Neurology Now Episode 1

[00:00:00] Pete: This is Neurology Now, the podcast that explores the fascinating and complex world of neurology. Join us as we explore the human brain and beyond with expert guests who share their knowledge and insights. Welcome to the Neurology Now podcast.

[00:00:14] Pete: And of course, it’s May 1st when we’re recording this podcast. And that’s National Stroke Awareness Month. And we’re here with Dr. Irfan Altafullah, the MD from the Minneapolis Neurology Clinic. And for the past decade, he’s been the director of the Stroke Center at North Memorial Medical Center.

[00:00:31] Pete: Dr. Altafullah, thanks a lot for joining us here today and I’m really excited to get into this. Obviously many of us have been impacted by stroke from family members or even personally, so making light of this to make this our maiden voyage and our first podcast with you and your organization is really exciting.

[00:00:48] Pete: So thanks for joining us here today.

[00:00:50] Irfan: Thank you Pete. And as you said, for us this is a big month. May is National Stroke Awareness Month, and so I’m glad we are doing this podcast [00:01:00] to hopefully improve people’s understanding of stroke and visibility. I do wanna make a small correction and I probably will give away my age when I do that.

[00:01:11] Irfan: I’ve been director of the stroke program at, not for 10 years, but for 25 years.

[00:01:15] Pete: Check that 25.

[00:01:17] Irfan: Yeah, I was just an infant when I started, so.

[00:01:19] Pete: Yeah.

[00:01:20] Irfan: And yes, the stroke program at North was the very first program certified as a primary stroke center by the Joint Commission. So that was a big feather in our cap at the time.

[00:01:32] Pete: Boy, I have a lot of questions that will weave in over those 25 years, and I’m looking forward to hearing your perspective of how this has all evolved in terms of your role in prevention and treatment and those kinds of things. So I’m looking forward to getting going on that. And I think the early question out of the box would be, you know, really what is a stroke and how is it defined? And are there different levels of that?

[00:01:59] Irfan: [00:02:00] Sure. So a stroke, the generic term, reflects a brain injury, primarily due to lack of blood flow to some part of the brain. And there are two different types of strokes. One that is caused by a blocked pipe, pipe being the vessel that carries blood to different parts of the brain, so a blocked pipe.

[00:02:26] Irfan: The other is a hemorrhage, which is also a type of stroke that is due to a pipe bursting. So if we think of the plumbing analogy, we can relate these two types of strokes, to events that happen in our lives from time to time. And the vast majority of strokes are of the first type, almost 80%. And that is strokes that occur due to one of the blood vessels to the brain or some part of the brain being blocked by debris of some sort. And we’ll [00:03:00] talk a little bit more about what the debris is it is and where it comes from and so on.

[00:03:05] Pete: And then in terms of that, we see some people who have a severe stroke as far as the levels are concerned, and they end up passing away. Then there are others that are severely, maybe the right side doesn’t work as well or things like that, and they have to go through a lot of rehab.

[00:03:24] Pete: And then there are others that seem to get back to life normal. I’m sure we’ll get into that a little bit deeper, but how do you classify the various levels of stroke?

[00:03:33] Irfan: Well, let me again give you an analogy with which our listeners can relate more easily. Think of a four-lane freeway and there’s traffic flowing on that freeway continuously, and the traffic is cars, trucks, vans, whatever. The same thing is happening in blood vessels, except, what is flowing through those vessels is blood. And blood itself has [00:04:00] many different types of elements. There’s plasma, there’s well serum, and red cells, white cells, and so platelets and so on and so forth.

[00:04:07] Irfan: Now, think of this freeway that I talked about that has four lanes and all of the lanes get blocked. What do you think is gonna be the consequence of that? A massive traffic pile up behind the obstruction. And nothing beyond that, the freeway will be empty. Alright? That is a large stroke.

[00:04:31] Irfan: A smaller stroke would be one lane that’s being cleaned, so it’s gonna cause a little bit of hassle, but not so much. So that’s the size principle. Now I’m gonna change to a location principle.

