Stroke Signs, Symptoms Treatment | Dr. Reza Jahan – UCLA Health

good afternoon I'm Reza Jehan I'm a physician from UCLA Medical Center I'm a specialist in what's called interventional neuroradiology it's not the usual type of field that you guys probably have heard about like a surgeon or pediatrician or an obstetrician I'm a specialist in doing work in the blood vessels in the brain so the sorts of diseases that I treat are listed here strokes brain aneurysms brain vascular malformations brain head and neck tumors and brain tumors we do some work with tumors as well but predominantly would deal with blood vessel problems in the brain and spine and one of the areas that I'm interested in that I've been working in both in my research and in patient care has been stroke and that's what I'm here to talk to you about today is stroke and one of the things the most important message I want to convey to the group here is how to recognize stroke there's a lot of treatments now available for stroke and the important thing that you need to be able to walk away from here and do is to recognize stroke symptoms and understand that you need to call 9-1-1 immediately if you are having stroke like symptoms or you see somebody who's having stroke like symptoms and get to the emergency room treatment is available but time is of the essence and I will cover that as we go through this topic that's probably the most important message I'm going to convey to you I do all my procedures through the blood vessels so we don't crack the head open we do don't do neurosurgery in the brain we don't open the brain up we do everything from the inside so when I go up and treat a stroke patient for example or a brain aneurysm I go in through the artery in the leg the way cardiologists also go in through the artery in the leg and go into the heart except I go into the brain so my specialty is up here I go from here go into the brain and do all my work come out put a band-aid here done so it's a referred to as minimally invasive minimally invasive surgery so we don't actually cut the brain anymore for a lot of these products of problems you see here again as I mentioned stroke is my area of interests and that's what I'm here to talk about so I'm going to begin by defining stroke what is stroke so stroke is a sudden impairment in brain function what does that mean the brain controls a lot of vital functions in our body the one that is most noticeable to everybody is controlling movement and sensation so the your ability to walk to move your arm and also your sensation being able to feel the touch or temperature or pain this sensations and motion is controlled by the brain if you have sudden sudden paralysis or sudden loss of sensation that would be a stroke now stroke is a general term all it means is that there has been damage in the brain or there's impairment of brain function it does not imply what the cause is there are many causes for a stroke there are many causes for a stroke and there's two main types of stroke there's two ways that the brain can get damaged and cause a stroke one is if you bleed into the brain that's one way if you bleed for blood vessel in the brain bursts and you bleed into the brain then the brain can get damaged and you will manifest symptoms that are referral to the area of the brain that's damaged if the area that's damaged from the bleed is the area that controls movement you'll be part will be paralysis if it's sensation it will be loss of sensation if it's speech it will be loss of speech if it's in an area that controls it's large enough that affects all those areas then it'll be a combination of all of those no movement paralysis loss of sensation and speech problems so bleeding is one way that that can happen that you can get brain impairment a function that happens typically in the setting of long standing high blood pressure people who have long standing high blood pressure damage the small vessels in the brain the small blood vessels in the brain and over many many years many many years damaging the blood vessels in the brain can eventually lead to one of those blood vessels burst bursting open and bleeding openly into the brain yes uncontrolled blood pressure uncontrolled high blood pressure that type of stroke is called hemorrhagic stroke you may have heard that term or bleeding stroke to put it simply hemorrhagic is a fancy way of saying bleeding so it's a bleeding stroke a hemorrhagic stroke another way that the brain can get damaged is if the blood flow to the brain stops obviously all the organs in our body need blood flow for nutrients oxygen sugar and to carry away waste products we need blood to come up bring nutrients up and we need blood to wash away the waste products and take them away so when you stop the blood flow to the brain the brain begins to starve for oxygen and begins to starve for nutrients and it stops working because it no longer has the fuel it needs to continue to work it's like running out of gas in a car the engine will stop when it stops working then the part of the brain that stops working will manifest symptoms so again if it's a part of a brain that controls movement you have paralysis part of the brain to control sensation you'll have sensation problems and for parts of rain that control speech will be speech problems so that type of stroke where the blood flow stops is called an ischemic stroke that's an ischemic stroke okay so two types of stroke ischemic from lack of blood flow and hemorrhagic from a blood vessel bursting the type of stroke that I treat that I'm a specialist in treating is the ischemic stroke when the blood flow stops I've trained in going in emergently and finding the blocked blood vessel and reopening it and when I do that I have to do it very fine and very quickly after the patient starts having symptoms otherwise it will be too late and the brain will already be dead and there's no point in reopening the clogged blood vessel if the vein is already dead that's why I need to get to people fast and that's why people have to get themselves in emergency room very very fast yes once a person starts having one can they get more you mean in the future yes did one of the risk factors for having stroke is a history of stroke okay that's true so that if you've had a stroke already that increases your risk of having a stroke in the future so I want to give you some facts about stroke stroke is the fourth leading cause of death in the United States used to be third used to be third now it's fourth due to very hard work and prevention by the American Stroke Association American Heart Association fourth leading cause of death in the United States over 700,000 people have a stroke each year 133,000 die from their strokes stroke kills more than twice as many American women every year as breast cancer and yet it's not as well known as breast cancer I think people are very well educated about breast cancer and the American Cancer Society has done a phenomenal job in educating the public in breast cancer not so with stroke were very new at this these are not treatments that were if that had been around for 30 40 years so these treatments that we're going to talk about are rather new and therefore the education of the public is lagging behind so one of the reasons we do these kinds of seminars we want to make sure that we spread the word about stroke and make sure that people know that treatment is available yeah but you get again you need to get to us fast seven million stroke survivors in this country it's a leading cause of disability and here's the most important fact up