Episode 47: Stroke and the Brain: What You Need to Know for Prevention and Recovery with Dr. Theresa Sevilis

 In this episode, stroke neurologist Dr. Theresa Sevilis joins us to break down what really happens in the brain during a stroke, who is at risk, and how recovery can unfold.  Dr. Sevilis also emphasizes the importance of addressing chronic conditions like hypertension that raise stroke risk, and how everyday choices—like choosing vegetables over fast food or staying active—can lower your chances of having a stroke.  We explore the crucial role lifestyle plays in healing—why sleep, nutrition, exercise, and stress management matter as much as medications for creating the environment the brain needs to rewire and form new connections.  We also discuss the importance of family and social support, the effects of alcohol and marijuana on stroke risk, and why strokes are increasingly being seen in younger patients. This is a must-listen for anyone who wants to understand stroke prevention and recovery more deeply. 

Find Dr. Sevilis at TeleSpecialists

Resources

American Stroke Association

Canadian Stroke Best Practices

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The content in this podcast is for general reference and educational purposes only. It is not meant to be complete or exhaustive, or to be applicable to any
specific individual’s medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis or treatment. This podcast does not create a physician- patient relationship and is not a substitute for professional medical advice, diagnosis or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different so make sure you consult your own healthcare professional before seeking any new treatment and before you alter, suspend, or initiate a new change in your routine.

Transcript

Episode 47: Stroke and the Brain: What You Need to Know for Prevention and Recovery with Dr. Theresa Sevilis

[00:00:00] Before we start today's episode, I would like to quickly read you our podcast disclaimer. The content in this podcast is for general reference and educational purposes only. It is not meant to be complete or exhaustive or to be applicable to any specific individual's medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis, or treatment.
This podcast does not create a physician patient relationship and is not a substitute for professional medical advice. Diagnosis or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different, so make sure you consult your own healthcare professional before seeking any new treatment and before you alter, suspend, or initiate a new change in your routine.
 Welcome to the starting day. We're your host, Dr. Kitty Dotson and Dr. Sarah Sheets. Two internal medicine doctors who spent years practicing traditional primary care. Over time, we realized something was missing from modern healthcare, a [00:01:00] real understanding of how everyday lifestyle choices impact overall health.
We'll help you cut through the noise of the countless health influencers and their conflicting opinions because no matter who you follow, the basics of lifestyle medicine are at the heart of it all.
Welcome back to the starting gate. We're your host, Dr. Kitty Dotson and Dr. Sarah Schuetz. every 40 seconds, someone in the United States has a stroke, and every three and a half minutes someone dies from one stroke is not only the fifth leading cause of death in the US, but it's also the number one cause of serious long-term disability.
So what makes this even more striking is the American Stroke Association says that up to 80% of strokes are preventable through lifestyle change and managing medical conditions. So while we often think of stroke as a disease of older adults, about one in seven strokes happens to people under the age of 50.
And so today we're gonna really break down what is a stroke, what's the difference between an ischemic stroke and a hemorrhagic stroke? [00:02:00] And then really understanding what are the warning signs of stroke and what can we do to help lower our risk and not deal with a lifelong 
disability and today. We are honored to have an expert in the field, Dr.
Sevillis, she is board certified in both neurology and vascular neurology. She's a vascular neurologist and director of academic advancement for Teles Specialists. Thank you so much for joining us today. Can you tell our listeners a little bit about yourself? 
thanks for having me here. I'm very excited to share some hopefully helpful knowledge on stroke risk prevention with everybody today.
as mentioned I work with tele specialists, which is a large telemedicine company in which we provide acute stroke care to nearly 500 hospitals across the country now. And what that means is when you come into the er, you get to see one of us on a screen who's there to really help guide the care team on the ground and help make sure you're getting the possible acute stroke treatments or care that we [00:03:00] can.
I've been doing this for nearly a decade now and really enjoy that opportunity to help people on probably what's one of the worst days of their life when they come in for terrible, scary event like a stroke. So we've also had the opportunity to really branch out and build some of our educational programs to try to educate er primary care physicians and residents on stroke and treatments.
 we also have ongoing in which we're trying to help improve the systems of care and how we can create the most equitable care across the country to all patients who may be in need. 
And what made you interested in strokes to begin with? 
 So my initial interests, I started out in college as an exercise science major and really liked the idea of trying to keep the body healthy.
I thought I would do cardiology for a little while. And then just fell in love with neuroscience and how the brain worked, and also saw it as the final frontier in medicine. We know [00:04:00] so much about so many organs, but the brain, there's still so much mystery there and things that we haven't quite put together yet.
So I think combining that passion I found in med school with my prior interest and cardiovascular and just general health really ended up. With stroke and some ways I say stroke called me rather than me being initially interested in it. I'll never forget one of my attendings, my intern year told me with stroke you have it or you don't.
You have to make split second decisions that affect the rest of somebody's life. And some people can do that, and other people hem and haw and think and stall. Especially when you think of your classic neurologist as they're stereotyped to being the really analytical type. A lot of people, aren't prepared to make those split second decisions.
 I'm so glad that you chose that because you now work at a place where you can impact people all across the us, which is amazing.
 Yes, it's been a great opportunity to grow where I [00:05:00] saw lack of care very early on. Nothing makes you feel as good as when a patient says to you, I can't believe . You're all away here in my rural town to take care of me.
This is amazing. That shouldn't be how it is. You should expect good care no matter where you are, and I'm happy we get to be there for those patients. Oh, that's great. 
 To get us started, can you just explain what is actually happening in the brain when you have a stroke?
So you'll hear different definitions of stroke or I guess different types of stroke, the main types of stroke are what we call an ischemic stroke, which is probably what most people are thinking about with stroke, and that is. When you have a blockage of a blood vessel in the brain, so that means that you are not getting blood flow to a part of the brain, and that oxygen, no ability to function.
And if that blood flow continues to be absent, that tissue essentially dies and you lose [00:06:00] that part of the brain. The other type of stroke is what we call a hemorrhagic stroke or bleeding type of stroke. So that's bleeding into that area of the brain, which can also inflammation death of certain parts of the brain.
 And when it comes to talking about strokes some of the terminology that we hear a lot of as well, is the word mini stroke or TIA, how do you explain that to people to differentiate that? 
So what we consider a TIA has definitely changed a lot over time. It used to be any stroke-like symptoms that lasted less than a day.
And with the inventive MRIs and better imaging, we realized a whole lot of those were just strokes, but they were too small for us to actually see. , This is actually a heavily debated subject as is a TIA even really a thing or should it be? So what I explain to patients is it really basically is a stroke.
 [00:07:00] It's just that you're lucky enough to not have deficits. So I like to see it as your get outta jail free card. You got away with this one where you're still functioning and you're not having any permanent deficits. Now it's time for us to do something because your biggest risk for an actual stroke in which you could have disabling is the next 24 hours.
So I know people come to the hospital with a TIA or they're saying, but I'm all better and I wanna go home. And having that conversation is something that happens every time I'm on, is explaining why it's important to stay and get that workup. Figure out what your risk factors are and what we can do about them immediately.
'cause you're at the most risk right Then at that moment in time and try to make them more grateful that it was a TIA and that they are talking again moving again and emphasize how important it is for us to figure this out so they can that way. 
