← The Neuro Experience
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- [00:00]
Dr. Braden Dimm
Now, when you have a blockage of a blood vessel and that oxygen and nutrients are not getting to those brain cells, they only have a little bit of time before they lose the ability to function and they can actually die pretty quickly within a matter of minutes without getting that oxygen and nutrients that they need.
- [00:17]
Louisa Nicola
They're actually now categorizing or looking at Alzheimer's disease being vascular dementia, a disease of the blood vessels of the brain.
- [00:24]
Dr. Braden Dimm
Any part of the brain that has any function, if that part of the brain is damaged, then that specific function will be lost.
- [00:31]
Louisa Nicola
Hi everybody, welcome back to the show. It's Louisa Nicola. I'm a neurophysiologist and human performance coach. Strokes are not just medical emergencies. They are public health issues that require immediate action. These events occur when blood flow to the brain is disrupted, causing severe brain damage. Alarmingly, women are disproportionately affected, facing higher incidence rates and more severe outcomes. In fact, team, this gender disparity highlights the urgent need for focused research and healthcare policies to address the unique risks women face. To amplify this conversation around stroke prevention, treatment and the systemic inequities that aggravate these health outcomes, I have brought on a board certified neurologist, Dr. Braden Dimm. He is a very well accomplished physician who specializes in cerebrovas vascular disease and stroke care. He has made significant research contributions with publications in respected journals like Neurology and Stroke. So in this episode you're going to learn all about stroke care prevention, the differences between ischemic and hemorrhagic strokes, and we're also going to learn about the gender disparities. You're going to learn the risk factors and how to prevent the onset of a stroke. Let's welcome Dr. Brayden to the show. Strokes are primarily characterised into ischemic and hemorrhagic types. Ischemic strokes, which constitute about 88% of all strokes, occur when a blood clot blocks or narrows an artery leading to the brain, often due to atherosclerosis. Can you take us through the pathology of an ischemic stroke?
- [02:24]
Dr. Braden Dimm
Sure. So ischemic strokes, like you mentioned, are definitely the most common and that happens due to a blockage in the blood vessel and that can be due to a number of different reasons. So there's multiple different types of blood vessels. So we have arteries, which are the muscular blood vessels that take blood away from the heart to organs like the brain, and then there's veins which take blood back to the heart. Now, most of ischemic strokes happen due to Blockages in those arteries, which is the blood vessels leading up to the brain, and that blocks off the blood flow to those little tiny blood vessels called capillaries, which allow blood and oxygen and nutrients to feed those brain cells. Now, when you have a blockage of a blood vessel and that oxygen and nutrients are not getting to those brain cells, they only have a little bit of time before they lose the ability to function. And they can actually die pretty quickly within a matter of minutes without getting that oxygen and nutrients that they need. Now, there's a lot of different reasons why might. Why somebody might form a blood clot. And we actually divide strokes into different buckets depending on the cause that we think happened. Now, those causes include things like atrial fibrillation. So atrial fibrillation is pretty common amongst the elderly. And that happens due to the heart not pumping effectively. Specifically, the top chambers of the heart are not pumping effectively. And that leads to the blood in the heart slowing down. And when blood slows down, it's easier for that blood to form into blood clots. The blood clots are when the liquid blood coagulates into solid objects. And that blood clot, if it gets into the bottom of chamber of the heart, that can be pumped up into the brain and it can block off some of the major arteries that feed majority of the brain. And that can often lead to some of the most severe strokes. There's a lot of other types of strokes or causes of stroke, and those include large blood vessel strokes or large artery strokes. One type of large artery stroke is called carotid stenosis. And the carotids are the blood vessels that are in the neck and supply the majority of the front part of the brain. Now, if that becomes narrowed, then not enough blood flow can get to that part of the brain. And if your blood pressure drops, that can lead to symptoms. But probably the more common reason why carotid stenosis leads to a stroke is because that plaque buildup in the wall of the artery, some of that plaque can actually break off and lead to a blockage down the line, right? So blood flows from the artery in the neck into the brain, and if that gets blocked off, then that can lead to that cell death that we talked about.
