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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP
Programme 1. - Stroke
RADIO 4
THURSDAY 09/02/06 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
TONY RUDD
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
MYERS
... 150,000 a year in this country, the third commonest cause of death and the leading cause of serious disability. Why are we not better at preventing and treating stroke? There's a lot that we can do to reduce our risk factors but once a stroke has happened our chances of getting timely treatment are variable and the provision of rehabilitation services patchy, to say the least. Well if you or a member of the family has suffered a stroke what information do you need? Or would you like to pass on. Call us now with your questions 08700 100 444 or you can e-mail checkup@bbc.co.uk. And in the studio with me is my guest Dr Tony Rudd, he's a consultant stroke physician at Guys and St Thomas' Hospital. I'm wondering Dr Rudd, in the first instance, whether part of the problem here is that we're not as familiar with the symptoms of a stroke as we might be, if someone was clearly having a heart attack.
RUDD
I think that's absolutely right and many surveys actually have shown that about half the population think that stroke is a problem of the heart itself, not the brain, which it is. So the main common symptoms of stroke are weakness, paralysis down one side of the body, perhaps affecting the face and the arm or the arm and the leg or even all three, sometimes people lose their ability to understand what's being said to them or produce words, they become, what we call, aphasiac. T hey may get disturbance of their vision. Almost anything that the brain controls, is responsible for, can be affected by a stroke.
MYERS
Let's go to our callers, there are plenty of them waiting to talk to us, and I think the first one up is Mark Amey. Mark, your question please for our expert today on stroke.
AMEY
Hello. My mother was an 82-year-old who was quite fit and active. She had a devastating stroke about two years ago and in fact she died of the classic respiratory problems a year ago. However, the question is there were three things where I think perhaps I should have done something different during the course of the stroke and beforehand and presumably the question is what should other people do if they find themselves in the same situation. If I can take them in reverse order. I was actually with her at the time of the stroke, the ambulance came very quickly, she was in casualty within about half an hour. I was able to tell them she'd had a previous recent history of minor TIAs - transient ischaemic attacks - which in her case took the form of vision disturbances. And I said to the doctor at the time I thought you'd be giving her a clot busting drug and he said - ah, um, well we don't necessarily do that. So the first question is should I have been more insistent or what was the reason why they might now have given her a clot busting drug?
MYERS
Mark, let's deal with that question because that's quite an interesting one and very relevant and let's leave it at that. Let's talk about that business of getting clot busting drugs - after all if we're talking about a blood clot in the brain cutting off the blood supply, yes why not get rid of it, why not use a drug?
RUDD
Well the first thing I think I'd say Mark is that you - I think - have responded very appropriately by getting the ambulance there very quickly, that's a message which we're really trying to drive home to everybody, that if you have any symptoms that might be due to stroke dial 999, get into casualty as quickly as possible. Now not all strokes are appropriate for clot busting treatment, about 1 in 10, or slightly more than that, of strokes are actually due to bleeding into the brain and if you give clot busting treatment to those patients then you will actually cause much more harm than doing good. For many of the other sorts of stroke then clot busting treatment can be effective but unfortunately in this country we've been really quite slow in getting services going to be able to deliver that and at the moment in the UK there's only about 20 hospitals that are doing it. So that's really the problem. I suspect that probably your mother went to a hospital where they were not set up to deliver the treatment.
MYERS
Okay, I won't go into all the other points that I know that you wanted to make Mark because we've got so many people who've e-mailed and are hanging on the phone but that's an interesting first point that's been made there - it is important to get into hospital if you can although it doesn't necessarily follow that you're going to be a candidate for clot busting drugs and not everywhere, in fact not many places, are set up to deal with that approach to the stroke.
RUDD
Having said that, I mean even so getting into hospital quickly is going to give - deliver significant advantages, there's lots of things that we can do, quite apart from clot busting treatment, which will contribute to getting a better recovery than if you sit at home and do nothing.
