​Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Today's episode is one you're going to want to save and share with friends and family because we're talking about how to identify signs and symptoms of a stroke, what to do when you suspect a stroke, and what recovery looks like.

We're sharing a simple checklist that can transform an often confusing and terrifying situation into a set of actionable next steps. We're also going to clear up myths and misinformation around treatment windows and options, and explore what no one tells you about life after a stroke.

First, let me introduce my guest, Dr Shyam Prabhakaran. Dr Prabhakaran is an internationally recognized leader in vascular neurology and stroke research and treatment, and is the James Nelson and Anna Louise Raymond Professor and Chair of the Department of Neurology at the University of Chicago. His scientific expertise includes stroke epidemiology, imaging, predictive analytics, and health services research.

Dr Prabhakaran is also a national volunteer expert for the American Stroke Association.

Welcome to the WebMD Health Discovered Podcast, Dr Prabhakaran.

Shyam Prabhakaran, MD, MS, FAHA: Thank you. Nice to be here.

Pathak: So great to have you, and I'm really interested in all of the various types of work that you do as it relates to stroke. But before we jump into my questions, I'd love to ask about your own personal health discovery—your “aha” moment that brought you to your current work and research on stroke. What issues or questions from patients arose that inspired what you do today?

Prabhakaran: Well, that's a great question to start. I've been, obviously, in the field of stroke for over two decades. However, when I look back to the early days, there was a kernel of inspiration when I realized how few patients get proven treatments.

So there was a proven treatment 20 years ago, and there are many more proven treatments today, but 20 years ago, that was tPA (alteplase), delivered to patients who came to a stroke hospital quickly. And we realized early on that that drug was given to very few people who were having a stroke.

And a lot of those barriers, albeit some are due to the patient’s recognition and understanding that there's something you can do about it, but a lot of them were system barriers—getting the patients to the right hospital and the right teams to assess them, and then quickly performing assessments and delivering treatments.

So that “aha” moment was when I moved to Chicago in 2006 and realized there was no system in place to deliver that treatment quickly when you called 911. So that then sprung a series of conversations, initiatives, and completed projects that really tried to reorganize the system of care for Chicagoans.

Pathak: So let's kind of go through a step-by-step approach, starting off with helping our listeners understand what exactly a stroke is, how you define it, and what's happening in the brain when someone is having a stroke.

Prabhakaran: So a stroke is when the brain experiences a vascular injury. The vascular part is blood vessels—typically arteries, although rarely it can be veins. But when arteries are either not able to deliver oxygen due to blockage—that's ischemic stroke—or the arteries burst and now the blood is pouring into the brain, causing pressure and damage—that's hemorrhagic stroke.

So that's what a stroke is. It's a vascular problem of the brain, kind of like a heart attack of the brain. “Brain attack”—we've used that in the past. So those are all the same; they're all synonyms for a stroke.

And what happens is those immediate effects of either blockage of an artery or breakage of an artery start to create damage in the cells of the brain, which are exquisitely sensitive to oxygen and glucose—more so than almost any other cell in your body. They start to become impaired, not functioning, and then potentially die within minutes.

And so restoration of blood flow, or stoppage of the leakage of blood in hemorrhagic stroke, is critical to mitigating damage and, of course, making sure the outcomes are the best they can be.

Pathak: We know that stroke is now the fourth leading cause of death in the U.S., so help us understand why stroke is so common and if there have been shifts in demographics with regard to risk profiles since you've been practicing over the course of your career.

Prabhakaran: Yeah, you know, stroke is a common disease. It's often due to risk factors that we see that are very common in the population, such as high blood pressure, diabetes, and obesity—the epidemic, of course, has been a problem in the last couple of decades. Atrial fibrillation, which is a specific type of irregular heartbeat, can cause stroke, as well as smoking and other lifestyle factors such as poor diet and lack of exercise.

So we know those types of conditions are risk factors for stroke, and they present often in later life because they accumulate in the arteries and cause damage, resulting in either blockage or breakage.

But we have seen some shifts where midlife occurrence of stroke is increasing, and, scarily, it's happening in women and minority groups. So that's also worrisome—that despite all of the efforts to reduce the public health burden of those risk factors, we are still seeing some increase in stroke earlier in life.

Pathak: So important for people to recognize the symptoms. And you know, you mentioned earlier you think of stroke as a brain attack, and I think there is a lot of recognition, at least in the lay public, that a heart attack is gonna come with chest pain or shortness of breath. Can you help us understand and walk us through B.E. F.A.S.T., for example, as some of the warning signs for stroke?