- [05:25]
Louisa Nicola
That is so interesting. So many things just came up. First of all, as we age, our arteries tend to tend to narrow just due to the natural aging of our heart and our arteries. Is that correct as well?
- [05:41]
Dr. Braden Dimm
So, unfortunately, that is true. That's not a natural part of aging. It's not a normal part of Aging, but that happens due to risk factors that accumulate, leading to damage to the blood vessel wall, which then leads to plaque formation and narrowing. Now, in a perfect world, you know, as we age, we wouldn't have those things, but it is very common.
- [06:03]
Louisa Nicola
So you've got the arteries, and then you've got the veins, and you've got the capillaries. Now, capillaries are different to arteries because the arteries actually have, like, you mentioned, the smooth muscles. So they. They've got muscles. That's why they're like pipes, like pumps. Whereas these little capill can die off during high blood pressure or hypertension. Right.
- [06:26]
Dr. Braden Dimm
So that can happen as well. And that's actually a different type of stroke. So we call those small vessel strokes. Small vessel strokes happen when those small little blood vessels that are really invisible to the naked eye, even with advanced imaging, which live deep in the brain. When those shut down due to that accumulation of risk factors like high blood pressure and. And cholesterol and diabetes, then those, you know, it's like. It's like roads leading to a city. And if. And if that can't get there, then there's a blockage, and that leads damage to that part of the brain.
- [07:00]
Louisa Nicola
But you. So my father, back in 2019, he. He has afib, and he wasn't taking his medication, and he ended up, you know, having an ischemic stroke. And that was in the right temporal lobe. And he's had some, you know, he's. He's great. I've just seen a decline in his cognition, and he's got some, you know, his lower limbs on his left side are not functioning as well either, and his was mainly due to the. Mainly due to afib. But if we actually look at the differences between the arteries and these little capillaries, let's just say these capillaries, they end up dying off. When they die off, is it true that if they are supplying a certain aspect of the brain, even if they're minor, you know, deep, deep. Every single neuron in the brain needs blood flow to function, and if it doesn't get blood flow, that neuron will die. It ends up being. I guess it ends up, you know, cell death, if you will. So is that how we end up with these neurodegenerative diseases over time?
- [08:14]
Dr. Braden Dimm
I'm. I'm really sorry to hear about your father there. And I. I think that you're right that, you know, this. This type of stroke can affect part of the brain and. And any part of the brain that has any function, if that Part of the brain is damaged, then that specific function will be lost. And so there's. There's many different parts of the brain. Like you mentioned, the right temporal lobe can be involved in things like language interpretation and, you know, how we. How we hear and, and, and speak and things like that. Now there's. You also mentioned about neurodegeneration. So when you have a stroke, multiple different things happen. So not only is there that immediate damage which, which leads to that loss of function, there's also a lot of inflammation that occurs. So that brings us into this topic of, you know, what is neurodegeneration and what are the different types? So stroke can lead to two different types of neurodegeneration. It can lead to vascular dementia, which is when you slowly lose different parts of the brain, and each of those parts of the brain shut down and you lose that function. But that inflammation that can happen as a result, as a result of a stroke can also increase your risk for Alzheimer's dementia, which is the most common type of dementia. Now, these things can often overlap. So when you have a stroke, not only are you losing that part of the brain, but you're also causing the inflammation and you're having this overlap syndrome of Alzheimer's dementia and vascular dementia.
- [09:52]
Louisa Nicola
They're actually now categorizing or looking at Alzheimer's disease being vascular dementia. It's a disease of the blood vessels of the brain, which really just even emulates the fact that preventative measures such as diet, exercise, and sleep are absolutely fundamental to the health of the blood vessels. So, I guess, you know, as you're speaking, it's even more clear to me that preservation of blood vessels is important.
