- Slide. The stroke is the fifth leading cause of death in the United States. And, it is the leading cause of long-term disability. So, that means that-- Of strokes have more disabilities than anyone else with other disease processes. It affects around 795,000 people annually in the United States. And it happens about every 45 seconds. And again, stroke doesn't just occur in the elderly population. Strokes can actually occur at all ages, from before birth until death. Next slide. Coloration than any of the other areas. Kind of the South is in a much darker coloration. And this is because this is known as the stroke belt. So living in the South is actually one of the risk factors for having a stroke. And in North Carolina, it is more North Carolina and South Carolina it is more prevalent than when you look at the Midwest or even the West coast. Next slide. So just to highlight. There are two different types of stroke. The most common type of stroke is the ischemic stroke. And this is where a blockage, most people say it's a clot, interrupts blood flow to the brain. And in that interruption of the blood flow to the brain, it causes damage to an area of the brain. Depending on what area is affected, is the area that's going to affect you physically. So it could be your speech. It could be something physical as weakness on one side of your body or the other, it could affect your eyesight. So it just depends on where in the brain that clot occurs in the damage part. The second type is a hemorrhagic stroke. and this is basically a leaky vessel. So, this is what happens when we call someone that has potentially has a head bleed. And an artery in the brain either breaks or starts leaking. And it's typically due to high blood pressure. And just to kind of share a quick story with you guys. I had a patient that was in his forties, early forties. Came into the emergency room that had a headache. And blood pressure was found to actually be almost in the three hundreds, on his top number. And so he actually had a hemorrhagic stroke from the increase in his blood pressure. He didn't even know he had high blood pressure. So, hemorrhagic strokes are very serious. And well, any stroke is very serious and you should seek medical attention as soon as possible. Next slide. So just going into a little bit more of ischemic stroke. Which is again, that lack of blood flow to the brain. Let's talk about some risk factors that can affect you. It could put you at a higher risk for having a stroke. But your first one is high blood pressure. The American Heart Association recommends that your blood pressure remains less than 120 over 80 consistently. Sometimes our physicians want your blood pressure to be a little bit higher depending on other conditions that are going on. But we like to stick to the 120 over 80 or less than that as a good blood pressure. High cholesterol. So this is where that living in the South kind of comes in. We like our Southern food, right? And so, cholesterol has three different things that we look at. We look at our total cholesterol, which is our numbers all combined. We look at our LDL or low density. And we look at our HDL, which is our high density. We want our low density to be low. We want that number to remain low because this is your bad cholesterol. So this is, if you look in the picture, this is where that plaque builds up. That fat builds up in the artery and causes a constriction where blood flow has a harder time to get. Our HDL, which is our good cholesterol. This is the cholesterol that helps to fight off that bad cholesterol. We want that HDL to be high and that number because it's gonna carry that bad cholesterol all away and back to our liver so that we can digest it and get it out. The HDL also is what prevents us from strokes and heart disease. Diabetes, this is one of the most common that we see as diabetes being a risk factor. So Type 2 diabetes is the most common type. And that means that your body is resistant to insulin. So we would like for the your A1C, which is a lab work that your physician enroll to be under seven. Again, A1C shows what a three month period of your blood sugars are. And again, physicians will adjust that due to age. They may want your A1C to be a little bit higher, if you are an older population. And lower if you're in the younger population. But seven is a good number to remember. Obesity, we all know that being overweight can cause us to have high cholesterol. It can cause us to have diabetes and it also can