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Strokecast


Feb 28, 2022

If you have a hole in the middle of your heart and it's not supposed to be there, is that a problem? Should it be fixed? The answer is a resounding, "Maybe."

Dr. David Thaler and his colleagues looked at the impact of PFO closure on stroke patients and found that often, the best solution is to leave it alone. They developed a scoring system to help neurologists and cardiologist make the best decision on a patient-by-patient basis.

Dr. Thaler joins me in this conversation to talk about the research and recommendations.

(If you don't see the audio player below, visit http://Strokecast.com/PFO)

About Dr. Thaler

Dr. David Thaler stand in a medical office wearing his white doctor coat, looking at the camera.

Dr. David Thaler, MD, PhD, FAHA, is the Neurologist in Chief at Tufts University Medical school. He is the Chairman and an active professor in the Department of Neurology.

Additionally, he continues to treat patients and is a clinician focused on stroke care. He  continues to work to advance the field with a research focus on acute management of cerebrovascular disease, secondary stroke prevention, cryptogenic stroke and patent foramen ovale (PFO).

Dr. Thaler's training involves work at:

  • Oxford University
  • John Radcliffe Hospital, UK
  • Brigham and Women's Hospital
  • St. Elizabeth's Medical Center

He is a Board Certified specialist in Neurology and Vascular Neurology.

Stroke Basics with Dr. David Thaler

Dr. Thaler works on projects ranging from advance neurological  research to the fundamentals of stroke education. This video is an excellent, short introduction to stroke  that is also sharable:

https://youtu.be/i_gtxYQlECc

One of the things that is especially interesting about this video is that in describing the symptoms of stroke the first one he mentions is tingling on one side of the body. This usually isn't mentioned as a stroke symptom by most warnings.

In episode 156, coming up in a few weeks, I talk with a survivor who had this exact symptom and was told by first responders that she definitely wasn't having a stroke and by emergency room personnel that she probably wasn't having a stroke. It turns out she was having a stroke.

BEFAST and AHORA are excellent starting points for recognizing the signs of a stroke, but they are not comprehensive. They do not cover every sign of stroke. They are just a useful short hand.

Stroke symptom graphic highlighting BE FAST (Sudden change in Balance, Eyesight, Facial symmetry, Arm control or speech/language means it is time to call and ambulance),

A graphic of the AHORA pneumonic device to help spanish speakers recognize a stroke.

What is a PFO?

A PFO is a hole in the heart. Roughly 25% of the population has one. I have one. Guests Misha Montana and Christine Lee both had PFOs that led to their strokes.

After we are born, our blood follows a path through the heart. It comes in the right side. When the heart beats, the blood on the right side heads out of the heart to the lungs. There, it drops of CO2, picks up oxygen, filters out clots, and heads to the left side of the heart. It will pour into the left side and when the heart beats, it sends that oxygen-rich blood on to the brain and other parts of the body. Then that blood drops off its oxygen, picks up CO2, and heads back to the right side of the heart to start the whole cycle over.

Before we are born, though, the process is different. While we are developing in our mothers' uteruses, we don't breath air. All the oxygen and nutrients we need to build fingers and toes and kidneys and hearts and brains comes from the umbilical cord.

Since we're not breathing air, there's no point in sending blood to the lungs. Instead, in utero it goes straight from the right side of the heart to the left side of the heart through a hole in the middle. That hole is called a Patent Foramen Ovale, or a PFO. It normally closes on its own shortly after we are born.

A quarter of the time it doesn't close after birth, and that allows unoxygenated, unfiltered blood to sneak across the heart, skip the lungs and drag a blood clot to the brain.

So, if you've had a stroke, and you have a PFO, should you have surgery to close that hole? Maybe.

Christine and Misha had their PFOs closed. I did not

Dr. Thaler's research helps doctors make the best recommendation for the patient: to close or not?

Neurology, Illustrated

When you visit the doctor's office, what do you see on the walls? Probably posters showing the warning signs of stroke or heart attack. Maybe information about COVID-19 protection and policies. Probably lots of important, useful, stressful, and boring text.

If you visit the Neurology department at Tufts Medical Center, you'll have a different experience. There you'll see art all about neurology -- from centuries old brain drawings to photos reflecting the impact of stroke on world events to modern pieces exploring the diversity of the brain and nervous system we live with today.

You can also see these images and read more about them at  Neurology, Illustrated on the Tufts website.

Here's a video of Dr. Thaler explaining the program.

https://youtu.be/hNodeeqhK8c

International Stroke Conference Panel

I will be moderating a panel for the Stroke Connection program from the American Heart Association's International Stroke Conference called "Post-Acute Rehabilitation After Stroke: Getting It Right." I'm pretty excited about it.

The Stroke Connection program is in its second year. It's goal is to connect researchers and academics with the general stroke community. The idea is that we can all benefit when scholarly scientific research is shared with the broader community.

Tickets to the webinar are available from the American Heart Association for $10 each. You can learn more, see the list of all the available webinars, and register to attend here: https://www.stroke.org/es/stroke-connection/iscstrokeconnection/stroke-connection-at-isc-registration

Hack of the Week

Slow down. Kawan Glover explained that doing tasks after stroke often means stopping and pausing for a few seconds to think about what you want to do. How can you break your task down into smaller tasks and movements.

In the pre-stroke days, we could more easily do tasks that involve all sides of our body without even thinking about it. A subtle shift of weight or minuscule flex of a finger could be all it takes to complete a particular movement.

We built this symphony of movement gradually over the years from the time we are a new born exploring our limbs to the time of our stroke.

After stroke, we may be tempted to do physical things the same way we did before, but we might not be able to yet. The symphony is broken. The automated process is broken. And the consequences could be anything from failing a task to spilling a beverage to falling and picking up another head injury.

To reduce the chances of that happening, pause. Take a breath. Break down a task into multiple little steps and figure out how to accomplish them. Then do it.

As the carpenters say, "Measure twice. Cut once,"

Links

(If you don't see the list of links below, visit http://Strokecast.com/PFO)

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Where do we go from here?