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The Good Question Podcast
Revolutionizing Stroke Care Dr. Ritvij Bowry On Mobile Units & Emergency Brain Treatment
00:27:15
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- [00:01]
A
You're listening to the Good Question podcast with Richard Jacobs. Our goal is to make each of our guests exclaim, hmm, that's a good question. I don't know the answer. Because when that happens, it means you, the listener, may be inspired to learn more beyond the interview and to ask great questions yourself that lead to new insights. In this podcast, we cover historical and current anthropology, comparative religion and history. Welcome. And let's get started.
- [00:36]
B
Hello, this is Richard Jacobs with the Food Question podcast. My guest today is Ritvij Bowery, MD. He's an associate professor and a neurologist at UT Health in Houston. So we're going to talk about what's called neurocritical care for people that have had strokes and those kind of problems, and what's called vascular neurology as well. So welcome. Ritvic, thanks for coming.
- [00:55]
C
Thank you for having me. Glad to be here.
- [00:57]
B
Yeah. Tell me a bit about your background and how you got into stroke care.
- [01:00]
C
Oh, well, so after medical school I was interested in acute brain injury and then that's what led me to training in neurology, which was four years after medical school. And then I was really attracted towards sort of the acute brain injury model where you can intervene fast in order to save brain and, and some of the complications thereof. And stroke is sort of the, the hallmark of acute brain injury where there's time sensitivity to treatment. So followed by NEUR residency, I then did fellowship training, which is sub specialization of neurology in vascular neurology, focused on stroke and the different types of stroke essentially. And followed by that, I did ICU or critical care training as well, focused on all acute brain injuries that include stroke, also traumatic brain injury, and really focused on the overall care, the comprehensive care of these patients. And then that's also part of my clinical and research responsibilities now.
- [02:06]
B
Yeah, my brother had a, the stroke last May and I don't know what they gave him, but they gave him some kind of clot busting drug within like 45 minutes of it happening, luckily. So they said he was spared a lot versus what would have happened, you being in the field. My guess is like, what are some of the early interventions that can help people and when, like what circumstances are needed for them to work?
- [02:28]
C
Well, so essentially, you know, there are three types of stroke. You know, the most common type of stroke is when a blood vessel that goes to the brain gets abruptly blocked, you know, because of tiny blood clots that can either form along the blood vessels going into the brain or from somewhere else in the body. Most Commonly from the heart, you know, around the heart. And because of that, the treatment for this kind of stroke, which is called ischemic stroke, is extremely time sensitive. And if you're seen, evaluated, and potentially treated with the most common sort of clot busting medicine, you know, we often call it kind of draino for the blood blood vessels, then the chances of not only surviving but actually having a better outcome where you can minimize disability are actually very high. So there's, there's basically two types of medicine that can be given in a very short time period. And that medicine really gives people a very high chance, as I mentioned, of surviving and, and getting, and preventing disability. And as an extension beyond that, if the clots are very big and are very exp. And expected to cause a very significant amount of disability or high risk of death, then in addition to this kind of blood th medicine, clot busting medicine, as you said, we can also do surgical, neurosurgical, minimally invasive procedures where we go inside the body with wires and catheters and navigate into the brain, into those blood vessels in themselves, and then we physically try to take those clots out as well in order to even enhance the potential of saving brain and minimizing disability and obviously saving lives.
- [04:14]
B
What are the names of the, the drugs that are used in this way?
- [04:17]
C
The two most common used medicines, one is called alteplase and the second is called tenecteplase. So in.
- [04:27]
B
Stroke's pretty scary. It's weird. It's like a fuse blows in your head and it just takes a long time to recover from what I can see. You know, it's, it's to be a year for him soon. He's doing good, he's recovering, but it's just very slow progress. You know, he, I don't know how common it is, but he lost like, you know, his peripheral vision of one eye, his one hand. Really usable. He's working on that. His leg wasn't usable. It was all numb. You know, just at first you couldn't even speak to him. He just would, we'd be like nonsensical. And then things became clearer and clearer over time, but took a number of weeks to really get anywhere. And then now months and months to really make good progress, you know, certainly.