 So you said the greatest risk after a [00:08:00] TIA would be that first 24 hours, and then does the risk still persist after that?
Yes. So after you've had a TIA, the highest risk is 24 hours. Then in a week you're still high risk and then it goes down slowly over time. But once you've had a stroke or a TIA, you now are a third more likely than the rest of the general population to have another stroke.
The single biggest stroke risk factor is having had one before. 
 Yeah. So it's if you do get that, get outta jail free card that some may have. It is definitely a time to be. Paying attention to all your risk factors in trying to make sure that you are reducing that as much as possible. Before we talk about risk factors, 'cause that's where we wanna spend a lot of time today, I think it is important for our listeners, 'cause not everyone understands how a stroke may present.
And you talked about how you're having to make split decisions 'cause this is something that is [00:09:00] in emergency. How do people recognize that they need to be rushing to the ER for a possible stroke? 
One of the mnemonics that we most commonly use is B.
FAST used to be fast, but then we realized we're missing things. So b fast means balance. So if you have a sudden loss of balance. Unable to stand up or unable to walk normally veering to one side. Any of those things would count under balance or feeling like the whole room's spinning around you.
Eyes, meaning you lose vision, you get double vision. f is for face. So that would be, drooping, arm weakness in one of your arms. legs too, So sudden weakness on one side of your body speech, which could be slurring your words, or somebody talking nonsense And then the tea is for time just to remember that it's critical to get somewhere immediately . Now one of the challenges is we can give these mnemonics, it as we can, but at the [00:10:00] end of the day, the brain is different for everyone and it's very complex and people can present in all different ways.
 I like to say if you notice your loved one having any really sudden difference in whether it's strength, the way they're moving, the way they're talking or behaving, it's best to err on the side of caution and just them in. 
And when you mention sudden, what is that kind of timeframe that people typically see this change occur?
 Somebody will be talking to you completely normal, and then all of a sudden either not speaking or word salad or you could be holding your cup of coffee and just drop it and then not be able to lift that arm up again. One of the common things you hear is it just came outta nowhere.
I didn't have any warning. It can't be a stroke. There is no warning in stroke. Strokes just tend to happen. There's no lead up. Over a few days, there's no, I wasn't feeling well. For the most part, there are certain situations [00:11:00] where things can happen that probably contributed, but for the most part it comes out of nowhere without any sort of warning.
 And are there any symptoms people coming in to that maybe isn't included in this or , they come in with a symptom and they're very surprised that you end up telling 'em it's a stroke that they thought it was gonna be something else and then they end up finding out it's a stroke. 
 What falls under balance or quote unquote dizziness is probably the most common. And that's where they just, it, it also depends on where I say the variability in the person themselves.
I will never forget one patient I had in residency. He did yoga every day. He stood on his head for the morning and then he just felt off after that and was saying he was dizzy, he could do all the tests. He looked perfectly normal. Nobody would've thought anything was wrong with him.
And he had a pretty moderate to large size stroke in the back part of his brain in the balance center. But because he trained himself so regularly, every day he noticed it. But on testing, he looked completely [00:12:00] normal. So what you do daily and how you take care of yourself really matters. But also it can be really subtle.
And I think giving benefit of the doubt to patients when something's off. Even if we can't see it, sometimes it does end up being a stroke. That may not be surprises to the patient as much as it is to the ER doctor or whoever else saw them. Like, Oh. But listening to our patients and hearing that if it's off for them, sometimes that's all that matters.
That's the struggle when you just feel something's wrong. Better to get it checked out Because that's probably the thing that always breaks my heart every time I hear it is I was just waiting to see if it went away.
Yeah. I think so many people just wanna see if that feeling is gonna go away. 
It felt strange. My arm was kinda heavy and I just figured I'd take a nap. But when you do that, then we can't help anymore 'cause we're so limited in the time window in which we can do things. So that I'm just gonna go lay down.
I'll sleep it off. The worst thing you can do in that moment. But I get why people [00:13:00] do it because nobody would think that relatively minor change that they're feeling is actually a stroke or I don't have stroke risk or there's been no warning.
So why would I think about that? I'm too young for a stroke, really is not a thing anymore or really never was. But now we know for certain that age is not a factor in stroke strokes happen from in utero through nineties. You don't even have to be born 
yet 
to have a stroke. 
Now, when people are experiencing this, 'cause I also have seen this go wrong.
When they're experiencing these stroke symptoms, what should a person do? Should they drive themself to the er? Should they call an ambulance? Should they have someone else take them? What is typically the advice that someone should hear in this situation? 
Always 
call 
9 1 1 . 
And the reason for that is you don't know which hospitals a stroke center.
 If they're not a stroke center, they can't help you. So the closest hospital to you may not be the best place to go, but the EMTs will [00:14:00] know the closest stroke center that's something that people don't necessarily know is every hospital is not equipped to take care of a stroke patient.
They may not have neurology services, they may not have CT scans that are immediately available or the processes in place to take care of a stroke. And if you drive yourself to the closest place, then they don't take care of strokes. All they're gonna do is put you in an ambulance and send you somewhere else.
So now you just lost a lot of precious time and a lot of precious brain cells. 
 Yeah, and I think the other thing people probably don't think about, even if you know you're going to, university hospital that's just 15 minutes away or somewhere that you've heard as a stroke center, when you call 9 1 1 the ER is ready for you.
They've heard about you, they know you're coming in with a stroke. They're gonna be prioritizing you through everyone else that's there. Now when you walk in the front door and then there's 10 people waiting in line to check in, again you're losing time where it's, even if you feel like you're close and you know you're going to a stroke center, just [00:15:00] calling 9 1 1 is gonna set you up to, bypass to the head of the line there.
So I think it's just always important if you think you're having a stroke, call 9 1 1. 
 And the centers that have telemedicine, we get called for those EMS calls at the same time, the hospital gets called that it's coming, then they call us and we're on screen so they get care that much quicker.
By going in that way. 
And when we talk about the time, can you just give our listeners an idea of what that timeframe is that you're trying to hit to make a difference in the treatment you receive?
the time window we have for the stroke medication, which is a strong blood thinner, there's two of 'em. One is called TPA and one is called TNK, that you get to try to break up a clot that's blocking a blood vessel in the brain. It's four and a half hours. , And that's from four and a half hours from the time you were last normal.
So say you went to bed normal and you woke up in the morning at seven o'clock, you're no longer in that [00:16:00] timeframe. So that's another important thing is that time is what we live by and it is a very hard thing for people to get right. A lot of people think it's four and a half hours from when their symptoms started.
We get that a lot from EMS too, and it's a constant kind of reeducation point is we need to know when you were normal and functioning, not when you noticed the symptoms so giving, if you do call 9 1 1 for a family member. Making sure you give EMSA phone number even if you are following behind them.
' Every second counts. And if we can call and ask the right questions to clarify what that time is early on, it makes a really big difference. And then the other treatment we do, which is a procedure, most people understand what a cardiac catheterization is, where they go in and do an angioplasty and open up a heart vessel.