Prabhakaran: First, it's important to note that unlike a heart attack, which is associated with severe pain, a stroke or brain attack is often painless, although some people will have headaches, but it's not the dominant symptom as it is in chest pain and the heart. So there isn't the same warning, like, oh my God, something horrible is happening because my chest hurts or my head hurts.

And as a result, there can be a lot more varied types of symptoms that a patient or family member might dismiss or say, ah, I don't know what that is. It might not be anything serious, and it's not crying out, I need to go to the hospital. Having said that, there are probably simple ways of assessing the majority of stroke presentations. Your brain is responsible for everything you do.

So theoretically, one stroke is gonna be very different than another stroke, 'cause a different part of the brain, different person, their symptoms are gonna reflect differently depending on what part was affected. Having said that, F.A.S.T. stands for face droop, arm weakness, and speech abnormality. Those three things, F, A, and S, probably account for 80% of the presentations of stroke. So one of those, or all of those symptoms, are gonna be present in about 80% of stroke patients. So a facial droop on one side, an arm that's not moving or weak on one side, or slurring or incomprehensible, garbled speech could be a cardinal sign of a stroke in about 80% of the cases.

Because there are some other types of presentations—the 20% or so—we adopted the term B.E. F.A.S.T., which adds two more letters, B and E, which is balance, which can be off in some people suddenly feeling off balance or leaning to one side or falling to one side. That could be a sign of a stroke in some people. And the E, eyes—visual loss or double vision—visual symptoms could be a sign of a stroke. So the B-E-F-A-S pretty much capture a lot of the presentations of stroke, and the T is time, so wanting to emphasize it's time to call 9-1-1. That time is of the essence when you have any of those symptoms that I just went through: balance, eyes, facial droop, arm weakness, and speech abnormality.

So we tend to wanna emphasize that these types of symptoms are a stroke until proven otherwise if they occur suddenly. So the suddenness matters. Like, if you're noticing these symptoms over the course of a month, the chances of a stroke are less. Something serious could still be going on, but in terms of specificity of stroke, the suddenness matters because it's a vascular problem where blood vessels suddenly either block or get broken open.

Pathak: And in your experience, are there other symptoms that people sometimes overlook or confuse with something else? So I think it's really important to reset in terms of just the suddenness and recognizing how critical this window of opportunity, the time frame, is. Are there other symptoms beyond what you've mentioned in B.E. F.A.S.T. that folks might confuse with something else?

Prabhakaran: Sometimes dizziness is a symptom that people experience, and it's a woozy feeling or a spinning feeling that may be a stroke, and it should be thought of as a potential stroke if it's sudden and unexplained in somebody who's never had it before, especially an older person.

But it can also not be a stroke. It can also be something in the inner ear that's benign. So that's part of the job of doctors—we have to help figure that out. It shouldn't be on the patients and the families to diagnose and treat when they're not trained to do that. So we want the umbrella and the blanket to be big, you know, just as broad as you can be.

So anything that's sudden and neurological, we'd rather you err on the side of caution and let the experts tell you, no, it's something else. We've checked it out—not a stroke. That's good. So I tend to think of it as any sudden neurological symptom—think stroke until proven otherwise, until told otherwise.

Pathak: That's really helpful, and I wanna pull in another piece because in newer guidance and recommendations that you've worked on, there's really considerations around pediatric stroke as well. So I would think that when you think about stroke and the profile, you're thinking about B.E. F.A.S.T., the suddenness, time component, but I think for a lot of us, we're also thinking about an age or a certain type of demographic. So help us understand why we need to shift that perception.

Prabhakaran: Well, part of it is that even though patients who are younger shouldn't be having strokes, and it's extremely rare in a pediatric population to have a stroke, when it does happen, you still need the same urgency and quick decisions around diagnosis and treatment because, again, the stakes are still high. The time is still brain, and the brain that's injured in a child versus an adult is still gonna have a disability associated with it, and we wanna limit that disability.

And so the attention that we wanted to place on pediatric stroke in these guidelines that we'll talk about was to say there are some things we could do to improve the diagnosis of pediatric stroke and then begin to offer some treatments that are evidence-based, and pediatric stroke is different. It's no question about it—the causes are different, often due to congenital problems, congenital heart disease, for instance, or coagulation problems or tears in arteries that occur due to sports or activities.

These are different than most adult strokes, which we talked about as being from hardening of arteries or heart problems like AFib. So while they are different, and they may even present differently, more diffusely, more atypically, we have to have our antennas up as healthcare providers, and especially our pediatric colleagues in emergency rooms and in hospitals, to say, think stroke still, and rule it out with the great testing we have now with imaging, and then also consider treatments in select cases. We've adapted and seen evidence of success in pediatric cases as well. So that's the logic behind the attention. Stakes are high. You have to be looking for it and thinking about it to diagnose it and treat it, and we wanna have the same urgency around it.