cause us to have high blood pressure. So it's really important that we work to be at that ideal weight instead of being overweight, because that's just gonna cause more damage and make our body work harder. Smoking. Smoking We all know. We've known this for years that it's bad. Smoking actually creates hardening of your arteries, which again can constrict blood flow. And of course, it affects oxygen to your brain and it also affects your lungs. Atrial fibrillation. AFib is a very common heart dysrhythmia that people have. And it is where there's quivering of the upper chambers of your heart. So, your heart isn't beating appropriately. And with this, it can cause blood clots. And those blood clots can then, be put into the bloodstream and go to your brain, which can cause you to have ischemic stroke. So with this, we like to, for people to take some type of blood thinner. And it's really important that you take that blood thinner and you maintain that blood thinner because that's what's gonna prevent those clots from happening. Illicit drug use. Over the years, we've actually seen pretty much an increase in strokes related to illicit drug use. And, a lot of this has to do with heroin and cocaine. The increase of blood pressure with these medications and the effects that it has on the heart can cause people to have strokes from it. An excessive alcohol consumption. Again, the longterm effects of excessive alcohol consumption on the heart can create issues with trying to get blood flow to the brain. Next slide. So with ischemic strokes, you have sudden onset. And the symptoms sometimes people can say, "Well, they're just very general, "so I want to go take a nap "and see how I feel when I wake up." And that's the worst thing that you can do. When you start experiencing these sudden symptoms, it is important that you call 911. And you get to the hospital cause time is brain. So that would be weakness or paralysis on one side. So that could be just your arm. It could be just your leg. Or it could be your arm and your leg. It also can affect your face. So, that would be a facial droop. Just trouble seeing. So, if you start to have a loss in vision in your peripherals, or the upper part of your vision or lower part. That can be a sign. Also, if you start to see double. That also can be a sign that there's something going on. Difficulty speaking. I like to call this sometimes a word salad where someone's talking, but it's just words coming out. There's nothing that makes sense. And so, or maybe they can't talk at all and you can really see in their face that they're trying to talk. Those are reasons to get to the emergency room. Loss of balance or trouble walking. A lot of people think or have a history of vertigo. Which means that they have a loss of balance and maybe the room is spinning. And they think, "Oh, I'm just gonna go lay down "cause I've had this before." But a loss of balance and trouble walking suddenly needs to be addressed by a physician. You need to come to the emergency room. And that severe headache. I told you about that 47 year old guy that came in and blood pressure was elevated. Only thing he had was a headache. Ended up that he had a head bleed because of his blood pressure. So that sudden severe headache is also a sign. We really, really want you to get to the emergency room as fast as you can. When these symptoms start. There's medications that we can give you, to help stop the effects of the stroke. But there's a time shrink with that. And so we need you to get there. No less than 4 1/2 hours. Or no more than 4 1/2 hours from the time that these symptoms start. But the sooner you get there, the better off that you'll be. Next slide. And this is just a great way to remember. Stroke is F.A.S.T. So F stands for facial drooping. A is for arm weakness. S is for speech difficulty, and T is for you to call 911, because remember, you'll hear both Ryan and myself say it multiple times. Time is brain. The more time that you do not get treatment, the more long-term effects that you will have from a stroke. And the more damage can be done to the brain. Next slide. There you go. Every minute counts with stroke. We don't want those brain cells to die off and to cause long-term effects. So you need to get to the emergency room. You'll hear time is brain, every minute counts. And it, I can't stress that more. With everybody out there, get to the emergency room if you start to have these symptoms. Now, I'll turn it over to Rayada for the second part.

