Episode Transcript
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Diagnosing a Stroke
Interviewer: If a patient has a stroke, the quicker a specialist could see that patient can often times make a huge difference in the outcome afterwards. What do you do if there is not a specialist around? It's called "Telestroke". We're going to learn more about it right now from Dr. David Renner. He's a Ï㽶ÊÓƵ of Utah neurologist, also practices at St. Johns Medical Center in Jackson Hole, Wyoming. So the fact that you could actually diagnose a stroke victim by a video phone call leads me to believe that a lot of what you do is a visual diagnosis and not necessarily instruments or other technology.
Dr. David Renner: When we speak to a patient we really are getting a large understanding of what their neurologic examination is like. Just visualizing their movements when I'm speaking to them, tells me almost as much as performing a physical exam on them.
Interviewer: Really?
Dr. David Renner: When you can hear and see the patients, even if you can't touch them, you can almost always arrive at the correct medical decision.
Interviewer: Is it a challenge seeing them on a computer screen versus real life? I mean, is there some kind of loss there?
Dr. David Renner: No, not really. I've been practicing vascular neurology for 13 years now. Pretty quickly you can you can understand exactly what you've got to go to on your neurologic examination to make the decisions you need to.
Types of Stroke
Interviewer: What specifically are you looking for when you are speaking with them?
Dr. David Renner: First of all, as I'm speaking to the patient, try to understand if the left or the right brain is involved. Then, I try to make an understanding of whether the front of the brain or the back of the brain is involved. At that point, I try to identify which of four major blood vessels would be involved in this patient's neurological syndrome.
Interviewer: Do you have certain questions you ask? This is my left brain question, this is my right brain question.
Left Side Stroke
Dr. David Renner: I kind of do. The first thing I do is I ask is if a patient can understand me well and can try to get all the words out correctly. Then immediately after that I usually try to assess their ability to articulate words and to come up with language.
Interviewer: And is that left or right?
Dr. David Renner: That's left brain. That's asking them questions, like, repeat after me say the "Queen lives in England. If she we're here I would go, no if's, and's, or but's about it". That last sentence, "no if's, and's, or but's about it" is a very sensitive sentence that allows one to assess whether or not the left brain has been affected by stroke.
Right Side Stroke
Interviewer: Okay, then what do you do for the right brain?
Dr. David Renner: The right brain is a lot more difficult. This is, actually, a good example of why telemedicine is a wonderful option for the emergency room. It's because a lot of right brain strokes can be missed. Physical examination is absolutely helpful when trying to identify a right brain lesion.
Back Brain Stroke
Interviewer: Okay, what about rear and front, since we're talking about this?
Dr. David Renner: Front and back, well, the back of the brain holds the high priced real estate in the brain and that's the stuff you can't afford to lose. If I thought that this person was having one of their two vessels in the back of their brain involved, I would immediately dispatch a fixed wing to fly them to Salt Lake City if there was something that we could do endovascularly. So, this brings another really important concept up and that is that stroke treatment does not only involve just clot busting medications, but now we can take little catheters and go up into the brain and we can do angioplasty, which is opening up a narrowing and we can do stinting, which is placing a little metal tube to keep the artery open. We do other, even more complicated vascular procedures, but we make a decision immediately when we see a patient on the Telestroke unit as to whether or not we should fly them in immediately for an intravascular procedure.
Interviewer: What are the back brain questions or what are you looking for there?
Dr. David Renner: Well, those are the things you can usually pick out fairly quickly when a person has eyes that don't move together, when they have subtle facial numbness, when they have subtle facial weakness, slurring speech, unprovoked loss of consciousness where they come back to consciousness right away, spinning vertigo, and subtle signs of weakness on one side of their body with sensory changes on the opposite side of their body. Those are all classic features of back of the brain strokes.
Frontal Lobe Stroke
Interviewer: And let's cover the front, what are the questions there?
Dr. David Renner: The front of the brain would be, would usually produce symptoms like weakness of the face and arm more so than the leg or difficulty generating language and not being able to come up with the right word.
Interviewer: Any final thoughts?
What to do During a Stroke?
Dr. David Renner: The most important thing to remember about stroke is, if you think that you're having acute neurological symptoms of stroke you must get to the emergency room as fast as you can. You should not think about it, you need to call 911 and get there immediately so that way we can start treatment and hopefully open up the artery that might be blocked and give you back all the function that is being taken away from you. Every minute that you wait you lose millions and millions of cells in your brain.
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