Online Health Chat with Dr. James Gebel
May 11, 2010
Cleveland_Clinic_Host: Each year, nearly 800,000 Americans suffer from strokes. A stroke occurs when the blood supply is cut off from part of the brain. The chances for survival and recovery improve when treatment begins within the first few hours of stroke warning signs.
James Gebel, MD, is a staff physician at the Cleveland Clinic Cerebrovascular Center in the Neurological Institute. He sees patients at both Cleveland Clinic’s Main Campus as well as Lakewood Hospital. He specializes in the management and treatment of stroke/cerebrovascular disease, intracerebral hemorrhage, neurological critical care and clinical stroke research.
Dr. Gebel received his medical degree from the University of Cincinnati College of Medicine. He completed residencies in neurology and neurological surgery at Cleveland Clinic. He completed a stroke fellowship at University of Cincinnati Medical Center/University Hospital, Cincinnati, Ohio and a second fellowship in neurointensive care at Cleveland Clinic.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. James Gebel. We are thrilled to have him here today for this chat. Let’s begin with the questions.
Stroke: What are the Risk Factors?
shaneme123: What are the chances of encountering a stroke due to aortic heart valve surgery and what are the chances of having a stroke post surgery?
Speaker_-__Dr__James_Gebel: There is always a risk of stroke with any type of surgery, and the risk of stroke is higher with valvular heart surgery than most surgeries. The risk is higher if it is a mechanical (prosthetic) valve than if it is a pig or cow or cadaveric (bioprosthetic) valve. If there is also coronary artery disease and a CABG (bypass surgery) is being done, this further increases the risk of stroke. Stroke can result from blood clots forming on the old heart valve as it is being removed, on the new heart valve after it has been inserted, and there is also risk of stroke related to the fact that blood is generally more prone to clot after surgery.
There is also risk of stroke due to the amount of time being spent on the heart-lung machine bypass pump, which does not do as good of a job circulating blood to the brain, as a normally functioning heart does.
The surgeons take steps to minimize all of these risks, but they are never zero, and strokes still occur even in technically perfectly done surgeries.
I always recommend that any patient undergoing open heart surgery have a carotid Doppler or other imaging of their neck arteries before undergoing surgery, since if the neck or brain arteries are narrowed, this is something the surgeon would want to be aware of.
shaneme123: If a patient has undergone some sort of chemo, does this increase the chance of a stroke?
Speaker_-__Dr__James_Gebel: No. Chemotherapy does not in and of itself increase the risk of stroke, unless it were a situation where, due to a drug interaction between the chemotherapy drug and a blood thinner that a patient was already on, the blood became too thick or too thin. However, having cancer does increase the risk of having a stroke.
shaneme123: If you suffer migraines; what does that do to your chances of having a stroke?
Speaker_-__Dr__James_Gebel: Having migraines with visual auras or other neurological symptoms (migraine with aura or complicated migraine) increases the risk of having a stroke, especially in young women and women on oral contraceptive medications. Smoking increases this risk even more.
Having "common" migraines (migraines that do not have auras or neurological symptoms) has not been associated with an increased risk of stroke.
petrom: My father had a stroke in his 50's and a small one in his 60's. My maternal grandmother had a stroke in her 50's or early 60's. Should I take any preventive measures based on that? I also know that I have high titer of anticardiolipin antibody in repeated tests. I understand that it may affect clotting too, right? Grateful for an answer.
Speaker_-__Dr__James_Gebel: Having a family history of stroke increases your risk of stroke and is what is known as a non-modifiable stroke risk factor. In terms of personal prevention measures, it depends on your own personal risk factors for stroke.
Controlling untreated high blood pressure, diabetes, high cholesterol, not smoking, and getting regular exercise and maintaining a healthy body weight all lower one's risk of stroke, as does taking one enteric-coated aspirin tablet daily. High titres of anticardiolipin IgG are most strongly associated with increased risk of stroke. Equivocal titres can be repeated to see whether or not there is a persistent elevation of the titre (the value) or not, and unless there are clinical features of an actual hypercoagulable state (thickened blood causing blood clots), isolated equivocal titres are not generally thought to be associated with increased risk of stroke.
It is beneficial to know if your parents and relatives had a particular type of stroke. For instance, if they all had blocked up carotid arteries, you would want to get a carotid Doppler study to screen your carotid arteries to see if they are blocked.
jjkm4: What are the odds of having another stroke while on Coumadin? I also have Atrial Fibrillation & a pacemaker. They tried to fix the Atrial Fib but wasn't successful. I am also taking Lipitor®. This question is for my twin sister.
