Save Your Brain. Prevent Stroke. ft. Dr. Sudhir Kumar | The Sid Warrier Podcast |

Introduction and Importance of Stroke Awareness

[00:00] Hi everyone, welcome to today's podcast episode. We have a very interesting topic to talk about today and a very important one, one that can possibly save your life or the life of someone in your family. And that topic is stroke. Stroke is a very important topic that all of us should know about because it's

[00:20] something that can happen to any one of us at any point. And to talk about stroke, today we have a special guest with us, Dr. Sudhir Kumar from Apollo Hospital in Hyderabad. Dr. Sudhir, welcome and thank you so much for joining the Sid Warrior podcast. I'm honored to have you here both as an expert subject

[00:40] expert on the matter and a fellow neurologist. So you are the first neurologist on my podcast, so welcome. Yeah, thank you, Dr. Sith. It's my pleasure to come to your podcast and it's a topic which is dear to you and plus to me and it will benefit a lot of our viewers also and listeners. So definitely it's a very important and timely topic.

Real-Life Stories of Stroke Patients

[01:00] Yes, absolutely. Stroke is something that we grew up seeing through MBBS, MD and DM and our understanding of stroke has evolved so much over the past few decades. Earlier our understanding was that it is a sudden

[01:20] sensation of blood flow to the brain and there is nothing much that can be done about it but over the last decades so many more treatment options have come. There is so much more hope when it comes to stroke both in terms of preventing stroke and in treating stroke. So I would like to ask you

[01:40] right at the start some anecdotes or some stories that you remember when it comes to stroke. Yeah definitely because stroke is one of the commonest diseases. So unfortunately we end up seeing lot of patients with stroke even though we do not want to see stroke patients but you know almost we can say

[02:00] other than heart attack and cancer, stroke is the most common disabling disease and also responsible for many deaths. So, if I remember some stories of real stroke patients who I saw, almost I see one acute stroke case in a day. So, the one woman who was almost slowly

[02:20] 93 years old and she had a sudden onset weakness of just the right hand and she was staying alone. I think the irony is that she, her son was a doctor and he is a very qualified and famous doctor in the US and but when she had the stroke she was alone at home but she knew that there is something wrong at around

[02:40] 9 pm she came to our emergency and I was there and then she was in the window period for thrombolysis. But if you look at you know we look at something called as anhydrous stroke scale score to see decide whether we can give the clot-buster drug or not. So that was coming as 2 or 3. But the woman it was the right hand and she will be handicapped because she is staying alone and

[03:00] has to do everything on her own. So we spoke to her son on the phone and he also agreed that and with the consultation with the patient also. So both of them decided that she needs the clot-buster drug even though she is 93 but she has to be independent and we proceeded with the treatment and she had a good outcome and so that is one of the

[03:20] cases I remember distinctly it was almost more than 10 years back. The second case or story which I remember nicely is that it was a conversation happening on the phone. So, one mother who was talking to her daughter who was in different city and during the conversation the daughter on the other side she

[03:40] what is there is something wrong with the mother because she was asking something and the answers were not up to the mark. So in our neurology language what we call is verniculophagia. So there is some amount of comprehension issues and she realized there is something wrong. So she called the neighbor and neighbor came and saw and again it was diagnosed to be a case of stroke and she could

[04:00] be also thrombolyzed and given the treatment. The one common thread that all these stories highlight is how stroke can present in many different ways and how acutely it can come. Just a patient is completely fine, in fact they are not a patient in one second and at the next second they are

Recognizing Stroke Symptoms Using FAST

[04:20] personality can change, they are not able to use their hand or their leg, they are not able to speak or they are not able to understand. Depending on which part of the brain the stroke has affected, the presentation can be very varied. So, the awareness that patients need to have is

[04:40] that there is no one way that stroke can present. It can be many different ways. Yeah, definitely. So, you know, the B one of the common words we remember is something by the letters FAST which is widely used and F refers to the face which is the facial droop or asymmetry on one side, A refers to

[05:00] the arms where one arm is weak and it tends to sag down and S refers to speech whether difficulty in speaking or comprehension and T for the time. So, we have to recognize that they are all in time-bound manner that stroke symptoms can be it is an emergency and they should come to the hospital as early as possible. And having

[05:20] said that there could be a few other symptoms also like sometimes vision. So, suddenly if somebody is not able to see especially in one half the visual field or somebody becomes a toxic what we call in coordination, they have a drunken kind of gait or sudden severe headache. So, there are some of the other symptoms which can be common symptoms of acute stroke. Acute stroke, absolutely.