- [05:02]
C
So, I mean, you know, it's certainly unfortunate your, your brother experienced that. But at the flip side, it's reassuring as, as obviously you're going through as a family member to see sort of his progress and just, just like recovery is very complex. Certainly there are some Stroke patients who do make a full recovery. A lot of the time though, it's sort of a spectrum of recovery and trajectory of how people recover and what sort of quality of life they end up having, as you said, and are experiencing. When it comes to stroke, it's not always about sort of life and death, but it's often also more importantly, arguably about quality of life, uh, as, as stroke commonly can impact people's ability to live their lives, you know, work and, and talk and speak, their functions of their daily life and as an extension of that, even affect the people around them, friends and family.
- [06:01]
B
Yeah. So what, what kind of research questions are you looking to answer for our surrounding stroke?
- [06:05]
C
Well, there, there are many, many common sort of questions that are being, that are being studied. You know, I specifically am involved in pre hospital stroke research. So you know, going back to what we talked minutes ago, right. We sort of have a saying or a mantra in our field, which is time is brain. So every minute matters for every minute that goes by and someone's having this ischemic stroke because of blood clots, up to 2 million brain cells, neurons can essentially be affected and die. So you know, the common paradigm has been and is still very much prevalent in the world, which is, you know, if you're having a stroke, wherever you are, at home, at work, you know, you 911 or the equivalent thereof depending on which country you are, and you get transported to the closest emergency room or center so that you can be seen, evaluated and treated appropriately. Now there are many challenges as you can imagine, starting just from the recognition of stroke symptoms to the ultimate transport to an emergency room or an appropriate hospital where people often get delayed and they cannot get these clot busting treatments or the care that is mand and really necessary in the first few hours. So my research that I've been involved with for a little more than a decade now is that in Houston, Texas, we were the first in this country in the usa, where we actually changed the paradigm of stroke patients, where rather than them coming to the emergency room, we were basically taking the emergency room to them, wherever they are on site. And the way we did that is we essentially took an ambulance, a standard ambulance, and we outfitted it with all the appropriate treatment, medications, tests that are necessary. The main that is really important in the first few hours is a CAT scan. So we actually, we actually put a CAT scanner, a portable CAT scanner on a, on an ambulance and we had a team, not just me obviously, but FELLOW Physicians, nurses, CT techs and paramedics. And we actually went out to patients on scene, wherever they were starting to have stroke symptoms, in order to see them right, as fast, fast as possible, to get them evaluated as fast as possible and to treat them appropriately. So if they were candidates and they met criteria with that clot busting medicine in order to basically expedite the delivery of this care. And this was part of a large clinical trial that we did in coordination with other sites in the US as well. And then ultimately a few years ago, we actually showed that the treatment by a mobile stroke unit, ambulance, as we call it, was actually superior to the standard care in terms of getting patients, stroke patients, better faster. Not only better faster, but also ultimately, three months later, preventing and minimizing their disability compared to the standard treatment. So this has been sort of a focus. You know, there's many mobile stroke units now all across the country, if not the world. So this has been my focus now is to extend this to really all acute brain injuries that also have a time sensitivity to them in order to see them and evaluate them and triage them to the, the most appropriate center as fast as possible.
- [09:34]
B
It seems like, I mean, I, I don't know. But with heart attack, people are more aware that they're having potentially that problem. Stroke seems to come on so suddenly and it's so debilitating. You know, people can't walk or speak or any of that. What can they do about it? Even if they suspect they're having a stroke? It seems like, I don't know, you know, besides never being alone, what are you supposed to do? Protect yourself?
