Types of Stroke

This article was originally published on Atlanta Business Chronicle on May 19, 2023.

Stroke is the fifth leading cause of death in the United States. The Georgia Department of Public Health reports the state had the 12th highest stroke death rate in the country. Georgia is also part of the “stroke belt,” an area of the southeastern United States with stroke death rates 30% higher than the rest of the nation.

As the leading — but preventable — cause of disability, stroke can happen at any age.

Stroke is a medical emergency, meaning the blood flow to an area of the brain is cut off, depriving brain tissue of oxygen and nutrients. When this happens, brain cells start to die and abilities controlled by that area of the brain, such as speech or muscle control, are lost.

New drugs and new advanced treatments — such as the Tigertriever and Artemis — are helping reduce the death and disability impact of stroke, as well as comprehensive care programs and innovative hospital partnerships that expand stroke services into rural areas.

Physicians from Wellstar Health System and the CEO of a hospital in northeast Georgia joined Atlanta Business Chronicle to discuss stroke prevention and the future of stroke care.

Panelists & moderator

• Dr. Rishi Gupta, Endovascular Neurologist and Co-Medical Director of Neuro Care
• Dr. Ashis Tayal, Vascular Neurologist, Wellstar, Director of Neuro Care Network
• Van Loskoski, CEO, Stephens County Hospital
• David Rubinger, Market President & Publisher, Atlanta Business Chronicle; Moderator

What is stroke, screening and secondary prevention

David Rubinger: Dr. Tayal, set the stage for us about the definition of stroke.

Dr. Ashis Tayal: A stroke is a sudden injury of the brain due to blockage or rupture of an artery in the brain. Injuries to the brain and disability can vary significantly.

The most common, ischemic stroke injury, is due to obstruction of an artery that causes a loss of blood flow to a critical part of the brain which damages the brain rapidly.

The other type of stroke is hemorrhagic stroke, where there’s a rupture of an artery, bleeding into the brain, or the surfaces of the brain, and that is called an intracerebral hemorrhage or a subarachnoid hemorrhage.

Rubinger: I think Americans have become a little better educated as to who’s at risk for stroke, but why don’t you walk us through that. Who would be a potential stroke candidate?

Tayal: High blood pressure, or hypertension, is the most common risk factor for both ischemic and hemorrhagic strokes. High blood pressure is an extremely common but controllable condition. Almost 80% of people have hypertension as they’re getting older.

Other risk factors include diabetes associated with elevated blood sugars causing accelerated blockage of arteries and high cholesterol, which can be related to diet and genetics.

Atrial fibrillation, a common heart arrhythmia that occurs as people get older, also places people at risk for the most severe and disabling types of strokes. And plaque buildup in specific arteries of the neck and brain also leads to an increased risk of stroke.

Smoking is another risk factor. Many adults still smoke despite a lot of progress in stroke treatment, and smoking puts people at risk for different types of stroke.

Rubinger: What about atmospheric things like stress and other areas like that? How does that play into it? Or do those things manifest themselves because of the other underlying physical conditions?

Tayal: I don’t view stress, in and of itself, as a risk factor for stroke. I think that’s more related to people’s environments and their own personalities and how they respond to stress. I do think people who are under undue stress can have poor lifestyle habits, and those poor lifestyle habits, whether poor eating habits, smoking, weight gain or lack of exercise, can lead to conditions that increase the risk for stroke.

Rubinger: So how is the healthcare system doing treating strokes? Do you believe that what’s going on at the primary care provider’s office is helping or do we have a way to go?

Tayal: In the United States, preventive care has improved the treatment of risk factors that lead to stroke, but communities must maintain routine checkups as many of the risk factors are silent.

There are improved treatments for hypertension, more aggressive treatment for diabetes, and more efforts at smoking cessation. Just the fact that we treat hypertension better than we did a generation ago has had a great impact on lowering the prevalence of stroke.

That being said, some of the most exciting work on stroke has often been done in the area of acute treatment of stroke with clot-busting drugs, catheter-based treatments and medications to protect the brain during an acute injury.

Rubinger: Has pharmacology gotten better in terms of the hypertension medicines that are out there? Have anti-cholesterol medicines improved in recent years?

Tayal: In the past, healthcare providers were often undertreating people with hyperlipidemia — high cholesterol — and not fully appreciating the benefits of significant reductions in cholesterol levels. For example, we’ve learned that driving cholesterol down into much lower ranges under 55 mg/dL can benefit our patients who have vascular disease as a cause for their stroke.