Increase in Stroke Cases Among Young People

[05:40] When we see the incidence of stroke over the last few years, we have noticed an increase in stroke happening in young people. So earlier stroke used to be considered an old person's disease. You know like heart attack, memory loss, this happens after 50, after 60.

[06:00] But now we are getting more and more cases in the young and this is especially unfortunate because young people can take their health for granted. They think that we don't have to be so careful, all these diseases will happen later. What do you have to say for that? Do we take health for granted and what can we do to

[06:20] change this? Dr. Sridhar is absolutely right. So, when we were training, all the books and the professors told stroke is a disease of older people, 60 plus. But by the time we became actual practicing neurologists, we saw just that all patients are younger, at least a decade younger than the Western figures population and then as we

[06:40] we are seeing in the current in the last few years even the patients are in their 20s, 30s and 40s very commonly. So, this is not a good thing and then straight away we can look at few of the reasons, possible reasons for stroke affecting our younger population and one is that the working hours have extended. So, in our parents time I do not remember

[07:00] working beyond 5 pm on even one day. So by dot 5 o clock he will be back home. But today like when you ask somebody do you finish work by 5, he will think it is a joke. So routinely they work for 12, 13, 14 hours and as a result the sleep gets reduced. So reduction in the sleep time, stress levels have gone up because people have more aspirations.

[07:20] So, our parents, they thought of buying a home close to retirement, but now people, as soon as they have a job, they want to take loan and then have a, buy a home. So, the EMI's are going up. So, financial stress, personal stress, men's. So, stress is also common and then not to forget because of all this the time for exercise has reduced

[07:40] So, people are more sedentary sitting for 8 to 10 hours in front of computers, availability of junk food. Junk foods are freely available. So, we do not remember in our childhood going to restaurants or eating, that is a rare occasion. But today it is like a norm to go to restaurants and then ultra-processed foods have become very common.

[08:00] are all multiple factors which have led to increase in the risk factors for stroke and strokes affecting younger population also. Yes, absolutely and you have highlighted some very important lifestyle changes that have led to this. None of these changes have happened overnight. There is a gradual shift but we can

[08:20] definitely see the trend and it seems to be getting worse with every passing generation. Sleep habits seem to be getting worse, the amount of stress that people are taking seem to be getting worse, which makes this conversation even more important because in that case, the likelihood of stroke happening in younger patients will go up.

Immediate Steps to Take During a Stroke

[08:40] which is a very scary thought. Yeah that's what so we have already seen in our recent published data that prevalence of diabetes, hypertension, obesity, overweight all have gone up in the younger population and almost I think 4 out of 10 youngsters they are affected in one of these you know two or three metabolic disorders what we discussed.

[09:00] When it comes to an actual case of a patient having a stroke, there is a lot of confusion and panic around it because the relatives are not informed, they don't know what this is, they don't know what is happening. To the patient themselves, it can be a very scary moment to suddenly find that they're

[09:20] unable to lift their hand or unable to lift their leg. What are the immediate steps that a patient or their close ones can take if something like this were to happen? Yes, stroke is a medical emergency, no doubt about that and it is quite scary because suddenly at one moment the person

[09:40] is normal and the very next moment they become a patient and that too with severe disabilities and sometimes patients can rapidly worsen also. So, what the family members should do is that they should not panic because that is the time when you know it is a we have to work with full caution and you know calmness and what is required is to make sure that you know