[00:04:45] Irfan: Imagine the same freeway close to downtown. So a lane closure there is going to have a far greater impact than out in the boonies, right?

[00:04:58] Irfan: So that’s the location. [00:05:00] So the deficit from a stroke depends on two basic parameters. There’s many more, but two basic ones are the size of the stroke and the location of the stroke. The brain is organized in such a way that different parts of the brain have very specific functions. There is a part of the brain dedicated to speech, another to vision, another to hearing, and so on. If the stroke happens to involve the part of the brain that controls speech, well, that’s the function that’s gonna be affected. If it involves the part of the brain that affects the arm or the leg, well that’s the function that’s gonna be affected. That’s the location principle.

[00:05:46] Pete: Well, explained perfectly for me. And I’m sure if I can get it, everybody else gets it. That’s absolutely terrific. And there’s something that’s a part of this and you hear it, it’s called Act Fast. [00:06:00] What does that principle entail?

[00:06:02] Irfan: Right. So when you think about various emergencies that happen in our lives, medical emergencies, I mean, I think the prototype would be a heart attack. Now everybody knows what most of us, I think, know what the symptoms of a heart attack are, right? Sudden chest pain and elephants sitting on my chest, so on difficulty breathing, all that stuff.

[00:06:23] Irfan: So pain is a very powerful or a ruptured appendix, for example. Same thing, right? Severe pain and so on. Strokes typically are not painful. Typically, there are always exceptions. So then the symptoms of a stroke are much more subtle and many times go unrecognized by patients. So some years ago, there was a concerted effort on the part of our societies and organizations to come up with certain frameworks that are easy for people [00:07:00] to remember and are helpful in alerting patients, family members, friends, whoever that someone might be having a stroke and acting quickly.

[00:07:13] Irfan: So the first acronym was FAST, that’s been updated by the way, the last few years to call, and it’s now called BE FAST: B, E, F, A, S, T. So B stands for balance. E stands for eyes, F stands for face, and and so that’s how the acronym goes.

[00:07:36] Irfan: If you get vertigo or dizziness. Or if you get loss of vision in one eye or both eyes, or partial loss of vision. If you have a facial droop or weakness on one side or the other. If your arm is numb or weak, that’s the A. If your speech is slurred or suddenly becomes gibberish, then,[00:08:00] you could be having a stroke. So that’s the B E F A S.

[00:08:06] Irfan: The last letter is T and it stands for time. We have a slogan in our world or business. And the slogan is time is brain. In other words, time is off the essence. The quicker you get to a hospital, an emergency room, where there are specific treatments available for stroke, the better you’re going to be. Every minute wasted is tens of thousands of brain cells being damaged. The brain is extremely sensitive to lack of oxygen and glucose, and that’s what blood carries to the brain.

[00:08:45] Irfan: So if you don’t have blood flow, then the brain cells are starving and they’re dying every moment. So the sooner you get to where you can get the proper treatment, the better off you’re likely to be. All of the things being equal.

[00:08:58] Irfan: I was just summarizing [00:09:00] by saying the BEFAST acronym is hopefully a quick way to remember what the symptoms of stroke are and then what to do. Not your daughter or your friend or your doctor, call 911.

[00:09:15] Pete: So to that point, how many people do you think ignore symptoms or deny them and say, ah, it’s nothing. And it sounds like there’s some buildup to this where almost half of the people are having many symptoms occurring before it actually occurs playing it to get going and get there.

[00:09:36] Pete: Where do you draw the line between being paranoid and listening?

[00:09:40] Irfan: Yeah, that’s a good question. And you know, you actually asked two or three different questions right there. So let’s first talk about the warning signs of a stroke. There’s a condition called TIA, transient ischemic attack. Ischemia means lack of blood flow, and the transient, of course, is temporary.