- [10:25]
Dr. Braden Dimm
Absolutely. I think that that brings us back to this earlier point, which is an ounce of prevention is really worth a pound of cure. So if we can preserve our blood vessels as we get older and prevent that damage that leads to plaque buildup and the narrowing, then we can really go a long way to preventing that disease that builds up in those blood vessels. That can lead to strokes, that can lead to vascular dementia, and also to Alzheimer. Alzheimer's dementia. When there's that inflammation that happens. And there's a lot of different ways that you can do that. There's a lot of different ways that you can take action right now to prevent the risk of stroke, the risk of Alzheimer's dementia, you know, decades into the future. And that really kind of comes down to focusing on what are those risk factors? What are your risk factors? The most common risk factor for a Stroke is high blood pressure or hypertension. And a lot of people don't know what their blood pressure is. If they go to the doctor, they might hear, you know, their vital signs being taken. They might hear a couple of numbers, but they don't really know what those mean. And they might not know, you know, is that in the high range? Is that in the normal range? So, you know, if I could do anything right now to. To spread awareness, it would be really kind of to get awareness of what is your blood pressure and trying to take ownership and control about that. So blood pressure, when you get it checked, try to pay attention to the top number and the bottom number. The top number is systolic blood pressure, which is when your heart pumps. And that's the strongest pressure that occurs when your heart is actually doing that pumping motion, leading to blood perfusing the rest of your body and your brain. And the bottom number is diastolic blood pressure. And that's when your heart is taking a little break. And so that blood pressure goes down as your heart takes a break from pumping. Now, the best blood pressure to have, especially for stroke patients, is. Is gonna be in the normal range, which is, you know, gonna be less than 130 of the systolic blood pressure, that top number over 80, the diastolic number of that bottom number. So if you have a less than 1:30 over 80, that's usually a really good blood pressure. But if you have a blood pressure above that, then you're starting to get into the territory of, well, you know, you really should start thinking about how you can take this, take actions to avoid letting that get higher or letting it stay high like that for a long time, because high blood pressure really damages the. The blood vessels and. And it can lead to plaque formation. Right. So it combines with the other big risk factor for stroke, which is high cholesterol. So if you. If you have those cholesterol particles that are building up in the blood, then those will. Those will land in the blood vessels, and over time, that builds up and it becomes plaque, and it can lead to that narrowing.
- [13:12]
Louisa Nicola
It's not just about having high blood pressure, getting on an ACE inhibitor and just bringing it down. It really is about figuring out what is driving the high blood pressure and hypertension to begin with. And I know for a fact, after the numerous amounts of studies that I've read on exercise, that exercise can be one of the best interventions for lowering blood pressure, along with, evidently, diet and stress management. But exercise, I think, is one of the best ways that we can manage that blood pressure, bring it back down to baseline levels.
- [13:48]
Dr. Braden Dimm
Absolutely. I totally agree with that. The American Stroke association recommends at least 30 to 45 minutes of exercise, aerobic exercise, at least three days a week. And you know, I often joke that if you want to have a positive study in medicine, a study that shows positive effects, just study the effects of exercise on health, any aspects of health. Because exercise has been proven time and time again to be extremely important for your body in so many different ways and extremely important for your brain as well.
- [14:19]
Louisa Nicola
Actually, can we just touch on that for a little bit now? Because that's my area of expertise. I just, I just print. I just had a review article get printed in the Journal of Aging and I specifically looked at the association of resistance training on dementia and Alzheimer's disease. And it turns out that there is a very, very strong correlation. You can definitely increase gray matter volume and really prevent your yourself from getting mild cognitive impairment. But let's, let's just look at it from a structural perspective and a blood vessel perspective. From what I've seen in the literature, it really does have to do with blood flow. And if we go back to what we said about the arteries having muscles around them, the more times that you, I guess, contract and constrict the blood vessels, the stronger they become because they're like muscles. You know, you've got the concentric and eccentric phase of a muscle contraction. I mean, I guess it would be just the same as the blood vessels. So the more that you are able to pump that blood, I guess, the better efficient the, the blood flows over time. And the way that we do that is via exercise. This episode is sponsored by zocdoc. Guys, we know that there are things in life that you have to compromise on, such as time spent with family, convenience of a shorter commute, or personal preferences in daily routines. But when it comes to your mental and physical health, there should be no compromise. ZocDoc is a free app and website where you can search and compare hundreds of types of high rated in network doctors, including mental health providers, and instantly book appointments with them online. In fact, I see my chiropractor now every two weeks. I was always sketchy on chiropractors. If you know me, you should know this. When I found him on zocdoc, I went through the reviews. It was so simple and so easy for me to book him in. I booked it in and now I've been seeing him for the health of my spine, which is the health of my brain and my mindset. I now see him every two weeks. So you can find any provider, mental health provider, physical health provider, who offer in person appointments, virtual visits or both. Whatever works for you. And the best thing about this app is the typical wait time to see a mental health provider is just four days. That's it. You can even score same day appointments. So if you are in need of a provider, go to zocdoc.com neuro download the app, it's completely free and book a top rated therapist, psychiatrist or psychologist. Today that is zocdoc.com neuro yeah, that sounds about right.