[10:00] their airway breathing, they are not compromised. Sometimes they can have vomiting. So, make sure that the saliva or the secretions, they do not choke the airway. So, turn them on the side and if any bleeding is there, those things are not so common. Another thing is because they are weak and paralyzed, they have a tendency to fall. So, make sure that they do not try to walk once they have fallen down, give them some

[10:20] support and put them on a chair or on the bed. So that is the first aid and then immediately they have to call the ambulances. We have in Apollo 1066 is the, in most of the cities we have these ambulance services which are fully equipped. So as early as possible we have to transport the patient

[10:40] from the home or wherever the stroke has happened to the nearest stroke ready hospital and all Apollo hospital has stroke ready and but in case there is no Apollo, the nearest hospital which is stroke ready, the patient should be transported to that hospital and that is the first thing and nowadays we have trained paramedics, ER physicians,

[11:00] they have facilities in the ambulance also to they can you know the first aid and BP can be stabilized because we know that for clot-buster drugs the sugar and BP should be normal. So, those things can be stabilized by the time patient reaches the emergency room and definitely as soon as the person reaches an emergency then we have the

[11:20] trained people, immunizing physicians and the neurologists will take over the care from there as per the stroke clinical pathways. Yes. A very important point to highlight here is the essence of time because a lot of patients miss out on valuable treatment options

The Golden Hour and Why Time Is Critical

[11:40] simply because they take a wait and watch approach that let me see maybe this will get better in a few hours, let me drink some water, maybe let me sleep for some time. We cannot highlight enough the importance of the golden hour. So can you tell us a little bit about that? Yeah, that's

[12:00] is a very crucial point you have brought on and let me give some real statistics or the numbers to that and we use the phrase called time is brain and why do we say that. So, after a patient has suffered stroke where the blood supply to part of brain has got blocked or reduced, then every minute is crucial. So, if you look at per minute

[12:20] time that is passing after the stroke, about 1.9 million neurons die. In a single minute, 1.9 million neurons. If you look at synapses, that is the joining of the two neurons. So, about 14 billion synapses they get damaged. And if you look at the length of the myelinated neurons or what we call

[12:40] called nerves that is about 12 kilometers of nerves. So, this much of damage happens in a single minute and if you look at the 1 hour, let us say somebody has delayed the stroke treatment by 1 hour, then almost 3.6 years of aging, it is equal to 3.6 years of aging. So, normally also when a person becomes older, the brain ages.

[13:00] or degenerates. But after a stroke, just one hour of delay in the stroke treatment can lead to 3 and a half years of premature aging. So, we are looking at significant neuronal loss or nerve damage in the brain with every single minute. So, even though we know that stroke treatments work up to

[13:20] four and a half hours. One did not wait till the end of that four and a half hours, earlier the middle. So, it can, if it is done in let us say 20 or 30 minutes, we can save much more neurons of the brains than let us say if somebody gets to treatment at one and a half or even two or three hours. When a patient reaches the hospital, you already talked about clot-pustered treatment.

Treatment Options: Clot-Buster Therapy and Surgery

[13:40] treatment and just so that the audience understands when a patient suffers with stroke, a part of the blood circulation stops because there is a clot that is interrupting the blood flow and this clot-buster treatment will go into that blood vessel and dissolve that clot so that blood circulation starts and the sooner we dissolve that

[14:00] clot, the more brain we can save and all the statistics that you mentioned will apply here. When we think of clinical interventions to treat stroke, what else is there that a patient can expect once they reach the hospital? Yes, I think these are very important points to discuss, Dr.

[14:20] to say it. So, we only mentioned about the clot-buster therapy that is the commonest treatment we offer to the patients and that is that can be done in the hospital only because many patients say can we keep some tablets of aspirin at home and we will give aspirin tablet and that will dissolve the clot. The answer is no. See no aspirin or no tablets can dissolve the clot. So, they are mainly to

[14:40] prevent recurrence of the stroke. But when the patient has suffered a stroke, the only treatment is by giving the injections which can be done in the emergency or in the hospital setting only at the moment. And so that is why coming to hospital is important and in the hospital once scanning is required in most often once CT scan is done that is enough for us

[15:00] to decide whether patient is eligible for this treatment or not. And then their advanced treatments also sometimes we have bigger clots in the bigger arteries of the brain and then mechanically the intervention radiologist or neurologist can take the patient to cath lab. Again that should be done as early as possible the windows may be slightly 1 or 2 hours extra.