to 80 are preventable so we're going to talk about some risk factor management's and these risk factors are very similar to the same risk factors you deal with for treating heart disease obviously the risk factors that give you blood vessel problems in your heart are the very same risk factors that give you blood vessel problems in the brain leading to blockage of a brain artery if you block a blood vessel in the heart what happens you get a heart attack right you get a heart attack if you get a blockage of a blood vessel in the heart and you probably all know what that is you get chest pain rating down the left arm and up to the neck sort Nisour breath I think most people are very well aware of heart attack symptoms stroke same risk factors can lead to clogging of a blood vessel indeed in the brain and you have you can have a stroke so the risk factors for heart disease and stroke very much overlap and you manage your heart your risk factors for heart disease you're probably already doing a good job managing your risk factors for stroke on the average someone suffers a stroke every 40 seconds in the United States just some facts about stroke for you to know about and these are well-known stroke survivors you may recognize all or some of the names up here including President Gerald Ford who had suffered a stroke okay here's very important slide know the signs of a stroke so we talked about how the brain controls movement and sensation so sub number one sudden numbness or weakness of the face arm or leg so if you can't move your arm or leg or you have sudden numbness in your arm or leg or face that is a sign of stroke okay numbness and movement it happens always in one half of the body or the other okay so it's usually the right or left side that gets involved it is uncommon almost unheard of to have a stroke that will affect both arms at the same time okay the reason for that is because the left brain controls the right side of the body okay it's the opposite side of the body that the brain controls so movement and sensation on the left side of the brain translate into weakness and numbness on the right side the right brain on the other hand controls the left side of the body okay the left side of the body so problem up here translates into left-sided weakness and numbness so it's one half of the body that usually gets affected okay arm and leg on one side or the other face arm leg numbness and weakness on one side or the other that gets affected that's from the stroke now when that happens just as I mentioned you can't tell from the symptoms whether it's hemorrhagic or ischemic you can't tell until you get a cat scan done then you can tell because in a cat scan you'll see a bleed okay or you see a blocked blood vessel but from the symptoms you can't tell whether it's a bleeding stroke or an ischemic stroke where the blood vessels clogged okay the next one sudden confusion or trouble speaking or understanding okay speech speech problems sudden trouble seeing in one or both eyes typically what happens in a stroke is you lose half your visual field you don't go blind typically in one eye or the other but if I'm looking straight ahead I can't see past midline in this direction or past midline in that direction that's what usually happens you lose your let's say peripheral vision on one side is usually what happens with the stroke but if you have sudden trouble seeing and one or both eyes you need to be seen right away yes no it does not necessarily have none of these necessarily need to be permanent you can recover from these we'll talk about that sudden trouble walking dizziness loss of balance or coordination all of which are warning signs that you may be having a stroke need to call 911 get to the emergency room sudden severe headache with no known cause this is particularly true with hemorrhage with bleeding stroke okay with the skimming stroke it's not typical for you to get a headache when the blocked blood vessel is the cause of the stroke you don't typically get a headache but when you bleed in the brain you get a headache okay yes because it'll become it will be combined with symptoms it won't just be a regular headache it will be combined with these other symptoms okay it will be combined with other symptoms typically okay so another eponym that I like when you're up if you observe you think you're observing somebody that is having a stroke is this fast fast F face ask the person to smile if you have paralysis on one side of the body once I'm saying one side of the face that the lip the corners of the mouth will not lift up properly one corner will lag down compared to the other side okay so ask them to smile if you see asymmetry in their smile that wasn't there before that's weakness on one side or a arm ask the person to raise both arms if they can't raise both arms one arm is weak problem s speech ask the person to speak a simple sentence and then T time if you observe any of these signs call nine-one-one immediately okay fast face arm speech call 9-1-1 time is of the essence to get the person to immediate treatment let me explain to you what a mini-stroke TI a or transient ischemic attack is you've probably heard this in relation to stroke what it is is transient in all the symptoms we talked about weakness numbness speech problem eye etcetera it's transient symptoms that last a few seconds to maybe an hour or so it's transient it goes away now you're never going to know up front whether this is going to go away or not so you need to get to an emergency room no matter what soon as you start having symptoms you get even if you normalize you get to the emergency room okay but a transient ischemic attack is symptoms come and they disappear let me explain to you how that happens how is it possible for you to have symptoms that up and then go away the way it happens is that a blood clot can block a blood vessel and give you symptoms now the first thing that happens when a blood clot blocks a blood vessel your body goes immediately into work to dissolve the blood clot it recognizes that there's an obstruction this blood clot should not be inside a flowing blood vessel the body recognizes that that blood clot is does not belong there or instead of proteins in blood that immediately start dissolving when they see a blockage in a blood vessel they go into action to try to dissolve the blood clot so sometimes if you're really lucky that blood clot can dissolve because your body does it your body takes care of it it is particularly true when you have a small blood clot a tiny blood clot ok the larger the blood clot the less likely it will go away on its own but a small blood clot can resolve on its own your body will dissolve the blood clot if that happens you can imagine you have symptoms your body dissolves a blood clot the blood vessel reopens and the symptoms go away that's at EIA and that's how it happens okay that's how t is so if you show up in the emergency room typically people with TIAA they show up in the emergency room they're back to baseline they don't have any symptoms anymore and when we look at the blood vessels in the brain everything is open because the clot has resolved okay but T is are extremely important the reason they are important is because they are a warning sign for a future stroke okay so people who have a t IA have ten times the risk of suffering an ischemic stroke okay ten times the risk so the risk is highest in the first 48 hours it remains high over three months and 35% have a stroke within three to five years therefore number one if you have a TI you're not going to know to TI it