[00:09:59] Irfan: So [00:10:00] a TIA that is colloquially called a mini-stroke, is the exact same symptoms of stroke that come and go away within minutes, 10 minutes, 15 minutes, 20 minutes, something of that order. And therein lies the rub. Yeah, your arm goes limp, and then it gets better and the patient says, huh, I wonder what happened.

[00:10:25] Irfan: But because the symptoms have gone away, they may or may not recognize the predictive value of that symptom. So yeah, unfortunately, many times, because of the very transient nature of these symptoms, those warning signs get ignored by patients and their families. If you have an aneurysm, which is also a type of stroke by the way, that is expanding and about to burst, start getting sudden severe headaches.

[00:10:55] Irfan: Now, you know, many people have migraines and headaches. It’s very common, [00:11:00] but I’ll take my example. Fortunately, I’m not a headachey person. I’m fortunate that I don’t get headaches if I suddenly start having severe headaches out of the blue. That is a red flag for me saying new onset headaches, or let’s say I have a history of migraines, but I’m typically get one headache a month, or you know, even less and it’s mild. But all of a sudden I start getting five headaches a week. So a change, a new onset headache or a change in the character of an existing headache pattern, that could be a warning sign.

[00:11:38] Pete: Is the TIA, if you have multiple over time, is that cumulative in terms of damage?

[00:11:46] Irfan: No. By definition, a TIA does not damage the brain. If it does, then it becomes a stroke. That’s the only difference between a TIA and a stroke. Everything is the same. The mechanisms are the same. The only difference is, in TIA, [00:12:00] there is no structural damage to the brain. It’s a functional impairment.

[00:12:04] Irfan: Portion of your brain stops functioning for a few minutes because it’s not getting blood, but fortunately, blood flow is restored before the damage occurs. Otherwise, it’s a stroke.

[00:12:15] Pete: So let’s get into risk then and how to mitigate that. First, what are the risk factors that may be known and may not be known?

[00:12:26] Irfan: That’s very good question. So we tend to divide risk factors into two categories, those over which we have some influence, and those over which we do not have influence. So let’s start with the latter category first.

[00:12:41] Irfan: Genetics is always important. If your parents have a certain disease, you are much more likely to get that disease than a person who doesn’t have that same history.

[00:12:50] Irfan: So first thing I always tell my patients is you must pick your parents very carefully, so you inherit the right kind of genes. But, you know, we don’t have a choice there.[00:13:00] And so, hereditary is very important and you can inherit risk of stroke from your parents, grandparents, siblings, and so on. I mean, your siblings inherited with you.

[00:13:10] Irfan: That’s one. Ethnicity is another. There are different rates of stroke amongst Caucasians, african-Americans, Hispanics, Asians. Fascinating, and that’s very complex. It could be genetics, it could be access to healthcare, it could be in a number of things, diet, so on and so forth.

[00:13:34] Irfan: But there might also be some other component that we don’t fully understand. But this much we know not only is the risk different, the patterns of stroke are very different too amongst Asians, for example, Chinese, Japanese patients tend to have different types of strokes than Caucasians do. Very interesting.

[00:13:52] Irfan: Yeah. Caucasians tend to have more disease extracranial in the neck and the carotids, for example people in the far [00:14:00] east Japan Korea, China tend to have more disease intracranial, so the treatment is a little different and such. So I mentioned ethnicity, I mentioned race. I mentioned genetics.

[00:14:13] Irfan: How about age? For every decade after the sixth, the risk of stroke doubles. So if it’s one in the sixth decade, it is two in the seventh decade and four in the eighth decade. And eight in the ninth decade. So as our population is aging and we are living longer, the risk of stroke keeps rising with advanced age.

[00:14:40] Pete: Wow. Fascinating.

[00:14:42] Irfan: Gender might have some differences. Women tend to have more strokes because they live longer than men on average. So those are the major unmodifiable factors. We can’t really control all that. But what we can control are the modifiable medical [00:15:00] risk factors, and the number one is high blood pressure.