- [17:23]
Dr. Braden Dimm
I'm not as much of an expert in the pathophysiology of you know, this a sedentary lifestyle but you know, and how that would affect your, your blood vessels. But what we do know is that you know, exercise while, you know, exercise itself can lead to a transient increase of blood pressure while you're using your body. Over time it can lead to a lower blood pressure while you're resting. Not, not exercising allows your body to be in a state of high blood pressure all the time. And if you give your body that, that exercise to say, hey, here's what, here's what I, you know, here's what I would need higher blood pressure for and you allow your body to relax after that it, you know, it better understands what it's like to, to have a healthy blood pressure.
- [18:09]
Louisa Nicola
So exercise is definitely one of the best things guys that we can be doing to preserve our blood vessels over time and obviously to help combat any form of hypertension or just, you know, bring that blood pressure back down to bas line. I want to talk to you about what actually occurs during, you know, when you have a stroke because I know that there is something called the golden hour.
- [18:33]
Dr. Braden Dimm
Yeah, absolutely. Now we're getting into, you know, the territory of stroke that, that I do on a near daily basis, which is, you know, acute stroke care. Now stroke can happen very suddenly, you know, if you, if you start to have a stroke and that's when you know that blood clot blocks off part of that brain. You will notice that within a minute or two because the, the, those neurons, those brain cells will stop functioning. And you will notice that. Now brain cells can, you know, so blood vessels give a lot of blood to different areas of the brain and when you have a blood clot, it doesn't immediately shut the entire blood vessel down, you know, and leading to the immediate death of that part of the brain. Oftentimes what happens is that there's a partial blockage and that means that there's, there's a little avenue for blood to squeeze by the blood clot and give just enough blood flow to a part of the brain to allow it to hang on for a little bit of time. You know, not enough people know that. You know, first of all, how to recognize a stroke. And this is a good opportunity for me to share the American Stroke association, you know, mnemonic called be Fast. So recognizing a stroke is, is usually when something happens to one side of your body or the other. But we use the mnemonic of be fast. Be Fast stands for B, which is balance. If you, if you're, if you suddenly lose your balance, you suddenly become very dizzy and you can't figure out another reason why that must have occurred, you know, it could be due to a stroke. E stands for eyes. So you can actually have a stroke in your eye itself or in the back of your brain in that occipital cortex that processes vision. So if one eye goes out completely and you can't see out of that eye or one half of your visual field goes out, that could be a stroke. Then there's, then there's F for face. So if one half of your face becomes droopy, that could be due to a stroke arm. So we often, you know, ask the, ask patients to test, you know, can you hold up both arms in the air for 10 seconds? And if you can't, if you have that drift there, that could be due to a stroke. S stands for speech. So you can either have garbled speech due to slurred speech or you can have the inability to talk because that part of the brain that commands language that's been damaged by a stroke. And then finally, T in the B FAST stands for time. And like you mentioned, you know, there's this golden hour. There's, there's, there's, there's partial blockage where some part of the blood is getting to that part of the brain that's screaming out for help. And if you can get to the hospital within four and a half hours, sometimes, you know, there's a little bit longer than that, but usually it's within four and a half hours. Then we can offer a clot busting medication to try to open up that, that blockage and try to rescue the part of the brain that you know might be slowly dying because it's not getting enough blood flow.
