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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP Programme no. 1 - Strokes
RADIO 4
THURSDAY 12TH JUNE 2008 1500-1530
PRESENTER: BARBARA MYERS
CONTRIBUTORS: LALIT KALRA
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
MYERS
Hello and it's very good to be back with you, ready, willing and I hope able to answer your questions today on the subject of stroke. Now we're very much more aware these days of the risk factors for stroke - high blood pressure and carrying excess weight are just two of the obvious ones - but strokes are still the third most common cause of death, indeed by the time this programme is over five more people in this country will have had a stroke, hopefully not among our listeners. Lives can be saved by FAST action - FAST, by the way, is a helpful acronym, we'll find out what it stands for later. But even if you survive a stroke you may be left with disabilities. There's much that can be done to aid good recovery though whether you feel that you've been able to get all the help you need is another matter and it's something you might wish to raise with our expert in the studio today. He's Lalit Kalra, professor of stroke medicine at King's College, London. Our first caller would like to speak to him.
Ian Taylor, over to you in Oxford, what's your call - what's your question? Well we thought we had Ian Taylor waiting to speak to us, I don't think he's there for the moment. Let's try another call, let's see if we can go to John Axford. John, I don't know if you're there waiting to speak to us in Dover? No, okay not for the moment, so sorry about that, new series new problems, that's the way it goes.
We're going to be talking I know about some new and rather good news, I think it's fair to say, Professor Kalra, which is about the changes that have been made to make sure that people do have much better access to stroke treatment and that's really rather good news, it's something I know that at your centre in King's College, London you already have underway but what can we hope for and expect in the very near future that's going to make things much better?
KALRA
Thank you Barbara. I think there is a lot of good news for your listeners, especially regarding stroke. As a lot of people may be aware the national stroke strategy was released early this year, it was end of last year, which has a very clear cut programme of managing strokes much better than we have in the past. It's all about preventing strokes, it's all about acute treatments for stroke - things like thrombolysis given at the right time to as many people as you can possibly can. It's about good rehabilitation. It's about setting up centres of excellence - places like King's College, London where we work in association with Guy's and St Thomas', or places like Oxford and quite a few other places in the country which will be providing this quality care.
MYERS
Because the truth is now still a good many people - I think it's 150,000 people a year, if I'm right - actually experience a stroke and we've already said that one in three - for them it will be fatal. And those figures are not good and they haven't much improved or not improved as much as they might, what difference do you think as things change under the new strategy what difference do you think that will make to outcomes for people?
KALRA
I think we've got a lot to look forward to. Just going by very conservative type calculations we believe that where we implement this strategy properly we will be saving about 500 lives a year in Britain, we will preventing about 2,000 people a year not being disabled because of stroke. And what is even better we will be saving money because people will spend a lesser time in hospital and probably have better outcomes requiring less social care. So there's all to play for.
MYERS
Well if people are wondering what's happened to our phone lines then I'm wondering too. And I'm so sorry this is Check Up, it's a health phone in, but unfortunately we seem to have some severe technical gremlins which of course is why I'm hogging the limelight for the moment and talking to my guest today Professor Lalit Kalra.
What is working is our e-mail system and so I'll go to an e-mail from Lucila. Lucila is speaking on behalf of her mother who's 80 years old and sadly has had a stroke, in fact she's in an acute unit at the moment, and Lucila makes the point that mum was very physical, she was very physically active and now she's in a wheelchair and I think both mum and of course Lucila and family are trying to get their heads around the fact that she's somewhat stuck in a wheelchair. She's having physio, she's having other treatments but the question is really how much recovery might she might make and how much effort can they make to help her with her recovery, including more physio if necessary, perhaps even buying in extra physio. I think I'm speaking from personal experience having had my mum have a stroke, you feel so desperately concerned and really want to seek all efforts, all means, to help, so what can you do in this situation, what would you say to Lucila?
KALRA
Barbara once again this story shows how devastating stroke can be, how we could be perfectly normal, working, functional one day and the next moment everything's taken away from you. The hard thing about stroke is that if you're not treated, if you haven't had thrombolysis, you end up with a degree of deficits, there's a long period both of recovery, rehabilitation, but also for readjustment. My only advice would be I think it's a bit early to start making plans. I think there is a period required to see what rehabilitation actually achieves. I think she's in a very good unit, I'm sure that the physiotherapist will have charted out what her deficits are, what treatment she requires and it will take time, there is no instant cure. There always has to be an adaptation at the end of the day because quite often stroke damages various parts of the brain and we lose function. Total recovery may not happen and then there's a need for adjustment but that comes with time, that - professionals help you with it. But I think it's very, very early in the day for her to plan the rest of her life. I think it's a question of waiting and seeing what the professionals have to say, working with them.