- Good afternoon everyone, hope everyone's well. I see we have several people on the call, that's great. I see Betsy and Donna, Jessica, Katie, and Linda. I'm able to pull up all the participants names. So that's great. I love... Even though I can't see you today, at least I have your names in front of me. And because well I do like be stroke talks, I love to be very interactive with the audience. And thank you very much, Katie. Great job on discussing the signs and symptoms of a stroke. Also the risk factors and how we can decrease our risk for having a stroke. All those are very important issues to know about. And thank you, Courtney for inviting us to be part of your best health virtual seminar today. Can you advance the slide please, Courtney? And maybe another time again, time is brain. Another, maybe advance one more time. Okay, let's talk a little bit about treatments. Katie mentioned those and I can remember a long time ago when I was actually a child, my grandmother had a stroke and there wasn't many, if any emergency treatments available. Back in the fifties, sixties, seventies, actually. But in 1996 is when, a medicine called tPA or activase was FDA approved for the emergency treatment of stroke. So that was like wonderful. That was like the greatest advance in treatment of stroke. Originally it was, we were able to only give the tPA, which is an intravenous medication within three hours of onset of symptoms. But then a few years ago, that time window increased up to 4 1/2 hours from onset of symptoms. So that gave us another extra hour and 1/2 that we could actually administer this emergency medication to people. So that was great. That was wonderful. It helped a lot. So, but the quicker we can give patients this medicine, the better outcomes it'll have. So it's even better if we could give it in one hour after onset of symptoms. Or two hours. So the message is just don't delay. As soon as you start having any one of those symptoms that Katie talked about. Please call 911 or get to your nearest emergency room immediately. Because I think that is so very important. I actually, I had, I went to the emergency room this morning. We had a lovely lady come in. That was actually at the gym. And all of a sudden she couldn't talk or raise her right arm. So someone at the gym was pretty savvy about all this. And they called 911 immediately. The best thing to do, right? Immediate recognition of the signs of a possible stroke. First thing you do, you go, someone goes to call 911. And so they got Forsyth County EMS immediately on the road. Immediately notified on the road. And so they were there within maybe 10 minutes, I think. And so they, we have actually also provided education for our local EMSs. So they knew immediately that this patient, this person may be having a stroke. Because they were having definite signs of a stroke. And they got her to the emergency room immediately, which is like the best thing to do. And they notify us in route. So, on the way they call us, they tell us they're coming in with a possible stroke patient. So the stroke physician on call, and I as the stroke nurse coordinator, we rushed down to the ED. Because again, every minute counts. Actually, 1.9 million brain cells die every minute after a stroke occurs. So this is important. So everybody, EMS knows it's important to get the patient to the emergency room as soon as possible. And of course we, the physicians and the nurses at Wake Forest Baptist know it's so important to get to emergency room. So, everybody's rushing to get there. We actually meet the patient at the back door quickly assess her and take her immediately for a CT scan. That's the very first test or scan that we have to perform. The reason being we want to rule out a hemorrhage or bleeding in the brain. Okay, that's the initial first thing we have to figure out and we have to identify if there's any bleeding in the brain with this lady, there was no bleeding. So that was great. That meant that it was the ischemic or the blood clot kind of stroke that Katie was talking about. So we could administer this intravenous tPA immediately. So after the scan, we got her back to her bed in the emergency room. EMS had already started IV which is great, which helps save time. We had checked for labs. EMS drew labs on the way in which is also another big help. We have to check some basic lab work to be sure everything looks good. And then we got the tPA started probably within 30 minutes of her arriving in the EV , which is like, great. We actually have a goal that we set for ourselves as doctors and nurses. So we want to get this tPA started. Our goal is less than 45 minutes now. So, we made our goal. So, that's super great. And so that's just helping the patient. Improving the patient outcomes. So we got the tPA started and within an hour, her speech was coming back. She was able to talk again, and also she was able to move, start moving her right arm a little bit. And then, we took her to our neuroscience intensive care unit for close observation for 24 hours, which is our routine. We want to watch and observe and care for that patient very carefully and very thoroughly for up to 24 hours after administration of this medicine. So I just had to tell you that story cause we just kind of have to celebrate. You know, the patient family were so excited that she's already so quickly getting better. And of course, we as the stroke team at Wake Forest Baptist celebrate too. Because it's great. We love it when it all works perfectly. Please advance the slide if you would, Courtney. Thanks. Besides this great medicine that we have available. We also have now a procedure that we can do, which is super spectacular. So we have a second treatment, emergency treatment that we can provide patients. And it is called a thrombectomy. Okay? In the word thrombectomy, ectomy means removal of, thromb is a