So that's usually how I try to explain it, except they take a turn and they go up to the brain instead and they try to pull out the blood clot if it's a really [00:17:00] big one and one of the larger blood vessels. And that procedure can be considered for up to 24 hours. The thing is though, that's not the majority of cases where there are candidates for that, the medicine is used far more often.
So it's really that four and a half hour window is. Really short when you think about being normal and somebody noticing it, getting to a hospital, getting a CT scan, seeing everybody, making sure we know the medicines you're on and that you don't have a reason that you'd be a really high risk for bleeding, that we can't give you the medicine.
So a lot has to happen in a very short period of time. 
Yeah. So again, , if you have any question, just act like it's a stroke until proven otherwise, call 9 1 1 and then hopefully everything will fall in that window for you so you can get the best options that you can.
And I always say, never feel bad. Come in, get checked out. That's what we're here for. We want to make sure you're okay. If it's not a stroke, we're [00:18:00] just as happy as you are. We don't want you to be having a stroke either. But I'd much rather people come in, even if they are worried about appearing silly or overreacting.
Nobody's thinking that. We're thinking that you're being proactive and taking care of yourself and great if it's not a stroke, and if it is, then we're here to help you. So there's never a reason to feel silly for just calling 9 1 1 . when it comes to strokes, , as you had mentioned, is once you have one, you're at high risk for more.
I feel like a lot of times we talk a lot about our heart health and we don't spend a lot of time talking about our brain health and all the different things that we can be doing to reduce this risk.
What are some of those risk factors that make the biggest impact in your stroke risk? 
think part of why that happens is that cardiovascular , is all lumped together with cerebrovascular. There's a lot more research, there's a lot more data on heart attacks than there are on stroke. And stroke has just gotten [00:19:00] so lumped in with that where we're assuming a lot of things are the same for good reason 'cause it's both blood vessels getting blocked.
So it does make sense. But yeah, there certainly are some differences in, in strokes. First heart attacks. We always say all the cardiology came first. They had the procedures, they had the drugs. They were using it all first. And it took us longer to safely do it in the brain being a much more fragile organ than the heart is.
And I can tell you in my training, all we ever used to do was say, oh, just think about what everybody says to protect your heart. That's the same thing to do. It's very limited, the education that is given to neurologists and then therefore what's given to patients about how to really use lifestyle and not just the drugs to prevent stroke, it's really not talked about and training at all.
But focusing really on those other disease processes and how to treat those. So cardiovascular disease is [00:20:00] obviously a big risk factor. 'cause if you have any blockages in your blood vessels anywhere, we're dealing with blood vessels again. So that's a risk. And along with that is your high blood pressure diabetes and high cholesterol.
So all the things you would typically think of for your heart health too. . When you wanna start getting into more of the lifestyle risk factors. And in our society that has become so sedentary that's a huge factor in people not moving around not getting the same amount of exercise.
And I think we're seeing that for health across the board as society moves to internet and sitting in front of computers all day long, nobody's outside moving around as much anymore, and our diets are getting filled with processed foods, chemicals, basically just all sorts of stuff that really is not, natural for our bodies to be processing and to be keeping us healthy.
 it's easy to think about stroke risk factors. The way you get taught them is, okay, I'm gonna take my aspirin, I'm gonna [00:21:00] take my statin, and I'm gonna make sure my diabetes and blood pressure is good. Send people on their way. That is the classic training and standard medicine and all of those things are important.
Not trying to downplay those things by any means, but there is much more that you can do. And I think one thing that gets lost, because when you have a heart attack or you have a stroke, you come out of that very differently. You have a heart attack, you survive that. You might be a little generally weak, do some cardiac rehab, but you're not having trouble with one side of your body or with your balance or with your vision. And while we go through therapies to try to help patients get that functionality back, the idea of sending a stroke patient off to the gym to go start exercising afterwards or telling them to go start taking walks every day, that may not be safe.
It is something that has to be considered is how do we get them from what they have deficits wise to a place where they can exercise and where they can get physical [00:22:00] activity And it's something that I think needs a lot more attention than it really currently. there is stroke like rehabs in which you go and do some therapy, but it really is more focused towards the actual deficits that they're having.
And then you get cleared and sent on your way. I would love to see that extended further. Let cardiac rehab centers where, okay, your deficits are gone. Now let's focus on your long-term exercise goals and How do we get you strength training so that you are more metabolically healthy? How do we get you getting that 150 minutes of cardio a week?
We love to throw out these numbers oh, you need this, but how do you do that? And what does that look like for you? If you don't like to walk, what if you enjoy some other sort of activity? How do we help patients figure out what's gonna keep them motivated and inspired to stay moving?
 And we know that moderate to vigorous physical activity can reduce stroke risk by up to 25%. What's actually happening in our body [00:23:00] that's providing that decrease in the risk when we're exercising for our brain, 
a lot of that really comes from the cardiovascular component.
I really do feel like that aspect is very similar. It's not something that's happening to the brain tissue, it's what we're doing. Keeping the blood pumping, getting the blood vessels more functional and overall, reducing your lipids, getting your blood pressure better. Blood pressure is a very big factor for stroke Not necessarily the ischemic, but even more so the hemorrhagic, the bleeding kinds of stroke. So having high blood pressure is the number one biggest risk factor there. At least modifiable risk factor. If you have an aneurysm, you have things like that, you can't control that. But if we can get you to have normal blood pressure, that is a huge part of the bleeding of strokes.
So a lot of things are relatively indirect because the brain organ itself is not what's causing you to have a stroke. It's those blood vessels that are 
in your [00:24:00] brain. 
And I think that's a good clarification 'cause I think people get confused 
about that.
Yeah. The brain tissue dies because of the lack of blood flow to that area or the bleeding in that area 
 one of the coolest things about that that you don't get anywhere else , or at least not in the same way, is so you lose one part of your brain. And when you think about when you're recovering and everything else you're doing to try to get better after a stroke is other parts of your brain are now trying to rewire themselves to do what that dead tissue did.
And so people expect okay, am I gonna be better tomorrow? You're asking your brain to do something incredibly complex. You're asking it to learn all these new skills and information and a part of the brain that has never had to control that before. And some people's brains do a great job at it, other people's don't.
So I think that is a big question we get asked all the time is when am I gonna get better and am I gonna get better? Or how much better? And I [00:25:00] wish we knew, but we cannot, we don't really have , a good idea of what. Makes one person have a large stroke and end up completely back to their baseline and another person can have a relatively small one and really not recover.
 So it's really very individual. Sometimes it's the location. There are some parts of the brain with very tightly packed neurons there that are very important and can't be made up for as easily. But other than that, age is one of the big ones. If you're younger and have a stroke nobody wants to have a stroke at a young age, but you do tend to recover a lot better than somebody who has one and say their eighties or nineties.
Not that they can't recover, but it, it definitely is more challenging for the brain to rewire itself at a later point in time. Also, 'cause you have less neurons. ' cause our brains do shrink over time, so there's less there to try to make up for it. it's a very complex process of recovery there.
 while people say three [00:26:00] months is when you'll have an idea of how you'll be doing and where you'll be going with it. The end of the day, I've seen patients recover to a year and beyond. So I say never get discouraged 'cause it didn't happen early. But it's the work, it's the therapies, it's the exercise, it's the care of yourself and going above and beyond.