MYERS
Is recovery time something that you can map out and from your experience with patients in your own clinic can you see a sort of - whether it's a curve, I'm not sure graphically how you might represent it, but what is the sort of course of recovery - is it the same for everyone, is it the same length of time?
KALRA
I think everybody's an individual and I think that's very, very important to remember. I think everybody recovers fairly quickly in the first few days after stroke because there's a lot of swelling associated with a stroke and that goes down and people feel better. There's also a phase of early improvement when the brain improves very rapidly and that can be anywhere between a few weeks to up to three months. There are now indications that the brain recovers much longer than that and this is a slower process. How much in-hospital therapy can help that is an open question, probably not but what is important is that once people start getting better, if they don't sit back and wait for things to happen, where they actually listen to the therapist and keep active. We now know that the brain can regenerate, a lot of factors dictate that, we're still researching on those areas. The good news is people by and large get better.
MYERS
Good news. Lalit this has turned into a very interesting interview, for which I'm very grateful but I think we can go to a caller, let's try again to speak to John Axford who's in Dover. I don't know if you can hear us now John.
AXFORD
...[indistinct words]
MYERS
Okay, well anyway it's over to you with your question about I think it's your mother - mother-in-law is it?
AXFORD
Mother-in-law yes, thanks for that. Just picking up on what your specialist was saying earlier about keeping active. My mother-in-law is in her mid-80s, had a series of TIAs about a month or six weeks ago, since when she has been diagnosed some - prescribed, rather, some regular medication but one of the side effects of this is that she's lost a bit of confidence about going out and so on in case there's a full blown stroke at some time. Now the question is are these ITAs a precursor to a full blown stroke, are there any preventive measures we can take, should she live her life normally and so on?
MYERS
Thanks for that. Now I think - are you talking about TIAs, I think this is what some people call mini strokes or minor strokes or transient strokes, I think perhaps if you can explain to us first professor what these TIAs might actually be and whether in fact they are likely to lead to something more which is obviously what - what John's mother-in-law's worried about?
KALRA
John can I ask you a question - was your mother-in-law investigated for these TIAs?
AXFORD
She was yes, she had a brain scan and heart monitoring for a while as well.
KALRA
And did they look at her arteries - the carotid arteries?
AXFORD
I believe so yes.
KALRA
Right and all those were clear I presume?
AXFORD
Slight worries about cholesterol but apart from that pretty much as you expect an 85-year-old lady to be.
KALRA
Just sort of looking at the various presentations of stroke quite often people suffer TIAs, which are fairly classical things that come on and then go away fairly quickly. But quite often as we get a bit older people also start getting mini strokes in which small parts of the brain get damaged because smaller arteries in the brain get blocked which may mimic TIAs. And there's a distinction to be drawn because in one there's a lot of treatment possible - things like carotid surgery, getting the heart rate sorted out or anti-coagulating. In the other one the treatment's slightly different. And I suspect that having been investigated, having any serious disease of the carotid arteries of the heart ruled out what we're left with is the usual preventive medication with things like aspirin, good control of blood pressure, good control of diabetes and active lifestyle, John it's very important that she stays active. I know if you have strokes you lose confidence but the important thing is not to let it get to you, it's to keep active.
MYERS
Okay thank you for that, I hope that's been helpful to you. Let's go to another caller, since we've now got the lines back up, I can see how many people are waiting there to speak to us. Sandra is in Herefordshire and I think has had two mini strokes, what's happened to you Sandra?
SANDRA
Hello.
MYERS
Hello.
SANDRA
Well I'm really a new girl because only yesterday I was confirmed as having had two TIAs in a week and I was confirmed that at the stroke clinic at my local hospital which I actually can't praise highly enough...
MYERS
Well that's good news.
SANDRA
... because the attention I had there was so reassuring and professional and patient and caring.
MYERS
So this is all very new for you, can you just say, perhaps for the benefit of listeners, what you experienced with these two mini strokes?
SANDRA
Well I'd like to say, first of all, that - to use that awful phrase - I seemed to have experienced all the things that tick the boxes. I had tingling in my right arm, pins and needles that I had for about three weeks and I thought - I put it down to the use of my laptop, I had been finishing an Open University course and I'd been sort of working on that. And then I did - when the thing happened to me, a week last Monday evening for the first time - just had a strange sensation in the head, got off my bed where I was watching some TV and had my right leg - felt very heavy and weak and my throat seemed to sort of suddenly go very dry and my tongue - I couldn't swallow and I realised I couldn't formulate my thoughts and I just actually was seen by an NHS Direct out-of-hours doctor who thought I'd had a TIA and who referred me to my own doctor the next morning for blood tests in case it was a virus. I didn't have a test. He referred me to the local stroke clinic but I didn't get my appointment until yesterday and so that was about 11 days I think.
