Peloton Instructor Bradley Rose on Returning to Life After Stroke

Episode Transcript

Dr. Daniel Correa:
From the American Academy of Neurology, I'm Dr. Daniel Correa. This is the Brain & Life podcast. In the coming weeks, we are looking forward to introducing you to a variety of voices along with me here on the Brain & Life podcast. Today you might recognize Dr. Sarah Song from our discussion about carotid artery dissection and stroke in our past episode with Timothy Ahmanson. You may also have noticed her name on the editorial board of Brain & Life magazine, make sure to check out the magazine and website, or even seen her coverage with NBC News or the American Heart Association about stroke rates in Asian Americans. She works as a stroke specialist at Rush University Medical Center in Chicago, and when she isn't at the hospital, she dedicates her time to improving the recovery and outcomes after stroke, reducing disparities in stroke with a special interest in stroke among women and minorities. Thank you Sarah, so much for joining us again on the Brain & Life podcast.

Dr. Sarah Song:
It is my absolute pleasure.

Dr. Daniel Correa:
So Sarah, what exercise or movement do you do or enjoy?

Dr. Sarah Song:
Well, I used to be a big runner, and then I had a baby last year, and one thing I've really enjoyed doing recently is taking my baby for walks, and I bundle her up, and I take her to the Botanic Gardens here in Chicago. What about you?

Dr. Daniel Correa:
For me, just before the pandemic, thankfully, I found a running community here in Harlem, and I was bitten by the bug to start picking up running and I did New York City Marathon last year, and now I'm training for the Chicago Marathon this coming fall where I'll also be fundraising to support the CURE Epilepsy organization's team.

Dr. Sarah Song:
That is so awesome. I commend you.

Dr. Daniel Correa:
So today we're going to hear from Bradley Rose, an online fitness instructor, who not only had a stroke at age 32, but also was able to work his way back into the studio and onto the bike. After my interview with Bradley Rose, we will be back with Sarah to discuss different types of stroke, treatments, stroke prevention, and getting back to activities.
Welcome back to the Brain & Life podcast. Today we're joined by British actor turned fitness coach, and now a Peloton cycling instructor, Bradley Rose. He was climbing the fitness coaching environment only to have his world shocked and turned around by a stroke at age 32. Through the process, he was told he had an abnormality in his heart and then faced the challenges and the realities of healthcare costs and navigating the whole system. We're so glad he's here today to talk to us about stroke in the young. Bradley, thank you so much for joining us.

Bradley Rose:
Thank you so much for having me here.

Dr. Daniel Correa:
So I wanted to go back to the beginning. You grew up in Norfolk, England. You eventually ended up getting into sports, and acting, and cycling. What came first and what really drew your attention and interest into those two areas?

Bradley Rose:
I've always been a really sporty kid growing up. That was my sort of thing. Acting was also another component of my life that I absolutely loved, and it kind of meshed all into one many years later, but I started off as an actor, went to drama school, and then moved to America, and was working, and doing the sort of scene out there with an actor, and an agent, and a manager, and auditioning, and I randomly sort of fell into this fitness world. My friend was like, "Why don't you come to the studio and take a class with me?" And that's literally how it started. I was like, "This was so much fun. This was awesome. Loved it."
And then they basically out the blue offered me a job, and then that's kind of how things steamrolled on the sort of fitness front. I loved being in front of people, loved fitness anyway from my early background, and I was in America doing both things at once, acting and fitness, and I was able to combine all my personalities really that I sort of bring to everything, and that's really the story of how I got into fitness.

Dr. Daniel Correa:
And you made a transition once you were into doing fitness instruction and cycling instruction to working from in-person classes to the virtual realm with Peloton, and do you feel like that was just a natural step with your acting experience and your connection to the camera, or how was that transition for you?

Bradley Rose:
Yeah, I don't look at it really as that much of a change. I think it's kind of the acting on TV, acting on stage. It's the same medium, but there's just certain things you heighten or taper down. For me, it was an easy sort of transition, an easy process being in front of people or just being me alone and the camera, because I started in the pandemic, so it was just literally me in a room talking to a camera, no one I can see. I loved the experience. For me, it was still getting a chance just to be in front of people, which I was very, very fortunate to be able to sort of do at that time.

Dr. Daniel Correa:
So it sounds like the fitness studio has been sort of the center of many of your transitions, and as I understand it's where you first had your symptoms that brought you to medical attention. You were actually in the class. What was it that you first noticed and what happened?