- [09:55]
C
Say, very valid and a very. That's a great point that you just made, you know, so when it, when it comes to str stroke, unlike heart attack, right. Pain is often not one of the features seen most commonly when people have a heart attack. One of the first telltale signs is chest pain. So automatically people seek medical care. And stroke pain is not very commonly seen initially. So that continues to be one of the biggest challenges all across the world is that education and trying to get patients and people around them to recognize the signs and symptoms of a stroke. Stroke. While there are many different signs and symptoms of a stroke, the best way to sort of, you know, see if and to assess is whenever people lose a function they can normally do, which is meaning they can, they, they can certainly talk, they can normally walk, they can't feel in half of their body, they can't see in half of their world. While it could end up being other things, those are the common telltale Signs of a, of a stroke, you know, and, and there are many different acron out there. One of the most commonly used acronyms that, that is used in the stroke world all across the world is one we call B fast. And what that stands for is. The B is for loss of balance, like if you suddenly have loss of balance or coordination. The E is for, for eyes, if you suddenly can't see or the changes in vision. The F is for face if there's sudden onset of, you know, one side of the face is drooping or is abnormal compared. The A is for arms and legs, which is basically the sudden onset of weakness or inability to move. The S is for speech. So sudden onset of difficulty speaking, getting the words out or speaking clearly. And the T is time T, you know, and so, you know, time sensitivity to basically call 9 1, 1 or the equivalent number thereof wherever in the world and to try to get emergency care as fast as possible so that you can be taken to the close. If there's a mobile stroke unit, ambulance that can be dispatched so that, that can get on scene to assess people who are possibly having a stroke.
- [12:19]
B
Yeah, again, a heart attack, I can see you maybe calling or pressing a pendant, a button on it. But the confusion that comes with stroke, is there any reliable method for someone having one to report that they're having one? Or again, it's just so sudden, so debilitating that there's nothing that you could do. No matter how simple you make it. There's just no way to, you know, to capture everyone that has a stroke or most people that are having a stroke.
- [12:44]
C
Exactly. So you know, there's a lot of research that's being, being done where we're trying to all across the world in our community, in our stroke neurology community where we're, we're trying to figure out blood tests, you know, in the pre hospital world, where if there's a blood test that can potentially identify a stroke and maybe even differentiate what different types of stroke are occurring. Because in general there's, there's three different types of stroke. One is, two of the three are because of bleeding inside the head in and or around the brain. And the other one, as we've talked about, the more common type of stroke is the one that is because of blood clots and the treatments are very different, as you can imagine. So there's a lot of research being done in trying to sort of figure out if there's a blood test that's fast and efficient and reliable that can differentiate these strokes. A Lot of research is also being done into optimizing, optimizing pre hospital infrastructure and triage algorithms between different emergency medicine providers and the community at large in trying to, you know, not only identify patients who could be having a stroke, but once identified, in trying to get them to the appropriate hospital as fast as possible. Because there's also many different levels of hospitals and you know, in the community and really all across the world where there's different levels, where there are some hospitals that are very low acuity hospitals that are not really equipped to recognize, let alone treat and triage strokes that then end up getting transferred onward to other bigger hospitals. And as you can imagine, that can lead to significant delays in the appropriate treatment for stroke patients. So there is a lot of research being done all across the world in these two avenues as we speak.
- [14:36]
B
When people have a stroke, what's the number one way that they get into the medical system? Is it like a relative that's sitting with them, them or a caregiver that reports it? Like, how is the reporting happen?
- [14:46]
C
Mostly, actually, right. I mean, the recognition, you know, right on scene. If patients are, if a stroke patient is able to communicate and talk, then certainly, you know, they can and are potentially able to have access to a telephone or to alert bystanders. You know, then that is one way. But more commonly, it's usually the bystanders, co workers, family, friends, who sort of see a sudden change in behavior. And the most common way stroke patients are seen is by alerting the emergency medicine system and then getting taken to the closest hospital center that's appropriate. In other cases, it's less common that people are, you know, family, friends, coworkers are sort of driving people to the emergency room. While that does happen, that is generally discouraged just because of, you know, the acuity and sort of the other medical complexities that can occur in a time sense sensitive manner. So the, the advice is always to pick up the phone, call 911 or the equivalent thereof and say you think you're having a stroke so that you can be seen, evaluated, triaged and treated as fast as possible.