[00:15:05] Irfan: High blood pressure is the single most important modifiable risk factor for stroke. The sad thing about high blood pressure is that it is symptomless. People don’t know they have high blood pressure until they measure it. Okay? That’s one type two diabetes, high blood, cholesterol, obesity, and obesity plays into all of these.

[00:15:28] Irfan: If you’re overweight, you’re more likely to have high blood pressure, high cholesterol, type two diabetes, but it may also be independently a risk factor. Smoking. Lack of physical activity. That also plays into some of these other things. You know, if you’re not physically active, you’re more likely to be maybe overweight and also more likely to have high blood pressure, so on and so forth.

[00:15:51] Irfan: So these are the major modifiable risk factors for stroke, high blood pressure, diabetes, cholesterol, smoking, lack of physical activity being overweight and [00:16:00] such.

[00:16:00] Irfan: And then, there’s probably a host of other factors that we don’t fully understand, but over time, hopefully we will unravel those as well.

[00:16:08] Pete: Well, it’s just really fascinating how it all intertwines. How you’re born a certain way with genes, how then your lifestyle can impact that with your decisions and choices that you make. And then, you know, usually age, something’s gonna get you, it’s gonna, it’s just how it goes. So that’s really fascinating.

[00:16:29] Pete: But some really good things I think that people can take with them and say, you know what, if I’m not moving well enough, that’s really the precursor to your diet changes. You’re moving better. You’re taking care of your body and then those things start to mitigate a little bit or reduce. So good stuff there.

[00:16:45] Pete: Now, if someone comes in and they need to be diagnosed, how do you go about that process?

[00:16:52] Irfan: Yeah, there’s two major ways of diagnosing stroke. One is clinical, you know, you get the history from the patient, [00:17:00] and the other is imaging. So when a patient arrives in the emergency room, for example, with sudden onset of paralysis and inability to speak, we pretty much know they’re having a stroke.

[00:17:11] Irfan: What we don’t know is whether it is one kind of stroke or the other. It’s very, very, very difficult to tell. Whether a certain stroke is due to hemorrhage or ischemia, in other words, lack of blood flow or leakage of blood, and the treatments are diametrically opposite and different. So we have to do an imaging study, a CT scan or an MRI that can tell us whether there’s bleeding in the brain or a different type of stroke, the ischemic stroke.

[00:17:41] Irfan: There are certain things that mimic stroke. They’re called, you know, they’re called stroke mimics. And they can look like stroke, but they’re not strokes. So we have to do certain blood tests. For example, you might not know that hypoglycemia, lack of glucose can mimic stroke. I mean, it can look like a stroke totally,[00:18:00] until you check the blood sugar, and that might be very, very low.

[00:18:04] Irfan: And then you give them some glucose and all the deficits go away. Sometimes in the elderly, especially if they’re septic from an infection, they can initially look like a stroke. Or a brain tumor can look like a stroke or subdural hematoma, or there’s many other things. So the process is clinical history, imaging, and blood work.

[00:18:27] Irfan: Between these three, we can do a pretty good job of identifying the type of stroke that someone might be having.

[00:18:34] Pete: And when it’s identified, is there one where you have to act a little bit quicker with what you’re going to do from a treatment perspective? And so what’s that timeline look like and what’s the treatment?

[00:18:46] Irfan: So the timeline has been changing a little bit. When we first started off with this treatment, nearly 25 years, 26 years ago now. We had a three hour time window. Meaning, we could only use these drugs that dissolve the [00:19:00] blood clot and open up. So let’s go back to the plumbing analogy with which I began.

[00:19:04] Irfan: So let’s think, say your kitchen sink is clot, what do you do? You pour Drano. So there’s a chemical that dissolves the thing that’s blocking your pipe and opens it up and whatever needs to flow starts flowing. So that’s exactly what we do. We use biological Drano. And the first biological Drano was called Alteplase or TPA.

[00:19:24] Irfan: We have now moved to a second generation Drano, called Tenecteplase. Regardless, it’s a chemical Drano. It dissolves whatever might be blocking the blood vessel, the plug, and hopefully distorts blood flow. You can only use it within about four and a half hours. So I told you in the beginning it was three.