Bradley Rose:
Wow. Yeah, so I was working at a boxing studio, Rumble Boxing in New York City, just teaching a morning class, and it's kind of blurry and hazy and it's almost like a patchwork puzzle that I've sort of put together, what I remember, and what people around me were telling me, and I was on stage, and all I can remember is everything just going black, and then sort of opening my eyes and being like, "I have the world's worst headache." And I was like, "Something does not feel right." In my head I was like, "You must be exhausted. You've been teaching all these classes. You're also doing acting. You're flying around, jet lagged." In my head I was like, "You're just tired. Chill out." But I jumped off the stage and kind of stumbled, and I was walking around.
I couldn't think of what to say, and then I was like, "I just need to get out of this room," because the music was blaring, the lights are flashing, which is probably the worst sort of situation to be in. So all I remember is walking out the door of the studio, taking the mic pack off, and giving it to another instructor that stood there, and I was like, "You've just got to go teach." And then I went down into our office, and what I remember is putting my head in my hands. This was also on the desk, and relaxed my head down, and just thinking, "This is horrific. Whatever I'm going through isn't normal." And I thought I'd been there maybe five, 10 minutes, and then next thing I kind of remember is someone tapping on the shoulder and being like, "Are you okay? What's going on? You've been here for three hours." And I had no idea. Yeah, I had absolutely no idea.
In my head, I was like, "Oh, I don't feel great." I was like, "Can you give me some headache tablets? And I think I've just got real bad headache or a migraine. I think I'm exhausted." And in my head, I was like, "I've got an audition coming up." I was teaching at 7:00, so by this time it was like 11:00. I was like, "I better get to this audition." I am walking out the studio, walking down the street, and I had no idea where I was. I couldn't think of anything, like simple things, like the subway stop or the street name, anything like that was just confusing to me. So I called my wife, and I was like, "I don't feel great. I've been sent home. I'm not going to go to my audition. I don't know where I am though." And she was laughing. She was like, "What are you talking about?" And I was like, "Yeah, I'm not sure where I am."
And she's like, "Well, what do you mean? You're in New York City." She's like, "Where are you stood in front of?" And I was like, "Well, there's a big triangle building in front of me." And she's like, "Do you mean the Flatiron?" She's like, "You're at work." And I was like, "Yeah, I think so." I'm like, "I'm not sure." And she's like, "All right, get on the subway, go to this [inaudible 00:08:54]." She had to type it down. She's like, "Write this down," typed it down. She's like, "Go home and sleep it off." Once again, she was like, "You must just be exhausted." And I was downplaying things like anyone does at that time. You're just like, "Oh, no, don't worry about it." I just kept saying, "I'm exhausted. I just need to go to bed." And so she basically told me where to get off on the train. So I went home, and I went straight to bed, which now knowing that's probably one of the worst things you can do.
And then I woke up the following day, but in the evening. So in my head I was looking at the clock being like, "Oh, wow, I've slept all day. It's the evening now," and then I look at my phone, and there's tons and tons of missed calls from my wife, and messages, and I'm like, "What the hell is going on?" And that was kind of the first sort of piecing that something wasn't right. And if I'm honest with you, yeah, we both were suddenly like, "Okay, something is really not good." So she came straight over and was like, "Let's get you to the doctor now." Unfortunately, I didn't have healthcare at the time, which is one of my problems with the fitness industry, if I'm honest with you. Like any fitness studio, they don't offer healthcare to their instructors, which is absolutely bonkers that these guys are doing these workouts for hours a day and the company they're working for will not offer them healthcare. That's a whole nother subject.
So we went to I think it was Med MD, and we said what the problems were, the issues, and their diagnosis was, "You're exhausted," exactly the same as me. You're just exhausted. You need to take three, four days off work, recover, chill, and then you'll be good to go. That was it. So I go back into the studio four days later and-

Dr. Daniel Correa:
What did your wife think though?