[15:20] that does not mean that we have to delay for that and there the clots can be removed mechanically and very rarely surgical options are required especially in a person who has a big clot in the back of brain in the posterior fossa. So, there sometimes emergency surgery can be life saving or sometimes in the one half the brain is totally in fact

[15:40] it and the big clot is there and swelling. So, in these conditions, surgery can be life-saving. So, surgery does not remove, you know, increase the functions, but at least in some cases it can be life-saving. All these things can be done in the hospital setting. So, it is a team approach. We have a team of radiologists, interventional radiologists, neurologists and neurosurgeons who all work

[16:00] together in emergency physicians and the critical care doctors. So the entire team is responsible and not to forget the nurses who are responsible for all the caregiving. Yes, absolutely. That gives a comprehensive view of what the patient can expect once they reach the hospital. But even before they reach, as we have spoken,

[16:20] Stroke can happen anywhere. It does not come with too much warning. So you might be driving, you might be at the gym, you might be in the shower, you might be in the office. So everyone should know what is the first step to do. As you said, ABC, which is taking care of airway, breathing, circulation, getting your blood

Stroke Recovery: Rehabilitation and Medication

[16:40] pressure checked, making the patient lie down. But also equally important is knowing what number to call and many people will know key emergency, we have to call an ambulance. But in that moment of panic, they might freeze, they might not know what to do. So,

[17:00] how important is it to have that stroke helpline or that emergency number that everybody almost has on speed dial so to speak? Yes, that is very important. So, one number, emergency number should be there. So, whether we call it stroke number or heart attack number, so if there is one single number

[17:20] that is well-enquered. But at least so that number should be known to the entire family and it is like how we have for police and then fire alarm and many other things. Similarly, we should have a medical emergency number and as of now we have the Apollo gives 1066, then the comment side we have 108 and sub

[17:40] hospitals they have their specific stroke helpline numbers also like few hospitals have that. So basically so it should be planned because normally we do not plan for the unfortunate events. We only plan for the good things like where you are going for vacation next time and we have the travel agents number very very handy. But we have

[18:00] to also plan for unforeseen or unfortunate events like this because this is a matter of life and death and once we have that number prominently displayed somewhere at home, then we will not panic at that stage or even a family physician or physician's number, so that can be also very handy. So, they can guide the person, patient to seek

[18:20] Faster help. I feel this is a good idea to have stroke drills. Just like we have fire alarm drills and emergency evacuation drills. Just have drills of what will happen if somebody in your family has a heart attack, what will happen if somebody in your family has a stroke and this can be done at a residential level, at a society level.

[18:40] a very good idea, it will probably save lives just by doing this practice. When somebody has a stroke and assuming that they got to the hospital in time, they reached in the golden hour, they got their throat buster treatment which we call thrombolysis. After that, is there anything else that

[19:00] we can do for them to improve their quality of life and does the treatment continue after that? Yes, I think that's a very important point. So, we can classify it into two parts. One is the medical part and then the rehab part. So, medically our aim is to prevent a recurrence of strokes. As you know, like if somebody has got a stroke once, the risk

[19:20] recurrent stroke meaning the stroke happening again is almost 20 or 30% minimum. So, in that we have to take care of the risk factors like blood pressure, diabetes. So, BP should be kept within 130 by 80. For diabetes HBA1C target should be below 7. If they are overweight or obese then weight should be

Preventing Stroke: Lifestyle Changes and Annual Checkups

[19:40] normalized, lipid levels should be kept normal and then exercise should be part of the routine at least 30 to 40 minutes of aerobic exercises 5 days a week what is recommended. So, and then of course healthy food. So, these are these both a long way in preventing a stroke recurrence and whatever medicines have been prescribed by the doctors. So, please take

[20:00] regularly just because they may feel well. So, they will reveal why we should take medicines, but the medicines are to prevent the recurrence of the stroke. So, you may feel well, but does not mean that you should stop the medicines. And then the second and most important part is the rehabilitation where the person despite all these treatments, they can have some residual disabilities like they can

[20:20] have weakness of the hand or leg, the speech may not be totally normal, memory may be affected, swallowing may not be fully functional. So for all these things we have a physiotherapy or rehabilitation unit and in our hospital it is a big unit is there and very with good equipments and good physiotherapists, occupational therapists, peace therapists, swallow therapists.