[00:19:45] Irfan: We’ve been able to push the window out a little bit longer, so within four and a half hours of symptom onset. After that, you can’t use it any longer. That’s treatment number one. Number two, if you don’t dissolve the [00:20:00] clog with Drano, what do you do? You call a plumber. What does a plumber do?

[00:20:05] Irfan: They put in a snake. And dislodge the clot, well, that’s exactly what we do. So we do a procedure called mechanical thrombectomy. So if we can find a plug in a blood vessel that’s accessible, we put in a wire, catheter, put in a snare or a vacuum tip device, and suck the clot out.

[00:20:27] Irfan: So we have two different types of treatments, chemical thrombectomy, or removal of the blood clot, mechanical thrombectomy. Sorry. The first one was dissolving the blood clot, and number two is removing the blood clot.

[00:20:42] Irfan: Sometimes we use the two treatments in combination. Sometimes we use just Drano if we don’t see a discrete blood clot or if it’s too far into the brain to actually get in there with the wire. Sometimes we [00:21:00] use just thrombectomy. If someone comes five, six hours after their symptoms began, we can no longer use the chemical, but we can still pull the clot out and patients tend to do better than if we didn’t do it. Sometimes patients wake up with strokes, so we don’t know when the stroke happened.

[00:21:19] Irfan: If you wake up at seven o’clock and you can’t move your right arm, the last known well times is how we define it, was 11:00 PM. Now, did the stroke happen at 1115? Or at six 30 in the morning, 20 minutes before you woke up, you don’t know that. So we used to default to the last known well time, but now we have some more advanced imaging techniques that can actually tell us approximately when the stroke occurred.

[00:21:44] Irfan: Is there salvageable brain? Is there likely to be a good outcome if we remove the plug and restore blood flow, so we can now treat wake up strokes and extended time window strokes. So, you know, there’s always [00:22:00] progress going on. People are always trying to push this window open for as long as possible, giving patients the best chance.

[00:22:08] Pete: From where you first started to where it is today, do you feel as though the advancements have been significant or has it been pretty much in good hands for that period of time?

[00:22:20] Irfan: Well, that’s interesting that you asked that question. We were having dinner three or four days ago with a young neurologist. You know, we interview people to hire in our clinic group and so on. So we were having dinner with this young neurologist and we were. I was talking about my generation and how amazing it has been for us.

[00:22:39] Irfan: So I started doing neurology. I began my residency almost 40 years ago. Okay. I started practicing 35 years ago next month. It’s been an incredible privilege in the right of a lifetime to be this transitional generation that has seen all these advances. So I knew what [00:23:00] stroke treatment was like before. We did it right during my residency and the chemical that we are talking about was approved by the FDA, I believe in 1996 or thereabout, 95, 96, and I began my medical practice career in 1988 after my residency. So for eight, nine years, we treated patients without any specific way of treating stroke and came this chemical. That was really exciting.

[00:23:28] Irfan: Lots of scary because there are some side effects that we really haven’t talked about. And then many years later became mechanical thrombectomy, and today it’s a different world altogether, completely different. We are treating patients with newer drugs. We are getting deep inside the brain and sucking and pulling these clots out.

[00:23:47] Irfan: And the whole chain of care has been developed. So paramedics, emergency room personnel, radiology and imaging, and lab, and you know, everything has to work together to make it happen very [00:24:00] quickly. So it’s been an incredible journey. Yeah.

[00:24:03] Pete: What I think is fascinating about that journey is that if you’re the type of person that isn’t willing to be nimble and evolve and change and look into new things, because a lot of people like to just get up and go to work and know A, B, C, D, but in your line of work and what you’re doing, it’s always evolving and getting better.

[00:24:23] Pete: And it’s fascinating to hear you say for 40 years, this is what’s changed and here’s how it evolves. But it’s not standing on your hands either.