Pathak: We've mentioned several times time is brain and the importance of time. So for our audience, help us understand what this term means and why every minute matters when it comes to stroke.

Prabhakaran: Yeah, I mean, I guess it came from a lot of different cultural references. At first it was time is money. Then it was time is heart, and now time is brain, and it's all saying the same thing. These are precious commodities, right? Your health is precious. Your brain is probably the most precious thing you have.

Any damage that happens to your brain totally changes your life. It limits what you can enjoy, what you can do to earn a living. It changes your family and the economics of your family. So time is brain is a mantra because of the significance of the brain. And then secondly, it's a mantra because we know that there's a time dependence to the benefit of the treatments that have been tested and proven to work in stroke.

You still are better if you could get that drug minutes earlier than you got it—even if you did get it, you're still always gonna be better the sooner you could get it. So we want everybody to strive for that earliest potential opportunity to get the treatment that could reverse the damage or at least mitigate the full extent of it.

Pathak: So let's dig into the stroke guidelines. So the new guidelines you helped write include updates for both adults and children. So what would you highlight as some of the biggest takeaways for patients and families?

Prabhakaran: Yeah, so there's a lot of updates. First of all, the guidelines hadn't been updated for almost seven years, so we needed to update these guidelines because so many things had changed in the last seven years, including devices that were introduced that improve outcomes in stroke patients by removing clots from the brain's arteries when they're blocked.

That is an update. We needed to review and place new recommendations around the eligibility or the kinds of patients who could be treated and these types of treatments offered. We've now expanded that up to 24 hours in a large group of patients who present to the hospital.

So 24 hours—even though I just spent time telling you that time is brain—it still means that at least we're now not just talking about patients who only come in within three hours or four and a half hours or six hours. We have a lot of options up to 24 hours that are proven. Am I still gonna say earlier is better? Absolutely. In the 24 hours, earlier is better, but at least we have tools all the way up to 24 hours. So that's one big update.

And the second big update related to intravenous treatments, which are blood thinners given through an IV to break up a clot. Now we know that a drug called Ectoplase is probably equivalent to an older drug called Alteplase, and more and more hospitals could start using that drug, which is easier to deliver, can be given in one push as opposed to a push plus an hour-long infusion, which could, you know, come with errors.

And then a third sort of major update we touched on was introducing pediatrics as part of the focus of healthcare providers to do better at identifying, diagnosing, and then beginning to think about treatments that are actually proven in that population. Less evidence there, but definitely wanting to push that envelope so that we can do more for our youngest stroke survivors.

Pathak: That's great. That's really helpful. So clearly these recommendations are aimed to reduce long-term disability after stroke and to optimize outcomes.

So help us—from that moment that someone observes it, they call 9-1-1, someone has arrived in the ER with stroke symptoms—what should family members expect will happen in this sort of step-by-step approach?

Prabhakaran: Yeah, so that's the best-case scenario. It was witnessed, they took action, they got to the appropriate hospital, and I think the appropriate hospital also is something we're trying to do better at, so that our EMS colleagues identify severe symptoms and think, okay, maybe that is better for an advanced hospital, which we call thrombectomy-capable or comprehensive, and those with mild symptoms could go to a local stroke center, a primary stroke center, but all of them need stroke centers of some type if you're suspecting a stroke.

So that's the first decision, is getting them to the right hospital. And then once you're at that hospital, the rapidity with which a stroke team is called—that means that neurologists, potentially neurosurgeons, radiologists, are all activated as part of the emergency room response. Those people are assessing the severity of the symptoms, the time from which the symptoms may have started, or the last time the person was normal, and getting them quickly to the appropriate imaging.

Now we're recommending that everybody with severe deficits, suspected large vessel occlusion, large artery blockage, should get vessel imaging along with their plain CT scan or plain brain imaging. So in addition to finding out whether the brain has suffered injury on the first scan, we wanna know what the vessels are doing—if the vessels are injured or blocked or ruptured, that is information that's going to make very, very clear what to do next.

And the team then wants to get them to the scanner, the report or the results of that scan reviewed and interpreted, and then decisions around treatment are based on that. Time from last known—if they're within a certain window, four and a half hours from presentation—that would be potentially an IV drug; Ectoplase or Alteplase could be given. And if they have a large vessel occlusion, then they may be eligible for a thrombectomy, a removal of a clot, or both. Again, all of those are then decided very rapidly. So that's the process we expect in that early window.

