BEFAST to Save Brain From Stroke

portrait collage Dr. Priya Narwal, Brooke Medel, Kristen Bryant

Dr. Priya Narwal, Brooke Medel, and Kristen Bryant from UConn Health’s Stroke Center share their expertise on the UConn Health Pulse podcast. (Photos by Tina Encarnacion)

Whether it’s the acute care during the medical emergency or the recovery and rehabilitation that follows, UConn Health continues to earn recognition for its stroke care. Dr. Priya Narwal, interim medical director of UConn Health’s Stroke Center, Brooke Medel, stroke nurse navigator, and nurse Kristen Bryant, interim stroke coordinator, share their expertise, and remind us that BEFAST (Balance, Eyes, Face, Arm, Speech, Time) is still the mantra when it comes to recognizing and reacting to stroke.

(Dr. Priya Narwal, Brooke Medel, Kristen Bryant, Chris DeFrancesco, May 2024)

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Chris: When it comes to stroke, we know time lost is brain lost, and that’s why recognizing a possible stroke and acting right away are so crucial. Today on The Pulse, a lesson in what to look for and how to react.

This is the UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better, and ideally leave you with some health information you’ll find useful.

I’m Chris DeFrancesco. Now when someone is having a stroke, the clock is running and the precious moments lost can be the difference between life and death, or within that, where the patient lands on the spectrum between recovery and disability. That’s why we have the acronym BEFAST. And here to tell us more about that, and what else we should know about stroke, are Dr. Priya Narwal, the interim medical director of the UConn Health Stroke Center, and Kristen Bryant, the interim clinical program coordinator, and Brooke Medel, stroke nurse navigator, all from UConn Health. Thank you all for joining us today.

Dr. Narwal: Thank you, Chris, for having us.

Chris: Now, the last time we talked about stroke, and Brooke, you were here for that, the mantra was “BEFAST.” that’s still the conventional wisdom, right? Let’s start by explaining what that is.

Brooke Medel: Absolutely. Thank you, Chris, again, for having us. BEFAST is an acronym. The most important thing is it’s a sudden or acute change. One moment you are fine, and the next moment you are not. without any other reason or explanation as to why that could be. You don’t have to have all of these symptoms, which is important to recognize as well.

So “B” is for “balance,” which is a sudden onset of severe dizziness or trouble walking. “E” is for “eyes,” that’s a vision change, blurry vision, double vision, partial or total vision loss in one or both eyes. “F” is for “face,” that’s facial drooping, where one side of the mouth looks lower than the other. It’s kind of what everyone thinks of when they visualize a stroke. “A” is for “arm,” which is always only going to be on one side. It will be arm and/or leg, weakness, numbness, tingling, not being able to move or use it like you typically could. It could be as simple as numbness in your arm and/or hand, and as severe as not being able to move your arm at all and it being completely flaccid. “S” is for “speech.” That’s slurring of words, having a hard time getting words out, or not being able to talk at all. And then “T” is “time,” which is the most important. Time is brain, which is the mantra that we live by here. Don’t take a nap. Don’t think it’s going to get better on its own. Call 911 and come to the hospital right away.

Chris: OK. So that’s BEFAST, and “T” being the time. And we want to take an ambulance whenever possible in this situation, correct?

Dr. Narwal: Absolutely. Right.

Chris: And why is that?

Dr. Narwal: So the “T” is time to call 911. That’s what we tell our patients. And the reason why it’s so important to call 911 and have EMS there is not only do they recognize the symptoms as whether or not it’s a stroke, but also they will call ahead inform the ER nurse, the triage nurse, to activate a stroke alert, as we call it. So the radiology team, neurology team, pharmacy team, the ER team, all of us are aware, we’re expecting a stroke patient, and all of us are present in the ER to deliver acute care.

Chris: So the stroke alert, that’s, I think that might be a relatively recent development in our stroke care here. And I think UConn Health has won some awards or gotten some recognition or accreditations for how UConn Health handles stroke, correct?

Kristen Bryant: Yeah, so we started our first stroke alert, I believe was in 2015. So we’ve been doing it for almost 10 years now, and we’ve really been able to kind of make the process more efficient and get the patients in and receive timely care. And like you mentioned, we have received multiple awards for our stroke care. We recently received an another award for Mission Lifeline, which recognizes stroke care, and we also received an additional award from them as well regarding our care of their diabetic patients who have stroke. We’ve also received the Women’s Choice award, which also includes additional information about patient satisfaction.

So not only does our data really show that we treat our stroke patients well, but our patients also feel the same way.