Bradley Rose:
Maybe there's something else wrong. She couldn't tell, because I was pretty normal to talk to and stuff like that. It wasn't like a major, major issue had happened. There was no drooping. There was no sort of real massive issues with my speech. It's mainly my memory that was the problem and feeling in my left hand, but because I was a boxer, I was always like, "Maybe I've just damaged something. Maybe I've hurt something," and working out I feel like something is not quite right. So that was her sort of thought on it. She was like, "You need to get another opinion on this." But in my head, once again, I was going, "We haven't got healthcare." I was like, "Where do we find a doctor? We don't know what's wrong. We've just gone to this doctor. They've said, 'Everything is fine.'" We're in this weird position where that doctor had said we were fine, and I felt better, and I was like, "Right, I should just get back to work and get back into it. I've had a few days off." That was sort of my mentality on it.
So then I went back to work, and the people taking that class said, "You're slurring a lot. You don't make a lot of sense of what you're saying. You need to come out of class. You need to stop." So once again, that class finished, and I stopped, and I was like, "Yeah, something is really not right," and that's when we were like, "Okay, we need to go to a real doctor," and we went to NYU to sort of get things looked at.

Dr. Daniel Correa:
What was it then that they first started doing with you and tests or otherwise that helped them figure out with you that something more was going on?

Bradley Rose:
I don't know the name of it. I think I've almost hidden that away because it was so disturbing. I was a confident guy sitting in front of a doctor and him pointing, and this is what it is, a sheet of paper, and he pointed to an animal, and he was like, "What's that?" And I was like, "Well, it's a kangaroo," but it wasn't. It was a hippo. And then there was another one, and he was like, "Well, what's this?" Another animal on there, and I didn't know the name of it. So I was like, "I'm not sure what that one is." And he did a bunch of other things like math, simple arithmetic, days of the month, and stuff like that. I can't remember exactly what they were, but I basically massively failed that, and that's when he was like, "You've had a stroke," which was kind of shocking.
And I think because my wife knew there was an issue, so she called her mom, and one of her friends was a neuro doctor, and she called me and was like, "You need to go to a neuroscientist or a stroke specialist ASAP." And she knew people at NYU, and she was like, "Go see these people. Just get a test done and see what's going on." So that was kind of how that sort of escalated. It was basically my wife, which it was a good thing to have.

Dr. Daniel Correa:
Sometimes the family are the best advocates for us. So Bradley, they got an MRI. You saw the doctor, I'm presuming a neurologist and stroke specialist like you described. What did they tell you was actually going on once they had more of the testing done?

Bradley Rose:
Yeah, I had the MRI, and they noticed there was a hole in my heart, and from what I was told, I think it was an atrial septal defect, an ASD, and a blood clot went through which caused a TIA, which is a transient ischemic attack, I believe.

Dr. Daniel Correa:
Transient ischemic attack, yeah.

Bradley Rose:
So that was the diagnosis of the doctors in America.

Dr. Daniel Correa:
So the pictures of your brain didn't show a new stroke. They thought that the symptoms you had were transient from a clot?

Bradley Rose:
From what I understand, yeah. They also did the test when we went to England, and they showed the little gray area of your brain. They were like, "This is where the strokes happened."

Dr. Daniel Correa:
It sounds like eventually with some of the pictures they were able to see the area where the stroke damage had occurred, and so sometimes when we talk about a transient ischemic attack, these are the events where not enough blood flow gets to the area of the brain and no scar or damage occurs. Other times when we take pictures later on, we can see that maybe tiny little spots of damage did occur, and we see them show up later time. So it may have been just a difference between the pictures that you had between the time.

Bradley Rose:
Yeah.

Dr. Daniel Correa:
And at that point, once you knew this information, they're telling you, "Okay, well, not only you have this small hole in your heart that maybe can cause a clot to go, and that's giving you episodes. It's affecting blood flow to your brain." I mean that's a lot coming from a guy who's used to just being super healthy, doing boxing and cycling classes. How much of a change did that feel and what made you concerned about your regular lifestyle at that point?

Bradley Rose:
I mean, it was instantly life changing. I think you never expect anything like this to kind of happen, and definitely at a young age, you kind of think you're invincible. I also was struggling I think with just not being able to do anything, and it was kind of like it's a weird thing, right? So I always tried to say that I was okay. I think this is something that looking back now, I was always like, "Yeah, I feel good. I'm okay. Everything is all right. I can deal with this." But that was far from really what was going on.

Dr. Daniel Correa:
I think sometimes, especially when we're younger, like you described, you're always trying to say, "Oh, maybe it's something else." And it's great when it is, and when you're relatively healthy it might just be a headache, but when it's this worst headache of your life like that, it's important to get it checked out. Before all this, you didn't have migraines?