[00:24:31] Irfan: Well, but if you think about it, a lot of things have changed in society too. We didn’t used to have smartphones, we didn’t used to have internet. We didn’t used to have worldwide web. We didn’t used to have this video conferencing or podcasts and all of that. So, you know, this change all around us.

[00:24:47] Irfan: It’s not just in medicine. So some changes are disruptive. They’re revolutionary. You know, you can talk with the smartphone, the worldwide web, the internet, you know, getting groceries [00:25:00] delivered to your house through an app on the phone. I mean, this is all incredible, right?

[00:25:04] Pete: Right.

[00:25:05] Irfan: 30 years ago, you would’ve, someone would’ve laughed. I don’t know if you guys are even old enough to remember this, but there used to be comics of Dick Tracy, you know, talking on his video.

[00:25:15] Pete: Yeah, his watch!

[00:25:17] Irfan: That was a comic, that was a fantasy. Today you can do it!

[00:25:21] Pete: So then you begin to wonder, did somebody know something? It’s crazy, isn’t it?

[00:25:25] Irfan: Yeah. I don’t know if the author of the comic series knew that or not, but it was aspirational. Right. This was what we wish. Jules weren’t wrote about going to the moon. God knows how many years ago, I don’t think he foresaw rocket technology. It was just, you look up at the moon and you say, boy, I wish you could go there.

[00:25:40] Irfan: And we did. So all these incredible changes happen and you know, some medicine is no exception. And I know for my generation has been blessed to see this changes occurring. And yes, it has changed, stroke care revolutionized it.

[00:25:56] Pete: In terms of after you’ve been [00:26:00] treated and cared, there can be obviously some long-term short-term effects. Can you kind of share what people could expect with that?

[00:26:08] Irfan: Right. So recovery from stroke is also a very complex scenario. To try and simplified it, we need to go back to what I began with, which is size of the stroke and location. The more severe the stroke, the less likely you are to recover completely, right? Less logical and intuitive.

[00:26:29] Irfan: Then comes the function of age. The younger you are, the better you’re gonna recover, right? The brain has more plasticity when you are younger, and I think we all know that we lose, you know, X thousand brain cells every year. I don’t know the number exactly, but. As we get older, sadly our brain cells start disappearing, and the peak, by the way, for those who might be listening is somewhere in the mid twenties to early thirties.

[00:26:58] Irfan: So it’s [00:27:00] been a downhill process from there on.

[00:27:02] Pete: So enjoy it kids while you can.

[00:27:04] Irfan: There you go. And that’s why children learn so much fast. I’m gonna just look around you. So, age is a big important factor. And then comorbidities. You know, if you’re sick from various other medical conditions, your overall recovery is likely to be less good, and there may be other factors, you know, collateral, blood flow in the brain and so on.

[00:27:23] Irfan: If you’ve ever had a previous stroke, or not, that’s going to influence your recovery. The majority of recovery occurs in about 90 days after the stroke, and then slowly thereafter. But majority, I would say is 90 days.

[00:27:37] Pete: And then in terms of advocating from a healthcare and support perspective, from a victim, How is it best?

[00:27:45] Pete: You know, and I’ve had many discussions with people in the medical field. I’ve always said, you have to talk. You have to communicate and really share. I think that’s the best form. But are there other ways that patients can [00:28:00] best advocate for themselves in this situation?

[00:28:02] Irfan: Absolutely. And again, one small correction. In the stroke war, we don’t like using the word victim. We call them stroke survivors. Because you don’t want the victimization mentality. A survivor tends to fight back and do what they can to advocate for themselves and others. So yes, we have at North Memorial, for example, we have fantastic programs for stroke survivors and their families.

[00:28:26] Irfan: Don’t forget, stroke affects a family. If a breadwinner has a stroke they may not no longer be able to work. If they are in the working age, many elderly patients of ours, the women may not be driving. I know it sounds an inaccurism today, but decades ago, that was the case. You know, maybe the wife didn’t drive, and so the husband gets a stroke.