In the fight against high cholesterol, newer medications that prevent the absorption of cholesterol are now available. Recent developments have led to the discovery of a new underutilized class of drugs called PCSK-9 inhibitors that are highly effective.

To say Cindy Mejia is “busy” is an understatement. 

She’s constantly crunching numbers as an accounting manager for a large research institute, trying out new recipes in her kitchen at her Roswell home, or trying to keep up with her little granddaughter (who just discovered how much fun it is to run).

But one Wednesday in September, Cindy woke up and reached for her computer, trying to get an early start to her workday. She felt a little groggy and couldn’t remember her password but didn’t immediately realize something was wrong.

Then she stood up. Her right arm and leg weren’t functioning, and that’s when Cindy knew what was happening—she was having a stroke.

“The first thing I thought was, ‘I need to get to Wellstar North Fulton right away,’” Cindy said. “I knew the hospital was nearby and has a good reputation.”

That decision ultimately saved her brain and life.

For Cindy, the critical care she needed was close to home, too—she lives four miles from Wellstar North Fulton Medical Center. There, her care team sprang into action, bringing her the treatment and peace of mind in a moment of crisis.

“From then on, I felt well taken care of,” Cindy said. “I was relieved, and I knew I was going to be OK.”

Cindy's close-to-home 'pit crew'

When a patient has a stroke, every second matters. Each minute that ticks by could be the difference between a permanent stroke and a return to routine. So at North Fulton, Cindy’s care team assembled quickly to save her brainpower.

“We’re like the pit crew on a NASCAR team,” said Dr. Ed Malcom, an emergency medicine physician at Wellstar North Fulton. “We have our emergency stroke care response down to a science. Everyone knows their role and works together to act quickly.”

Cindy was one of the first patients at Wellstar North Fulton to benefit from the hospital’s new addition to its stroke program. While the hospital has been a primary stroke center for years, the introduction of thrombectomies at the hospital gives patients a close-to-home, life-saving option for stroke care—saving them both time and brainpower.

A thrombectomy is a minimally invasive procedure used to unclog an artery, restoring blood flow to the brain and preventing further damage. It does not involve cutting of the brain but instead starts with the insertion of a catheter through the patient’s groin.

“Recently, we’ve developed our own capability right here in the North Fulton area to pull the clot out of the brain. That’s a giant leap forward,” Dr. Malcom explained. “It's good for the whole state because there's only a handful of hospitals that do that, and it's good for the residents that live in that North Fulton area to have a hospital so close. They don't have to take a helicopter ride somewhere to get that procedure done. It saves time.”

For Cindy, having that procedure just a few miles from her home, right when she needed it, helped save her brain function.

“If Cindy would have gone to a different hospital that didn't provide this care, then it would have been a long time before she was able to have blood flow restored to the brain,” Wellstar Neurosurgeon Dr. Benjamin Zussman said, explaining how critical each section was when it came to Cindy’s care. “The delay could have been 30 minutes or even an hour, and it's possible that she would have had permanent stroke, permanent damage to her brain instead of making the recovery she did.”

Offering thrombectomies at Wellstar North Fulton has brought long-needed stroke services to the area north of Atlanta, so patients like Cindy don’t have to travel into the city through busy traffic to get the treatment they need. 

Proximity to care is especially important for critical situations like strokes, said Dr. Rishi Gupta, director of stroke care at Wellstar.

“Any disease that is time-sensitive where patients need to get to the hospital quickly, get treated quickly—the geography is everything, particularly in bad weather when helicopters cannot fly,” he said, explaining how logistics can impact life-saving stroke care. “We need to be able to provide services in the communities the patients reside and the North Fulton program is uniquely positioned to do that.”

Signs of a stroke can include a loss of balance, dizziness, blurry vision or sudden vision loss, drooping in the face, arm or leg weakness, and difficulty speaking. Patients who experience any of those symptoms should call 911 and seek medical care right away. 

Cindy said she is glad she got to the hospital as soon as she could—“I am so thankful that I took quick action and that I had Wellstar so close.” At Wellstar North Fulton, she not only received the highest level of stroke care. Wellstar takes a multidisciplinary approach to stroke care, including specialists such as critical care specialists, neurologists, neurointerventionalists and physical therapists on the care team. 

“When you're feeling pretty healthy, you don't think a stroke can happen to you. It happens so quickly. You don't necessarily get a warning,” Cindy said, sharing the importance of listening to your body’s signals when it comes to health. “You can feel one way one day or one minute, and the next minute, it changes.”