It's not the aspirin I'm giving you, it's not the statin, but actually taking that time to really challenge your body and your brain, both physically and mentally depending on what your deficits are, to really help that rewiring happen and help you actually improve and recover. So while risk factor is one aspect, risk factor reduction for exercise.
It's also a huge component of the recovery and keeping all of that brain tissue as as possible and helping your body with that, that rewiring and figuring it all out so that you can regain things that you lost. 
 That's a great [00:27:00] explanation because that is so unique. That's different than how we look at different organs in the body when we're talking about exercise and it's doing multiple things and that's why it's so powerful for stroke.
Yeah. 'cause it has direct effect on the vasculature and improving circulation, which is probably gonna help you heal from a stroke, not just thinking about the prevention, but then exercise also increases BDNF or brain drive neurotropic factor. I wonder if that has any component in, restoring any of those neural connections, if that assists in that in any way.
 There is so much research going on, we just have little. Solid evidence on how it does. There's so many different little chemicals people are studying or different pathways and ways that they're trying to find it. And I think we'll get there, but we haven't quite found anything that solidly works to improve things yet.
 In the meantime, exercise. 
Yes, exercise and trying to eat healthier. I think those things matter because making sure [00:28:00] that you are, as I know carbs the bad word, everybody just thinks, oh, if I eat carbs, I'm gonna get fat. Carbs are the worst thing in the world lately. But really carbs are the only thing your brain works off of.
So making sure that you're not going keto after your stroke, your body doesn't wanna have to work to convert protein into carbs, to give it to your brain to do the work it needs to do. And carbs doesn't mean go eat a loaf of bread. It means eat your fruits and vegetables so that way you're getting your brain the fuel it needs to do that recovery and that repair.
I like to tell patients your brain is in recovery mode for at least a year. It's working on healing itself. If you think of a bruise that you get on your arm and how you watch it change colors and the stages and it goes away, the same thing is essentially happening in your brain. You damage some tissue.
It's trying to, resorb little bits of blood that have happened. Trying to regroup itself and repair itself. It [00:29:00] just takes a whole lot longer in the brain and you wanna really get your rest sleep. Another really important one, we haven't touched on getting your sleep. 'cause that's when your brain repairs itself.
It's focusing, it's doing a million things while you're awake. But when you're asleep is really when we see the most. Pair going on at a microscopic level, cleaning the garbage outta your cells and doing all this stuff to make your brain function optimally. So letting your body rest when it's tired and fueling it appropriately during the day make a huge difference in that process.
And I, I think it's really important for patients to think of it in terms of they have control and it's not just taking your pills every day. ' Post-stroke depression is huge. People we're fine and then all of a sudden they lose a lot and just split second. And it's really hard to deal with, especially when we know depression is brain chemical issues.
And now you're having damage in your brain that's also [00:30:00] going to interfere with brain chemicals. And it's a very common issue to have that lack of motivation. So I think empowering patients to realize. How important all the little things they do, such as what they choose to eat, getting themselves out of bed to go take that walk or go to therapy or do whatever they can to really help themselves it back is really important in both the cognitive aspect of themselves motivated and helping recover from the depression component too.
 Yeah. And yet depression is an anxiety or also some of those risk factors for stroke., If you have depression or anxiety, you're at increased risk of stroke. But then if you have a stroke, you're at an increased risk for depression and anxiety. And so it can be a bad cycle there. 
 And it's really interesting how in the last, decade or so, it used to be patients would come in and they had this.
Huge stressful event where just been so [00:31:00] overwhelmed and so much either stress or anxiety, depression, whatever going on in their lives. That's why I had a stroke. And we never previously had any evidence of that. It was always no, this is just something that your body did. you didn't eat well, you weren't taking care of yourself in other ways.
And maybe the stress impacted that. But it's very interesting now that we actually do have some studies showing that depression and the changes that happen with that actually increase platelet adhesion, which means the platelets getting stickier and blocking up in the blood vessels, which would increase your risk from stroke.
So the idea that it wasn't related always rubbed me the wrong way. I am like, how do you get so many patients that come in and say All this stuff's going on, and how do we say stress really plays new role? nice to see the evidence coming out now that it does, and, taking care of your mental health in that way is one of the ways to reduce your risk of stroke if you are having major depression or anxiety or just completely overwhelmed with stress in your life.
Yeah. That is increasing your stroke [00:32:00] risk as well as your heart attack risk and everything else. So those are just as important to address as 
any of your other risk factors. I know that's one of the things we always like to talk about on the show with lifestyle medicine because I feel like until I did a lot of education and lifestyle medicine, I didn't address people's stress as a risk factor in, in actually, like how can we.
Reduce how you're responding to this stress because it's making a big play in your overall health. And so we know this about stroke and we know this about our heart health as well as many other autoimmune conditions. You name it. Stress has a big impact. So I really think it's important for our listeners to hear this is, we can't always get rid of stress in our lives depending on what that stress may be, but we can try to manage it differently and knowing even though we can't see what's happening in our body, it is making a difference in our [00:33:00] overall wellbeing.
Yeah. And in your risk of other disease and even diabetes, and certainly in blood pressure, which you've already said to us, is the number one risk factor for strokes. So really thinking about. How you're managing your stress and is there anything specific that you tell patients that have suffered a stroke and are now dealing with a new onset depression?
Any specific thing that's particularly helpful for them is are there specific cognitive behavioral therapists that help in that regard? Or is it the same standard approach? 
in general, I think staying positive, knowing that you may recover, giving yourself a little grace and know that there'll be good days and bad days.
And trying to be somewhat mindful of how you're reacting because you know a lot of patients very hard on themselves. You know those type A patients who're probably getting it related to stress, who really want everything to be perfect and feel like they're doing everything perfectly. And just think, sometimes you have to take a step back and breathe.
[00:34:00] And also we do have studies that show. Study were specifically to Prozac, but that taking the SSRI improved motor recovery. And so you have to pause there and say are they approving motor recovery because they're getting outta bed to do stuff 'cause they're not as depressed? Or is it truly coming from the brain?
Chemicals we don't really know, but most patients will be very hesitant to take something like that because they're like, I'm not crazy. I just had a stroke. Like, why do I have to take, a depression or anxiety medicine? And, the stigma around that. And they're very hesitant to do it.
But I do tend to encourage it as a short term, not forever, it's not a lifelong thing, but if we add data that shows that people can get their motor function back and meaning moving their muscles and their strength think of it that way. I think it's. The overlap. I personally think you're more treating the depression and that's what makes the motor come back better because they're more able to adhere to their plans and just more motivated to do so when you're not feeling depressed, [00:35:00] but can't prove that either way.
So if it is truly just doing the motor, that's usually generally how I present it, is that I know you're gonna have heard of this as a, a psychiatric medication, but we have evidence that it improve your stroke and get your strength back. So let's just do three months and let's plan on that and see if it helps you.
And sometimes that's what you need. Other times it's give yourself grace. It really depends on the patient kind of getting to know them. And often I will say to their families, you know them better than I do. Are they the person that's gonna overdo it? Are they the person who's gonna underdo it? And that's how we need to approach their plan going forward.