[00:28:51] Irfan: Now both people are stranded. Maybe they live on a second floor of the apartment. Now you can’t negotiate stairs. Maybe their bedroom is on the upper floor of the [00:29:00] house.

[00:29:00] Irfan: Common occurrence. So one of the questions we always ask stroke survivors and patients. So tell me about your living situation. Is everything on the same level?

[00:29:09] Irfan: How often do you have to go to the basement, so on and so forth. So, we have programs at the North Memorial, through the North Memorial Stroke Program, and I would encourage listeners to contact the stroke center at North Memorial if they are interested in learning more about these programs.

[00:29:24] Irfan: For patients, we have a lovely program called Coffee and Conversations. So patients come there along with the speech therapist, then we have it every week and they can share their experiences and so on. We have a program called Discovery Circles. And so we have lots of different programs that are actually approved by the American Stroke Association.

[00:29:44] Irfan: And there are other stroke centers in town. We are not the only act in town. So people can go to the Minnesota Department of Health website and they have a terrific listing. If you look under the search for Stroke programs, you will find [00:30:00] a listing of various programs that different hospitals in and around the Twin Cities in Greater Minnesota offer for stroke survivors and their families.

[00:30:11] Pete: Well, I think it’s really impactful because it does through personal experience impact. The entire family, just with how your daily routine works, how the breadwinning is done, and these are all real things that when the lights turn out as a group, you need to do that. So to have those resources available is absolutely huge.

[00:30:33] Pete: And I’m sure as those have gone, there’s been a component of how those have evolved too, looking at different components and if you could once again give a spot where everybody can go to within your organization from a support perspective.

[00:30:49] Irfan: Yes, as I said, you can call the stroke center at North Memorial hospital, and they can, they have wonderful resource. You can [00:31:00] go to the Minnesota Department of Health website and look up the stroke programs to search there. There’s a whole listing of the Minnesota Stroke Association. They have a big presence in the Twin Cities. You can go to their website and call them, and they’ll give you some information as well.

[00:31:15] Irfan: Part of the challenge that we have, and I think we need some advocacy here, is payers, insurance companies don’t reimburse for these rehabilitative programs very well. That’s the sad part. They will pay tons of stuff for their huge care and then they will deny treatment for aphasia programs, occupational therapy programs, you know.

[00:31:38] Irfan: The purpose of all of this chain of care is to restore the person to as high a level of function as they possibly can after the stroke. And it’s very important to provide support and systems for, patients and their families, stroke survivors and their families so that they [00:32:00] can adapt to their impairments.

[00:32:03] Irfan: First of all, improve to the extent they can and then be adapt to what they’re left with. And you know, people do amazing kinds of stuff. I mean, you know that the human spirit is very resilient and people find ways to accomplish what they need to do despite what has happened to them.

[00:32:21] Pete: They sure do. And there’s plenty of tools out there when things maybe go as unplanned and this has been absolutely wonderful. Obviously with May being National Stroke Awareness Month.

[00:32:32] Pete: What a great way to start it off. I know I’m more aware about everything after this discussion, and hopefully those that listen to this podcast will feel the same way. It’s been our first and I’m really happy you could join us, Dr. Atlafullah, as obviously you have a wealth of knowledge in that area that you are very, very close to and means a lot to you.

[00:32:52] Irfan: Thank you very much for having me. And as I said, it’s quite appropriate that we do this kind of public education and [00:33:00] informational sessions for during the stroke awareness month. So it’s especially significant that way. Thank you very much.

[00:33:06] Pete: Thank you and thank you all for joining us for this episode of Neurology Now. We hope you found it informative and engaging. If you enjoyed this episode, please subscribe to our podcast to stay up to date and help us educate our community and beyond. We welcome your feedback, comments, and suggestions for future topics. So please feel free to reach out to us through our website or social media channels.

[00:33:28] Pete: That’s gonna do it for today’s program. I’m Pete Waggoner. So long everybody.