Pathak: So then let's talk just a little bit about what you mentioned as potentially different causes and then potentially different downstream management for stroke in children or young people, where it may be more of a dissection or an injury to a blood vessel. What should we know about that?

Prabhakaran: Well, I mean, I think diagnosis of the stroke in a child is important, and there are ways to do that. Typically, we avoid radiating them with CT scans. Most child neurologists will opt for an MRI in children. And so getting an MRI/MRA—the angiogram vessel part of the MRI—quickly is, I think, the right approach to diagnose whether a stroke is even happening, because it can be a mimic. It can be migraine, it can be a seizure. And so finding out that it is a stroke is critical. And then based on that information, looking at the cause of the stroke, deciding whether it's somebody who still warrants the traditional treatments, which might mean thrombolytic drug intravenously given medication, or sometimes, if there's a big stroke and a blocked artery, just like in adults, you may still want to consider a thrombectomy, pulling the clot out. They're less proven because studies in children have not been done as rigorously as they've been done in adults, so we want to have some caution around that. And you want to have absolute certainty that you're in a place where there's a team of child neuro experts, child stroke experts, and that's probably going to be at your most advanced pediatric hospitals, the children's hospitals in your region. And so that's one part of it. And if it is due to a specific cause—a congenital heart problem, or a dissection, or a coagulating problem—those are then going to be decisions about management that that team of experts has seen before and hopefully will give very, very expert advice around.

Pathak: Let's talk a little bit about the aftermath and recovery. So just as you mentioned, your brain is in control of everything, so stroke can look different for everyone. Help us understand why recovery after stroke can also look so different for different people. What are some of the most common challenges stroke survivors face, and what are some of the lesser-known challenges that folks might not realize?

Prabhakaran: So, despite all the wonderful things that our guidelines reviewed and all the success we've seen in treating stroke in the last couple of decades, most of our patients still are surviving with some disability. So they likely had some damage to brain tissue that was not fully reversible because, as I said, minutes can produce that type of damage. And as a result, they're going to live with some disability. And so recovery from that starts almost immediately. You're trying to mitigate secondary damage first in the hospital—pneumonias, low blood pressures, these types of medical issues that can worsen the brain's function even after the stroke has been treated. So you want to avoid those types of complications. Good medical care can do that and then get you on the road to rehabilitation. And that's going to mean trying to work with physical therapists, occupational therapists, speech therapists, because the most common disabilities that we know occur is weakness on one side of the body that begins to limit either walking—in which case, you're talking about learning how to walk again and/or using assistance devices to walk—arm and hand function, which might impair the ability to eat, the ability to dress, the ability to have dexterity with your hand. And that might require occupational therapy or the kind of focused attention on fine motor movements and dexterity. Or it could be speech, which again is a common manifestation, and it could be as mild as slurring your words a little bit and knowing how to enunciate more properly again and learning to strengthen the muscles around your mouth and pharynx. Or it could be aphasia, which is mixing up words or not understanding language that is spoken to you, and all of those might require intensive speech exercises and speech therapy. So those are the kind of expectations we have—that some of our survivors will have disability—but largely we also know that disability improves over time. So wanting to give people optimism that if they put in some effort, they get the services around rehabilitation and work on that for periods of months, typically they're going to see improvement over time. One of the things I do tell patients about is they may get better, and people may start to say to them that they look great again, but they may notice internally that they're not normal, that they're a little bit not as good as it used to be. And that is psychologically a tough thing. And so kind of also dealing with the psychological aspects of stroke is critical, whether you've made the recovery but you don't feel it, or you're just not where you want to be and it's affecting your mood. So making sure you are addressing that. And finally, I'd say the caregiver burden is something we don't want to lose sight of. The caregivers also need support because they're often doing a lot to take care of their loved one.

Pathak: And then I do want to pull on what you said also around the psychological impacts. Help us talk through some of the sort of emotional, psychological impact.

Prabhakaran: Losing functions that you relied on and that are absolutely core to your identity is a huge impact that you just can't underestimate. It is who you are, whether it's physical or language or emotional—these are who you are—and it changes like that in a stroke. And so thinking about it from that perspective, you realize why people have psychological impact from having had a stroke. It is, for many, they don't feel like themselves all of a sudden. And so to deal with that, I think, is challenging. And I think some people develop depression from it, social anxiety, reclusiveness—all of these things can happen after a stroke because of what it does to their self-identity and self-value. But we want to give people the positive that it is just a change to you. You're still contributing, you're still having an impact on your world, you're still able to enjoy the things in your life, and we're obviously working with you to get more and more of that as you recover. But there is a real impact on mood. The fatigue level of stroke patients is another factor that they can't quantify, but they just don't have the energy to keep doing things. And so giving stroke patients an empathetic approach is critical because I think you can't fully understand what they're going through, and I think you have to give them a little space so that if they are having a bad day, you have to understand why.