because you're not going to know ahead of time whether it's going to go away or not you need to get an emergency room right away number two need to figure out why you had the TI so why did where did this blood call come from you need to figure that out and you need to resolve the problem otherwise another one's going to come up then next one may not dissolve okay so when you have a TI a at UCLA at least we admit you you get admitted and you get immediate workup to find out why you had the TI a if we find a problem we fix it to protect you from future stroke so TI a is very very very important it's a warning sign and it's a problem that needs to be investigated and fixed right away yes if you have what what do you think what about the pacemaker no no you can do it you can do cat scan you can't do MRI you can't do MRI but with a cat scan you can image the brain adequately and find out the problem in the brain with a cat scan we have sophisticated imaging now with CT scan where we can identify a stroke with a CT scan and also we can image the blood vessels in the brain with a cat scan and see whether something's clogged or open so MRI is better but we have cat scan as well okay so cat scan works just as well in the immediate evaluation it's fantastic so not a problem if you have a pacemaker or not a problem you get a cat scan yes the workup can they determine its clinical history only so it's not like I do a blood test and say okay you had a TI your blood tests came back positive it's by your symptoms if you come up and say look I had weakness paralysis speech problems no I'm fine that's a TI a done a complete workup let's say you had a TI a because you had a narrowing in a blood vessel here and a clot from that broke off and went to the brain and cause you to have a TI a so what mean for we find that and we fix this so that it doesn't cause a big stroke next time so you need to have workup when you have a TI a to figure out what happened why did you have a TI I can't tell you how many times I see stroke patients who come and you got the patient you're rushing them to the angiography suit to treat them you talk to the family oh yeah they had a TI a two months ago what was done well we don't know what was the cause of the TI we don't know nothing was done there was no work out nothing TI a very very important to get a proper workup when you have a TI a-okay you have to find the cause there are 20% or so of people where we never find the cause we don't find the cause but 80% or more we find the cause and we fix it so you need to get workup if you have a TI a these are some myths about stroke which we hope to dissipate stroke is not preventable cannot be treat it only strikes the elderly happens in the heart recovery ends after six months none of those are true up to 80% of strokes are preventable it's not true that they're not preventable cannot be treated not true it requires emergency treatment like heart attack in fact we tend to prefer the term brain attack because it signifies the importance and urgency of getting to the emergency room and getting treatment when you are having a stroke so we're beginning to more and more use the term brain attack rather than stroke to emphasize the importance of getting through emerges from and getting emergent treatment so stroke requires emergency treatments that's not true anyone can have a stroke it's not true that the elderly only have a stroke the younger stroke patient I treated was 14 years old so anyone can have a stroke stroke is a brain attack again a term that we prefer to emphasize the importance and urgency of this disease it's a devastating disease and it's a life-changing event if you don't get proper treatment it can be stroke recovery can last a lifetime you can recover from stroke for every s yeah so first of all there's twenty percent of people who have strokes and we never identify a cause so they fall into that category of patients that do not have it we can't find the cause we don't know why they had the stroke some strokes happen from trauma and there's no way to fix that some strokes happen from a brain aneurysm that ruptured into the brain you know we talked about hemorrhagic in the scheming so that ADA puts that 80% includes hemorrhagic and ischemic strokes and there are some things in the brain that we don't screen for and that can subsequently cause a stroke like we don't screen the population for brain aneurysms we don't it's some people have done the studies it's not cost-effective we can't afford it to the society to screen people for aneurysms if we did that would increase the number to eighty to eighty five ninety percent but some things we can't yes kiai a heart attack yes they do because when you have a stroke there is a massive release of a chemical from the brain because of the rain damage that affects the heart it's not uncommon for stroke patients who also have a heart attack at the same time or during their hospitalization at some point to have a heart attack it's not uncommon it is due to the surge of chemicals from the brain due to damage in the brain and so those two do indeed go hand-in-hand yes what's the name of that brain it's the epinephrine norepinephrine the adrenaline yeah yes yes we'll talk about that that's another heart problem that can lead to a stroke that that is a preventable that's part of the 80% that can be prevented so there was a drug for that yes yes the family history of stroke increases your risk of having a stroke I don't know if I don't remember off the top of my head by what percentage but it does you're more likely to have a stroke if you have a family history of stroke particularly at a young age if your family had strokes at young age yes I'm talking about the trauma category with a large amount of mental stress be enough to cause a stroke no not usually very very rare it would be uncommon stress chronically over many many years can be damaging to the body in general but over the short term now people were just asking about the risk of stroke there are things you cannot change there are things you cannot prevent or change to decrease your risk of stroke they're listed here age the older you get the greater your risk of having a stroke the risk of stroke increases with age you know unless somebody comes up with the Fountain of Youth we're not going to be able to solve that problem ever age is one thing you cannot change race african-americans Native Americans and Alaska Natives have a higher risk than those of other races this is largely due to risk factors that are higher in this population for example african-americans have a higher incidence of high blood pressure and diabetes so therefore they're more prone to have strokes gender stroke is more common in men until age 75 then women have more strokes than men that's largely because of the higher life expectancy of women but up to 75 it's more common in men things you cannot change family history somebody just asked about this the risk of stroke is greater if a parent brother or sister had a stroke or TIAA and that is particularly true if they were young when they had their stroke or TI a younger than 50 yes no not for these risk factors no absolutely not you know if you had a problem that required anticoagulants but you don't want to have treatment for these risk factors active treatment these risk factors mean that you need to be extra careful you need to control your diet keep your blood pressure in check exercise and obesity those things need to be kept in check and don't smoke so if you have these risk factors you need to be extra vigilant of course we all