Neurohospitalist at the McKay Dee Hospital in Ogden, Utah, Melissa McDonald, MD, talks about how stroke patients are becoming younger and younger.
Interview conducted by Ivanhoe Broadcast News in 2023.
Talk to us first about a stroke and the symptoms that people first notice.
McDonald: Strokes come on very suddenly, typically. You’ll notice sudden weakness on one side of the body, numbness on one side of the body, typically, vision changes on one side or double vision, sudden loss of balance or coordination, difficulty speaking, difficulty swallowing, and all those will come on in a minute you won’t have it, and the next minute it’s all there.
Talk to me about the importance of time and how important it is to get to a hospital.
McDonald: We always say time is brain in stroke. Every minute counts. Even though we have several hours to treat a patient, or even up to 24 hours in some cases, 2 million brain cells can die per minute in a stroke. We always tell people to call 911, get right into the hospital. Don’t try to sleep it off, don’t try to hope it goes away. Just come right in.
What is the typical age that you used to see for stroke patients? What age do they usually have to start worrying about that?
McDonald: It depends on the patient, but usually the risk factors for stroke, the traditional ones are high blood pressure, high cholesterol, diabetes, and those tend to occur later in life or take their toll later in life. Over the age of 60, 65 is typically when the stroke risk starts to be increased and you can expect that, with those risk factors, you’d have a stroke.
You guys have been seeing younger patients, right?
McDonald: Yeah, we do see a lot of younger patients with stroke. That can be for different reasons. More and more young people are having those risk factors of high blood pressure, high cholesterol, diabetes, and may not realize the importance of getting that treated or may not be visiting their primary care doctor because they’re so young. Then we also see strokes in young people for a lot of other reasons. Drug abuse is one big risk factor. Methamphetamine, cocaine, even marijuana can increase your risk of stroke when you’re young. We have seen several patients per year, at least, with strokes from high velocity neck manipulations. That’s like when a chiropractor or someone twists your neck really quickly that can tear the arteries that supply the brainstem.
Have you seen a lot of them?
McDonald: We see more than a few a year. I would say we see five if it’s a bad year up to eight or ten per year, just per hospital. And some of them can be quite devastating because the brainstem and the cerebellum are in a enclosed compartment that only has so much room. So they can be devastating strokes. Sometimes they’re just mild and sometimes they’re really bad.
And that’s just from going to the chiropractor, right?
McDonald: Yeah. It’s not just that. It could be that or it could be being on a roller coaster. Sometimes we don’t identify a reason why the arteries have torn. But anything that can twist and shear the vessel that’s running up through the vertebral bodies can cause a stroke.
That’s crazy. I’ve never heard of that. So when that happens, are there the symptoms instant or do they not start until hours later?
McDonald: Sometimes they’re instant. Sometimes it takes a while after the vessel has been torn for a clot to form and then go to the brain.
Like a while, as in days?
McDonald: Could be hours to days, could be right away.
With these younger stroke patients – you had already touched on this, but just go over it again – just the risk factors and why we’re seeing that in patients.
McDonald: More young people are having the traditional risk factors for stroke that we would normally see in older people. High blood pressure, high cholesterol, diabetes, which is mostly probably related to our lifestyles where we’re inactive and we eat unhealthy diets. Smoking is a big risk factor for stroke and heart attack, excessive alcohol use, drug use of methamphetamine, cocaine, even marijuana, neck manipulations or neck trauma. Then there are paritable risk factors, like cardiac abnormalities, structural abnormalities of the heart, and blood clotting disorders that might run in the family, or it might be acquired by that person. Pregnancy itself is a risk factor for having excess clotting in the blood. And oral contraceptives can also increase the risk of clotting.
Just living?
McDonald: I would say the main thing for people to focus on is the things that you can modify. So things like eating healthy, exercising, limiting your stress, and whatever that looks like for that person. And just living a healthy lifestyle, not doing drugs, not smoking, not drinking excessively, those are things that we can prevent. And then there’s other things that we can’t do much about.
When you see them, the younger patients, I imagine they typically don’t think this is a stroke, right?
