Gone are the days of stroke having only two outcomes — death or disability — now that we have a window of time to treat what still is very much a medical emergency. For Stroke Awareness Month, Dr. Priya Narwal, medical director of UConn Health’s stroke program, joins Dr. Anthony Alessi to discuss how stroke care, recovery, and even prevention have evolved over the years, how the UConn Health Stroke Center harnesses that expertise, why it remains critically important to “BE FAST.”
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Transcript
Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up to date and timely medical information provided by national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. This podcast is not designed to direct your personal care in any way, but that should only be done in conjunction with your physician.
I’m your host, Dr. Anthony Alessi, and it’s great to have as my guest today, Dr. Priya Narwal. Dr. Narwal is an Assistant Professor here at UConn Health in the Department of Neurology. She’s also director of the stroke program. This is especially timely because the month of May is stroke month where we raise awareness about stroke and the treatments for stroke.
And what better than to have an expert in that field with us. Priya, welcome to the show.
Dr. Narwal: Thanks, Tony.
Dr. Alessi: Let’s talk a little bit about your directorship of the stroke program. Again, that’s a fairly new term in terms of having a program in neurology to direct one specific entity. Can you talk about the stroke program here at the University of Connecticut?
Dr. Narwal: Sure. So when we say a stroke program, it means that the hospital is equipped to provide specialized stroke care and meet the needs of patients who have stroke or are experiencing stroke-like symptoms. So, what that entails is being able to identify stroke symptoms, realizing how urgent it is to address stroke symptoms, and also have a team in place, a team that consists of different specialties and departments such as emergency department, radiology, neurology, neuro intervention, ICU, to be able to provide expedited care to these patients.
Dr. Alessi: Let’s back up a little bit. Let’s define stroke because it’s an old term. We’ve been using this term for many, many decades, and yet it’s still so relevant. Can you share for our listeners a little bit about the specific types of stroke?
Dr. Narwal: Sure. So, a stroke is a medical emergency that is caused by interruption of blood flow to the brain. When we typically use the term stroke, in general, we are alluding to ischemic stroke or strokes caused by a blood clot interrupting the blood flow. However, strokes can be ischemic due to lack of blood flow or hemorrhagic or bleeding types of strokes that are caused due to rupture of blood vessels in the brain.
Dr. Alessi: So, when we talk a little bit about the history of stroke itself, I’m still old enough to know when it was an untreatable condition, right?
Where you brought someone to the hospital and you had them do some physical therapy, but there was nothing to do, right? And then we went to baby aspirin or using aspirin only, and now we’re using terms like “neuroplasticity” and “penumbra” and “antithrombin therapy”. Can you take us through that history of treating strokes a little bit?
Dr. Narwal: Right, so as you said, you know, earlier we did not have much to offer to our stroke patients in terms of acute treatment or minimizing the risk of disability going forward. The main focus was on secondary prevention, meaning you had a stroke, and what do we do to prevent it from happening again, which is where the aspirin came in.
However, in the late 90s, we had this incredible drug that was FDA approved, which was Alteplays or tPA or loosely called the clot buster, which if patients met certain criteria, we could give that medication and it had a positive impact on their long-term functional outcome. So that was a huge game changer when it came to acute stroke treatment, and that was the case for a long time, however, the treatment window was four and a half hours. So, if you were last known well within, you know, the previous four and a half hours, then we could treat you with the medication. But if you know, someone went to bed, woke up with stroke-like symptoms, there wasn’t much more to offer.
Also, if patients have a blood clot in the brain that is large, the clot buster may not work too effectively and those patients may not have as good of an outcome. So, in the past decade or so, we have this new intervention that we’re able to offer to patients, which is called “clot retrieval” or “mechanical thrombectomy”.
So again, if patients meet certain criteria based on what their exam findings look like, what their imaging findings look like, and they have a blood clot that we can go after, we will do that, and that has shown to have a positive impact as well.