Bradley Rose:
Not really. I mean, I would have them, but very, very rarely. It was not like a common thing.

Dr. Daniel Correa:
This was really a very new and much more severe type of headache than you've ever had before?

Bradley Rose:
Yeah, it was a type of pain that I can't explain it. It was just sharp, searing pain, but it wasn't just for a second. Sometimes you get something in your leg or whatever, but this was continual. But I think this is another thing to understand is a lot of people that I've spoken to after it, they don't realize what they're going through. It doesn't put you in the hospital bed. So a lot of the time, it's a few days later or a week later that it actually gets caught or picked up of what it actually is, and that was the case for me.

Dr. Daniel Correa:
It sounds like they did other testing to see if you had other possible causes for stroke. We're often looking to see if someone has diabetes, or cholesterol issues, or high blood pressure issues, or other reasons for clots. When they did all those things, did you have any other causes, possibly?

Bradley Rose:
No. There nothing else came through at all. I think they said they wouldn't even know where to start looking where a blood clot could have formed. So they did all those tests, and they said that everything was normal.

Dr. Daniel Correa:
So that's great and reassuring, and this is often the situation when we do see a hole in someone's heart, and they've had either recurrent issues, or something as significant as yours, we start talking about sort of the benefits and potential of closing that atrial septal defect or the ASD. Now, as you've mentioned, you, like many people in the United States, unfortunately, were dealing with also the challenges of the cost of the healthcare system and limitations of just having insurance. So how was it for you just considering not only this treatment and this procedure, but the fact that you had to figure out doing it without insurance?

Bradley Rose:
Yeah, I mean, I'm unbelievably fortunate that I could go back to England and get this done. Otherwise, from what I was getting told, we're talking of hundreds of thousands dollars worth of debt, because I didn't have healthcare. My wife was also she works on her own, so she didn't get healthcare or she didn't have it through her company. So that was the real problem, and then we did have healthcare, but it was so unbelievably expensive and so limiting in what it covered that we decided not to. We were spending like $400, $500 a month, and we were like, "This isn't covering anything." So we decided. We were like, "There's no point even doing this." So we went, "We're young. We're healthy. I'm a fitness instructor. You're young and healthy." So we were just like, "Oh, we don't need this." And then, of course, we got hit with this, and it was a huge lesson, but like you said, a lot of people in America are in the same boat, in the same situation.

Dr. Daniel Correa:
I'm glad that worked out for you, but it's just that much more of an example of we all need to make sure we have healthcare coverage, and if we have financial issues limiting that, then to touch base with a primary care doctor or social worker to see what things you might be eligible for, but in these situations it's just so essential because a stay in the operating room or the ICU can turn out to be a major impact on your life.

Bradley Rose:
Yeah, I mean, the limiting things we had done in America set us back, and it was just to find out what had happened.

Dr. Daniel Correa:
Yeah. No, that's tough. So when they were recommending the closure of your ASD, how are they describing the procedure and your understanding of the benefit or the risks of it?

Bradley Rose:
They just basically when I was in England, it was Dr. Rick Bean, and Ed Leithen who were my doctors. They'd said that you need to get them closed in case there was a blood clot again. This is the best form. It was like they explained it as a PFO closure, but I don't know if that's the technical term of the way they explained it, and I remember now is an umbrella, a little umbrella going in. It almost opens up to cover the hole. They said that this was the best way to do it, to stop another blood clot going through.

Dr. Daniel Correa:
And so then you were going back home to get this medical procedure. What was that feeling like?

Bradley Rose:
I think once again, everyone was up in the air, and lost, and confused, and it was a really tough time to go home into that. Also, just my parents didn't know anything about strokes, so they'd sort of put their own thoughts, and feelings, and stresses, and fears, and worries into it, same with my sister, and it was great in the fact that going home and having family there to take care of me, but it was also I think very difficult because no one really knew what was happening or how to go about this, because I had to once again get back onto the NHS, and find a doctor, and my sister knew a doctor, so he kind of helped us get back on, but it was just tough in having to kind of go back home, and just how confusing it was for me, and how I was in denial that anything was wrong, and my parents were... Parents are parents. They're going to worry and stress.

Dr. Daniel Correa:
I think it's a challenging transition I think for everybody, and many people can relate to that, I think. When you go from being healthy to all of a sudden having a medical issue that needs to be taken care of, doesn't really matter what age you are. I think many people all of a sudden feel like everyone is telling them what to do.