Do we need to motivate for movement or are they the person that's gonna work themselves to exhaustion I need to give them a limit. Tell them this is your exercise max for 
the day. Not that I don't love those patient, as you just mentioned. 'cause rest and sleep is also gonna be just as critical as the physical activity.
So all of our listeners, you can't get by without doing all the pillars. That's right. 
Yes. You have to think about all the components. If it's, you need to be limited to getting up [00:36:00] three times a day. If I need to tell you, you can only take three walks for this first week, and then I'll tell you a little touch base again after that.
I love the motivated patients, but there are definitely those that need to be pulled back and I feel like I'd probably be one of 'em. So I can understand probably that personality type a little better. I would have to have roles, I 
would 
definitely have 
to put limits on Sarah for sure. 
Yeah.
Yeah. You get to set some boundaries and other people who need the motivation. You know what, if you. Wanna be able to pick up your grandkid again. You're gonna have to go take these walks there's definitely a, I think a lot of individual that need to be taken here. Like most of lifestyle medicine, none of us live the same life. And you have to find out what incentivizes each patient to do all the right things. Eating right, moving right, and sleeping right.
And you brought up a pillar just then that, that I actually hadn't really been able to find much data on or connection. But you were talking about motivating with family or asking the family. And I think that social connection is probably really important in the recovery process, maybe even more than the prevention process.
[00:37:00] But social connection and support during recovery, I imagine is. correct. Oh, it's huge 
if you're gonna recover or not. I think so much of that depends on the family you have, particularly if you have an aphasia. And aphasia is difficulty either understanding speech and what's going on in the world around you or being able to express yourself and say what you're thinking doing.
 That's when the social connection is so and so many people shut down ' cause you can't communicate your wants and needs anymore. And it's very interesting to see what a supportive family can do for those patients. I've had so many patients come back and they've developed their own form of language, like the spouse, can totally everything they and need.
But that's time, that's effort, that's dedication of a loved one to being able to interpret what they're trying to communicate when they can't speak anymore. And. I've seen some amazing cases where it's [00:38:00] that's all credit to usually the wife, sometimes too, but more often than not, when I've had those great scenarios, it's a very dedicated wife who has really been able to figure it all out.
And she would be like interpreting his answer to my question that are like grunts and hand gestures and to me mean absolutely nothing. But to them, they have their own new language that's unique to them. And I could only imagine, that one particular patient that always comes to mind because his wife did such an amazing job.
, What his life would've been if he didn't have somebody who was willing to do that for him. I don't think he would've been doing anything that he was then. He, she was taking him out places, still going to see grandkids, sporting events going around. Yet he is completely nonverbal in a way that anybody else could understand but her, so those family members that really dedicate and are there for patients is huge.
A big shout out to all the caregivers out there. Yeah. 'cause it's hard work. It is hard work. 
Oh yeah. Yeah. And then they need their own support groups too. And those [00:39:00] exist and if you are one of those and you're feeling burnt out, definitely search for them because it is the hardest job because in a lot of cases it ends up being a forever job.
 when you do have a stroke like that where somebody's never gonna speak or walk again it's lifelong. It's not like that shorter term recovery from other disease processes. 
Yeah, no, that's so true. I do wanna bring up one pillar that we haven't touched on yet, and that's risky substances.
Could you just touch on both smoking and alcohol use and how that plays into risk? 
smoking, again, similar to cardiovascular disease, it is a big factor in the buildup of plaque in the arteries, stiffening of the arteries, and therefore increasing your risk for stroke. , And that includes cigarettes than vaping.
 There is no reason to think that vaping is any safer. , But the one thing about smoking is that you can stop and we can see things reverse. So it's something that is very worth addressing and probably [00:40:00] one of the things that gives you a lot of bang for your buck because you can actually reverse the damages that it's in those blood vessels and therefore reducing your risk factors.
\ I haven't actually looked this up, but one thing that I think is unique to brain over cardiovascular is that marijuana use is actually a stroke risk, whereas I don't know if it causes the cardiac issues, but. we found is those who are really heavy marijuana users, it actually causes vasospasms of the blood vessels in the brain, which means they squeeze tighter and just hit these little block offs of just the muscles in the blood vessel squeezing.
And we actually do have some data of that. the suspicion was there for a long time. I did my residency in LA and growing up in an area where there was, marijuana was legalized first, we would see 20 somethings who were no risk factors, very heavy marijuana users, and.
There was just no way. I believed that it wasn't related. So it's nice that [00:41:00] we actually do see those valo spasms now where they've done, to actually show you those blood vessel spasms 
 . And in regards to that, is there a difference between smoking it and gummies per se?
Just as this is now across the US there's, it's legal in so many places. You see all these different options and how to use marijuana, 
so the data comes from smoking. So I don't think we know at this point if the gummies would have the same effect. There's certainly potential and I think it's something that you do need to be aware of, even if you're using it medicinally and not recreationally, is that there is certainly a potential for it in any form.
 the. Other kind of risky substances, cocaine, amphetamines, those all make your blood vessels constrict and increase your risk for stroke as well. So that maybe not legal substances, but still substances to be very aware of that because honestly, it surprises you sometimes when [00:42:00] you have 80 year olds in nursing homes who are suddenly trying these things for the first time.
Yeah, the gummies is a big one. That would be in all sorts of different contexts of people thinking they're having a stroke or sudden memory loss or strange feelings throughout their body. And then all you find out is they used a gummy for the first time But that was a trend for a while.
I think early pandemic that the gummies were gone around the nursing facilities for the first time. I guess nothing else to do. I would say, did you take anything? Maybe a gummy Oh yeah. I had three of them. And just call the ER doctor back. I'm like, okay. Hydrate them. Give 'em a little time.
 They, they did some gummies. But nobody thinks of asking your 80-year-old patient that Yeah, you don't, but we need to now. Honestly, I don't blame them. At that point, you lived your whole life. You didn't do anything. You get proposed with the idea of trying something new.
You're 80, you wanna do it, whatever. You made it that long. You wanna experiment. Experiment. But we have to realize there can be consequences to those experiments. And definitely realize anybody can be using substances that are risky and should deserve that conversation. 'cause [00:43:00] I'm sure that 80-year-old taking the gummy there has no idea that could increase the risk for stroke.
Exactly. 
Because they've only heard about smoking. They're probably familiar with that, but have not heard about marijuana use. 
And your teenagers, 20 year olds when you have a 20 something year old who has a stroke, they are just like, what in the world? This is not supposed to happen to me.
And none of them would've thought that just smoking a little marijuana that's legal now is what could cause that. But it does. And you remind them cigarettes are legal, they cause how much damage, alcohol's legal, it causes how much damage. So just 'cause it's legal or not has absolutely nothing to do with its ability to harm your body.
. And with all the energy drinks and, nicotine gums and all these kind of uppers that people are using for energy, do you see any of those causing a problem when it comes to stroke 
energy drinks? definitely. The in same ways they, they're causing damage to your heart.
And really it's coming from the cardiac side of it when you're giving yourself these massive amounts of [00:44:00] caffeine. They can throw themselves into AFib and then throw clots to the brain. So that's one mechanism. Also, the hypertension, when you're having all that caffeine, it increases your blood pressure.
I actually had this conversation with a patient not that long ago, having five of those monsters or big energy drinks a day, relatively young patient. When you're basically on a constant infusion of it, you're keeping your blood pressure high and giving yourself that, that increased risk.