[20:40] So their roles are very important and because the person has to get back to the full functional status as early as possible so that they can join the jobs, they can start doing the household chores. So those are equally important because every month or every week lost without functioning is like it is a financial loss also and plus it is a burden for the remaining family members because they need

[21:00] to patient for the for helping in the daily activities. So that is where physio therapy comes in very handy. Dr. Sudhir, you mentioned advanced stroke ready hospital that you have to reach a stroke ready hospital as soon as possible. What does that mean exactly for a layman to understand?

[21:20] I think the basic minimum is ability of a CT scan because CT scan is required to rule out brain hemorrhages and then if they can have advanced imaging facilities like say CT angiography or MR angiography, CT perfusion, diffusion. So, just

[21:40] has to mention two lines about that. Sometimes we are not sure when the stroke happened. For example, the person was sleeping. So, when he went to sleep, he was normal. When he woke up, he was having paralysis. So now when do we decide when the patient suffered a stroke? In such cases, this advanced imaging like what is called as diffusion-perfusion mismatch, which came done by

[22:00] scan or MRI that comes in handy. So, a good stroke ready hospital should have ideally that, but as I said minimum respiratory scan and then the personnel. So, personnel we need a good emergency team, ICU team, neurologist, neurosurgeon, interventional radiologist or neurologist, so that it is like a 360 degree care of the stroke patients.

[22:20] and not to forget the post-stroke care that is reamination setup. So, once a hospital has all these things, they are the best stroke-ready hospitals. But the minimum stroke-ready hospital should have the specialty for intravenous thrombolysis. So, players of a CT scanner, neurologist, radiologist and a neurosurgeon, if they are available, then stroke care can be done.

[22:40] taken up. Dr. one question I wanted to ask you is as a young person who is watching this, what steps can they take for themselves and for their family members, their parents to avoid stroke or to reduce the risk of stroke? Is there any steps like that?

[23:00] that is the most important because we all know prevention is better than cure and when it comes to stroke, stroke is no exception because as I said, stroke treatments work only in the first four and a half hours and as you know, unfortunately about 10% patients only are able to get this best treatment. 90% of people are not able to reach stroke

[23:20] ready hospitals in time. So, the best chance for a person is to prevent the stroke and stroke prevention is easy, provided one is motivated. So, for that definitely is the lifestyle is the most important. So, sleep, go to bed early, sleep adequately about seven hours minimum, get up early and then have

[23:40] 30 to 40 minutes of time for exercising. You can do what you want whether you like running, jogging, brisk walking, cycling and then also strength strain 2 or 3 times in a week. Healthy food is a must. So, we all know what healthy food is. So, home foods avoid too much of sweets or carbohydrates, have good amount

[24:00] of protein, real leafy vegetables, fresh whole fruits, a handful of nuts per day and then try to reduce the number of working hours whatever is possible, 8 to 10 hours may be the right thing and then while sitting because we all need to sit for long time. So, there is something called as breaking your setting.

[24:20] So after about 30 to 40 minutes of sitting just get up, stretch yourself for 1 or 2 minutes and then come back and sit. So that can be something good. Aim for about at least about 8 to 9,000 of steps in a day. So that would go a long way in ensuring that and keep checking your blood pressure. You know have a small digital instrument at home, keep checking blood pressure.

Conclusion: The Need for Awareness and Preparedness

[24:40] And once a year, check your lipid profile, cholesterol, blood sugars. Because many times we see young people, they say, oh, we are totally healthy. How can I get a stroke? But when we check the Hb1c8.3, so they have been diabetic for six months, they did not know. Big B comes as, you know, 180, 110, which they never knew. So half the times we do not know because we do not check.