MYERS
Let me put all this to the professor because ...
SANDRA
And with my second - I had a second one on Sunday you see, we're now waiting - I had a second one and I'm wondering could that have been prevented?
MYERS
Well I mean certainly the professor here - and I can see him, he's shaking his head when you talked about going to the doctor and you know then waiting. So that said, you sound fine now, can you just say that you're feeling okay now and you've regained some of these ...
SANDRA
Well [indistinct word] I'm feeling pretty weak and wobbly but I mean I was very slurred and my neighbour who came to my assistance - I live alone out in the country and now I've been told I can't drive for at least a month and then to be reassessed. I was slurring, my right eye drooped and the facial muscles on the right side of my face looked marginally affected. But amazingly the next day I started to recover.
MYERS
Okay well let's get a comment on this, thank you very much for giving us a little bit of detail. So Lalit what would you want to say for Sandra?
KALRA
Well Sandra thanks for sharing this story with us. But I think there's no doubt that you actually did have a TIA.
MYERS
This transient ischemic ...
KALRA
That's a transient ischemic attack - that's a classical description, if I've ever heard one. And I'm a bit surprised I must say - 11 days is a very long time to wait after a TIA. The good news is that the new stroke strategy says that something like that, especially a TIA, where you've had two TIAs perhaps and I do know your age, this should have been treated as a matter of some urgency and you should probably have been investigated within 24 hours, if not at least within the next five days. So there is still a way to go in terms of actually getting it right. Can I ask you a question - have you had any investigations here to note?
SANDRA
Yes I did, when I went to the stroke clinic yesterday I had forewarned them that I'd had another attack on Sunday and I was very anxious that things could be put in motion and I had the carotid artery sort of ultrasound and I had the scanning of the - a CAT scan. I've got to have some sort of echogram or something for the heart muscle now because the carotid artery and the head scan didn't show any abnormality but they don't know what's caused it. I've just started literally taking medication, I mean I've never taken a tablet in my life before and I've started a statin last night, a dispersible aspirin this morning and something rather unpronounceable called di ....
KALRA
[Indistinct word]
SANDRA
... this morning.
MYERS
Okay let's not go into too much detail on the various medications but does it sound now as though at least ...
KALRA
That sounds absolutely right.
MYERS
... everything is being done appropriately at this point.
KALRA
That's absolutely appropriate. The only shame is that this perhaps should have been done a week or so ago.
MYERS
And that would be - would be a kind of key message wouldn't it that these TIAs or what seem to be - again people are saying mini strokes - things that don't seem too too serious at the time need to be taken seriously because in fact whether they might lead to something is really what's important about them?
KALRA
Absolutely, I couldn't agree more. If it was our hospital you probably have had everything done within the next 24 hours or so because it should be regarded like chest pain is for heart attacks.
MYERS
And that's the gold standard and that's the key point that I mentioned earlier - FAST - perhaps you want to just very briefly explain what we mean by FAST and why it's important that people think about the FAST acronym.
KALRA
FAST is an acronym just to make people aware of what a stroke's all about and get to the hospital or a stroke centre actually as soon as possible. F stands for face, A is for the arm, S is for speech and T's for test. So if you have weakness of one side of the face, doesn't matter which side, weakness of the arm or leg and you're unable to speak or you're unable to speak think of it as a stroke, it's like a crushing chest pain for MI - go to the hospital, go to a stroke centre.
MYERS
And you don't need all of those symptoms just anyone of them?
KALRA
No anyone of them is ...
MYERS
Is a red flag.
KALRA
Is a red flag.
MYERS
That means a blue light.
KALRA
It's a blue light and you don't go to your doctor, you call the ambulance.
MYERS
Okay let's go to Edinburgh, another caller Cornelia waiting to speak to us, had a stroke in September, concerned about loss of sight. Cornelia, how can we help you if we can help you?
CORNELIA
Well I just wondered if there was anything I can do. I'm taking a supplement called Retinex which is supposed to help with the sight, I've lost half my sight and one doctor said I'd probably never get it back and another doctor said I might get it back so I'm really stuck between two stools, I don't know what's going to happen. Is there any chance that I might get my sight back? I actually had a cataract operation last year and the eye where the cataract was removed is much better than the other one, I've still got a cataract on the other eye.