MYERS
Okay, let's move to Lou Hammerson, who's waiting to speak to us, and Mark did mention TIAs there, I hope you'll tell us Tony a little bit more about TIAs, but it's something that Lou is concerned about. Your question Lou is?
HAMMERSON
Yes thank you, good afternoon. About four weeks ago I had two mini strokes, on a Monday I had a mini stroke, I didn't know it was a mini stroke but I started to mumble incoherently and I couldn't walk. And it lasted all day long and in the evening it disappeared. I was okay on Tuesday and then Wednesday the whole thing started again. Fortunately my wife was off work that day and she got to me to the hospital at A&E at Doncaster and they kept me in about five hours, did a lot of tests and they came and told me that I'd had two mini strokes. And I had a clot busting drug about four years before as I had a slight heart attack. And what I'd like to know from you is can you tell me if these two mini strokes that I had are a prelude to something a bit more ominous, something a bit more severe?
RUDD
Well I think that you've done the right thing again really in terms of getting help quickly. The fact is that these mini strokes should be taken very seriously. In quite a large number of people they are a warning sign that a major stroke may happen. Now if you get them investigated and treated quickly then we can reduce that risk very considerably. But the figures are actually up to about something like 20-30% of people who have a mini stroke who we also call - you may be more familiar with the term of TIA or transient ischaemic attack - 20-30% of people will be having, as I say, within the first - go on to have a complete stroke within the first month. So yes you've done the right thing, got treatment and investigation done quickly. I think it's important to make sure that they've done all the tests that are necessary because some of them are more difficult to obtain within the NHS than others. And perhaps one of the most important ones is to make sure that they've done the scan of your neck ...
HAMMERSON
No they didn't do that. The doctor asked for that to be done, he asked for a - the scan on the neck, the carotid artery, and they didn't do that.
MYERS
What's the value of having that done, let me ask that of Tony, what's the importance of ...?
RUDD
Well what we're looking for is whether or not there is a large amount of narrowing of the artery going up into the brain, if the arteries are very narrow then less blood can get through and it might be a sign that actually the thing's going to block off altogether and if that was to happen then you could end up with a major stroke. And there's good evidence now to show that if that artery is very narrowed then an operation to clear that atheroma - the sort of furring up of the artery - can reduce the risk in the longer term of having a further stroke.
MYERS
So it would be sensible for Lou to press for that in fact?
RUDD
I think you should go back and say when's this going to be done because the quicker it's done the quicker we'll know whether or not there is something that needs to be done in terms of an operation.
MYERS
Thank you very much for that call Lou. And just to say again then the signs of a TIA, of a mini stroke, which could be the sign of a bigger stroke to follow, just remind us of what they might be so people might actually pick up on those as kind of first aid signs.
RUDD
Right, well they're exactly the same signs as you'd be getting with a stroke. So weakness of the face, weakness of the arm, weakness of the leg, loss of speech, problems with vision, are the most common things. And if that happens then call - dial 999 straightaway, do not hang around. I'm afraid that people are terribly slow at presenting themselves with these symptoms - they look after their cars better than they do their bodies, I've never met anybody whose car breaks down in the middle of the road and they sit there for eight hours waiting for the thing to get better and yet I frequently come across people who develop symptoms of stroke, their bodies stop working and yet they sit there waiting for everything to get better.
MYERS
Celine Pinter's on the line next, has migraines - I wonder if migraines are a sign of a stroke, possible TIA, what's your concern Celine, do you think there's any connection?
PINTER
I actually suffered from migraines for quite some time, a number of years, and although the number of times I got them has declined the severity has increased and so the last one I lost my speech for a number of days. The doctors thought I'd had a stroke but that wasn't in fact the case. But I was told subsequently that I may have an increased risk of suffering from strokes in the future, then as there's a family history I just wondered really what I should be doing to avoid the possibility of a stroke and is there a link?
MYERS
It is interesting because this - one of the thing's that happens I believe with migraines, happily I don't suffer, but you get a sort of blurred vision, is that something that you've experienced Celine?