[25:00] So, annual health checkups are a must for, I would say even 20. So, once you have crossed 20, yearly once check your blood sugar, cholesterol levels and blood pressure can be checked at home and then so all these things if they are done properly, what one figure says that almost 90% of strokes can be prevented if we

[25:20] take care of all these things. Are there 10% of genetics which is not in our hand or unknown factors? Doctor, I would like you to just conclude this conversation because bringing it back to stroke, like we said, it's such an important thing. So what is the final message that you would like to give to our listeners? Yeah, so

[25:40] thing as we have already highlighted, stroke is a medical emergency, it is life threatening, it is a major cause of disability. So, we have to give it same importance what we give to heart attacks or cancers, it is in the same category of disability. So, and if anyone you notice either you or your family member or friend, wherever it

[26:00] is having facial weakness, weakness of arm, weakness of leg not able to speak properly, it could be a stroke. So, make sure that their airway breathing is all fine, check their blood pressure and then call for the ambulance and transport the patient to nearest stroke ready hospital. We have both treatments available now and timely treatment can

[26:20] save lots of brain, lots of neurons and save lives also. So, that is what is the message. So, there are treatments. About 30 years back there was no treatment, but in 1995 onwards we have thrombolysis, clot-busted drugs. So, it is not something new, 28 years old. So, many people still feel that it is experimental, not experimental.

[26:40] proven all over the world they are safe and effective. So don't feel scared about receiving the clot-buster drug. It's the standard of care in every country. Incredible. Doctor, I have one question to ask you which we may or may not include in the podcast. But because stroke happens so suddenly and there is a lot of fear and panic

[27:00] around it. There are treatment options that are being offered especially slightly outside of urban areas which are unproven. These could be some unspecified injections, this could be stem cell therapy. So a lot of these different treatment options that takes advantage of the

[27:20] fact that patients are confused and they are in a panic. Do you have anything to share about this? Yeah see our patients our people are gullible so because there is no restriction on the marketing so in newspapers and media and everywhere anybody can put any ad and the media people can

[27:40] we are not responsible because they will have some claws, but public they do not know that. So, that is why they can get misled. So, what I want to say is that the only approved treatments are claw-pustered drugs, what is called thrombolysis and the mechanical thrombectomy where the claw can be removed and that can be done in a stroke-ready hospital of modern medicine. As of now, the

[28:00] is no alternative treatments. Stem cell treatments as you mentioned for stroke they have not been FDA approved. So, there still if somebody is offering it should be a part of clinical trial which should be fully authorized by the local bodies. So, as part of research it is fine, but as part of treatment where the person will be charged hefty amount

[28:20] of rupees, it is not authorized. And we know some traditional treatments like I used to work in CMC Malor during my student period and after that. So, near to that place the person who used to offer pigeons blood and whatever and he used to have a queue of patients lined up for that treatment. So, not

[28:40] wear them it's called. So those things are definitely not scientific and people should not fall for them. Thank you so much for highlighting this very important point because the treatment options that are available if done well have remarkable effects. So I hope that awareness spreads. Thank you so much Dr. Sudhir for joining in.

[29:00] And a big thank you to Apollo Hospital as well for playing the role that you do in spreading awareness. Like doctor said, stroke is an extremely important thing for everyone to know because it can happen to anyone, it can be devastating, but the good thing is that treatment options are available. Make sure that you know what stroke can look like, make sure that you know what

[29:20] you can do if you or anyone you know has these symptoms. Remember ABC, find out the stroke hotline number that works in your area and find out the stroke ready hospital that is closest to you. With that, I will sign off on this podcast. Dr. Sudir, I hope to meet you soon probably at the next neurology conference. I'll

[29:40] look forward to meeting you. Thank you Dr. Seid, it was a pleasure talking to you and it was very nice and you have done a remarkable job of doing this podcast. I enjoyed it. Thank you. Thank you so much. Thank you everyone. Bye. Take care.