Bradley Rose:
I've never fought so much with my family over stuff like this, and it felt very much like just everyone watching and treading carefully around me, and no one sort of talking openly and frankly about stuff, which I'd rather have just been like, "What do you think about?" I'd rather had an open conversation, but it felt very much like, "Oh, we've got to be careful. Maybe he's tired. Maybe he's upset. Maybe he doesn't understand this. Maybe..." And it's my own brain was like, "Why aren't they just talking to me about this?" If I could say to anyone, just talk to them. I think it's being open, having that conversation, and it's tough, and it's hard, but for me that was the biggest thing.

Dr. Daniel Correa:
In the news, a lot more people have become more aware of the mental health issues that can occur after stroke, sometimes depression, sometimes anxiety. One of the US senators, John Fetterman recently explained that he was dealing with post-stroke depression. Did you end up dealing with issues addressing depression, or anxiety, or your mental health trying to get back to activities after your stroke?

Bradley Rose:
I've never spoken to someone about it really, but I feel like I've had issues, but I came back to work, then time off because the pandemic, and then I went back into hospital because I was throwing up. I was getting very, very dizzy, couldn't really stand up straight. So I went to the hospital a couple of times during the pandemic at the heightened point of it. It was unreal being there. What the doctor seemed to think it was was vertigo, which I'd never had before. Now I get flight sickness, and really dizzy, and I get massive exhaustion if I don't sleep well, which I think my stroke is probably affected the most.

Dr. Daniel Correa:
Is there something you're doing to try to help rehab your balance with the vertigo or some other things you're trying to do to work on your sleep and these other issues that you've had?

Bradley Rose:
This is where I've kind of been over the past three years, two years is I've gone into a bunch of doctors. I went to a sleep clinic, sleep doctors, the vertigo thing. They really can't say or do anything about it from my understanding. I even at one point was like, "Well, maybe I am depressed," because once again, like you mentioned, there's a lot of talk about depression with stroke, and I was like, "But I don't feel sad or upset. It's more just exhaustion," but I got to one point, and I was like, "Right, I'm going to go to the doctor and ask them for depression medication." I was like, "Maybe that's what it is." Went through all that, got home, and I was like, "This just does not feel right. I know that I'm not depressed. I know it's something else."
So one of the harder things I've dealt with post-stroke is I still have issues. There's still problems, and there doesn't seem to be an answer, and it's now coming to the realization that I have to live with certain things, and now I have to take certain steps to make sure that I don't feel awful. So now I do a ton of things which kind of are almost like biohacking and testing things for the past two years to see what kind of works.

Dr. Daniel Correa:
I hope that with time as you're figuring out how your body responds both to your rest recovery, and other things that you work on, and maybe your physical fitness activities, you kind of find the right balance, and maybe with time your doctors also make some adjustments that help for you, but it can be a tough road balancing the mix of symptoms, and getting back to activity, and setting kind of a new expectation for your physical activity and your lifestyle.

Bradley Rose:
I mean, you said that perfectly. It's setting the new expectation, and I think that was the biggest thing that I've had to do, and before, I was like, "I can work out seven days a week. I don't need a break. I can do this." But now it's looking and going, "No, actually, I really can't do that." And there's certain things I'm going to do every day to try and make myself feel better, for a lack of a better term, because today I feel great, but yesterday I didn't sleep. I slept three, four hours, couldn't go back to sleep, felt horrific. So now I give myself that time and go, "I'm not going to go to the gym," and that's another great thing about Peloton is they limit the amount of classes we do per week, and they limit the hours that we work per day, and they are a great company in basically helping me create the best working environment for myself.

Dr. Daniel Correa:
Well, I'm glad you're being able to work towards a balance and a schedule that works for you both for your work and the other activities that you enjoy. Now, we talked some about just challenges of the healthcare costs and system. I'm wondering what you think about are ways where we can make fitness and wellness more attainable to everyone, because not everybody has the financial means to join these different online and training programs?