- [21:43]
Louisa Nicola
What's that called?
- [21:43]
Dr. Braden Dimm
The IV medication? Yeah, the IV medication. It used to be in the 90s, it used to be TPA or Alteplase?
- [21:52]
Louisa Nicola
TPA.
- [21:53]
Dr. Braden Dimm
Yeah.
- [21:53]
Louisa Nicola
Yes.
- [21:54]
Dr. Braden Dimm
But now across the country and across the world, really, they're moving over to. It's. It's not that newer, but it's, it's a newer process where we're moving to tenecteplase. And the advantage of using this new one, tenecteplase, is that it's easier to administer. One problem with TPA was that you'd have to give 10% of it as a push. And then 90% of that medication, you would have to, you know, hang in a bag and let it drip for an hour. So, you know, you weren't getting it all at once. It was taking a little bit too, too much time and taking a lot of resources as far as, you know, nursing to administer. But this new one, this tenecteplase, you can, you can push that immediately and get all of that into your system, you know, because as we say, time is brain. The, the faster that you can open up that blockage, the more blood cells that you can rescue.
- [22:44]
Louisa Nicola
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- [24:43]
Dr. Braden Dimm
That's actually a great question. I don't have a good answer for you. You know, that has to do with, you know, the, the pharmaco kinetics and the pharmacodynamics, But I don't, I don't really know exactly why that's the case.
- [24:55]
Louisa Nicola
That's really interesting. But I do, I do recall tpa and then obviously. So you've got anticoagulants, you've got antiplatelets, which are the. What's the difference between the two?
- [25:05]
Dr. Braden Dimm
Sure. So when it comes to, to prevent a stroke. So we just talked about acute stroke management, which is what happens when a stroke happens. And, you know, when, when patients are in the hospital with a stroke, I always like to answer the three questions. Those three questions are, you know, why did that stroke happen? How can we prevent this stroke from happening again? And then how can we get you through this? Right? How can we help you recover from that stroke? So we, we talked a little bit about why a stroke might happen, but let's talk about how we can prevent a stroke. So prevention, like we mentioned, a large part of that is managing and controlling your risk factors. But as a stroke doctor, a lot of what I have to do is decide what type of blood thinner might be the best for you. Now, blood thinner is, you know, a casual term for any kind of medication that would reduce your risk of forming a blood clot. Sometimes blood thinner is really reserved for a more powerful type of medication called an anticoagulant. An anticoagulant is a type of medication that it makes it harder for your blood to form into blood clots, makes it harder for that liquid to become solid. There's another type of medication called antiplatelets. Like you mentioned. Antiplatelets. Everyone knows medication. Aspirin. Aspirin. Sometimes people take this for pain, but we prescribe it in stroke prevention to try to help the platelets from sticking together, because blood clot formation and platelet stickiness, both of those can lead to blockages in the brain.
- [26:42]
Louisa Nicola
Now I'd love to move on and talk about the more devastating hemorrhagic strokes and talk about why they are so much more debilitating than ischemic strokes. So Hemorrhagic strokes result from a ruptured blood vessel within the brain, causing bleeding and increased pressure on brain tissue. And if I'm not mistaken, the number one, I guess, symptom of that is a splitting headache.
- [27:08]
Dr. Braden Dimm
Right. So ischemic strokes, which are the most common type of stroke, about 87% of strokes are ischemic. Then there's hemorrhagic strokes, and only about 13% of those are hemorrhagic strokes, which is really when a blood vessel ruptures and there's a bursting of that and blood is going where it's not supposed to go. It's not, it's, you know, it's supposed to go to the brain cells hemorrhaging. Right. And, and, and is really awful because, you know, not only is is blood building up in the wrong part, it's not going to where it's supposed to go. And that, like you mentioned, can be very painful. Now, ischemic strokes, they often don't lead to pain. So a lot of patients don't recognize that they're having an ischemic stroke because it's not painful. The brain cells themselves do not have pain receptors. Right. We did not evolve to have that capability.