Speaker_-__Dr__James_Gebel: The risk of stroke due to atrial fibrillation can be calculated by totaling up what is called a CHADS-2 score, which gives a specific annual risk of stroke. Your cardiologist can calculate the score for you. There is data for both coumadin treated and non-coumadin treated patients. Being on coumadin on average, reduces the relative risk of stroke due to atrial fibrillation by approximately 65 to 70%.
RobBob: I have read somewhere that there can be an increased risk for stroke or TIA's in people with a large waistline. I knew about this being a risk for heart disease, but is it also truly a risk for stroke as well?
Speaker_-__Dr__James_Gebel: Yes, obesity is a risk factor for stroke and especially abdominal obesity, which is what you are describing.
Poohba: My mother has osteoporosis. Her calcium intake is pretty high. What affect can this have? Can it increase her risk of carotid breakage?
Speaker_-__Dr__James_Gebel: Taking a calcium supplement does not increase the risk of atherosclerosis or stroke.
dd892: If a woman has had a stroke, can she safely take estrogen replacement therapy?
Speaker_-__Dr__James_Gebel: This is a controversial and unresolved issue. We do know for sure that women taking oral contraceptives that combine both estrogen and progesterone significantly increase the risk of stroke, and especially if the woman also smokes.
jjkm4: I recently found out that I have been having mini strokes. My heart & carotids are great. I was advised by my Neuro Dr. that a CAT scan will not detect mini strokes. Only a MRI can detect mini strokes. I have quit smoking, but I am on an aspirin regimen. My cholesterol, etc, - everything else checks out fine. I am scared of taking Plavix®. Do I need to have my blood checked for thinning or are there other things I should be doing? He says just a 325 mg. aspirin will not prevent stroke, but will thin the blood. Strokes run in my family.
Speaker_-__Dr__James_Gebel: Sorry, we cannot provide patient-specific advice in this educational setting. It is best to contact your treating physician as we cannot fairly evaluate an individual's circumstances in this format.
Fluter: What daily dose of aspirin is currently recommended?
Speaker_-__Dr__James_Gebel: For stroke prevention, the FDA and current clinical practice guidelines recommend a dose of 81 to 325mg daily. Enteric-coated aspirin is usually advisable, since it lessens the risk of aspirin-induced stomach ulcers.
Paulie: My mother-in-law had a bad fall and was taken off Coumadin. Other than Coumadin, what are other options for her?
Speaker_-__Dr__James_Gebel: It depends on why she was on the Coumadin. For patients with atrial fibrillation, the combination of aspirin and Plavix® is a second but less effective option for stroke prevention, but is still better than either drug alone for these specific patients.
helper: Other than surgery, what can be done for carotid arteries?
Speaker_-__Dr__James_Gebel: Carotid arteries, if they are narrowed significantly can be operated upon (carotid endarterectomy) or stented. If a patient is not a candidate for either of these procedures, then risk factor control and taking a blood thinning medication can reduce the risk of the blockage causing a stroke.
RosskoP: Can plaque form on stents?
Speaker_-__Dr__James_Gebel: Plaque can re-form on stents absolutely, as well as other reactions the body sometimes has to the stent, which can also cause narrowing to recur. It is important to understand that just because someone has had their carotid (or coronary) artery stented or operated upon to open it up, this does not mean the artery is permanently "fixed," especially if risk factors such as high cholesterol, diabetes, smoking etc. are not aggressively controlled, the artery can clog back up in years or even months, in some cases.
Lyngate: My dad has Atrial Fib. He had a stroke about 2 years ago. No symptoms or physical indications. I do not know the location of the stroke. I know it is hard to say without a consultation, but should we, his family, be worried? He now takes Warfarin and Coumadin.
Speaker_-__Dr__James_Gebel: Atrial fibrillation increases the risk of having a stroke. The specific annual risk can be calculated by his cardiologist using a CHADS-2 score. Taking Warfarin, on average, reduces this risk by 65 to 70%. There may be a new medication later this year or next year called Dabigatran which, if the FDA approves it, will be an alternative to Warfarin therapy, which appears to be somewhat safer and more effective than Warfarin.
You and your family should be alert to any signs of stroke your father has--- sudden onset of speech problems, vision problems, numbness, weakness, dizziness, or sudden headache - and if these occur you should call 911 immediately, so he can be emergently evaluated to determine if he is having a stroke.
lexus: What can you take to help prevent a stroke if you are allergic to or can't take aspirin?