KALRA
I think what your stroke has done has affected the part of the brain that deals with vision. Now unfortunately, especially so long after stroke, there is a bit of permanent damage so it's probable that the sight will not get back to what it was before the stroke happened. Having said that the brain is remarkable - there is a period of adjustment so after some time what does happen is people start adjusting to that loss of vision, you start looking around it, you start compensating for it. And some people do it to such an extent that they actually no longer aware that they have a problem till they're formally tested. So I suspect that will happen. But unfortunately stroke does leave a mark sometime. Does anything help? Probably not, I think it's probably the more you see as time goes on things get better. The important thing is to take your preventive medication so that it doesn't happen again.
MYERS
Cornelia, thank you for that. Caller in Oxford now - Janet wants to talk about carotid arteries, we've mentioned carotid arteries, perhaps in a moment we'll understand a bit clearer what the carotid artery is and what part it plays in all this but over to you Janet for your question for our expert today, what did you want to ask?
JANET
Ooh good afternoon. My mother is 92 and she had two transient ischemic attacks back in March. She had a brain scan and she had a scan of her carotid artery and it's 71% blocked. Her clinicians are now considering carotid artery stenting and I'm just concerned about the risks and benefits of this procedure in a lady who's 92, although she's incredibly fit and lives alone and is very independent, I'm concerned from what I've read that it's a relatively new procedure and I believe there is quite a risk of having a stroke while the procedure's being carried out and I just wanted to - well...
MYERS
Well you're asking the right person, perhaps we'll get a direct answer to your question but can you go round about it only insofar as to explain to us a little bit about the carotid artery and what the value might be of opening it out - I think which is what the stent would do?
KALRA
I think the fact that your mother's had two TIAs and they've actually found a carotid - 70% is perhaps the right level in the sense that - 70% means it does need something doing, you can't ignore it, you can't manage it medically. Age in itself is not a contraindication to carotid procedures, we have done carotid surgery on people as old as 94 at King's. So that in itself is not a criteria, the criteria is how fit is the person on whom you're going to perform the surgery. From what you've told us I think your mother probably would benefit by the surgery. Whenever you - sorry or carotid stenting - whenever you undertake a procedure there's always some risk/benefit analysis, yes there is a risk of the procedure, it's true, that ranges between 1-2% for surgery, perhaps slightly higher for stenting. But probably it's much less than the risk of a stroke over the next year or so.
MYERS
And the value to opening up that artery would be to make sure that these TIAs don't happen, that there's no further possibility of clots breaking off or indeed to make sure the blood is flowing probably up through the neck, I think, is where we're talking about into the brain?
KALRA
I think TIAs are a sort of a symptom of things going wrong in the neck, it basically means there's a plaque in the neck which is causing the stenosis is actually throwing off little clots into the head. And - or causing turbulence which stops the blood flow. By stenting it or by doing a carotid endarterectomy you stop that happening, so you reduce the risk of having a stroke by anywhere between 60-70%
MYERS
So that sounds like a thumbs up in this case, so thank you Janet for raising that. We go, I think finally, to a caller we were hoping to speak to at the very beginning of our programme when we had some technical problems and it's Ian Taylor in Oxford, so thanks for being patient, your question or your point please Ian.
TAYLOR
It was really more of a point relating to not necessarily getting to A&E crucially and early. My wife had a major stroke in January and fortunately was only about 15 minutes away from the hospital but she was given thrombolysis, which I understand is a relatively new clot busting drug, and we subsequently found whilst checking availability around the country for holidays that this was not available by any means in most of the hospitals around the country - some offer it from 0800 till 0800 during the day, some offer it only during the week, some don't have it at all - it does seem to be a relatively - well a very unfair lottery based on where you live and where you actually have your incident.
MYERS
So what do you want to comment on that in our last minute or so very briefly?
KALRA
Well I couldn't agree more, I think there's a lot to be done. The good news is that we have a national stroke strategy and we have centres - we've got centres - you mentioned the one in Oxford, at King's we offer a 24/7 service and you can see the difference it makes. I think there's a lot of pressure on commissioning authorities to actually implement this across the country. The good news is that the processes for implementing this are in place and hopefully by the end of this year we should see a lot of improvement in acute stroke care.
MYERS
That's very good news indeed and just as a final word of warning remind us again what the FAST symptoms are and what people should very much look out for a act on if they see them.
KALRA
The FAST symptoms, again to repeat myself, I can never get tired of repeating myself - Face, arm and speech test - so if there is asymmetry of the face or you find one side of your face is drooping or you've got weakness of the arm and leg or if you have difficulties in talking which has all happened suddenly do not call your doctor, call an ambulance.
MYERS
Thank you very much. Thanks very much for your expertise today Professor Lalit Kalra. Thanks for all your calls. If you missed anything listen again on our website at bbc.co.uk. You can download the programme as a podcast. For more information call 0800 044 044. And join me again, if you will, next week at the same time, bye bye.
ENDS
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