 2: 8:03

So lots of reasons why women might have a higher lifetime risk, but it affects everybody. Everybody . Okay. Now we're talking about strokes, the real deal here. What causes them,

Speaker 3: 8:14

Let me take one step back to kind of go to the definition of a stroke and then we will talk about what could be the mechanisms or causes behind a stroke. So we have two types of a stroke. One we call it ischemic a stroke in simple terms, when there is a blockage of the blood vessel in the brain and nutrient and oxygen doesn't get to the brain tissue, the other type is hemorrhagic stroke or basically bleeding type of a stroke, which means that the vessel walls are ruptured and there's a leakage of the blood to the brain tissue and causes all sorts of inflammation.

Speaker 2: 8:48

So listeners, you're getting a little mini medical school here. They say when you go to med school you learn a whole nother language. Two words that we throw around at at work all the time. I probably go and don't go a day without saying the word ischemic and hemorrhagic. Now you know, ischemic blockage, hemorrhagic bleeding. Exactly. Okay. So those are the two main causes.

Speaker 3: 9:06

So, and these two conditions have a major overlap in terms of risk factors, but they are also separate entities when it comes to their treatment and prognosis. And what would happen after we experience that, let's just start with this is chemical stroke or the type that there's a blockage of the blood flow to the brain. There are risk factors that we are all aware of. High blood pressure, diabetes, smoking, high cholesterol. These are all risk factors for any vascular event in our body, in our heart, in our legs, in our kidneys, but also in the brain. But brain is specifically very vulnerable to any form of blood clot formation. And that blood clot formation can be at the level of the heart or in our blood vessels everywhere in the body. That means that if you have a condition like atrial fibrillation, which is a irregular heart rhythm at the level of the heart, there will be blood clot formation in the heart and that clot can travel to the brain cause blockage of the blood flow to the brain and cause a stroke. Or if you have a condition that puts you at risk of having blood clot, any parts of your body that clot can travel to the heart and then can travel to the brain and cause a stroke. So what we are talking about when it comes to blockage to the blood vessels in the, in the brain, it means that that clot was formed somewhere either outside the brain or inside the brain. And when it is inside the brain, usually it's in the setting of having plaques and having high cholesterol, high blood pressure, diabetes,

Speaker 2: 10:36

Just like heart attacks,

Speaker 3: 10:38

Like heart

Speaker 2: 10:38

Attacks, like a brain attack. Exactly.

Speaker 3: 10:40

The clot can also come from other places and attack the brain. So

Speaker 2: 10:44

Clots, no matter where they are in your body, either travel to the brain or they form in the brain, they form an ischemic stroke. Here's a question. How long can the brain go when there's a clot before it causes permanent damage? That's

Speaker 3: 10:56

A great question. So no organ in our body is more vulnerable to lack of oxygen and nutrient because our brain is a very metabolically active organ. It really needs a great amount of oxygen and nutrient and energy to function. Everything we do is about a function that is reflected in the brain. For that reason. The brain levels are very complex in terms of kind of supporting each other. If there is a blockage somewhere, other vessels would help. But people are different in that network of the blood vessels. That's why the people have different vulnerability. But generally we would say that if there's a lack of blood to brain tissue for more than few minutes, you would start appreciating and seeing the adverse effect , which means that those neurons start getting damage . Sometimes the damage is reversible and sometimes the damage is not reversible and is all really time dependent. I think time is a very, very critical factor when it comes to stroke. It's management and what can we do to kind of decrease the burden of

Speaker 2: 12:04

A stroke? And we're gonna talk about what could be done when you call 9 1 1, what can be done if you get there fast enough to avoid that permanent damage? A few minutes isn't very long. Okay. Shift to hemorrhagic stroke. What's going on there? So

Speaker 3: 12:16

In hemorrhagic stroke, basically for some reason the vessel wall gets fragile and leaky and usually the most common cause for that leakiness or a fragility in the vessel is high blood pressure. By far. That's the most important risk factor. Unfortunately if you have high blood pressure, sometimes it might go unrecognized for a long period of time, but the adverse effect on the brain vessels would be lasting. And suddenly, unfortunately I've been in a position that I was taking care of younger individuals that they never had any medical issues or it , they never saw a doctor and suddenly they come with full blown stroke symptoms and there's a bleeding in the head because they had long lasting untreated blood

Speaker 2: 13:01

Pressure. So when you say patients or people out there listening, I don't have any symptoms of high blood pressure, I'm not worried about it. It's causing damage to the blood vessels in your brain even if you're not feeling it puts you at risk of stroke. I'm glad you mentioned that because we talk about high blood pressure a lot as a risk factor for heart disease. It's uh , probably the number one risk factor for hemorrhagic stroke.