- [27:59]
Louisa Nicola
That's why we can do open brain surgery with an awake patient.
- [28:02]
Dr. Braden Dimm
That's exactly correct. And I, and I've seen those, and those are, those are really amazing. You know, when, when you're mapping out the parts of the brain with language, you know.
- [28:11]
Louisa Nicola
Yeah, I, I'll interject there. I'm an intraoperative neurophysiologist, so I go into brain and spinal surgery, neuro oncological cases, brain tumors, et cetera. But I've done an awake patient, and I've got to tell you, it was, for me, it was scary to see. Not scary, but it's like I'm talking to you, but I can also see your brain.
- [28:33]
Dr. Braden Dimm
Yeah.
- [28:34]
Louisa Nicola
So, yeah, it's unbelievable.
- [28:36]
Dr. Braden Dimm
It really is. It's really one of the most amazing things that we can do. And, you know, and that's because the brain cells themselves don't have those pain receptors. Now when you have a hemorrhagic stroke, you do feel pain, and that's different. And that's because we actually have layers inside the skull called the meninges. And the meninges, you know, kind of surround the, the inside of the skull, and those do have pain receptors. And, and those are maybe thought to be you know, a primary cause of headaches, just kind of common headaches or, or migraines. But if you have a lot of pressure built up inside the brain that can push on the meninges as well. And those meninges are really what's, what's causing that, that splitting headache that, that that leads to, you know, that leads to stroke recognition or hemorrhagic stroke recognition.
- [29:26]
Louisa Nicola
Now the medications for that would primarily, primarily be the same. Correct. And the, the entire stroke care after that would be the same as ischemic. Thank you InsideTracker for sponsoring this episode of the show. We talk all the time about optimization and you can do a whole bunch of things through diet, exercise and proper sleep. But if you aren't measuring the impact that it has on your body, then you are missing out. InsideTracker provides you with personalized plans to improve your metabolism, improve your sleep, optimize your health for the long haul. And most importantly, it analyzes your blood and your DNA. So you have to understand where your biomarkers are. For example, apob, this is an extremely important biomarker. It's linked to cardiovascular disease. You must know these numbers if you care about living, if you care about living well and living long. So InsideTracker is an easy way to get these things done and they also offer tools for professionals. I know that I have a lot of professionals listening to this. I know I've got a lot of coaches listening to this. InsideTracker Pro is a no cost platform that allows your clients to share their InsideTracker analysis with you so that you can tailor their health protocols and training based on their results. Just go to InsideTracker.com Louisa you can get 20% off the entire InsideTracker store. Just use code Louisa20 at checkout.
- [30:57]
Dr. Braden Dimm
So it's actually really different. So okay, so ischemic stroke, like I mentioned, can be treated in that golden hour with clot busting medications. But hemorrhagic stroke, you know, up until recently it was, it was thought to be not quite as the ability to do something in that golden hour. Recently we have more evidence to suggest that if you can lower that blood pressure as soon as possible, then that leads to better outcomes. And so we, you know, we've really kind of, we've had a code stroke for a long time and code stroke has existed because we have therapies that can be given in that, in that golden hour to, to bust up the clot and return the blood flow. But what we found with, with hemorrhagic stroke is that if we can lower that blood pressure within that golden hour, then you are reducing the amount of blood that's accumulating in, you know, in the part of the brain that where it bursted and, you know, and you're preventing, you know, the compression of the surrounding structures. And so one thing that you'd want to avoid is you would actually want to avoid giving the clot buster medication for hemorrhagic stroke. You'd want to avoid things like, you know, the anticoagulants and the anti platelets, because those can thin the blood out and make you less likely to form blood clots, which, you know, blood clots exist because they are your body's natural mechanism to repair damage. You know, if there's been a split in the blood vessel, there's got to be some way where, you know, that that split closes back up. Otherwise you'll bleed, you know, forever until you. Until you lose that blood. So, you know, we want to allow the body to take that natural course and repair that blood vessel damage would ha which had occurred in the brain due to that hemorrhagic stroke. So it's actually quite, quite the opposite of how you would manage an ischemic stroke.