have to be vigilant but with these risk factors particularly so yes family history of aneurysms some we were not clear on aneurysm familiar of trends and aneurysms there's definitely certain genes that are associated with an increased incidence of aneurysms and families that's being currently studied there is a nationwide study to look into that yes Jeff question no okay things you can change which I mentioned blood pressure can be changed that needs to be controlled you need to talk to your primary care physician to keep that in check diabetes keep that under control reduce your risk of developing diabetes by exercising keeping your weight under control and eating proper diet high cholesterol needs to be controlled smoking stop smoking and physical inactivity and being overweight these are things that will increase your risk of having a stroke these are things you can change these are the same things that will give you heart health they're the same things that will give you brain health okay the same risk factors blood pressure diabetes cholesterol smoking and physical inactivity and being overweight so keep these are the risk factors you need to keep in check to decrease your risk of having a stroke too much salt in the diet use of some medicines such as birth control pills and hormone replacement therapy can increase your risk of stroke heavy use of alcohol and diet with few fruits and vegetables again these are things that increase your risk of stroke and that need to be kept in check in particularly in patients whom have the risk factors we talked about initially the gender the ethnicity etc family history so interestingly everybody knows that eating a diet high in fruits and vegetables is good for you and of course fast food is bad for you interestingly if you live near a fast-food restaurant you also have a higher risk of stroke so people actually studied the incidence of strokes and communities neighborhood by neighborhood and looking at the number of fast-food restaurants in the neighborhood the higher the number of fast-food restaurants in the neighborhood the greater your risk of having a stroke so if you have to move you need to move so let's talk about treatment okay is there treatment available for stroke I think there's slowly the attitudes and knowledge that the public is changing I have to tell you and be honest with you even physicians sometimes a compliant complacent about stroke treatment stroke there is emergency treatment available for stroke and that's I'm going to talk about that next what is available for stroke and again you have to get to the hospital fast in order to get appropriate to treatment one of my colleagues at UCLA did actually a quantitative study well it looked at people who had had strokes at various time intervals from onset of symptoms from looking at their MRIs he quantified how much brain tissue you're losing somebody comes in in an hour and they get an MRI how much brain tissue did they lose somebody comes in at 2 3 5 10 18 hours and looking at how much brain tissue how much brain you lose as the time goes on quantify that you lose about 1.9 million neurons every minute that a blood vessel is blocked so when the blood vessel is blocked in the brain you lose about 2 million neurons a minute fortunately we start out with a hundred billion so we can go even several hours and still be able to get that blood vessel open and and recovery enough to give the patient adequate recovery but this really quantifies for us how important it is to get to the emergency room fast to get these treatments so that we can stop this loss of brain tissue 2 million neurons a minute did drug there is a drug available now for stroke this drug was approved by the Food and Drug Administration in the mid 90s now so it's been a little bit's been 1516 years it took a long time long time for the community to get comfortable with giving this drug and community I mean the community of physicians this drug is a clot buster it dissolves blood clots it dissolves blood clots it is a drug TP a tissue plasminogen activator activator is the name of it it's actually a protein that our body makes but not enough quantities to dissolve large blood clots in the brain this is a drug we give to patients with stroke to dissolve the blood clot in the brain and reopen the blood vessel in the brain to save that patient from having further damage this drug has to be given within three hours of symptoms that's why it is so incredibly important to get to the emergency room fast within three hours more recently about a year or so ago there was a study in Europe that showed that the drug is likely effective even up to four and a half hours four and a half hours so now the American Stroke Association and the National Stroke Association recommend that the drug be given up to four and a half hours and in most centers most neurologists that come in and evaluate a stroke patient in the ER give the drug up to four and a half hours however let me emphasize one thing we've looked at the benefit of this drug in people that show up within one hour people that show up from one to two hours and people that show up from two to three hours and then three to four and a half hours the people that benefit the most are the ones that show up within the first hour then the second hour then the third hour then the three to four and a half hour so clearly the sooner you show up and get the drug the better your chance of recovery okay your your your decreasing your chances of recovery the longer you take to get to the emergency room that's been shown definitively you'll still benefit but less so than if you had shown up within the first hour when you show up at 4:00 okay so this drug is now FDA approved within three hours it is not yet FDA approved in the three to four and a half hour time window but neurologists do give it based on recommendation of the National Stroke Association now where I come in where I come in is people who get this drug and don't get better that's where I come in or people who don't get to the hospital within four and a half hours okay you get to the hospital of five hours six hours or longer then what do you do there's still a treatment available that treatment is what what I do is I go into the brain and I find the clogged artery and I reopen it okay and I reopen that clogged artery there are devices now that we have available to get into the brain blood vessels in the brain grab the clot and literally pull the blood clot down pull it out of the brain and we open the clogged artery the first such device was invented by a colleague of mine pictured here that's my colleague Pierre Gobin he's now at Cornell he invented the first device that was fda-approved at UCLA in 2004 we've been treating patients since then with this device more recently more readouts that was the first patient we treated in the world actually in 2004 more recently this is a picture of the device by the way it's what it does what we do is we take the device up into the brain arteries and put it beyond the clot and then literally we just pull it and it grabs the clot and pull we pull the clot out that's another picture of it that you can see there it's called the mercy device more recently and I'll show you what this is a case for example we treated and I don't think you have to be trained in angiography to understand this so this is a blood vessel in the brain that we're picturing and we're looking from the view from the front and I don't know if you can see that there is a stump of a blood vessel there the blood vessel starts out and then it abruptly stops