Speaker 3: 13:20

For hemorrhagic stroke, but also ischemic a stroke and ischemic

Speaker 2: 13:23

Stroke. It's

Speaker 3: 13:23

Specifically hemorrhagic a stroke, specifically affecting younger individuals and those who had long-term high blood pressure without any treatments. And the other thing with blood pressures is a little stinky situation, right? Because sometimes you don't have any symptoms, you just need to measure your blood pressure, you need to see your primary care physician and you need to be aware of that by measuring it. That's what we call it, silent killer. Right? Because you sometimes you don't have any symptoms.

Speaker 2: 13:48

So earlier um, you talked about the bfa. I wanna kind of summarize what are the symptoms of a stroke?

Speaker 3: 13:56

So a patient who can come with a stroke symptoms can have wide range of symptoms, but I'm gonna mention those major ones. The very first one is losing balance and impairment in gait. Suddenly you're walking and you feel like, oh I feel imbalance, I'm moving to one direction or

Speaker 2: 14:14

The other, walking into the wall or something. Exactly.

Speaker 3: 14:17

The other one is any acute or sudden onset change with your vision it , if you suddenly feel like, oh I can't see one side of my body or suddenly you see some blurry vision or double vision, that's can be a sign of a

Speaker 2: 14:32

Stroke and it's sudden

Speaker 3: 14:33

And it is sudden. But especially if it is lasting, you need to really seek medical attention.

Speaker 2: 14:38

Yeah, don't mess around if you're losing vision. Yes.

Speaker 3: 14:41

And then the other important thing is that, and actually that's something that many people would appreciate when they wake up early in the morning or they see a spouse that there's a sudden facial droop , there is a asymmetry in the face. That means that there are weakness in the face muscles. So other condition can cause that. But a stroke is one of them. And then with that you can have also a slurred speech. So you try to kind of say words but you cannot really say them very well as you used to be. Or you can have problem with your language, meaning that you have the word in your head but you cannot express it. And this is, this has never happened to you. These are all signs of a stroke.

Speaker 2: 15:20

Weird stuff can happen when your brain isn't getting the oxygen. Yes it needs. Yes. Really weird things. Why do the symptoms often affect one half of the body? People ask me that all the time.

Speaker 3: 15:31

Yeah, that's an excellent question. So our brains wired in a very interesting and fascinating way. Many information that we receive in our brain, they come through these sensory channels for example, in our skin, eyes, ears. We get all these sensory information, these sensory information come to us to the brain through the spinal cord. And then there will be process in what we call it cortices , which is basically surface of the brain where the gray matter where those gray cells are very important. But then when they are coming back to give command for action for example, like I'm moving my right arm right now, the information comes from the left side of the brain goes to the right side of the body and the information that comes from right side of the brain goes to the left side. So there's a crossing of the information. We don't know exactly why this happening, but it could be one of the very advanced developmental things that can happen only in human brain. And usually because brain is has such a different vascular anatomy in right and left side of the brain. So if you have a damage in one side, you usually see adverse effect on the other side. It is not always the case because there are some vessels that are in charge for both sides. But this is usually the presentation you'll come with one sided weakness.

Speaker 2: 16:50

It's fascinating. You and I both did anatomy. We both have looked at brains. I imagine you have. I know I have. We've studied them. We've got all this advanced knowledge about exactly what every square millimeter of the brain does, but we don't really know why or always. Yeah . And so that's fascinating. So I'm gonna pause this there 'cause I think we've earned a break. We're talking with Dr. Benham Seba and he is a vascular neurologist, a stroke expert at Hennepin Healthcare in downtown Minneapolis. When we come back we're gonna talk about the treatments and importantly methods for keeping your brain healthy throughout your life. Stay with us. We'll be right back

Speaker 4: 17:27

When he up and healthcare says we are here for life. They mean here for you, your life and all that it brings. He up and healthcare has a hospital HCMC and a network of clinics both downtown and across the west metro. They provide all the primary care and specialty care you would expect to find. But did you know they also have services like acupuncture and chiropractic care available at many of their primary care clinics and at their integrative health clinic in downtown Minneapolis. Learn more@hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

Speaker 2: 18:04

And we're back talking about brain health and stroke with Dr. Benam Seba at Hennepin Healthcare . Okay, we've talked about all this stuff that's kind of scary and all that. What kind of treatments are done before we get into preventive cares?