PINTER
Well it can range from a loss of balance, you're not able to speak, you can lose telephone numbers and all sorts of things can go on.
MYERS
So you can see why that might feel like the possibility of a stroke or a mini stroke. So let's get the expert advice on that - is there a connection?
RUDD
Well yes, I mean the first thing is that the symptoms, as you say, of migraine and stroke or TIA can be very similar. My wife suffers from very much the same sort of thing that you have, her speech becomes garbled, she speaks even less sense than she normally does ...
MYERS
Careful.
RUDD
Sorry. But then that gets better usually within a few hours and the headache obviously comes along as well. So the symptoms can be very similar. With migraine the symptoms tend to come on rather more gradually actually than the sudden onset that you get with stroke and that's quite an important distinction between the two. Very occasionally migraine can be put down as a cause of stroke but I think it's pretty unusual. And - bearing in mind of course that even people who've got a history of migraine can go on and have a stroke for other reasons. It's very important that - particularly if you start finding that the symptoms of your migraine are different from your usual ones then I would certainly seek medical help. But overall I think the risk of you actually having a stroke as a result of your migraine is very low indeed.
MYERS
What - I think you're also suggesting though is if you've got this stroke awareness, because I think you did say that there's something in the family as well, I mean if one does develop an awareness around the possibility of stroke what in general, Dr Rudd, would you say you can do, what should you be doing in terms of prevention?
RUDD
Well stroke is largely a preventable disease, if we got everybody's blood pressure in this country down to really nice low levels we'd probably be preventing 50-60% of all the strokes that happen. So - and so making sure that your blood pressure is as low as it possibly - as you can tolerate really is important, in fact probably virtually everybody in this country is running blood pressure that's too high, we're not designed to live with a diet and the amount of exercise and so on that we all take. So the belief now is actually that we should be getting blood pressure much lower than even - than sort of normal levels that your GP would be aiming for. So get your blood pressure checked, reduce your salt intake in the diet, make sure you're taking exercises - all the usual boring things - don't let yourself get fat, have your cholesterol checked.
MYERS
You're going to get double benefit from that because you're going to feel a bit better, you're going to look a bit better and I guess it's going to improve your heart health too.
RUDD
Absolutely, the way you prevent stroke and the way you prevent heart disease is identical.
MYERS
Okay, let's go to Edwin, thanks for the call Celine. Edwin Roberts in Lincoln, wondering about family connections, does it run in your family Edwin?
ROBERTS
Very much so.
MYERS
What's your nearest relative who may have had a stroke?
ROBERTS
My father's mother had a stroke and her two sisters and they all died from it because it was a long time ago and there wasn't the proper treatment ...
MYERS
And died at a young age?
ROBERTS
No they were getting on a bit.
MYERS
Okay yeah.
ROBERTS
And then my father, my granny's son obviously, and his sister, my auntie, they both had strokes within a year of each other and they didn't die of these strokes but they were pretty poorly. My auntie, they both suffered in different ways, because my auntie was in a nursing home because she was in a wheelchair.
MYERS
So what you're saying is you've seen close up what it does to families when people either die or indeed are left disabled, pretty devastating stuff. So let's us Tony Rudd, what is the hereditary link, is there a clear pattern emerging?
RUDD
There is a slightly increased risk of stroke if you've got a strong family history, as has been described here. But most of that is around things that we can do something about. So if you've got a strong family history there's even more of a reason why you should go and have your health MOT, or whatever you want to call it, around your blood pressure, getting your cholesterol checked, keeping your weight down, doing those sort of things. And if - I mean the question that often gets asked is whether or not you should be taking tablets to try and prevent stroke if you've got a strong family history, if you should be taking aspirin for example. There may be an argument for that, particularly if you've got a bit of high blood pressure. But overall I think the important thing is to simply do the basic things - get your general health sorted out and get yourself as fit as physically as you can. I think then your risks will be down to probably pretty much the level of the general population.