- [32:54]
Louisa Nicola
Why is it that women are disproportionately more affected than men when it comes to strokes?
- [32:59]
Dr. Braden Dimm
Sure. So, you know, there's been a lot of discussion, especially in the literature, about disparities in stroke and stroke care, and part of that has to do with, you know, you know, the gender differences. There's. There's a disproportionate amount of women who can get ischemic strokes for a couple of different reasons. I think that reason number one is that, you know, women tend to live longer and. And strokes tend to affect those who are older. So, you know, so just kind of by the numbers, you know, women would get a, you know, disproportionate amount of strokes. But in addition to that, the strokes that women get might actually be worse. They might actually have more severe or more disabling strokes. And that's probably due to the fact that women might have more atrial fibrillation or that afib that I talked about, which, you know, allows bigger blood clots to form in the upper chambers of the heart. And. And when the body pushes that and blocks the large arteries, then that can cause more severe disability. So for both of those reasons, women can have more strokes and more disabling strokes.
- [34:08]
Louisa Nicola
It's very hard to actually pick up on atrial fibrillation. Correct. I mean, you can't just go in and do an EKG and pick up on It.
- [34:18]
Dr. Braden Dimm
So you can find atrial fibrillation in a few different forms. So some people have permanent atrial fibrillation. And in that case, then, yeah, any EKG or electrocardiogram that you would do where you measure the rhythm of the heart that would find atrial fibrillation. Basically, you know, when you look at the ekg, you're looking for that small beat that is the top chamber of the heart and then the large beat, which is the bottom chamber of the heart. In afib, you're just going to find, you know, a flat background, and there's no small beat, there's no P wave, which is what we call it on the ekg, but you'll still find that in the large beat or the QRS complex, which is, you know, when the bottom chambers of the hearts are pumping and that show, you know, that has a big electrical impact when you, when you look at the leads on the chest. Now, there are other types of AFIB which are definitely harder to detect. There's, you know, there's persistent atrial fibrillation and then there's paroxysmal atrial fibrillation. And those tend to come and go. So if you do an EKG when somebody's not in the midst of an AFIB episode, then it'll look normal. You'll see the top chamber of the heart beating, you'll see that P wave, and you'll see that QRS complex, and it'll look like a normal EKG or a sinus rhythm. But, you know, if they go home, they could be in atrial fibrillation while at home, you know, but, you know, but when they came to the hospital to get that EKG done, then we just missed it. Now, there's a lot of ways to actually try to detect atrial fibrillation that, that you could not find with that ekg. So when you're in the hospital, we, we ask all of our stroke patients to wear telemetry leads. So telemetry leads are. When you, you do those, you know, the EKG leads on the chest. And instead of measuring that and printing it out on a piece of paper like you would for a typical ekg, you can monitor it remotely, and you can monitor it 24, 7. As long as you're wearing that on your chest, there's a central monitoring unit where you can check, you know, the, the rhythm of the heart constantly. But when we found that, you know, when patients go home, then that's, that's an area that we have not been able to detect. AFIB up until recently. But we do have new technology where we can have extended cardiac monitoring to, you know, where patients can wear something on their chest to, to measure that heart rhythm for a long period of time and see that, you know, in a 30 day period, you know, were you in atrial fibrillation activity or an episode of that for half an hour? Well, if you were, then, then we know that, that, hey, that's, that's a major risk factor for stroke and we can do something about that. In addition, we, you know, there's these Apple watches where, you know, they, they promote that they can detect AFIB activity. And, and so that's, that's a pretty new technology where you, you know, patients can take this into their own hands and buy a consumer device to, to see if they have afib, you know, at any given moment of the day.
- [37:21]
Louisa Nicola
Yeah, I, I think one of the best inventions that we can come up with, which I know doesn't exist yet, is a, you know, how you've got the, you've got the continuous glucose monitor. Wouldn't it just be incredible to have a continuous blood pressure monitor, for example.