- [15:59]
B
I mean, with stroke, is it the person self reporting or is it more of a caregiver or family member reporting it?
- [16:05]
C
More commonly it's the latter. As you said, caregivers, family members, coworkers, often people. Now, you know, people are, you know, in all walks of life. You know, they're engaged in, at work or at home or doing other things where, you know, there's no, there's nobody around. So that continues to Be part of the challenge that a lot of stroke patients are, you know, found on the floor or they're found in a compromised position because of the disability from their stroke. So they can't necessarily communicate or they can't really physically communicate with anybody to seek help.
- [16:42]
B
What causes a stroke to be fatal? What are some of the reasons?
- [16:45]
C
Well, in general, whether it's a bleeding type of stroke or the non bleeding type of stroke in general, what leads to mortality is age. So you know, the older you are, generally speaking, the higher the chances of mortality from a stroke, not solely because of age, but also the interaction of age with the size of the stroke. Generally, the bigger the stroke and the more brain volume it affects, the more potential of secondary consequences from the stroke in itself that can also increase the risk of mortality. And then the third major risk factor generally has to do with the medical comorbidities that people have. So what that means is if they have more heart, lung, kidney, liver problems, that also affects the trajectory of stroke in general, but it can also affect the survival in the first few days, especially because of the physiological and the metabolic stress that a stroke can cause. The domino effect that can lead to the body and the ability of the body to sort of under, basically sort of withstand the effects of the stroke. So there are, there are, there are a few other variables that can also affect more the mortality. But, but these are the three major variables. Age, associated medical problems and the size and the volume of the stroke.
- [18:13]
B
So what tends to be permanent effects that can't be rehabbed away? Are there any positive ones? Is there all negative and you know, what are like the predominant one?
- [18:22]
C
Well, generally, I mean it's a, it's a broad spectrum in the way stroke can impact, can impact people's cognitive and psychological well being, emotional well being. It can certainly have an impact on the physical well being, on people's ability, on their motor strength and or weakness. Their ability to interact with the world in the sense that it can impair the ability of the sensory, sensory function and the sensory ability for people to interact with the world, sometimes based on even their vision. It can often affect people's. And then all of these put together then can affect people's ability to work. It can affect people's interactions with their family, their friends. So there's a broad expanse of effects and impact that a stroke can have.
- [19:19]
B
Is there any like permanent amnesia? People like forget certain relatives or they lose skills they had and just never get them back?
- [19:27]
C
Yes, unfortunately that is quite common. A large part of the Impact of a stroke also depends on the part of the brain that's affected. Different parts of the brain do different things, control different bodily functions. So a large part of the impact is sort of governed by that. Also what goes into that is also people's, if they age, as I mentioned before, but also if they've had any pre existing disabilities from, you know, from prior strokes or from other medical conditions that they've had, those also weigh a large part into people's recovery and the impact ultimately that a stroke can have.
- [20:10]
B
So any new drugs or protocols that you're working on, like in the next couple of years, what do you think that you'll be able to contribute with your research to the, you know, to the cause of stroke?