Bradley Rose:
Yeah, of course. It is expensive. I think any sort of wellness journey can be an expensive journey for anyone at any level, whether you're joining low-cost gyms or just going out for a run or a jog and buying the equipment that you need. It can be expensive. There are many apps. There are many people on YouTube at all different levels that you can get up for free and take one of their classes. So then you can be doing yoga. You can do running. You can do weights. You can do calisthenics. You can do stretching. So it's not just like, "Oh, here's one product offering one thing." It's offering many different movement-based workouts for whatever level you are, whatever you want to do at that time.
I think the great thing about Peloton and these type of workouts is community, right? I'm always on that is it's being held accountable. It's having friends on the leaderboard. It's messaging your mates on Instagram, or a text message, or a phone call, being like, "Did you take this class?" I think if you start finding a community, that's where the fun will be, and that's what's going to keep you in it for the long term.

Dr. Daniel Correa:
Connecting with a community is so important in whichever way people do, whether it's locally with a dance group or in any other of the opportunities that we have also online. Bradley, thank you so much for joining us, for sharing your story about your stroke, and the ASD, and the atrial septal defect closure, and the journey and challenges you had navigating the healthcare system in two countries now.

Bradley Rose:
Thank you. Thank you for having me here. It's been great talking to you about it.

Dr. Daniel Correa:
Can't get enough of the Brain & Life podcast? Keep the conversation going on social media when you follow @NeuroDrCorrea and @Brainandlifemag or visit Brainandlife.org. Wow, that was so touching. Bradley shared with us his story of recovery and figuring out his diagnosis, and then later on how he managed getting access to the care to point where he had to even go back home to United Kingdom for his care. He experienced so much uncertainty with a cryptogenic stroke at age 32. Sarah, is this something you see often in your work?

Dr. Sarah Song:
I'm sorry to say I do. We've seen more and more young people having strokes than ever before. I think that there's probably a variety of causes. Stroke is much more recognized as something that can happen in the young, I've seen it in babies, I've seen it in young children and young adults. There's a higher presence of vascular risk factors in younger people now more than ever before, but also we're recognizing dissections like we've talked about before, and what he had, which is PFO, or an ASD, or a hole in the heart can really contribute to strokes.

Dr. Daniel Correa:
Now, I want to go back. I threw in a term there, but I want to make sure everyone's on the same page. Cryptogenic stroke, that's a big complicated name. So why do we use that term?

Dr. Sarah Song:
So cryptogenic is sort of a catchall phrase for we're not really quite sure. It's kind of a mystery, and there's no obvious cause. Another term that people use, not necessarily the same, but similarly is something called ESUS, or E-S-U-S, or embolic stroke of unknown source, where we see a stroke, and it presents like a stroke with symptoms just like a stroke, but we don't really know where it came from.

Dr. Daniel Correa:
So I guess in that instance we kind of have the sense that it's embolic, the type of stroke, or what we often will say is the modality, but we don't necessarily know what the cause of that clot or emboli was.

Dr. Sarah Song:
Absolutely. So cryptogenic really means just a mystery. We're not really sure where it came from. We definitely know you had one. We're not really sure after doing all the tests what caused it.

Dr. Daniel Correa:
You mentioned before that we are starting to see an increasing number of vascular risks factors in younger individuals. What is the full scope when we say, "Vascular risk factors," for people?

Dr. Sarah Song:
What I mean in this case is for example, diabetes is being recognized. Type two diabetes particularly is being recognized in a much younger population. High blood pressure is also being recognized, high cholesterol, and some of these causes are genetic, but some may be less so.

Dr. Daniel Correa:
For Bradley, as we would think in some people, he was doing so much fitness activities. He didn't necessarily have high blood pressure, and he didn't have any of these other risk factors, diabetes, high cholesterol. Sometimes those are masked, and people aren't aware of them, but even when he got checked out, he didn't have any at the time, but he did end up getting identified over his workup to have an ASD, but they also mentioned PFO, so what are those two abbreviations and terms? What do they mean?

Dr. Sarah Song:
Okay, so thank you for letting me clarify because this is very confusing to understand, but basically in the heart there are four chambers in the heart, and there's a septum in between what we call the right side of the left side of the heart, and a PFO or a patent foramen ovale, is like a flap in the interatrial septum, and this is normally something that closes at birth, however, it's present in anywhere from 20% to 25% of the population, and it's a normal variant, so it typically was not seen to cause any problems, and it's only been recently more recognized as something that can cause stroke, and that can actually be fixed. An ASD or an atrial septal defect is a hole, again, in the interatrial septum that allows blood to basically pass back and forth between the left and right chambers, and it can cause reduced heart function. It can cause arrhythmias later in life, and it can have symptoms as well.