Speaker_-__Dr__James_Gebel: You can take Plavix®, Warfarin, or Ticlopidine as alternative blood thinners. Taking cholesterol lowering medications (statins - especially Atorvaststin) has also been shown to reduce the risk of stroke, as does controlling blood pressure, blood sugar levels if you are diabetic, not smoking and getting regular exercise.
lauri242: I'm 57. There is a family history on mother’s side of vein/artery disease, @ 53 she died of massive stroke and had multiple aneurysms. I have had a TIA and in a recent screening was told my carotid arteries are more than 10% but less than 50% blocked. Is there something I should do? I take Simvastatin 20 mg (Zocor®) and my cholesterol is very low. Suggestions ?
Speaker_-__Dr__James_Gebel: I always recommend in anyone with such a strong family history of aneurysms, that they get a screening CTA or MRA of their brain arteries to be sure they do not have an aneurysm themselves. Not smoking and controlling high blood pressure are the two most important ways to prevent an aneurysm in the brain from forming or growing. Blocked carotid arteries should be periodically monitored with imaging studies, and controlling high cholesterol, blood pressure, high blood sugars, and not smoking are all ways to limit progression of disease.
Getting some other blood tests, called a high or ultra-sensitive C-reactive protein, a lipoprotein A level, triglycerides level, and homocysteine level also can identify treatable problems that may contribute to carotid artery plaque buildup and possibly reduce progression.
JPMorgan: Are there physicians who specialize in controlling high blood pressure? I cannot get mine in control. I am very worried about having another stroke. I had a brain aneurysm about 6 months ago. My pressure can go up to 190!
Speaker_-__Dr__James_Gebel: Nephrologists (kidney doctors) specialize in treating high blood pressure. I always recommend for anyone with very difficult to control high blood pressure that they get a sleep study to see if they have obstructive sleep apnea, a condition where you hold your breath at night and your body, due to lack of oxygen, releases a lot of adrenaline in the middle of the night, which drives up your blood pressure, even if you are on blood pressure lowering medications.
Stroke: How is it Diagnosed?
JJChang: If someone has a defibrillator or a pacemaker and can't have an MRI or MRA, how is a stroke detected?
Speaker_-__Dr__James_Gebel: Strokes can be detected by CT scans and by clinical history and examination, not just MRI scans, although MRI scans have a better ability to see small strokes and can see them sooner after they occur than a CT scan.
Ransome332: Are there any signs or symptoms that a person has carotid plaque?
Speaker_-__Dr__James_Gebel: Unfortunately no. The only sign is that you experience a stroke or TIA, or if your doctor hears a noise or bruit when s/he listens to your neck. Otherwise the only way to know for sure is to have a picture of the arteries taken, like a carotid duplex. Unless you are at high risk for stroke or have established coronary artery disease, this is not presently recommended for all people, as it is not cost effective.
There are some medical screening companies that will perform relatively low-cost screening examinations for carotid artery disease.
jjkm4: So, being that I am having TIA’s & am on aspirin, I really should ask what test they can do to find out why the TIA happened, my first experience with this situation. What kind of test should I ask about? I know that when I first had my left side go numb & trouble with speech, the ER treated me & did CT scan, but said that they couldn't find anything wrong and sent me home. I followed up with my doctor then he sent me to a Neuro Dr. They are great Drs., but if they can find out why I am having TIA's then I will suggest these tests. That would be great. Again, what test & I can request? Thanks.
Speaker_-__Dr__James_Gebel: Tests that can help determine the cause or mechanism of stroke or TIA include: imaging of the neck and brain arteries, such as carotid dopplers, MRAs and CTAs; pictures of the heart, such as transthoracic and transesophageal echocardiograms; and heart rhythm monitoring tests, such as Holter monitors or event monitors. Some or all of these tests may be appropriate, depending on a given person's circumstances, and sometimes additional tests are indicated based upon the results of the initial tests.
Whatever: What are the signs that a person is having a stroke? At what point would you call 911?
Speaker_-__Dr__James_Gebel: Sudden onset of inability to speak, slurred speech, inability to understand speech, sudden loss of vision, double vision, or a shade coming over your eye, sudden onset of numbness or weakness, especially on one side of the body, and sudden severe dizziness or staggering or sudden severe headache can all be signs of a stroke and you should call 911 immediately if you experience any of them.