do you see that stump there that that's point just barely sticking out there this blood vessels normal that ones okay but this one stops abruptly that stops because there's a blood clot blocking it so we go up with the device pull the clot out and you can see after reopened there's the vessel now open and it was blocked before so that's how it's done okay we use obviously x-rays and angiography to do our work so when we open we reopen the blood vessel and stop the stroke yes no this is an angiogram that's an angiogram the TPA are they doing it to everybody or it has to be a special yeah so IV TPA is not given to everybody you have to qualify for IV TPA one of the things we look at is a cat scan we have to do a cat scan before somebody gets TPA the cat scan has to show that there is no bleeding in the brain you can imagine giving a clot buster to somebody who already has bleeding in the brain that's just going to make them bleed more and it's going to be devastating okay one of the complications of these clot-busting drugs is that they can cause bleeding themselves there's a six percent chance that this clot busting drug can cause bleeding but it helps many many more people than that that's why we give it so you have to have a cat scan to make sure there's no bleeding you have to have an EKG to make sure that you're not having a horrific heart attack remember we talked about how strokes and heart attacks can go together and also there's a number of other criteria that we use to make sure that this patient will benefit most from the TPA there's several criteria we go down the list and make sure all of them are met if those criteria are met then you get the drug okay more recently we have a new device actually even better than the old device this is the device we use now it's largely replaced the old device same mechanism we go up grab the blood clot with it and pull the blood clot out to open the blood vessel this device has been working incredibly well in reopening clogged arteries we did a trial which I was intimately involved with as a national principal investigator along with my colleague at UCLA Jeff saber we compared actually this device to the previous device I showed you which was the Mersey device this device and this device was far more efficient and better at reopening clogged arteries compared to the old device so in and it got FDA approval in April of this year very recent a March of this year very very recent FDA approval for this device so now this has been the device of choice for stroke patients at least at UCLA so here's another example of a blocked artery so you see this artery comes to an abrupt stop there's one branch coming off down here but the rest of this artery is not moving forward so we bring the device up deploy the device and you see a gap here in the device this device is amazing because as soon as you put it inside the clot it opens the blood vessel up because it's like a stent you guys know what a stent is like a metal tube you can imagine that if there's a blocked clot and we put this across the clot it expands and compresses the clot pushes the clot away and opens up the blood vessel right away that's why we like this device so much because we get fast fast reopening of the blood vessel so as soon as we put the device across the clot it reopens there's a gap here because there's a tiny channel that's reopened inside the device the device is actually inside here right now you just don't see it on the on the angiogram and then once the channel is reopened then you begin to pull the device down and it's already grabbed the clot reopen the artery and you pull the device out and reopen the artery this is what the final would look like see the gap has gone because the clot was pulled down so we pulled the clot out and reopen the clogged artery this device works very fast so this this new generation of devices these new generation devices are working really really well we're getting very very high success rates in reopening clogged arteries with these kinds of devices again the trick is to get people to come to the emergency room fast enough for us to do this and that's one of the things that has been most challenging yes no because you never know whether you have a bleed like I said like I said when you have symptoms you don't know whether it's hemorrhagic or ischemic it could be either one you take an aspirin and you have bleeding in your brain you're going to make it a lot worse so absolutely not you do not recommend that okay okay any other questions so yes we do it under x-rays from here all the way from here yeah from this blood vessel here if you when you go home put your hand here you'll feel a pulse here just like you feel a pulse here like you feel a pulse here these are so from this artery from this blood vessel I can go anywhere in the body in this case I go up into the brain okay so we go from here the reason a lot of people ask why don't you go from here the reason is if I damage when I go in from here if I damage this blood vessel this blood vessel goes to the brain if I damage it when I go in I'm going to cause a stroke if I damage this blood vessel when I go in which only happens fortunately one or two percent of the time but it's not a big deal because this blood vessel can be repaired we can take our time we can fix it you're not going to have permanent problems from damage to this blood vessel it's uncommon complication it does happen but very rare and it's in the long-term it's inconsequential but if I go in here I damage this is big price to pay this is an unforgiving territory if I damage a blood vessel going to the brain I'm going to cause a stroke I'm sorry only from the inside only from the inside so I go in from the inside I go inside the blood vessel from inside the blood vessel I come up I come up I come up and I come up into the brain from the inside all of it from the inside never from I don't puncture the neck to go into the artery I puncture the artery in the leg to get in once I'm inside I can navigate easily upstairs with x-ray guidance get to you in a second yes no not at all not not at all so you know with with a stroke you get that paralysis the numbness the speech problems the blindness the facial weakness with a heart attack you get chest pain shortness of breath the chest pain is very different than the typical musculoskeletal pain that sometimes we get on our chest your chest pain of a heart attack have described and never had once I only can describe to you what people have described is it's like pressure on your chest like somebody took a belt and wrapped it around your chest and tighten the belt as much as possible people evidence it it's like a train running over your chest you feel tremendous pressure the pain is pressure pain okay not the pinpoint pain of musculoskeletal pain pressure and it radiates typically down the left arm or into the neck with shortness of breath and sweating that's not what you have a stroke okay it's not the symptoms you get the stroke yes yeah I had a stroke and it affected my speech only and now I've had vision problems where half of my vision was like a flame and it was both eyes ah and then I have vision problems for I have a little sparkle in a place that there is no Sparkle I understand and it's dead last a second or less and are those signs of a stroke not necessarily no those are not necessarily signs of stroke at all sometimes what happens after a stroke is you know what a seizure is you know what a seizure is a seizure yeah a seizure is when somebody for example have uncontrolled movements right so if you