Dr. Daniel Correa:
So it sounds like in some ways the ASD or the atrial septal defect might be more severe?

Dr. Sarah Song:
That's fair to say. So some ASDs, for example, can require more extensive interventions such as surgery.

Dr. Daniel Correa:
And Bradley himself ended up going ahead and moving forward with surgery. He wanted to get it done in the United States, but because of some access barriers with his insurance and immigration status, he ended up having to make his way back home for that procedure and recovery. When do you decide, or how do you approach a discussion with people about when they should have surgery on their heart to close this tiny little hole that we're not sure about?

Dr. Sarah Song:
So basically when you have an ASD, which is a hole in the heart, typically it is going to require closure, because that means that blood is passing from the left to the right chambers of the heart, and that can lead to atrial fibrillation, and it can lead to reduced heart function later in life. And as a result, those are typically not too controversial to close. Patent foramen ovales are a little bit different because for a long time, like I said, PFOs are quite common in the population. We weren't sure how much they were contributing to strokes.
However, trials have shown that closing a PFO in somebody who has a stroke and there's no other identified cause, and it does appear to be embolic, is most likely going to be beneficial. And the way that PFOs and ASDs... Although ASDs have other mechanisms by which they can cause stroke, but PFOs specifically allows the passage of what we call a paradoxical embolism where a blood clot will come from the venous side of the body like a DVT, if you've heard of a deep vein thrombosis or a clot in the leg, for example, and it can go up to the heart and pass from the right to the left side of the heart, and then go to cause a stroke on the arterial side. So trials have shown that closing these is actually likely to help prevent strokes, but it has to be a population where they've really looked for other causes. They're a little bit younger, typically less than 65 years old, and we really do believe that there is an embolic source of their stroke.

Dr. Daniel Correa:
So these holes causing a lot of turbulent flow in the heart. I imagine them as like you left your car window or sunroof a little bit too much open, and you're driving fast, and just the wind is whipping around in there, and then if you have a little litter sitting around your car, and that litter goes back out the window, you accidentally littered, and maybe that's that paradoxical emboli.

Dr. Sarah Song:
That is a great image. Your heart is a car with the window open. Yes, exactly. And I think that it's important to know that part of the workup for getting a PFO closed includes things like checking to see if your blood is thick for other reasons, maybe genetic, making sure that you don't have a rhythm problem such as atrial fibrillation that you just didn't know about, and looking at all the vessels in your head and your neck and making sure there's no other cause of stroke, so we can really say with confidence that if the PFO is closed, most likely that will reduce your risk of a future stroke from that PFO.

Dr. Daniel Correa:
And I'm wondering about the timing. I've had this discussion with individuals and families in the hospital myself, but with your experience working with many more stroke patients, Bradley mentioned for us, he started having this worst headache in his life, but he just assumed he'd been working so hard, and had been working so many hours that he needed rest, and took a nap, and it took him time, and until it wasn't getting better for him to get to the hospital, and then there was this idea and focus of like he had to get back to work. So sometimes people ask, "Can I get all these tests and everything done in the coming weeks or in a follow-up appointment," or how do you approach that discussion about when to come to the hospital and the importance of getting everything done?

Dr. Sarah Song:
So I think that whenever you have new symptoms that are concerning, you absolutely just need to get to the hospital as quickly as possible. Headache itself is a symptom of stroke, and I guess I'll clarify that by saying there are different types of stroke, right? So we know that there are blood clot strokes, there are bleeding strokes inside the brain, in the layers of the brain called subarachnoid hemorrhage, which is more classic for having a headache associated with it. However, when you have a stroke that's caused by a blood clot, your blood pressure may go up really high because your brain and your body is trying to get the blood to the areas of the brain that are deprived of blood because of a blood clot sitting in the way.
So whenever you have new symptoms like a headache or the more classic symptoms we talk about, weakness or numbness on one side, trouble talking, trouble understanding, loss of vision in one eye or both eyes, double vision, sudden vertigo or room spinning, whenever you have those new symptoms, you really do have to get to the hospital. And the reason you have to do so is that there are treatments that we can give you, medication treatments, and even possibly catheter-based treatments that are reserved for specific types of stroke, but those treatments are time dependent more than anything else. So getting to the hospital quickly is of paramount importance. Calling 911 also helps because then the emergency medical personnel are able to call to the hospital and make sure that you get a speedy process right in the ER door, right to the CT scanner, right to the ER personnel who are waiting for you.