Dr. Alessi: You know, it’s so interesting to me because as someone who doesn’t do that in the field of neurology, I think of it as literally they’re going in there and fishing out a clot from the brain.
Dr. Narwal: Right.
Dr. Alessi: It’s something that we would never even think of. And then watching someone get their function back, I think, for of those of us who have used these clot busting drugs, watching someone get better before our eyes after the administration is, it’s a powerful experience.
Dr. Narwal: It’s pretty incredible, and I think one particular case that left a mark on me was a patient who came with a top of the basilar occlusion, which as you know can be catastrophic.
Dr. Alessi: Right.
Dr. Narwal: And the patient came in, we were able to do a thrombectomy and he was discharged the next day from the ICU. That’s how good the outcome was.
The patient had practically no deficits.
Dr. Alessi: Alright, and can you describe a little bit, I think our listeners may not know what a "top of the basilar syndrome” is.
Dr. Narwal: Mm-hmm.
Dr. Alessi: Can you explain that severity to folks?
Dr. Narwal: Right, so the basilar artery is a big blood vessel in the back of the brain that supplies several critical areas that are essential to our basic function pretty much like being able to breathe and, you know, move our eyes and just be awake or conscious. So, when someone has an occlusion sitting at the very top of their basilar artery, this whole area of the brain that allows for wakefulness is disrupted and patients look comatose and have a really poor outcome.
Dr. Alessi: So that is phenomenal, really. Lately, we’ve used the "BE FAST" acronym. Can you talk a little bit about the acronym itself, and you know, has it been effective?
Dr. Narwal: I would like to think so. I do think it has helped a lot with community outreach. I do see patients in office who will tell me, you know, we called 911 because we saw this or read this somewhere.
I don’t know if we have a way to measure how effective it’s been, but the "BE FAST" acronym itself stands for “balance issues or dizziness”, “eye problems”, which could be double vision or blurry vision, or missing parts of your vision, “facial droop”, “arm or leg weakness”, “speech changes”, which could be slurred speech or word finding difficulties, and T stands for “time to call 911.”
Dr. Alessi: It’s kind of interesting because, you’re right, it’s probably hard to measure the success of it, but you know, I tend to think that anything that empowers a patient is important, whether it be breast exam, testicular exam cell, any self-examination, and certainly "BE FAST” lets somebody do their own self-examination. So, I’d have to think it’s effective.
Dr. Narwal: Yeah, I’d like to think that too. And also, you know, earlier it used to be "FAST” and then we added the "BE” because very commonly, again, symptoms affecting the back of the brain can be a little bit subtle, like patients may just feel dizzy or unsteady, and oftentimes they wouldn’t think much of it.
So that’s why having the "BE” in there has definitely made a positive impact as well.
Dr. Alessi: I want to talk a little bit about the role of rehabilitation. And, I go back to share a story. Back in the early 80’s, actually, I had just finished medical school, it was 1981, and my wife to be’s uncle had a stroke, and her mother would go to the rehab to see her brother-in-law and make him squeeze a ball so many times with this bad hand.
I mean, he would have to do it, so every day she would drive this home while he was in the rehab. And, you know, naturally I just graduated medical school, so I knew everything, right? So, I told my fiance at the time I say, “you know, I don’t know what she’s doing. That doesn’t do any good. OK? It’s a stroke, nothing’s going to get better.”
And sure enough, the guy regained the use of his hand, left the hospital, went back to enjoy his boating and whatever. So, I was proven wrong. Now we go forward another 40 years, right? And that’s all we do. We know to now use the bad hand to the point where sometimes, right, we immobilize the good hand...
Dr. Narwal: Right
Dr. Alessi: ...to get it going. So, I like to tell people that I learned the most about stroke rehabilitation from my now deceased mother-in-law more than any conference I ever went to. So can you talk a little bit about rehabilitation and the importance of early rehabilitation after a stroke.
Dr. Narwal: Absolutely.