Chris: Getting back to what happens when a stroke alert is called, UConn Health becomes ready to receive that patient before that patient is even here. Once that happens, take us through the life-saving and ability-saving, functional-saving measures that take place once the patient arrives.

Dr. Narwal: Right, so once the patient arrives, we receive a quick history from the EMS as to when they were last seen in their usual state of health. We review pertinent medications and medical history. The patient is wheeled to a CAT scan where they undergo a CT scan of their brain and also an angiogram to look at the brain blood vessels to see if there’s any occlusions that we need to act upon. Once that is done and the patient’s been evaluated, we decide, if they meet criteria, we go ahead with giving what is called a clot buster or thrombolytic therapy, which is an IV medication with the aim of breaking up a blood clot, which has been proven to improve outcome, functional outcome in patients who are having a stroke.

The other acute therapy we have here at UConn is intervention, or thrombectomy, where we are able to go in and retrieve a blood clot that may be blocking blood flow to the brain and does prevent disability going forward.

Chris: Alright, so that’s one element of this that we don’t have represented here in the room, is, Dr. Ketan Balsara does the mechanical thrombectomy, basically pulls the clot out to relieve what’s going on there. There’s a window where the clot busting medication works, so getting back to the element of time. Talk about that.

Dr. Narwal: Right. So, again, you know, all this emphasis on being fast or time is brain is because there’s a crucial time window where we can give the clot buster medication, which is three hours per FDA, but it can actually go up to four and a half hours. So it’s very important to know when a patient was in their last known usual state of health.

When it comes to mechanical thrombectomy or neurointervention, the time window is actually up to 24 hours. However, I always tell my patients, with that piece of information, don’t think you have time, don’t wait, still call 911 if you’re having any symptoms because the earlier we intervene, the better the outcome is going to be.

Chris: Plus, maybe not everybody’s a candidate for that intervention, right?

Dr. Narwal: Yep.

Chris: And then there’s the ischemic stroke versus what’s the other kind?

Dr. Narwal: Hemorrhagic stroke.

Chris: OK.

Dr. Narwal: So most strokes are ischemic. So about 80 to 90% of strokes tend to be ischemic strokes. And by ischemia, we mean lack of blood flow. So those strokes are caused by a blood clot occluding the blood vessel, leading to lack of blood flow to the brain.

Hemorrhagic stroke is a rupture of blood vessel causing a blood clot in the brain. And even though hemorrhagic strokes are less common, they cause more disability, tend to have worse functional outcome when compared to ischemic strokes.

Chris: Kristen and Brooke, we recently came out of Stroke Awareness Month. You were spending a good amount of time with that. Tell us a little bit about what this year’s message was.

Brooke Medel: Stroke Awareness Month is really, it’s multiple things that we really try to achieve here. The first aspect is awareness of recognizing stroke symptoms, because obviously time is brain. It’s important that the community understands the signs of a stroke and when to come and how quickly to get there. The most important aspect in my role, looking at community education and outreach, is looking at patients, understanding their personal risk factors as up to 80% of strokes are preventable.

So understanding those risk factors and being able to stay on top of those to maximize your stroke prevention risks is everything. It’s really important to be able to do everything you can to prevent your risk of stroke because obviously it’s disabling, could even cause mortality. So it’s really important to be educated on your personal risk factors.

We also use it as an opportunity, I call it like our Christmas time of year, because we really celebrate all the great work that all of our staff do, everyone that takes care of our stroke patient population, because it’s complex, it’s critical, things move quickly and can change at any moment, and we really value the work that everyone puts in day in, day out.

And lastly, we celebrate the stroke survivors because they survived a life altering event and they need to be celebrated and recognized for surviving, because that in itself can be really tricky and complicated. And I always want them to be proud of what they’ve accomplished, because when you’re in the hospital bed, it’s the worst day of your life and worst time of your life, but it does get better after that. And for them to be able to step backwards and look at that is incredible. So we like to celebrate all aspects of Stroke Awareness Month.

Chris: In the role of clinical program coordinator, Kristen, how do you fit into the overall stroke care at UConn Health?

Kristen Bryant: I kind of have the opportunity to oversee kind of the day-to-day functioning of the stroke program. So I review all of our stroke alerts to make sure they’re meeting all of the metrics they’re supposed to, address any issues if anything arises, but also, kind of like Brooke said, also celebrating our wins. One of my favorite things I get to do is kind of give our staff shout outs when they recognize if a patient’s having a stroke, are able to get them in quickly for treatment and things like that. And then kind of on the back end of things, I also review all of our data to ensure we’re not only doing the best for our patients, but also meeting all of the things we need to do to continue winning awards and recognition for the great care we provide too.

Chris: There may be a perception that stroke is an older person’s problem. Surely age is a risk factor? But at what age can you start seeing stroke?