McDonald: Yeah, it depends. We did have one patient who didn’t recognize his symptoms at all and his wife had to bring him in because she recognized he was having weakness and he didn’t recognize it or I’m not sure what exactly he was thinking. But yeah, I think a lot of people don’t think that they’re going to have a stroke under the age of 45 or 50.
So talk to me, then, about the mechanical thrombectomies at the hospital.
McDonald: So mechanical thrombectomy is a treatment that’s become much more used in the last 15 to 20 years. It’s a procedure where if we see a clot that’s blocking blood flow to the brain that’s large enough and in the right anatomic location, they can snake a catheter up through the groin, usually go up through the heart, into the arteries of the brain, and then deploy a device that can remove that clot, physically, mechanically, and pull it out or suck it out, or sometimes dissolve it, and that can restore the blood flow to the brain. It can be a really effective treatment for large blood vessel blockages.
How does that impact the symptoms they get afterwards? Does it increase the quality of life?
McDonald: Yeah. It’s been shown to improve outcomes in patients. So three months down the line, a significant percentage of them will do better than if they didn’t get the thrombectomy. Especially with these really large strokes, they can be really devastating and even cause death. We almost always recommend that people undergo that procedure, even though there are the risks of the procedure that’s minor compared to the risk of not doing the procedure.
What’s the percentage that if you have one stroke that you’re going to have another one?
McDonald: It depends what the cause of the stroke is and what we are able to modify in a person who has a lot of risk factors and they’re already on a lot of prevention. For example, if they had atrial fibrillation, their stroke risk might be like 10% per year. And then we add anti-coagulation and it goes down to 5% per year. It’s really dependent on what the risks are in that patient.
After a stroke, what side effects do you typically see?
McDonald: Some people recover 100%. They want to go home the next day after their thrombectomy. They don’t really even realize how serious it was because they have no residual deficits from that stroke. Other people will live with paralysis on one side of the body. One of the more difficult things to deal with can be difficulty swallowing, eating normally. Sometimes people require feeding tube, inability to speak normally, which is called aphasia. All of those can be lasting effects of a stroke. Young people do tend to recover a little better than older people because the young brain has more plasticity, but it can really affect a person’s life for a long term.
You did touch on this a little bit also, but just talk about what people can do to prevent a stroke. No one really knows. You said blood clotting runs in the family. Are there any other risk factors you may know that you’re more prone to having a stroke?
McDonald: I would say go to your doctor at an early age. Get check ups, get your blood pressure checked, get your cholesterol checked. If the doctor recommends treatment for those, do them, even though it might not make you feel any different. You’re preventing the stroke in the long term. You just have to trust that those medications are decreasing your risk. And I would say for young people with traditional risk factors, exercise, get cardiac exercise 30 minutes a day, or around 200 minutes per week. Eat a healthy diet. That means eating lots of fruits and vegetables, whole grains, beans, not eating a lot of beef or processed foods. Chicken and fish are the best meat sources. And we also know that having a way of dealing with stress, whether it’s meditation or community or whatever, might reduce your stress is healthier for your blood vessels and for your stroke risk. And having a good family support system, so just having a healthy lifestyle is probably the most important thing for most people. If you have migraines, make sure that your OB knows about migraines because you can be at higher risk for strokes with oral contraceptives. And if you have a family history of clotting, try to get a diagnosis of the person who has it. Know who in your family has it and get the name of it so you can tell your doctor because that might affect your risk of pregnancy or clotting in pregnancy developing- if you do develop a clot, you’ll understand what it is and what your risk is.
We talk about because we’re seeing it more younger patients. What’s the youngest you’ve seen?
McDonald: Even babies can have strokes. And I’m not a pediatric neurologist. But even babies can have strokes, and affect an entire half of their brain. Children can have strokes, 4, 5, 6, 7, 8, 9, 10 all the ages, Any age a person can have a stroke. And in babies, the symptoms are going to be a little different because they aren’t set up neurologically the way that kids and adults are after some development. But in most kids, it is going to be those same symptoms of weakness or numbness on half of the body. Sudden dizziness or difficulty balancing, talking, swallowing, anything sudden like that.
Is there anything you want to add?