And on top of migraine and other things, you're giving yourself risks that amount of caffeine is not naturally occurring in anything. And that was one of the things that I had discussed in that kind of education piece, is try switching to a cup of coffee, switching to a cup of tea, switch to something that has a normal amount of caffeine per volume of liquid.
And you're just, that would be enough. Even if you're still gonna have five a day, that's still gonna reduce your risk dramatically than having it in something that's so artificially high in caffeine. . I personally, way too sensitive to caffeine. I get palpitations over [00:45:00] a full strength coffee and I use half calf, . It blows my mind when heard the amount of caffeine, like 200 milligrams or something, and the caffeine drink, or one of them was a big cancer. It was like 400 milligrams, 400 milligrams of caffeine in one beverage. That's crazy. So definitely not something we recommend 
to touch on.
Another beverage. How is alcohol related to risk for stroke? 
Alcohol is not good for our brain cells, not good for the functioning of the brain individually, aside from blood vessel portion. But again, alcohol increases your risk for hypertension.
People who end up drinking a lot of alcohol tend to not be getting the other nutrients that their body needs to function.
 And so it's another one that is more modifiable, not as direct of an impact like the marijuana, where we can physically see what it's doing to the blood vessels. But really the damage it does to all the other organs leads to the damage in the blood vessels and then the damage in the brain. On top of interfering with how your blood chemicals are [00:46:00] working, you think about one of the stroke symptoms is being imbalanced.
And we do tests that are similar to the sobriety checkpoint tests, and people are like, why are you checking to see if I'm drunk? If one of the tests to see if you're drunk is one of the tests to see if you're having a stroke, pretty clear that you are doing damage or affecting the functioning of a very important part of your brain.
And while not strength specific, but that's one of the things we see with heavy alcohol use, is actually and shrinking of that balanced part of your brain. What really bothers me more about alcohol is what it does to your brain itself, even more so than your stroke risk factor, which is certainly still there too.
But there is that direct organ damage. And, shrinking of the brain and loss of brain cells that you are doing while drinking and stroke recovery is then impacted because you have less brain cells to recover with. On top of it, increasing all those other [00:47:00] risk factors doing to the blood overall there is not very much That's good nowadays.
 There really is no good amount of alcohol for you. and I never tell somebody that they can't, enjoy a glass of wine here and there except for right after your stroke.
I always recommend at least three months after stroke, zero alcohol. Your trying to repair. Don't make it harder. Don't kill cells while it's trying to regrow cells and trying to reconnect and make those new connections there in order to get you back functioning.
 That's a absolute no no, no in that recovery time period. But, beyond that, you wanna have your celebratory glass of champagne. You really enjoy your drink. I'm not saying nobody can have anything, but we can't pretend it's good for you. 
 And moving away from that old adage that it's okay to have, for women a drink a day and men two drinks a day, I think , there's too much coming out that what we used to give as an okay was too much.
Yeah. 
Even the American Stroke Association does say drinking an average [00:48:00] of even one drink a day does increase your risk of stroke. So as well as binge drinking. 
I still think of my grandma who lived till 93 and she had her one glass of red wine every night because she was fully convinced that was healthy for her.
She made it to 93, so it didn't hurt her at the end of the day. She still made it that long, but I don't think it was because of the of red wine every day. 
think it was despite that, and I you mentioned just a little tidbit on this, and I think just for a little bit further clarification for our listeners, you mentioned atrial fibrillation, which is an abnormal rhythm of the heart.
How does that link to a stroke risk? Because I know that's a lot of times when people start, when receive that diagnosis is sometimes the first time they've actually started thinking about stroke prevention because of that connection. So can you explain that connection for our listeners? 
Your heart is made up of.
Four different chambers, as we call it, four different spaces. And the two on the top are called the atria, and they [00:49:00] have their electrical activity that makes them pump. When you think about the bum boom of the heart, so one of those is the atria pumping. When you get atrial fibrillation , those atria are not pumping anymore.
They're quivering or shaking rather than doing a regular pumping motion. And when they're not pumping and moving that blood smoothly, through, they can start to develop little blood clots on the wall of the atria that are just shaking there. And then if they do get a good beat that breaks through, it can push that blood clot out of the heart and up into the brain and cause that blockage that's.
Essentially the stroke. Now they can throw those blood clots other places too. So the brain's not the only one that we worry about with this, but it is one of the biggest places that they end up landing. And that's where if you have atrial fibrillation, there's lots of different ways that we score it now and determine who needs a stronger blood thinner, who can just be on an aspirin.
And really [00:50:00] that's all educated guesses on how high your risk is of actually having one of those larger blood clot and there's lots of controversy with atrial fibrillation because as you get older, having a few beats of it here and there becomes increasingly more common as the hearts just for lack of better way of saying it, wearing out over time and not as functioning as perfectly as it does when you're young.
And do those few beats here and there matter as much as when it goes more constant and sustained. Some people live in that heart rhythm and they're just staying there all the time once it starts. And those are definitely higher risk and more people for the stronger blood thinner. Other people, it can be provoked by dehydration.
That's a kind of relatively common thing that happens to people and also with our lifestyle of taking care of 
yourself. 
 you can trigger it. the list goes on and on. Things that can cause you to flip into AFib for just a few beats here and there is quite extensive medications at other stressors on your body.
But that's really how it [00:51:00] ends up equaling a is when it forms those blood clots and sometimes it can even form a very large blood clot that can actually be seen on a, on an echocardiogram or when we take a look with the ultrasound at the heart. And then you really have to break down this large clot and hope you can do that without it big chunks up to the brain that can really do very serious damage.
 One thing I think we mentioned briefly, Sarah and I can't let go in an episode and that is nutrition. I know the Mediterranean diet has been shown to reduce the risk of stroke and when they've looked at risk factors for stroke, poor diet is one of those modifiable risk factors, and just increasing fruits and vegetables can reduce your risk of stroke significantly.
20 to 30%. What do you usually recommend to patients as far as not overwhelming them with a full diet overhaul but some way to, to get started as far as improving their stroke risk or recovery from a stroke, 
 I try to focus [00:52:00] mostly on those fruits and vegetables and trying to replace the processed foods
 preparing meals at home or avoiding fast food restaurants figuring out how they're eating in the first place is the first step. And then seeing what you can do to start making little improvements with them. sodium, such a huge component of the diet and the fact that the vast majority of sodium has absolutely nothing to do with what you're shaking on top of your food.
It's all in these prepackaged foods or in restaurants., When you start cooking at home a lot, my, I'm very lucky in that I have a husband who cooks for me on a regular nightly basis, and we go out to eat and I feel it. You go to any restaurant, even nice restaurants, and I come home craving water and feeling like I dehydrated from all the salt in the foods.
When you don't cook like that regularly, people just don't realize that. So I'd say for a lot of my patients, particularly. Those that are a lot [00:53:00] lower income and don't necessarily have the luxury of homecooked meals every night. the ability to buy all the fresh produce that they need is trying to find ways to work around the fast food stops.
Because I feel like that's the biggest factor in their diets that's the main staples. Starting to think about to eat things at home replace a snack with an apple or a banana. There are some fruits that can be relatively cheap or vegetables, frozen vegetables, great way to do it.