clot. So just to break it down, it's removal of a clot. So you see there, like it looked at the top picture. You see a little corkscrew, maybe it kind of looks like a corkscrew if you will. So the interventional radiology is we take the patient to what we call interventional radiology, which is an X-Ray. And so, the interventional doctor can actually thread a little catheter up through the femoral artery under fluoroscopy. So he's able to see the catheter moving through the femoral artery, up into the brain, and he threads this little corkscrew through the blood clot. And then can basically pull it out. Okay? That's one device. Then look at the very bottom right hand corner picture. We've of course over the years have perfected this procedure if you will. So in the right hand corner is a device called a stent retriever. And that, that is also threaded up through the femoral artery, into the artery in the brain that has the blood clot sitting in it. So it can, this little mesh device can envelop that whole clot. And then drag it out? It's like amazing. So as soon as that happened, as soon as we can renew that blood supply to the brain, either by dissolving the clot. The tPA will dissolve the blood clot, if you will, and renew blood supply to the brain. So this device actually gets in there and grabs if it's a big, what we call a large blood clot or a large vessel occlusion. If we can go in there and just envelop that blood clot and then drag it out, we have renewed blood supply to the brain again. And that's basically what we need to do. We just need to remove the obstruction of the blood flow to the brain and then get blood and oxygen to the brain. Cause the brain does not like to be without oxygen and blood flow very long at all. So, as soon as we can get that blood flow started back to the brain. The patient will actually, you can see the patient improve immediately. Actually last week we had a gentleman that came in. 68 year old man that was working on construction. And all of a sudden he developed a blood clot in a major artery in his brain. Fell off the roof. And thank goodness he didn't fracture anything, but he had had a big, massive stroke. He was not a candidate for the clot busting medicine because his lab work wasn't such that we could give a blood clotting medicine. So, our next tool in our toolbox was this thrombectomy procedure. So we rushed him to interventional radiology. Was able to do this procedure, remove that big monster blood clot in his artery. And before we were able to get him out, he was actually paralyzed totally on the left side. So his left face, left arm and left leg were totally paralyzed. So, but as soon as we got that blood clot out, he started moving, which scared the doctor to death. She almost jumped through the roof. She said, because before that he was totally paralyzed in his left arm, but then after the procedure and the blood flow was getting back to the brain, he was getting oxygen. And again, he was, you know, his arm started working again. And so he reached up and like grabbed the doctor's arm and about scare her to death. She said she about jumped through the roof. So it's very dramatic. It can be very dramatic improvement of the patient. So it's so very important for patients to get here as quickly as possible. So we can help them, cause it's great. We can help a lot of people now. But our message is, to the public is, please recognize the signs of stroke and get to the emergency room immediately so we can help you. Next side, please. So that next slide. So we used to only be able to do these procedures that I just told you about. The thrombectomy, removal of a blood clot. Just up to like six hours after onset of symptoms. So that's still not a lot. We give tPA three to 4 1/2 hours after symptoms onset. Then we could do the thrombectomy after six hours, but that's still not a whole lot of time. Cause sometimes patients don't get here for three or four or five or six hours or after. So, in 2018 it was a revelation. It was like the most amazing thing ever. The thrombectomy procedure was proven in a trial that it was effective and safe to do a thrombectomy up to 24 hours after onset of symptoms. So that was huge. That was, that revolutionized, if you will, the treatment of stroke. And a lot of patients will go to bed totally normal. And, they're in the middle of the night, they have a stroke. And so we call those patients. Those patients are identified as wake up patients, wake up stroke patients. So they get a bit normal, but they wake up and they have a stroke in the middle of the night. You know, they wake up, they're paralyzed, they can't talk. And there was previously, there was not anything we could do for those patients. And that really was so frustrating to me. Not to be able to help those patients. I mean, they're, you know, I always thought I started with stroke in the Stroke Center here at Baptist 10 years ago. So I thought, Oh, that is just the most infuriating thing that we can not help this patient, you know. But then after this became approved and we were able to do it in February of 2018, we've done hundreds of these thrombectomy procedures and we have helped so many people. I feel, you know, totally get back to normal. You know, walk out of here, out of the hospital and maybe two or three days after this amazing procedure. So it's, it was huge. Next slide please? Okay, we've talked about the blood clot or the ischemic type of stroke. Ischemic is a word that just means lack of blood flow to the brain. So 85% of strokes are the ischemic or the blood clot kind of stroke. So, majority of strokes are the blood clot kind of strokes that we can give, provide those two treatments we've talked about. But the other 15% of strokes are the hemorrhagic strokes. Hemorrhagic just means bleeding in the brain, okay? A blood vessel ruptures, like you've probably, have you heard of a patient