Speaker 3: 18:17

So when a patient comes with ischemic stroke, which is blockage of the blood vessels in the brain, we have a wide range of treatments available if patient is coming to us in a timely manner. Again, this is really time sensitive condition,

Speaker 2: 18:32

Timely manner, not two weeks later.

Speaker 3: 18:34

Yes. And we are talking about minutes and hours specifically. If a patient comes before four and a half hours, this is like kind of our timeline. We have a very effective medication, a blood clot busting medication that we would check all sorts of side effects and talk to the patient and the family. We say that we're gonna give that medication to you. That medication would bust the clot would restore the blood flow to the brain at the beginning you might not see totally resolvement of all the symptoms, but we know that three months down the road, patients who receive that timely treatment, they do much better in terms of their motor function, their recovery. But if the blood clot is very large and it is kind of trapped in the vessels that are at the base of the brain, actually we can, with the procedure, we'll put a puncture in the groin and then we'll go after that clot and we will remove that clot.

Speaker 2: 19:30

You can pull the clot right out with a exactly wire basically. Yeah.

Speaker 3: 19:34

Yes. And then patient will be admitted to intensive care unit will be closely monitored. So these are the two main staying treatments for an acute situation in a very short period of time.

Speaker 2: 19:45

So you can either bust up the clot with medications or you can mechanically go in there and pull it out. What if it's a bleeding kind of stroke

Speaker 3: 19:52

Before getting into the bleeding? I would say sometimes even we would be able to do both of them. We know we have the data. If you'll be able to bust the clot and remove the clot at the same time, you will be even better off. So when it comes to hemorrhage type of a stroke or bleeding type of a stroke, the research is really active in that area. But the very first thing that we would do, we would lower the blood pressure. So usually patients would come very, very high blood pressure. We will lower the blood pressure and that would help us to limit the expansion of the hematoma or bleeding in the head. And then one key question for us would be, is this patient taking a blood thinner?

Speaker 2: 20:29

So a lot of people are taking blood thinners.

Speaker 3: 20:30

Yes. And we need to know that because we can kind of reverse the effect of those blood thinning medication. It is always important to know what was the timeline for both ischemic stroke and hemorrhagic stroke because that timeline , and by timeline I mean that when was the last time that patient was feeling totally fine and suddenly symptoms started. That would really help us to kind of gauge our treatment towards the things that we think are must affect it in that time period of time .

Speaker 2: 20:57

What it always struck me is that the brain is enclosed in your skull. It doesn't have a lot of room to have a lot of extra fluid in there. So I imagine the brain is not to put too far a point on it kind of getting squished by the blood.

Speaker 3: 21:10

Exactly. The , there is a mechanical force by the blood to the brain tissue and that mechanical force can cause damage on top of the inflammation that because blood is a actually very chemical material and can cause a lot of inflammation. So both mechanical pressure and the inflammation would lead to brain damage. And sometimes that damage is really long-term damage. So time is your friend and you need to be really on top of

Speaker 2: 21:36

That time's your friend if you don't use too much of it, get there fast. Okay. I don't wanna spend too much time on treatments because other than to tell folks time, get in quickly and there are effective treatments by highly skilled doctors. What I wanna spend the rest of this episode on is brain health to try to prevent all this from going on. And that is an area of interest for you. I know I once heard a , a lecture by Dr. Seba here at Hennepin and I was blown away about some of the research that's done on brain health that starts way earlier than when you're an older adult. So talk to us a little bit about the importance of and what people ought to be thinking of throughout their lives for brain health.

Speaker 3: 22:16

I had a mentor that once told me that, you know, what is the best stroke is the one that never happened . Yes, yes . And I think that's what we should all think about. There is a good news here is that major neurological conditions like dementia and a stroke, they usually don't happen just overnight. There was a process for years and decades that led to buildup of those pathologies. And then finally we had that disease manifestation. And these two conditions, dementia and stroke are the most disabling conditions in the whole world .

Speaker 2: 22:48

Yeah. Living with a stroke that was not fatal but caused conditions is very disabled .

Speaker 3: 22:52

Exactly. And can cause also mortality. But what should we do to prevent, to get to that point that we kind of start all those treatments. And that's the concept of brain health comes that you need to take care of your brain tissue, your brain vessels, years and decades before to prevent dementia, to prevent a stroke. And how can you do that? I think now we have a very good evidence here in Minnesota. We , we were contributing to that literature in , if you are in your midlife and you are ,

Speaker 2: 23:22

So what's midlife? So let's say careful. Yeah.