They don't have to be fresh. You can get it from, the frozen section and that can be just as nutritious as if you're getting the fresh ones. But reducing the food, I think is the biggest. Thing that most of my patients end up needing and trying to help them come up with alternatives to that in ways they can get other foods.
Yeah. And for our listeners, if you've never looked at the nutrition facts from some of these fast food or even the quick [00:54:00] service options, 'cause I know there's a misconceptions like, oh, but I got Panera. If you look at some of these options and how much sodium is in the food, it will blow your mind because you, you can in one meal have twice as much sodium that you're supposed to have for the entire day at times.
So it's is worth just a look just to understand, especially if you're dealing with high blood pressure or you're wanting to reduce that stroke risk or thinking about your heart as well, making sure we're not intaking too much sodium. Just take a quick look and you'll see why we're giving the advice that we are.
 And that's another place where family comes in. Family talking to the family members, I'd say more than the actual patient, often makes a difference of thinking about what could you eat differently? What could they do to help you prepare something? Could you have carrot sticks available Could you make sure there's some apples and bananas or just thinking about any sort of fruits to have [00:55:00] around that are just easy for people to grab rather than the bag of chips. , I think the best place to start for some people, if they're not big fast food, is what's your snack that you grab most often?
If it's a bag of potato chips, that's a really great place to start. What can you grab instead of that bag that is far healthier? And if you really are anti fruits and vegetables, then maybe some nuts even that's better than grabbing a bag of chip. Ideally unsalted one. You could do that. 
And any other thoughts on, just thinking about the other.
Modifiable risk factors, obesity, high cholesterol, diabetes. For patients listening that may have those that have never had a stroke, do you have any particular suggestions for them as far as making sure they have those controlled to reduce their risks 
and I think it all kind of plays together, and the fact that if you are eating better and you're exercising, that usually plays a big part into the obesity factor.
Now, yes, some obesity is genetic, but I [00:56:00] don't feel like that aspect is necessarily as high of the risk factor as the being active and eating well. I think there's a very large misconception in our society that if you're not a stick figure, you're not healthy. But I love seeing that changing that muscle matters.
Having a little bit of fat on your body's not the end of the world. And I think it really comes down to how you are functioning and what you can do to do that. So the goal is not always a hundred percent about weight loss, but being a healthy weight often comes along with controlling the other risk factors.
 If you're a diabetic and your sugars are sky high, have something to do with what you're eating and putting in your body in inherently, you know that it's just part of it. So if you get that healthier diet and you control the diabetes, that's going to reduce your risk for a stroke. It's going to reduce your risk for heart disease.
It's going to make you feel better. It's gonna let you probably lose the weight that you're looking to [00:57:00] lose and be more active in general. I think these same things we've already discussed are gonna help all of those variables and in the end, reduce your risk for 
That makes me think, Sarah, we had Dr. John Kotter, a cardiologist at University of Kentucky on back in February, and he was talking about not thinking about diet and exercise and these other healthy lifestyle activities as a treatment for weight or obesity, but thinking, of, it as a treatment for your heart and your blood vessels.
And I think the same thing here. We have to get away from thinking about these healthy lifestyle patterns as being something to solve a weight problem. It's something to help your brain be healthy, to help your heart be healthy, to help you feel better and live a happier life that you can enjoy.
And so if we can dissociate those things, I think we'll all be a lot better off. 
And it's, not that it's everybody's problem, but thinking weight, BMI, they're very imperfect measures. Mean, everybody doesn't have the [00:58:00] ability to get their muscle mass weighed or their percentage body fat accurately done.
But those are the things that truly matter. Your weightlifter, their BMI is gonna be above a 25, but they're not unhealthy. Their weight also is probably gonna be something that would make other people wanna cry. But, to them that's what they're shooting for. Muscle weighs more than fat.
So the number on the scale is not what matters. Your energy level, how you feel. Can you function in your daily life? Can you run up a flight of stairs? Can you pick up your child or grandchild? Do you carry your groceries without issue? All those things matter so much more than the number on a scale because that doesn't truly reflect your functionality and your brain health, your heart health .
Our society, in my opinion, puts way too much emphasis on numbers on a scale that really are pretty meaningless when it comes taking care of yourself. So yes, making those decisions to care for yourself not to reach a [00:59:00] number makes a lot more sense. 
 So do you find that there are any big misconceptions people have about stroke or their risk for stroke that you wanna make sure we address today?
 Yes. I think it's very common for people to think of stroke as a disease of the elderly, and it absolutely is not anymore. And I don't know if it ever really was. I think that may have just been who we were looking for it in. younger patients are usually more female, if somebody's having a stroke in their twenties, while we do see it happen and men, it more commonly happens in women and a lot of it is often hormonally related.
' cause estrogen birth control pills can give you an increased risk, particularly for those who have migraine and migraines with aura can be at higher risk for stroke at a younger age. And I think in the past people just assumed it's your migraine or woman's being hysterical and all the stereotypical things that they do and they [01:00:00] would get ignored.
And if they never got an MRI or they never got the workup, we weren't diagnosing it. There is a big question of are we having strokes younger or are we just considering that it's possible and finding them. And because young brains recover better, , they didn't have those long-term consequences and we were just missing it.
I feel like the average patient I used to see when I started with neurology was probably 60. I would say my average age patient's probably in their forties now. and I don't know if we're doing a better job looking or if it's really shifting younger.
That's really hard to say. But we are finding those younger strokes, whether it's a product of our society being more sedentary early, or you hear about all the increased levels of anxiety, depression in children, the sedentary lifestyle and the mental health issues. Is that the years of that when it didn't used to exist now impacting them at a younger age because they're not getting outside, they're not doing the regular kid [01:01:00] things and all of that.
That's certainly a possibility. Or the other flip side to when people have strokes younger is that they have, hypercoagulable conditions or genetic conditions that lead their blood to be thicker and put them at a higher risk for stroke at a younger age. Pretty much if we see a male having a stroke in their twenties, majority of the time they have one of those conditions.
Or I've seen it with the really high use when we haven't found them. Not that sadly, you don't sometimes find the 22-year-old who has hypertension, has diabetes, has obesity, has high cholesterol, and you're like all the risk factors are, and we definitely did not see that 20 years ago where you had such a young age patients with these diseases.
 the big misconception would be thinking of this as a disease of the elderly. It is not anymore. And it really shouldn't be thought of that way. It's something that you can think of in anyone at any age. Honestly, I think we should be starting [01:02:00] to get, 
BFAs signs up in dorms in high schools.
Yeah. I have gone into my kids schools and told them about it, not only because. Young kids are many times the one we have that called 9 1 1 and saved grandma and grandpa or mom and dad. So it's wonderful to get them to know the stroke risk factors early, but also it could start happening to their peers and nobody else would necessarily be around to notice or identify it other than those kids.
So we need to get it out there earlier and make sure people know that it can happen at any age. 
You also just mentioned estrogen and the risk there, and we touched on this last week with Dr. Duval when we were talking about migraine, but we are seeing a trend in women as far as estrogen use going up again.
Are you seeing any increases in stroke related to women using more hormone therapy now the lower dose hormone therapy versus birth control? 