maybe that had an aneurysm? Had a aneurysm of the brain in a brain blood vessel? Like, you can have abdominal aortic aneurysms, but you can also have brain aneurysms. So you have a big balloon that kind of balloons out on the side of a blood vessel wall. And that balloon, the wall of that aneurysm or balloon gets really, really thin as time goes on. And all of a sudden, one day you might be going about your normal daily activities. But that wall, that gets so thin, that spot just is so thin it'll just finally rupture. It'll break and it'll rupture in the brain. So you have a lot of bleeding in the brain. That's called, that bleeding is around the brain. It's called subarachnoid hemorrhage, as you see on the slide. Also, arterial venous malformations, AVMs. We abbreviate to AVMs arterial venous malformations. That's just a kind of a tangle of blood vessels in the brain. So this tangle of blood vessels also can get very, very weak and bleed into the brain. The second type of hemorrhagic stroke is the intracerebral hemorrhage. Which just means inside the brain. Inside the main brain, there can bleed blood vessels that will rupture and bleed. A lot of times that's caused by high blood pressure. So, hypertension can cause a bleeding in the brain, if you will. And some hemorrhages or bleeds in the brain can just be spontaneous. You can just, you know, there, you may have normal blood pressure. And for some reason, your blood vessel walls may get really, really thin and rupture someday. So that's a little more challenging to explain sometimes. But those patients, hemorrhagic patients can have the very same symptoms as ischemic patients. And I wanted to be sure to point that out. So hemorrhagic patients can get, become paralyzed in the arm, leg, unable to speak Just all the other symptoms that an ischemic stroke patient can have. But the extra symptom or the additional symptom that a hemorrhagic stroke patient can exhibit is severe worst headache of their lives. So all of a sudden, you have this big massive hemorrhage in your brain. You will have the most excruciating headache possible if you can imagine. So that's one of the biggest symptoms, additional symptoms of a bleeding kind of stroke. Also there can be nausea and vomiting associated with that really severe, severe headache. Next slide please. I know we're running out of time. So I'll just quickly, I just want to show you a picture of an aneurysm. So that is, if you can see in that slide, that big, huge balloon on the side of a blood vessel. So that's what an aneurysm looks like. There's about a one to one ratio of unruptured and ruptured aneurism. So sometimes, I mean, aneurism can be sitting on the side of our blood vessel for years possibly. But until it ruptures and bleeds in the brain, we don't even know. We don't even know we have an aneurism. So actually, any of us could be walking around with aneurysm. But we won't know it unless we might get a CT scan for some other reason. Or unless, or until it bleeds. So, but you can see therefore an aneurysm that ruptures, the morbidity mortality is you know, mortality is fairly high, about 1/3 of the patients, will expire. And you see 33% of those patients that do have a hemorrhage from an aneurism may be dependent on others for care. And about another third will be actually, back to pretty much normal maybe and functional individuals. Next slide, please. And just want to quickly tell you about the treatment options. So there's things we can do to treat aneurysms. We can put a surgical clip on the left hand side, you see, where a patient has been taken to surgery and is having a clip put on the neck event aneurysms. So that's just obstructing the blood from continuing to feed that aneurism and keep the aneurysm growing. So if we can occlude or block that blood flow from that aneurysm. Then actually the aneurysm, will actually kinda start withering away. It will start getting smaller and smaller cause it's not getting blood supply anymore. So it'll start getting smaller and smaller and just kind of finally wither away if it will. The other procedure that we can do now, as has come into being in the last few years is called an endovascular coiling. Which is just a fancy word for, we can do this in radiology. So coiling, we have to do in surgery. I mean, clipping, we have to do in surgery, but cooling we can actually do it in X-ray or interventional radiology. So we can just take a patient to X-ray in the interventional suite and actually fill the aneurysm up with all these like spaghetti-like, it looks like angel hair pasta. Okay. So, you get your aneurism filled up with some angel hair pasta. And that will actually block any blood from being able to get into that aneurysm, into that sack. And then the aneurysm will slowly drop and blow away if it will . All right, next slide please. And that's just another picture of what a coil looks like. Next slide, please. So truly, it is a new day in stroke care. We've just come such a long way. In my years, I've been at Baptist actually for 47 years. I came here to nursing school and have been here ever since. Because I guess I think it's such a great place to work. And, I feel like we take such great care of patients and we truly care. I'd also like to mention our telestroke network. Which we have actually provided telestroke services to 20 hospitals across the state. Where we can actually beam in on a robot, on a telestroke robot, and actually help in nurturing physicians and small little community hospitals like Alleghany Hospital, Colo Hospital, Watauga Hospital for instance. In the care, emergency care of stroke patients. So a lot of patients have had access to all these wonderful treatments in, you know, Caldwell, Boon, Sparta, whoever. So, that's been quite amazing too. So, next slide Courtney. Do we have a minute, a few minutes we could entertain some questions from our audience.