Speaker 3: 23:25

<laugh>, this , uh, that, that cut off . I , I don't believe because you know, we are , uh, this is just a number, but we are biological all different. But if you are , uh, definitely younger than 60 or 65 years old, you have this golden opportunity. Even in older age, you have this golden opportunity to preserve your brain function and a structure by taking care of your blood vessels, being active, watching your diet, making sure that your blood pressure is under control, making sure that your glucose doesn't go high, making sure that you get good quality sleep, making sure that your stress is managed. And we have a very good data showing that even if you don't get this full blown stroke, these risk factors can lead to small damages to your brain, which will ultimately put you at risk of developing dementia. And that's something you can prevent and you want to prevent when you have the chance .

Speaker 2: 24:19

So you some of those things we've touched on, you know, keep your blood pressure under control. If your blood pressure is high , get it under control through your doctor. But you mentioned some other things. Sleep. Yes . Stress, exercise. We always think about cardio. I go to the fitness class to do my cardio. I'm in cardiovascular shape, I'm gonna care for my heart. But you're saying exercise, sleep, stress for your brain health. Say more if you could.

Speaker 3: 24:42

Absolutely. So whatever is good for your heart is good for your brain. But there is more into it because constantly every day we receive so much information and we put our bodies and our brain through a lot of stress. If you are really regulating things around you that would put your brain in a position that doesn't get stressed too much. Doesn't get damaged too much, you are basically contributing to overall brain health. And one of the key factors is having high quality sleep. When you pass all phases of sleep, when you get enough sleep , for example, we know that these days too much sleep or too little sleep is associated with future risk of dementia and a stroke, for example, there's this like ideal number around seven to eight hours

Speaker 2: 25:27

Of sleep per night.

Speaker 3: 25:28

Per night and type of sleep, time of sleep are very important. Stress. You know that those who have exposed a lot of stress, early life stress and midlife stress, their brain wiring can get different and can put them at risk of developing dementia in future. So again, you need to really be careful about what you would expose your brain to because that would be reflected in future risk of dementia, cognitive impairment, stroke, and all sorts of conditions that would lead to impairment of memory, impairment of your motor function and social interaction, your quality of life down the road.

Speaker 2: 26:08

It's really interesting. You said even earlier in life. Yes.

Speaker 3: 26:12

So we know that people have different levels of resiliency in their brain in response to all sorts of exposures that we get through the life and that early life resiliency, which means that you need to be getting good care when you are born. Emotional support, nutrient physical activity in kids, which we know that these days like not being exposed to a lot of preservative nutritions. These are all the things that would contribute to better wiring of your brain and giving you the resilience to any source of damage in years to come and decades to come. Yes, we need to start early and we need to be cognizant about that.

Speaker 2: 26:51

I like that, that that idea of resilience. Your brain is gonna see insults your whole life, but it's more resilient and can respond to those if you have good health throughout your life. Fascinating topic. The brain is so complex. It is the organ of our body that kind of at the, it's the central processing unit of the body. It is so complex. We have been talking about stroke, many strokes, brain health with Dr. Sabaan here at Hennepin Healthcare. Before I let you go, if you could wrap us up one more time with the B fast . I want everyone to know what that is and listeners, we're going to put some resources for you in the show notes. Go to healthy matters.org and we've got some graphics and some things we're gonna put there from Dr. Sabaan that will help you out with the basics of what you need to know. So tell us bfat.

Speaker 3: 27:39

Absolutely. BAT stands for balance eye. Any D eye issues, face. Arm, any weakness or sensory changes, speech changes, and T , it's time. Call 9 1 1. Seek medical attention. Time is very important when it comes to stroke and stroke care.

Speaker 2: 27:57

Dr. Ben, I'm Saba and he is a neurologist here at Hennepin Healthcare. Thank you so much for talking with us about this exceptionally important topic. My

Speaker 3: 28:05

Pleasure.

Speaker 2: 28:05

Great to have you on the show today. Listeners, there is so much to know about your brain health. I hope you got a base of information today, including some important life saving tips. But for more information, please go to healthy matters.org. Well , we will have some additional resources for you and I hope you'll join us for the next episode. In the meantime, be healthy and be well.

Speaker 1: 28:26

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden . To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. You got a question or a comment for the show? Email us at Healthy matters@hcme.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive producers are Jonathan , CTO and Christine Hill . Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well .