McDonald: Well, we have the BE-FAST that we teach people about, which is an acronym, balance, eyes, face, arm, speech, and time. So the first BE-FAS, without the T is the symptoms that you look for. And then time is just to remember how important it is to get in quickly. We always recommend that people call 911 because they can alert us when they’re on their way and they can take people to the right hospital for the right treatments. Recently there has been a lot of expansion of offering thrombectomy in different hospitals and to a larger number of patients. So there’s regulations of which hospitals are qualified to do that, any hospital can do it but we recently underwent this certification through the joint commission where we’re now a thrombectomy certified stroke center. Which means we have to do a certain number per year, per provider. And we have to keep up with a lot of educational and quality requirements that we didn’t necessarily have to before we became certified. So it’s different in different states what the protocols are. In Utah, they recommend that EMS bring patients if they look like they have a large vessel occlusion to a thrombectomy certified center if it’s within 30 minutes difference of like the other closest hospital. But it really depends on the area that you’re in. So we have- we have recently become certified by the joint commission to do thrombectomies as a TSC thrombectomy capable stroke center. But every area is going to be a little different. Who offers what?
So like not every hospital offers this?
McDonald: Not every hospital can do thrombectomy. So there are- there are stroke receiving center, there are different levels of stroke care. There’s stroke receiving centers where they just receive the patient and they may call a bigger hospital. There are primary stroke centers that meet other qualifications, but they may not be thrombectomy certified. And then there are thrombectomy centers, and then there’s comprehensive stroke centers. And so there’s different levels of stroke centers. So a receiving center might be able to give TPA, but then they’d have to transfer the patient for a thrombectomy, or they may not have a neurologist. So they would transfer the patient for further stroke work up and care. So not every hospital is going to do with thrombectomies.
What makes them stand out versus maybe any other local hospital?
McDonald: We are the only thrombectomy capable center within the Northern region, north of Salt Lake. We get a lot of transfers for thrombectomy. There are other hospitals in the area that do thrombectomy, but they haven’t gotten the certification yet. We just have a lot more experience than some of the other hospitals.
So on average, how many do you do a year?
McDonald: I think last year we did around 45. And this year we’re on track to do probably 55 or 60, just based on our number so far. So you want to go to a place that does more rather than just be one of a couple patients that gets a thrown back to me at the hospital.
And I imagine that also just affects your quality of life afterwards?
McDonald: Yeah.
So like we said, 45 last year with most of the majority. I know you don’t know the exact numbers, but it seemed like the majority were older. Like over 60?
McDonald: Yeah. Probably the majority were. I would have to look to see how many were younger, but I can definitely think of three or four or five that have been in the younger category. There are arteries called the vertebral arteries. And they’re called vertebral because they run up in the spaces where the vertebral bones articulate together. So they’re in the space that is limited and it can be affected by the movement of the bones. And so when there is- usually they’re okay with neck movement, but when there’s a quick neck movement in some patients who may be more prone to it, that can tear the layers of the blood vessels so that you get an injury to the blood vessel. And it bleeds. It doesn’t bleed out into the brain, but it bleeds into the- the space between the layers of the artery. And so it can block off the blood flow by making a bubble inside, or it can try to repair that tear by forming clots and then those clots can move up to the brain. I think it’s something a lot of people don’t know about. And yeah, we’ve seen several young women in the last few years who have had strokes as a direct result of neck manipulation or a tear in the vertebral arteries that goes up into the basilar artery. And then in young people, you get swelling where there’s not room for swelling in that area and that- that can cause death. And we’ve seen death in a couple of our young patients in the last few years. So yeah, I always- I guess I don’t know, might be controversial. I don’t want to affect anyone’s livelihood, but I tell all my family members, if you go to a chiropractor, don’t let them do that quick twisting of the neck because it’s not worth it.
Yeah, I’m happy that’s something that they have to learn in school.
McDonald: Yeah, And I think they know that there’s a risk and I’m not sure if they know every patient that develops a stroke because I think maybe some of them wouldn’t- wouldn’t keep doing it if they knew that there had been a stroke in a patient. I think the risk is relatively low and I think that’s what they learn. And I’ve heard from people who have learned it in school, like DOs, that they’ll not do it in older people because the blood vessels are a little more fragile. But it can happen in younger people. So I tell everybody, no, don’t- don’t get that done.
END OF INTERVIEW
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