- [Courtney] And if anyone has any questions, please place them up in the comment box.

- I wish we could do this live. It's a lot more fun live. And I would give you, I have, we have stroke magnet, stroke symptom magnets. We could give you some little brain, squeezy brains that we give can give patients or, or not patients, but participants of these conferences if we were live and hopefully someday soon we'll get to be live again. Does anybody have any questions? We love questions. We love to, how to clarify things. We try to make it very understandable for non-healthcare people, because we know that you don't understand some of these medical terms that we'll fill out. So, we'll be happy to answer any questions that you might have.

- I have one. If someone has a stroke, how much does that increase chances of another stroke?

- Great question. Katie, do you wanna help with that one?

- Hey, sorry I had to unmute. So yes, once you have had one stroke, you are at much higher risk of having another stroke. But the great thing about this is that once you've had a stroke, most of the time, your risk factors are quickly identified and become managed. So that means that if you have high blood pressure, we're going to make sure your blood pressure is under control with medication. Cholesterol, we're gonna make sure you have a lowering lipid medication. We are gonna make sure if you're AFib we're in control and we're on a blood thinner. So the neurology department and the stroke neurologist are gonna work hard to make sure that everything is well managed. And if you manage those. So, taking your medication as prescribed. Changing your diet to a heart healthy, low fat, low cholesterol diet. And then changing anything else like quitting smoking or cutting back on your alcohol consumption. Whatever it is that caused your stroke. Then your risk are then minimized because you're taking care of all of those issues that have caused you to have the stroke in the first place.

- Great. Thanks, Courtney. Absolutely. That was a great question. You know, one stroke does increase a risk. Because that means we've had one stroke. That means, we've got some blood vessel disease. You know, we've got some blood vessel issues going on, so it certainly does increase our risk for having another stroke. So, but as Katie said, just controlling, controlling, treating our risk factors. You know being sure your blood pressure is within normal limits. You're taking your blood pressure medicine. If you've been prescribed stuff, if you're on diabetes medicine. You know, you're keeping all those numbers, If you will keeping our numbers in good range in good levels, and good levels you know, greatly then decrease our risk for having another stroke. And also I wanted to mention real quickly Courtney, about our stroke support group. We're starting actually virtual stroke support group, which our first meeting will be on the fourth Tuesday. So that will be in two weeks I believe. It will be on the 29th of September from six to seven. We were hoping maybe that was a good time for people. And on the 29th, we will be talking about healthy eating for the brain. So, hope maybe some people that's on this call will be able to join us for the virtual stroke support group.

- All right. Thank you everyone for tuning in. And again, if you have any other questions that you would like to send, please send it to Behealth@workhealthguide.edu and we will forward it to Rayada and Catherine, Katie sorry . We thank you both again for speaking. And we look forward to hearing from you both again.

- Thank you very much, Courtney. We enjoyed it. Everyone have a good day. Thank you.