Stroke Treatment Options
RichS: If you believe someone is having a stroke, beyond calling 911 immediately, is there anything you can do to help them? Depending on where you live, is it better to call an ambulance for someone you think is having a stroke or to take them there yourself, if you think you can get there faster? How can you find out if a hospital has a Stroke Team and how do you get an ambulance to take someone there if there is a closer hospital? Or is it better to get them to the hospital ASAP, whether or not there is a stroke team?
Speaker_-__Dr__James_Gebel: We do not recommend that people who have just had a stroke be given aspirin at home like we do for people having heart attacks. This is because the person may choke on the aspirin pill due to swallowing problems caused by the stroke and also it is a blood thinner and we avoid giving blood thinners if we are going to give a stroke patient thrombolytic (clot- busting) drugs.
It is always best to cal 911 rather than attempt to drive a stroke patient to the hospital yourself because they may stop breathing, may start choking, or become medically unstable. The only exception would be if you live in an area with no EMS services. Ambulances, remember, also have sirens and can get through traffic faster than you can.
It is generally recommended that you go to a certified stroke center if one is close to you, rather than to a non-certified hospital, and this is another reason to call EMS, who will know what hospitals closest to you are most equipped to deal with a stroke.
Cleveland Clinic is, of course a certified stroke center.
Constantly: I take medicine for high cholesterol and am trying to be careful with my diet. What else can be done for major calcification in the thoracic aorta?
Speaker_-__Dr__James_Gebel: Aortic atherosclerosis is a challenging condition to treat. We use blood thinners (like aspirin, Plavix®, Aggrenox®, or Coumadin) and cholesterol lowering medications, usually high doses of "statin" drugs. We do not yet know what the best approach is for this problem, but are in the process of finding out via an ongoing clinical research trial, called the ARCH trial, sponsored by the National Institutes of Health.
mickmack: If a person had t-PA previously for a MI or CVA, can they have t-PA again for another CVA?
Speaker_-__Dr__James_Gebel: Yes, unless the stroke recently occurred (within 90 days) or unless the stroke was a hemorrhagic stroke (a brain hemorrhage), which is a permanent contraindication to t-pa and other clot buster drugs.
AGBlack: Is age a factor for being given t-PA?
Speaker_-__Dr__James_Gebel: Yes, age is a factor we strongly consider when deciding whether or not to give someone IV t-pa or not, especially during the new expanded 3 to 4.5 hour time window. There is no absolute age limit for giving IV t-pa within 3 hours if someone is otherwise a good candidate for the medication, but the older the person, the higher the risk of bleeding in the brain from the medication is and the more reluctant we are to consider giving it, especially above the age of 80. The older a patient is, the more individual physician judgment goes into deciding whether or not they are an appropriate candidate for IV t-pa.
TIAs (Transient Ischemic Attack or ‘mini stroke”)
VeryEerie: Are TIA's a symptom of a stroke or are they separate events? If separate events, what is the association with stroke?
Speaker_-__Dr__James_Gebel: A TIA can be a precursor to a stroke - the same way that an episode of angina (chest pain) can be a precursor or warning sign of a heart attack. Having a TIA increases your risk of stroke, and proper testing after one should be done to figure out why the TIA occurred, so that measures to prevent stroke can be identified and implemented.
The TIA is its own event, and when a stroke follows a TIA it can be in the same brain artery or a totally different one.
If you have a TIA, you should dial 911 and go to the emergency room immediately - the same as if you were having a stroke.
Hungry9: If your vision in one eye goes dark, should you call 911?
Speaker_-__Dr__James_Gebel: If you actually lose vision (the eye goes black or white and you cannot see out of it), you should call 911 and get it checked out at the emergency room as this could mean you have had a TIA. In general, it is good idea to call 911 for any sudden visual loss or change, just to be safe, although many conditions other than TIA can cause such symptoms.
The emergency room doctor will know what to do to sort out if a particular patient's case seems medically serious or not.
KitKat: My husband recently had a MRI to determine if he had a tumor, stroke or aneurysm. Can an MRI show if he had a TIA at any time?
Speaker_-__Dr__James_Gebel: The MRI can show if someone has had a stroke in the past. Sometimes a TIA leaves a very small area of damage that can be seen on an MRI scan, but in reality this means it was a very small stroke that produced short-lasting symptoms.
Speaker_-__Dr__James_Gebel: Thank you for joining me today. I hope that I was able to answer some of your questions. For more information on stroke, please visit us at clevelandclinic.org/stroke.
- To make an appointment with Dr. Gebel, or any of the other specialists at the Neurological Institute at Cleveland Clinic, please call toll-free at 866.588.2262 or 216.636.5860. You can also visit us online at clevelandclinic.org/stroke.
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