MYERS
Edwin, I hope that's good news, that's reassuring, look after your health and there's nothing inevitable about a stroke, in fact as Tony Rudd has said it's a preventable condition. But there is the further question of ethnicity and ethnic background. Linda Andrews is Afro-Caribbean, she's e-mailed, and asking about the history of - she has a history of stroke in the family, does it run in Afro-Caribbean ethnic groups?
RUDD
I mean I think that's a very interesting question. We've actually been running a study in South London where there's a very large African Caribbean population and have shown that the risk in the African Caribbean population is about twice that in the Caucasian population. Now part of that is to do with high levels of blood pressure and diabetes, which are both quite strong risk factors, as we've said already for stroke. There are probably other factors as well that we simply don't understand, there may be genetic factors and lifestyle factors that we've still got to explore. But certainly the risk is higher in African Caribbeans and that is a group that needs to be really well aware of their potential risk of stroke and do all the things we've talked about already.
MYERS
And we're talking about actually a lifetime quite a high risk overall for stroke, what are the figures?
RUDD
Well I mean if you're a woman then - and if you live to the age of 85 you've got about a one in five chance of having a stroke at some time during your life. If you're a man it's even higher than that, about a one in four chance. So if you're African Caribbean then that doubles that risk, makes it sort of one in two, one in three type of risk of having a stroke. So it's certainly worth doing something about it and we've got to get some research going to make sure that that situation does not persist for long.
MYERS
But the higher risk the more perhaps you should get your act together and do something about it.
RUDD
I mean I don't want people to go around feeling terrified that they're going to have a stroke tomorrow, the majority of them do happen - do occur once you get on later on in life but certainly it's worthwhile investing in your health when you're young because that will pay dividends later on.
MYERS
It's eighteen minutes past three, this is Check Up with me Barbara Myers talking to Tony Rudd, an expert on strokes. And we're going now to the phones again with Michael Garratt, who's waiting to talk us, he's in Gloucester. Michael, your question please.
GARRATT
Hello. I'm 63 and been under enormous pressure at work recently waking at about ten to three every morning, thinking about my work as a full time lecturer in law. On the 9th January I woke about 7.30, shaking with a terrible headache, that was initially at the front of my head but I also had stabbing pains halfway back in my head. Later it moved backwards in my head down to the base of my head. I saw my GP and wanted to see a neurologist but she said no let's do blood tests first. They showed a slight thyroid problem but no action required. I had shaking again after delivering a one and a half hour lecture about a week later and went off sick on 19th. I went to see my GP again on the 24th and has now been referred to a neurologist.
MYERS
Can I chase you along to a quick question please?
GARRATT
Okay, my blood pressure that comes very high I think when I'm lecturing and afterwards, that's what I worry about. Paracetamol doesn't help with the headaches. I'm wondering if this is a mini stroke or a warning whether I should go back to work or not.
MYERS
Okay, yes okay.
RUDD
Well I mean I think that I can be reasonably confident that this was not a stroke or a mini stroke that you had, it would be very unusual to get headaches without any of the symptoms that I talked about at the beginning of the programme - without any paralysis or problems with your language or vision. So I think that's - you need to look for another cause for your headaches and I think you may have identified it in the cause - the stress that you're having.
MYERS
Which raises the question, yes, can stress cause a stroke?
RUDD
Well that's a very interesting question and there's quite good evidence to show that stress can cause heart disease, there's much less evidence around stroke. I mean I personally believe that there's two sorts of stress, I think my life would be absolutely miserable if I didn't have any stress at all, so I think there's good stress and there's bad stress. And the stress that makes you really go flush and feel as though your blood pressure's going up and makes you angry and want to sort of start shaking, perhaps the sort of stress that you Michael are describing - that is harmful stress. But the good stress, where you're actually being put under - under pressure to achieve things, which you think you might not be able to, that I think is probably good for you. So we shouldn't be aiming for a completely stress free life but we should be trying to find ways of reducing that bad stress and there's good ways of doing that - learning relaxation techniques, doing meditation - those sort of things I'm a great fan of.
MYERS
Very helpful. Thank you very much. Marlise Ford on the phone next.