Rehab, you know, is still the cornerstone of post-stroke recovery. Early rehab is what we really like to emphasize on, which is why when patients are admitted to the hospital, they will be evaluated by physical therapy, occupational therapy, speech therapy, to make sure we have an appropriate plan in place when they leave the hospital, whether that’s going to a rehab or outpatient services.
You know, rehab makes a huge amount of difference. There are times when I’ll see someone in the hospital and they come to see me in office and I don’t recognize them ’cause that’s how much better they’re doing, just with rehab alone. And there have been advances in rehab as well.
So, the new device that was FDA approved was Vivistim, which is a vagal nerve stimulation. It’s approved for patients with ischemic stroke who have upper extremity weakness. So Vivistim combined with rehab has shown to have a positive outcome in terms of functional recovery. So that’s been incredible, and we have a bunch of patients here.
We do offer Vivistim here at UConn as well.
Dr. Alessi: Is it an external stimulator or an internal stimulator? How is that done?
Dr. Narwal: Patient can do it themselves, but it’s an implant.
Dr. Alessi: Yeah.
Dr. Narwal: But the patient, so, either they do it during rehab with the therapist, or they can self-stimulate it as well.
Dr. Alessi: OK. Going back to my mother-in-law story, do we ever do enough rehab?
Right. Someone may go to a skilled facility, right, and they’ll get physical therapy once a day, right?
Dr. Narwal: Right.
Dr. Alessi: And even in the hospital, it’s not possible for the physical therapist to be there the whole time, right. And it impresses to me the importance of family involvement, right. And we see that in foreign countries, right.
Dr. Narwal: Right.
Dr. Alessi: I practiced in Italy before when I went to medical school, and you know, the family is always at the bedside, and, even in Haiti, we would instruct the family on how to do the therapy. Have we gotten to a point where we can increase that, but what’s the solution to that?
Dr. Narwal: So, I think a lot depends on how much the patient can participate.
I think that guides a lot of where they end up going. So, if someone is requiring a lot of support or cannot stand up without 2% assist, they cannot go to an acute rehab and undergo that intensive therapy, versus someone who was able to do that. So, I think how much therapy they end up getting also depends on how much they can tolerate.
And, you know, once they leave the nursing facility, there’s always the option of doing at home rehab. And a lot of my patients actually just like you said, do exercises on their own. Like they will ask the therapist what can they do on their own and they will just, you know, squeeze the ball or open and close their fist and do all of that stuff all by themselves.
Dr. Alessi: Priya and wrapping up, what’s the future? What are we looking at in the future of stroke care, and I know it’s such an exciting field, but when you go to meetings and talk to people, what could we expect?
Dr. Narwal: I think in terms of acute treatment, one of the big next steps is broadening the number of patients we can offer acute treatments to, right?
So like if someone has a large vessel occlusion and their scan doesn’t meet the current parameters that we look for, we’re trying to broaden those parameters. Like even if someone has a larger core infarct, can we still go in and perform thrombectomy? Will that have a positive outcome on them? So that’s absolutely the big next step.
And the other thing that’s of great interest is focusing on etiology. You know, a lot of times people say, oh, they had a stroke. All you can do is give aspirin and that’s it. But it’s not that straightforward. I think a lot of focus is now shifting on doing targeted therapy in the sense of really, you know, focusing on the stroke etiology, trying to identify that and then addressing that as opposed to like a blanket approach.
Dr. Alessi: Priya, thank you. Thank you for your time today, and really thank you for everything you do here at the University of Connecticut and for our patients.
Dr. Narwal: Thank you for having me, Tony.
Dr. Alessi: Many thanks to our guests today, Dr. Priya Narwal, who’s director of the stroke program here at the University of Connecticut.
If you have any questions. Or ideas for future programs or any specific question for Dr. Narwal, you could just reach out to me at healthyrounds@uchc.edu.
Jennifer Walker is executive producer of the Healthy Rounds podcast.
Chris DeFrancesco is the studio producer of the Healthy Rounds Podcast.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.