- [37:38]
Dr. Braden Dimm
That, that would lead to, you know, a lot of studies to, to, to examine, you know, what is your blood pressure doing, you know, when you're sleeping, what is your blood pressure doing when you're exercising? Right. So that would be super interesting and I wish we had that sort of information in the hospital. We actually do have that sort of technology, but it's a, it's an invasive technology. So when, when patients are in the, you know, intensive care unit, when they're having a lot of nursing support and they're really sick, you can get an arterial line. So you can actually place a line into somebody's blood vessel, into that artery, and you can measure that blood vessel, that blood pressure in the artery itself constantly. So you can, you can monitor it continuously. But aside from that invasive procedure, there's the blood pressure cuff. And so when you go to the doctor's office, that's how you get your blood pressure measured, which is, you know, they'll inflate a cuff and then as it deflates, it looks for what your blood pressure is at given moments of that deflation period. Now that is kind of our gold standard of how to measure blood pressure without that invasive procedure. But I would love for a technology to exist, you know, that didn't require something like a needle going into your arm for sure.
- [38:55]
Louisa Nicola
Well, look, Brayden, what it seems like you're saying, and all of this is Prevention is better than cure. As long as we're sleeping well, we're exercising continuously throughout our weeks. You mentioned the Stroke Association. American Stroke association recommends the 45 minutes by three times a week of moderate to vigorous, I believe, or that's what the CDC recommends. But any form of exercise is good and then especially as it relates to strokes, it is lowering stress and stress management as well. But that has, that has been really wonderful. Thank you so much for sharing all of your insights and your publishing work as well. So where can a lot of people find you and read your, your work?
- [39:43]
Dr. Braden Dimm
Sure. So you can, you can search for my name on PubMed, which is the, you know, the, the literature search. You can also find me on social media. I'm on X or formerly known as Twitter and my handle is Braden Diminish, just with no spaces or dashes. And like you mentioned with my research. So I, I published on stroke and stroke epidemiology, which is the study of how stroke exists in a population. And the most recent study that I published was about stroke and post stroke depression. And I think this is a really important topic that not a lot of people talk about enough, which is, you know, stroke is a dis, you know, it's, it's a debilitating, disabling disease. Not only is stroke one of the leading causes of death, it's the third leading cause of death in women and the fifth leading cause of death in men, but it's also the number one cause of acquired disability in adults. And that disability leads to a lot of downstream effects in the economy and in patients. You know, if you're not able to do the things that you used to be able to do, then not only are you not able to do your job and contribute, but you're also going to need help sometimes with your daily activities. And we looked at post stroke depression specifically in a subtype of stroke called small vessel stroke. Small vessel stroke is when those small blood vessels that are deep in the brain, invisible to the naked eye, those shut down and, you know, by definition they're small, but they can still lead to disability. They can still be, you know, very severe, effective. And so we looked at if small vessel stroke was a different type of stroke enough to cause a difference in that rate of post stroke depression. So post stroke depression is fairly common and it can exist in, you know, up to a third of patients, you know, at any time after their stroke. And we found that to be similar in the, in the population of small vessel stroke. So even though it's a small stroke, it can still have disability and you can still have just as much risk of depression. We also looked for factors that was associated or predictive of who's going to get depression after this type of stroke. And we found that women in particular are at higher risk for post stroke depression. And so that really kind of calls out this need to screen patients after their stroke and, and say, you know, are you having symptoms of depression? Are you feeling, you know, no energy or really down or hopeless? Because post stroke depression is still something that you can treat. It's something that, you know, we really need to be more aware of. And not only should we ask patients to speak up, but we also need to ask them specifically and screen them specifically. And especially women who are at higher risk of this, they're about twice as likely to get post stroke depression as compared to men.
- [42:45]
Louisa Nicola
Unbelievable. I'm going to link that on your. I'm going to link that below so people can go and read. But thank you so much, Braden, for being part of the youe Experience podcast.
- [42:55]
Dr. Braden Dimm
Thank you so much for having me.