have a stroke in the area that controls your vision the equivalent of a seizure in that area maybe seeing these lights and flashing lights and so on do you follow me so it's not necessarily a stroke at all if it's not associated with anything else it would extremely unlikely for it to be a stroke particularly with the history of stroke do you follow me yeah yeah yeah often people describe funny signs and symptoms and headaches after a stroke and we I can never you know tell them that it means this or that or the other it really is meaningless and it usually leads to nothing those kinds of symptoms again the things you want to watch out for numbness weakness speech problem blind new blindness okay these are the things you look for that can happen yeah so the way things happen nowadays is you know we have we're obviously you say Lee's a large Hospital and we have a lot of community hospitals that work with us you know we can't cover the entire LA County so we're in collaboration with 10 or 15 community hospitals people get go to the community hospital and get the drug to IV TPA for example the TPA in the vein and then they get shipped to UCLA because in case they need somebody like me to treat them they're already at UCLA so this is sort of the the mechanism were working to serve the community we're collaborating with community hospitals that don't have people like me on board they do the work of giving the drug and then ship to UCLA for further management so this is for example a case patient was at an outside Hospital got the drug got the IV TPA and continue to have symptoms wasn't getting better so helicopter brought the patient to UCLA we take the patient directly to MRI to look at the brain see whether they have remember I said the drug can sometimes very rarely fortunately rarely less than one in ten cause bleeding so we do an MRI to look at the brain see what's going on is there's still a clogged artery in the brain that I need to go after if there is then we take the patient to the angiography suite and and we go up remember we work from the groin so there's patient lying on the table and we're going in from the groin we go in from the groin going to the brain arteries and reopen the clogged artery so here is a blood vessel that's clogged I think this one is more obvious you see a stump of a blood vessel there and that's it after it reopened you can see that it's completely reopened this is how we're working in the community to make sure that all stroke patients get the care that we're able to provide at UCLA it's impossible for every Community Hospital to hire somebody like me it's impossible it's not possible and not cost-effective but if the community hospitals which are primary stroke centers can give the drug patients get there fast get the drug and then get come to UCLA which is a comprehensive Stroke Center where they have people like me and we treat the patient and we open the clogged artery it's sometimes people come over and they get fine and we don't need to do anything they improved enroute to UCLA they improved and so we don't need to do anything but if case they do they're already at UCLA and we treat them and take care of them so just to highlight some of the most important things I wanted to get across we talked about the signs and symptoms I've mentioned those many times stroke prevention guidelines know your blood pressure have a check at least annually if it's elevated with your work with your primary care physician to control it find out if you have atrial fibrillation somebody mentioned a trooper violation in the audience atrial fibrillation is an irregular beat of the heart and this particular type of if there are many different types of irregular heartbeats in the heart when I eat too much caffeine I sometimes feel a skip beat you may you may all do that if you don't get enough sleep sometimes you get skip a beat here and there those are also irregular heartbeats but atrial fibrillation is a kind of irregular heartbeat that can lead to development of blood clots in the heart you develop a blood clot in the heart and then a piece of that blood clot can break off and get pumped into the brain and cause a stroke do you follow me so people with atrial fibrillation need to be on blood thinners to prevent the clot from forming to begin with okay that's why people with atrial fibrillation are on coumadin or more recently there's another drug called Pradaxa and there's a family of drugs like Pradaxa that are available now yes I'm sorry I can't hear you yiii unfortunately if you have atrial fibrillation you have to take a lifetime you have to take it to reduce your risk of stroke I'm sorry I'm not I know the comic book I'm not I'm not there when you have atrial fibrillation you get assessed for your risk of stroke and there's a grading system that we use to guide us as to whether a patient needs to be on blood thinners or not so it's called the Chad score and if a patient is above a certain number then those people will benefit from coumadin these have been studied extensively so there's a formal evaluation that we do if a patient meets the criteria then they get put on blood thinners there's people who don't meet the criteria don't need to be on blood thinners and have afib so it's not everybody where they fit but most people with afib typically are placed on blood thinners because they do meet the criteria for it yes comprehensive Stroke Center comprehensive Stroke Center yeah so UCLA USC also has people who are trained like us that do these kinds of procedures further down the street Long Beach memorial also I don't know if you guys know Long Beach Memorial in Long Beach Long Beach memorial also has this music in Orange County University California Irvine Hogue and Mission Hospital all have trained physicians like like what we do that can treat this yes Cedars also does I'm sorry I forgot yes Cedars also does st. John's does not not not yet they're not set up to do this not yet they have somebody who comes and goes and once in a while covers our house wonderful stroke but they don't have a permanent comprehensive stroke program yet yes we cover UCLA Santa Monica that's our group yes Kaiser sunset yeah thank you for reminding me Kaiser sunset I forgot about Kaiser sunset yeah yes are important both are important both are important so your blood pressure has to numbers you you all know that you have a top number and a bottom number and the top number is when you're when your heart contracts and forcefully pushes blood into the blood vessels that's the top number that's when the heart is pushing blood forcefully into the blood vessels when the heart relaxes in between heartbeats that bottom number is the pressure in the flowing blood when the heart is relaxing in preparation for the next heartbeat so two numbers both of them reflect the health of your blood vessels in the body both of them should be low acceptable the ideal blood pressure would be 120 over 80 ideal 120 over 80 the top the top number above 140 would be troublesome you should come down the bottom number above 90 would be troublesome and needs to come down blood pressure damages blood vessels and cause a stroke very slowly slowly over many years high blood pressure damages blood vessels over many years and if it's uncontrolled and not kept in check it damages the blood vessels so much that finally one of the blood vessels the wall thins out and bursts and causes a stroke that's a bleeding kind of stroke from high blood pressure okay so it's a chronic damaged people who have uncontrolled blood pressure from many many years also damaged