I have not personally. And I haven't seen any data to that effect, although I think it's a newer trend. That, [01:03:00] I don't know if we would see the data yet, but in my clinical practice I have not noticed that as an increased 
good.
Yeah, 
and I think to clarify for our listeners, and we talked about this in our menopause podcast that we did, is birth control is usually a higher dose of hormones versus HRT that many women are receiving for menopause. 
And using the topical estrogen through an estrogen patch is also going to have a lower risk of that than the oral estrogens as well as far as increasing clotting risks and stroke risks.
So just another thing to keep in mind, 
 An aside comment to that for any young woman who does have or still childbearing age, a woman who does have a stroke. Never let anybody tell you. It means you can't have birth control. It just means not to have estrogen. There are plenty of other types of birth control that you can use.
The number of times I've [01:04:00] had patients come to me and say, I was told I could never have birth control again. That's just not true. And that's a disservice to our female patients and make sure to know that you can, you just need progesterone only and there are multiple options. Yes. Thank you for that 
clarification.
And for anyone that's looking to find more resources and more education for themselves on stroke and risk factors, are there any resources out there that you feel are reliable for patients to go to? 
American Heart Association has some great resources on their website. Canadian stroke of society also has some really great resources and they give some very specific recommendations on things you can do. And they get a little bit more specific than the US recommendations 'cause they're not as strict on it having to be randomized clinical trials in order to make those statements where here we want everything to be Class one data.
And there they're a little bit more lenient on making some [01:05:00] recs that are really easy for people to follow. So I think their sites are a great resource 
well. Just to recap a few things we've talked about today. When you have a stroke, it is a portion of your brain that is not getting blood flow and then that portion of the brain essentially dies.
A TIA or a mini stroke is. Actually probably a stroke. It is just one that you got lucky enough to not have lasting symptoms with, but now we know that your odds of stroke will go up significantly from the general population if you have had one of these in the past. And so you need to be particularly careful about looking at those risk factors that we've talked about today. If you have any signs of stroke and you can think about the BFAST acronym, if you have any signs of anything that worries you at all that is different from your normal, it's always worth just getting checked out.
So call 9 1 1. That's the best way to get the best care and get [01:06:00] assessed fast because your brain is losing neurons quickly If you are having a stroke going on. So thinking about your risk factors, you wanna think about if you have any chronic diseases like high blood pressure, high cholesterol, diabetes, obesity, you need to make sure you're treating those also atrial fibrillation.
And then thinking about things like physical activity, diet, and even things like stress and depression that you may be experiencing. And if you are smoking, please try to. Seek help to stop doing that because now we know that you can reverse those risks that you have gained while smoking. And then alcohol, there's really no safe amount.
Drinking is going to increase your risk of stroke and do 
not switch those two for marijuana is what we heard today as well, because that is something that you hear a lot of people say I don't want the risk of smoking so I'm going to use marijuana. But you heard it here that it is also [01:07:00] increasing your risk of stroke.
And I love what you said about recovery after a stroke and really thinking about letting your brain heal just as you would let another body part heal. So making sure you're getting restorative sleep. Making sure you're getting good nutrition, making sure you're getting exercise and doing all the things to let your brain heal, avoiding alcohol, avoiding anything else that's gonna stress your brain to let it heal the best that it can.
And not to get frustrated. You'll have good days and bad days and don't think that in just a few months you may not continue to recover. You can continue to recover, keep pushing yourself and try to stay positive through that. before we let you go, can you just tell us a little bit about what a virtual neurologist actually does to help a patient that may come in with stroke.
So the kind of premise around telestroke, which was one of the really early adoptions of telemedicine. Is the [01:08:00] ability to have a stroke expert at the bedside, really anywhere and not just in these large academic or tertiary care centers. 'cause we do know that you're more likely to get treated for a stroke if you have a neurologist seeing you than by just the emergency themselves.
And so we're really there real time. . We might be on a screen, but the camera quality we have these days is very good. We can still see what people are doing. And we have nurses at bedside that are trained in how to be our hands for the things that you need to do that require a touch or interaction.
It is in some ways really a separate skillset because you are having to figure everything out without touching a patient. But there are a lot of tricks that we use in order to do that. One great example is I can usually get rolled into a room. Sometimes I know right away they're having a stroke because when you lay in the [01:09:00] bed and your legs are normal strength, both of your toes are pointing up.
But if I come in and I see one set of toes is pointing up and the other side is tilted over to the side, I already know that patient's weak one side. So just 'cause we can't touch you doesn't mean we don't have lots of ways of knowing that you're already having an issue. And so we really are able to use those cameras to, 
Figure out that you're having the symptoms you're having and get you care quicker.
If your ER doctor had to get on a phone and try to call a neurologist to come down and see you, which could take 10, 15 minutes if they're across the street in clinic or in a different part of a large hospital campus that's delay in care and we know. At least 2 million brain cells a minute that you're losing during a stroke.
So we don't really want those extra 10 minutes of somebody to walk there. or if you didn't have it at all, sometimes people and any smaller ERs would just wait. So we found that not only does faster care happen, but [01:10:00] it's also very interesting that when you introduce the idea of telestroke to some small hospitals, they'll say, but we don't see stroke patients.
We, we've never given the blood thinning medicines like ever. And then they implement our services and you treat multiple in a year and you realize you are seeing strokes, you're just missing them. So it's that extension of getting higher quality stroke care into smaller, more rural centers.
Because if we're not spread out and there isn't a lot of places in which you can see a neurologist, then there isn't going to be the ability to treat. At the end of the day, it's about 12% of strokes that get the blood thinner. And it's not really only because of eligibility it's because of access to care.
So having one neurologist sitting in a large center waiting for a stroke to come in versus having the neurologist be able to be on screen wherever they're [01:11:00] needed and constantly have their knowledge being used makes a whole lot more sense
for some people it can seem impersonal. It's really about being practical and my ability to be in 10 states in a day, that wouldn't happen otherwise. You would only be carrying in that one place and you see far more acute stroke patients and get far more treated when we can extend our hands all over the country as opposed to just one building.
 I love that. Do you have any stat to give of what you all have been able to accomplish?
We as a company we give the most blood thinner. I think the last I heard it was about 10% of the treatments in the US are given by one of our neurologists.
 We see about 20,000 patients a month. We see a ton of acute neurology patients.
 We're so glad you guys are able to provide care to these areas that wouldn't be able to have a neurologist guiding them in this scary time.
 As you mentioned, it 
would be for someone. So hopefully you all have enjoyed [01:12:00] today's show. We are so happy that you came on to provide all this information for our listeners and for our listeners, if you have a. Family member that has recently had a stroke or has high risk factors, please share this show so they can learn all this knowledge as well.
And as always, if there's a topic that you're wanting us to cover, please just send us a text. Click below or you can email us at contact at the starting gate podcast.com. We love to hear from our listeners to know what other information you all would like to hear and we're excited about next week.
Our last show dedicated to neurology that we're doing this month is going to be about dementia. Dr. Dotson and I are gonna take a deep dive into all the lifestyle factors that are related to this rapid rise in dementia that we're seeing today, and give you the information on how to do your best at decreasing your risk.
I 
look forward to talking to you next time.