Dr. Narwal: That’s a great question. So, pediatric strokes exist. Obviously, you know, we don’t see a lot of that. But increasing age is a risk factor. However, that’s not to say that younger patients cannot have strokes.

The only thing is, the risk factors for stroke in a younger patient are a bit different than in someone who’s, say, 85 years old. So that could be genetic. That could be related to things such as using birth control. It could be related to substance use or some other genetic disorders that may be undiagnosed and stroke may be the first presentation of that. So, you know, we have patients in their 20s, 30s, 40s that have had strokes.

Chris: What about stroke in women versus stroke in men?

Dr. Narwal: In general, over half of stroke patients tend to be women. Women tend to live longer, so their lifetime risk of stroke is greater than men. They also have some unique risk factors, such as pregnancy, which is a state where the coagulation profile or blood-clotting profile is altered, blood pressure can be really high, hemodynamic changes can occur. So that’s one women-specific stroke risk factor. In addition to that, there’s also birth control use. Like I said, migraine is also a known stroke risk factor, which is much more common in women. So those are some of the things to consider when we think of stroke in women. And when we talk about stroke in women, you know, with the traditional risk factors, such as high blood pressure, diabetes, high cholesterol, a-fib, that risk goes on increasing as women get older. And unfortunately, the data suggests that women are treated less often for things such as atrial fibrillation, with blood thinners, or with statins for high cholesterol. So that’s something that we have to be aware of and talk to our patients about.

Chris: We’ve talked about what happens when you come to the hospital and you had the acute problem addressed. But there’s a lot more to stroke care that comes after that. And I suspect, Brooke, as the nurse navigator, you really get involved at that point especially. Tell us a little bit about what happens after I recover from a thrombectomy and I’m kind of put back together and stabilized, and now I’ve got to worry about overcoming my deficits and such.

Brooke Medel: While you’re here in your stay, our case management team works on discharge planning as soon as possible. They work collectively with the patient, their insurance, their family, making sure that they’re set up for success. We’re closely, collaboratively with our outstanding rehab team, making sure the patient gets exactly what they need and set them up for the best possibility and best outcome for when they leave the hospital. We make sure that we try to support all of their needs before they leave, whether they have to go to rehab or they go home.

We’re very fortunate to say at UConn Health that over 50% of our patients do get discharged home after having a stroke, which is incredible, and salutes to the great work that we provide from the moment that they get to the hospital.

Chris: 50% as in a survival rate, or going home versus going to a nursing home?

Brooke Medel: Going home versus going to rehab or going to a nursing home or anything like that after having a stroke. And even after they leave the hospital, the care doesn’t stop there. I call all of our stroke patients. I try to meet with them and connect with them in the stroke neurology clinic, ensuring that they have all of the medications they need by time they’re discharged, looking at any barriers that may arise or exist and answer any questions, because you’re not able to absorb all the information that you get while you’re at the hospital. And once you get home, other questions will come up and arise. And it’s really important to understand and recognize that the care doesn’t stop once they leave here, and there is still someone that they’re able to connect with.

Chris: All right. Before we say goodbye, is there one thing or are there a couple of things that we should that folks might know about life after stroke, either the patient or those who may find themselves in the role of caregiver, that would be helpful for folks to hear?

Dr. Narwal: I know Brooke deals with this a lot more than Kristen or I do, but I will say that stroke symptoms do get better. That’s one thing I tell all my patients. For some patients, that may look like return to normalcy, like nothing ever happened. For some patients, it may be some degree of recovery and for, unfortunately for some patients, you know, it may be a very little recovery, but almost always they, they will look better than day zero of the stroke. And I think it’s very important to tell people that because it’s a huge life event and no one wants to be disabled or not be able to do what they were doing previously. So patients do get better and we are here to support them.

Brooke Medel: And I always say to everyone, you have to just learn to be your new best self. You’re never going to be the same person you were prior to your stroke, but it’s really important to recognize that you’ve overcome something and you have to just work with it and you will continue to get better.

And one of my stroke survivors, he says, that you have to treat stroke like a friend and keep it around. If you argue with it, you’re never going to be able to make a recovery, so he tries to make friends with his stroke and the deficits that he has to really embrace his recovery.

Chris: Brooke Medel is the nurse navigator of the UConn Health Stroke Center. Dr. Priya Narwal is the interim medical director, and Kristen Bryan is the interim clinical program coordinator, all from UConn Health’s Stroke Center.

And that is our time for today. For Brooke Medel, Kristen Bryant, and Dr. Priya Narwal, I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Be sure to subscribe so you can catch us next time, and please share with a friend.