other blood vessels in the body for example the kidney and end up going on dialysis because from uncontrolled high blood pressure they damage the kidneys same idea the kidney blood vessels get damaged and the kidney stops working because the valve vessels in the kidney have just been damaged in the brain you get a stroke in the kidney you've gone dialysis okay so high blood pressure damages many many organs the heart itself will get damaged from high blood pressure so very very important to control high blood pressure yes you see our other you know our vacations that is like stop taking their high blood pressure man what was it know the typical scenario is most of the strokes we see our patients with high atrial fibrillation whose blood whose drug was not working the way it was supposed to for example coumadin which is a drug that people take the finger blood is a very let me say temperamental drug it can fluctuate widely up and down in terms of how good it works with your diet for example you know so what you eat when you go on coumadin your physician will give you a list of things that you need to watch out and not eat because some of them will increase the work of coumadin thinning your blood too much some of them will block the coumadin and not thin your blood enough so sometimes we get stroke patients with atrial fibrillation who we take check their they're on coumadin but we check their blood and their blood is not thin enough the coumadin wasn't working as as it should have been other people go off coumadin with atrial fibrillation to for example have surgery for example you want to have appendectomies you want to have some other elective surgery and you have to go off the coumadin to have the surgery done you want to get a hip replacement you want to get a knee replacement you have to go off committed there's a risk when you go off coumadin before surgery during surgery and for a period after surgery during that period you're at risk so that's why it's very important to you know for the surgeon they know this to restart the coumadin as soon as they feel it's safe after surgery for atrial fibrillation so atrial fibrillation is common thing we see and usually the drug is not working well enough that's why they ended up forming a clot upstairs another thing we see is disease in the carotid here so disease in the carotid here means you have build up a plaque here in the neck artery a piece of that plaque can break off and go into the brain and cause a stroke okay that's why when you have your physician examine you they often listen with the status cope on both sides of the neck to see whether there's narrowing of the artery because when the artery narrows it makes a noise okay we're an artery narrows it makes a noise the other way to do it is to do ultrasound is a very simple thing to do is to do an ultrasound at the neck arteries to screen for disease in the neck arteries make sure they're not narrowed if you have 70% narrowing or more you should get treated because that increases your risk of stroke okay so those are probably the two most common things we see atrial fibrillation that caused the stroke or disease here that caused the stroke yes no not necessarily because remember we said other things can happen so there are many many causes of stroke just two two most common ones that we see are F atrial fibrillation and the carotid artery disease but but those things you should control of course yeah yeah with stroke it's screening the screening here if you have if you have a flip keeping that in check and then all the other things blood pressure a fib if you smoke stop maybe these are the things you need to do to prevent stroke if you drink alcohol do so moderation know your cholesterol if it's high work with your doctor to control it diabetic follow your doctor's recommendations carefully to control your diabetes these are the things you can do to reduce your risk of stroke these will also help you reduce the chance of getting a heart attack as well as you well know so these this is what you can actively do to prevent your to reduce your risk of having a stroke include exercise in your daily routine have low sodium low fat low fat diet if you have circulation problems both work with the doctor to improve your circulation and if you again most important again if you experience stroke symptoms which you hopefully all are educated on now you call 9-1-1 and get to the hospital right away people who don't respond to stroke symptoms they don't recognize the symptoms that won't be you because you now you know denial think nothing can be done not true worry about cost think symptoms will go 'we fear or don't trust hospitals so don't be one of these people respond to your symptoms and get to the hospital right away so be stroke smart reduce your risk recognize symptoms and respond immediately if you see symptoms in yourself or somebody next to you okay alrighty any questions I'm done yes yes and they have high cholesterol yes they are medication for both yes which means that you go cash and lipitor let's say okay that's not give them permission to eat sugar in fats because they're taking the medication no no not at all that's not at all true not at all true absolutely not no absolutely not absolutely not yes yeah so that's a evolving question right now we have an eight hour time window which is an arbitrary number we've come up with from accumulating experience over many years but the real answer to that question is we're developing very sophisticated EMR and CT technology to recognize how much of the brain is dead and how much is still salvageable so hopefully in the future in the very near future we will do do away with looking at the clock on my wrist and we will look at the brain itself if there is significant amount of brain that we can salvage no matter what time it is we're going to go after it if there's a significant amount of brain that is already dead no matter what time it is we're not going to go after it so this is forthcoming but right now we're using an 8 hour time limit as the time limit yes you use it or Chad how do you spell chid and what does it I don't remember off the top of my head it's an acronym for car D for assessing risk of stroke in patients who have atrial fibrillation yeah yeah a chat score okay tell me a little bit about alcohol usage so I I don't know what the upper limit of people's ask me how much is safe I don't nobody knows that how much is say we know that is the living an amount of alcohol can cause actually damage now a glass of wine red wine in particular has actually been shown to be beneficial for risk of stroke and heart attack and the reason for that is there's a chemical in red wine called reservatrol which you may have heard of which is a chemical that actually opens up blood vessels so you can imagine how that would be beneficial to open up blood vessels so and people are now working to create a pill out of that to make a pill out of that but I'd rather have a glass of wine so red wine it's like what does it do in the blood in the blood why this is why is it you mean the pathophysiology of how alcohol damages don't remember off the top of my head but it's damaging to the lining of the blood vessels amongst other things so that's one thing yes no no no yeah yeah not necessarily no I mean when I exercise my blood pressure goes up that high sometimes right so we're talking about not temporary rises in blood pressure which happens with all of us one with stress or exercise and so on we're talking about sustained high blood pressure that is uncontrolled okay okay thank you