- [20:20]
C
Well, with the research that's ongoing, both, you know, both on my end and sort of from a, on a, more, on a, on a, a larger global scale, you know, the big focus is on in trying to deliver not only the care for stroke faster, but also once the patients are identified, there's also a big focus on trying to come up with better treatments in order to get more patients treated in a more effective manner, both with clot busting medicines. Although these two clot busting medicines that I mentioned, alteplase and tenecteplase, they've been around for about 30 years in general now and they're well studied, they're sort of the standard of care globally. But there's also a big focus on trying to restore the blood flow by different techniques, different catheters, different technology for patients who are either not eligible for these clot busting agents or those patients in whom the clot busting agents are not as effective. So there's also a big push and a big research focus in trying to increase and improve the perfusion, the blood flow and the delivery of oxygen to the brain a lot faster in the first few hours. Beyond that, there's also ongoing research in recovery and rehabilitation in trying to, you know, develop better treatment modalities after the first few hours so that we can help patients recover faster, more effectively. There's this stem cell treatments that have been studied for many years now that are ongo. There's also transcranial magnetic stimulation that is being studied to stimulate certain parts of the brain with very low wave electrical magnetic stimulation in order to enhance their recovery. There's also research that is ongoing in trying to, you know, save brain, you know, and sort of freeze the brain so that we can prevent further brain injuries. In general. This subset of the field is called NEUROPROTECTION which has also been a focus for many decades. Unfortunately, many different treatments, medications, strategies have been tried. Nothing has really been established yet, although there are some promising signs which hopefully will pan out in the near future.
- [22:50]
B
Can vessels in the head be stented like in the heart or no?
- [22:54]
C
Short answer yes. Although the blood vessels in the brain are, are different in comparison to the heart and the rest of the body. So it's not quite the standard of care that is often employed in the heart. But yes, on a case by case basis, blood vessels in the brain can be stented more commonly. What is the standard of care is the blood vessels outside the brain in the neck are often stented more commonly as sort of the standard of care. If in order to prevent further strokes in the future. Future. If the stroke that we're talking about is caused because of the blockage of the blood vessel in the neck and or even surgical options in order to open up the blood vessels in the neck.
- [23:41]
B
Well, what about bypasses? Does that exist for any of the neck vessels or head vessels?
- [23:46]
C
Short answer again is yes, but again it's very rarely done. It's done on a case by case basis with in very experienced centers, in very experienced hands of neurosurgeons generally who do these kind of bypasses. But it's not the routine standard of care.
- [24:07]
B
And what kind of factors precede stroke? You know, it's not of course, no guarantee, but you know, if you have heart issues, does that mean you have a much higher likelihood of stroke or smoking or you know, what are like some of the major contributors to it?
- [24:21]
C
Well, so a lot of the risk factors for heart attack and heart disease are very similar to stroke as well, which include age, high blood pressure, high cholesterol, diabetes, heavy smoking, heavy alcohol use, illicit drug use, obesity. These are and certain heart conditions specifically. These are all the major risk factors for really both types of stroke, bleeding type of stroke and the non bleeding type of stroke. And that is also a big part of the sort of overall stroke care. In trying to identify and address and treat these risk factors so that going, going forward in a person's life so that the risk of heart disease and stroke can be minimized.
- [25:08]
B
Okay, very good. What's. Where can people find out more information about strokes and also look at your research, what's a good central repository for them to go to?
- [25:17]
C
Well, the American Heart association, along with that, the American Stroke association is a great resource that can be, you know, searched online. They have a plethora of resources, resources that would be the best place to start. Just recently the same organizations have issued the newest and the most contemporary guidelines for treating ischemic stroke. So all of that is all is also on that website in itself. And then there's also lots of resources for survivors of stroke and their caregivers and their loved ones as well. So really, the American Heart and the American American Strokes association would be the first place to start. With regards to my research, it is on the UT Health neurocritical Care website as well, where there's a plethora of resources as well. And then there is also an organization which is called the Pre Hospital Emergency Stroke Treatment Organization or presto. That is a global organization which is focused on these mobile stroke unit amp ambulances. If anyone is interested to to find out more information and how to get involved.
- [26:31]
B
Okay, well, very good. Thank you so much for coming on the podcast and explaining all this patiently. I appreciate it.
- [26:37]
C
Thank you so much.
- [26:38]
B
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- [26:46]
A
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