FORD
I feel that I'm a potential candidate for a stroke because of high blood pressure, despite treatment with two different medications, although I don't smoke, I'm lightweight, I keep a watch on my diet, I reduce salt. I understand that one way of diagnosing a stroke is via an MRI, I'm also a pacemaker patient, how does one go about diagnosing a pacemaker patient without the availability of the MRI please?
RUDD
Well I mean I think you would know or your doctors would know by having taken a good history from you and examined you probably as to whether you were likely to have had a stroke or not. So stroke is a clinical diagnosis, we don't actually need scans to be able to make the diagnosis of stroke, we need scans to be able to find out why it's happened and they're vital for that reason ...
MYERS
And whether it's a clot or whether it's a bleed.
RUDD
Absolutely because stroke is not a single disease, it's a whole range of different diseases with different treatments and different causes. As regards - I mean if you were at any stage to need a scan then with a pacemaker you can't have an MRI scan, it would make the pacemaker stop working and it would probably make the MRI scanner stop working as well, so that would not be a good idea. But there's no reason why you can't have an ordinary CT scan, which is almost as good in most circumstances.
MYERS
Is it reasonable for people to expect to have a test of some kind if they're worried or if they have perhaps the family history or they may have had a mini stroke, is it the sort of thing you can go along for a kind of well person test or an MOT and have a quick and easy test that's going to set you off on the right direction?
RUDD
Well there is no single test which is going to tell you whether you are going to have a stroke. The scans tell you whether you have had one in the past. I certainly wouldn't be recommending that everybody goes along and has their brain scanned if they haven't had symptoms, heaven knows what you might find, it would be better not to know really. But it's - so the answer I think is that we should be keeping the scans for the people who really need it - for the people who are presenting with stroke, getting those done quickly but not overloading the system really with what would be fairly useless investigations to try and put people's minds at rest.
MYERS
Okay, thank you for that. I'd like to throw in a quick e-mail here which is about hormone replacement therapy. And there's a sort of fear that that might increase the risk of stroke, I think that's something that's been talked about in the press, is it true? Should you not take HRT because of the possibility of increasing stroke?
RUDD
There is no doubt from the research now that taking HRT does slightly increase the risk of having a stroke but it's pretty small. And I think what you have to do as an individual, deciding whether or not you want to take HRT, is to look - is to weigh up the pros and the cons. And HRT is undoubtedly a helpful treatment for getting over difficult menopausal symptoms, it's undoubtedly helpful for protecting your bones from developing osteoporosis. So I think most doctors are perfectly happy to prescribe HRT for a few years over the period of the menopause, I think most would be quite keen to get people off it and not keep them on long term HRT.
MYERS
Thank you. Let's go to Diane who has recovered from a stroke or is in the process of recovering from a stroke, and has made good progress so far Diane?
INNES
Yes, yes very good. After eight months, mine was eight months ago, I made excellent progress in the first few months and then I reached a plateau, which I was told was normal. So I haven't made much - really any further progress. But the question is I just don't know to what extent I should push myself because my main symptom is exhaustion after very much activity, it's like a tsunami exhaustion, it isn't ordinary tiredness. Now pre-stroke I would have just pushed myself through that, that's the best thing to do but the fear, it's like a cloud hanging over you when you've had a stroke because you're so afraid ...
MYERS
Diane I'm going to just put your point because - thank you for sharing that, that you've made a lot of improvement and recovery and how much more is there to go, given that you're rather tired and finding it quite tough to move on to the next step.
RUDD
The symptoms that you describe are so common, it's often not written about in the medical books but virtually every single patient that I have with a stroke comes back to clinic and tells me they feel exhausted. So the message I think is to gradually build up the amount of exercise you take, get increasingly fit, and I think you'll probably find after a year or so that your levels of tiredness have got back to your previous level.
MYERS
Okay, that's got to be it I'm afraid, time is almost there. And more information on the action line or through our website. And join me again if you will please next week when we're talking about how lifestyle may be damaging your liver.
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