  1. why that time limit for the tPA?

  2. Nice video. I like tgis one as well.

  3. Can i copy full video and post it in my channel???

  4. Excellent. Thank you so much Ive learned a lot 🌟🌟🌟🌟🌟🌟

  5. iranian?

  6. Excellent video! Information that could save you and loved ones heartbreak. Delivery was relaxed and easy to understand.

  7. Talk about life and environmentthat leads to stroke in copper tone people. FOOD INHERITANCE IS THE HEREDITARY FACT.

  8. I see this was made in 2012. My mom had a massive ischemic stroke. She is paralyzed on the right side of body. She has no control over bladder or bowels. Her speech is very impaired. She is in a nursing facility. The stroke happened on November 14 2017. In September 2017 she went through a similar episode. The neurologist said she didn't have a stroke? He leaned towards a seizure? But now this! Both times supposedly she was gave this T-PA. Both times she was life flighted to St Johns Hospital in Tulsa. We live in rural SE Oklahoma. So on November 14th 2017 the neurologist told me, she had a clot in her brain. He said it's in a part of the brain he can't get to? I do not understand anything that's going on! She was diagnosed with A-Fib irregular heartbeat a long while back. When I expressed concern, her primary Doctor told me, people can live for years with an irregular heartbeat? I'm at a loss. Can anyone shed some light on this situation. My opinion is the so called ball was dropped several times on my mom's expense. Help needed.

  9. Very informative…..more power

  10. when I went to the hospital for a stroke I learned unless you're having a large vessel stroke there's really nothing they can do – but send you a bill πŸ˜‰

  11. 30:00

  12. mine starts by handn a spazem in the brain it still messes me off and on spelling and some movement of hands no one here helps me so I got to see how to keep it down

  13. Thank you. I have stroke in 2014, in speech affected. I am improving as day. your lecture eye open me. god bless.

  14. Excellent lectures on modern neurosurgery and Neurology.

  15. thank you so much for the information…

  16. yessss

  17. i wish he was my professor…nevermind though i have almost got it all in 1 lecture which i didnt get in my class lectures:p…thanks for uploading the part which i dont like in these lectures is they give epidimiological data of United States

  18. thanks a lot , my brother 4 month ago has an stroke his M I R report is as under: Finding: small old lacunar infarct seen in right basal ganglia (lentiform nucleus) measuring approx.5mm, Virchow robin spaces are seen bilaterally_normal finding.Normal signal intensity of grey and white matter is seen. No evidence of any focal area of abnormal signal intensity.

  19. Amazing, thanks a lot.

  20. this is a great explanation about the stroke. my lovely husband almost 3 weeks ago has an stroke we still want to wake-up of this nightmare. never spect you sale drugs. but I'm going to think about it.

  21. great information ………….thanks Dr. Reza jahan

  22. What a brilliant man ,how I wishΒ  I had this information before my stroke rather than after

  23. stroke me hard… heheheheheheh

  24. This is Vinita i am from India i was researching about Brain stroke treatment and came across this video.
    Thanks for sharing the insides of the treatment to be given for stroke patients…
    My dad had a stroke last year November and he has still not recovered from it and i was looking if you could help me with some treatment tips to help my father come out of stroke and recover.

  25. It's a great benefit to know little bit of very important things .

  26. very good ! Thanks !


  28. Thanks Dr. Jahan, learned a lot!

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