Pathak: So I'd love to ask you, in our final moments together, around what long-term management looks like for risk medication for a future event.

Prabhakaran: Yeah, that's a critical thing, and a lot of times, we focus on acute—doing all these things to prevent the damage in the beginning—and then we do focus on getting them better. But stroke patients, once you've had a stroke, are at risk for a second stroke and a third stroke, and so making sure that the cause of the stroke was identified is the first part, really, really important. So that means that diagnostic testing is done even after the emergency room, whether that's your heart or your blood, to look for what caused the stroke. And if it's specific to a cause like AFib, that means there are targeted ways to reduce the chance of a second stroke from occurring. Compliance, adherence to the recommendations prevent that second stroke is essential because all the good work you did to recover from the stroke could be for naught if another stroke happens on the heels, especially if there was a treatment you should be taking and it wasn't offered or it wasn't taken. So we really emphasize secondary prevention—we call that the prevention of the second stroke—and medications are part of it. Lifestyle changes, if that's what's needed, are part of it. Getting the coaching, if you need to work on certain things like exercise and diet, that's really essential. And, of course, we want to make sure it's affordable. We do sometimes see that, where patients are not able to take medicines not because they don't want to, but because they can't afford it. And so working with your healthcare providers to figure out what are affordable options for preventing the second stroke.

Pathak: I want to thank you so, so much for your time today. Really such an important conversation, and you've really guided us through every step of the way. I'd love to cede the last few moments to you to share key messages for anyone that's listening today to take away when it comes to stroke prevention or even just early intervention.

Prabhakaran: First thing I always say is you never want to have a stroke, so prevention is the first and primordial thing we should care about. So what I mean by that is 80% of strokes are theoretically preventable. So knowing your risk early in life, I think, is key. We realize now that waiting till your sixties to think about this is too late. So think earlier in life. So know your blood pressure. Know whether you have high cholesterol. Know whether your body weight is too high and whether those should be acted upon. So those are key messages for preventing a stroke altogether. And then, of course, if you're having a stroke, we talked about early recognition and early action—so recognizing the cardinal symptoms, F.A.S.T. and B.E. F.A.S.T. Those mnemonics capture a large percentage of stroke presentations, so sudden neurologic problems fitting into any of those symptoms. Call 911—that's your action. Call 911, and then the teams should be ready for you and know what to do next. It shouldn't be up to you to figure out whether I need a certain drug or a certain body head position. Those are all things that the doctors, paramedics, and healthcare professionals should figure out.

Pathak: That's great. So, so helpful. Thank you so much, Dr Prabhakaran.

Prabhakaran: You're welcome.

Pathak: I'd like to share my three key takeaways from our discussion today. First, it's important to know the signs of stroke and to BE FAST. The acronym stands for balance, eyes, face, arm, speech, and time. The red flags of a stroke may include sudden facial drooping, weakness, or speech changes, plus balance or vision changes. It's important to think stroke until a healthcare provider proves otherwise—it's time to call 911, not wait and see what happens.

Second, stroke care has changed a lot over the years, and while the strongest treatment interventions and benefits are within the first few hours, there are also options beyond that window. To be clear, this does not mean you should wait to seek treatment. It's a reminder that even if symptoms happened an hour or two hours ago, or you're not quite sure, it's still critical to call 911 and seek emergency care.

And finally, stroke prevention and recovery are an ongoing process. Very often on this podcast, we discuss how making small lifestyle changes can have a big impact on overall health and well-being. A clear example is that about 80% of stroke is thought to be preventable through lifestyle changes and management of risk factors. So that means shifting toward a more healthful diet, increasing physical activity, ensuring restorative sleep, managing stress—and these are the same lifestyle changes that can be beneficial in life after a stroke.

Whether you're living with changes after a stroke—and those could be physical, cognitive, or emotional—rehab therapies, mental health support, lifestyle changes, and caregiver support are not extras. They're an essential part of recovery. You're not alone in this, and it's absolutely okay to ask for help.

To find out more information about stroke awareness and Dr Shyam Prabhakaran, make sure to check out our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected]. This is Dr Neha Pathak for the WebMD Health Discovered Podcast.