Dr. Daniel Correa:
Bradley also shared with us the challenging progress of his rehab and slowly trying to get back to work and activities. As you're following up with people and their families in your clinic in discussing their recovery and rehab after stroke, how do you approach that return to work and activity discussion?

Dr. Sarah Song:
That's a great question. I encourage all of my patients to take a little bit of time off work, even though they look great, because I know that it's almost harder to look great after a stroke because you really... It reassures people that stroke may not be such a dangerous or terrible thing, and maybe it doesn't need to be taken so seriously, but I do think that people need a little bit of time to reflect and to get back to trying to feel more like their normal selves. Some patients describe it as having a little bit of PTSD after they have their stroke where they've had this huge traumatic event, and they just need time to process. Other people obviously may have more physical needs or rehab needs that require time, and we know that early intensive rehab is always better and is more effective at improving outcomes long term.
So I'd say that I recommend that people take at least two weeks off of work if they're able to, and I'm happy to give people as much time as they need. I think that there's a lot of different types of support that people need after a stroke, so not only the physical support, but the emotional support, whether it would be helpful for them to talk to a stroke psychologist or a rehab psychologist, spend time with family kind of getting things situated, so they're able to move their schedule around so they can do the therapies that they're going to need, and I'm always encouraging my patients to just take a little break.

Dr. Daniel Correa:
Along with mental health symptoms, whether it's a situational anxiety, or even some PTSD symptoms, or just reframing their mentality of their functional level, you mentioned several other sort of unforeseen or invisible comorbid symptoms or side effects that can come after a stroke. Sometimes people get back to the point where they're walking fine. You may not see a difference in one arm or one side of their face or the other that people around them aren't aware of. I know I often hear about fatigue issues and also memory or cognitive thinking changes. What kind of steps do you help people seek to address some of those symptoms?

Dr. Sarah Song:
People think that if you have a physical disability, that is maybe the worst thing that can happen, and I would argue that some of my patients would disagree, because they might have a little bit of trouble with communication. Let's say 90% of the time they're able to hold a conversation. They're responding normally. They're finding their words without difficulty, but then when they get tired, or it's the end of the day, or they're not feeling well.
Then those symptoms come up, and it can be really distressing for them, and it's almost more difficult to point out to someone and say, "Listen, I had a stroke, and I have a little bit of trouble with this," and to have to point that out is really, really difficult, because a lot of times people will say, "Oh, you look so great. You look wonderful. You look like nothing happened to you." But that's really about themselves, and their own mortality, and feeling reassured by looking at how good somebody looks after a stroke, but understanding that there's so much underneath, and regardless of whether or not we want to believe it, having had a stroke really means having had some small or large type of scar on the brain.
That means the brain is not the same, and the brain is constantly working to remake those connections and find new ways to do the same issues, but it can take some time. Depression is extremely common after stroke, but I think it's incredibly under-diagnosed and under-recognized. People may have emotional outbursts or emotional what we call lability where they can swing from angry to happy to crying, and sometimes those emotions might not be socially appropriate or in line with whatever the situation is going on, and that's also due to the stroke.
So I really encourage people who have suffered a stroke to talk about these things and to normalize these things, because these issues will get better over time, but it does take time, and it takes work, whether it's talking to cognitive therapists or working with a psychologist or occupational therapist to get through these things. I've seen people have trouble, for example, being in crowded spaces where they don't feel like they can navigate those spaces as easily as they used to, or being in a room where there's too many conversations going on, and they can't focus or they're confused because they can only really carry on one conversation well at a time, and they're embarrassed because they can't express that very well.
So then what happens is sometimes some of my patients will describe that they just avoid social contact because they don't want to go out into a party and have to deal with a whole bunch of different conversations, or they do get tired really easily, and to which I say, "You need to find the things that are going to recharge you in a way that you can manage, and opening up and allowing other people to know that you're going through that, whether it's maybe a couple of trusted friends who are aware of what's going on can really be helpful," and above all things, normalizing that this can happen, that it can get better, and most likely will get better, and just staying hopeful about these things, and being open and honest about them as well.

Dr. Daniel Correa:
It sounds like a lot of that are things that we could all incorporate into our lives, not just after stroke. Thank you again, Sarah, so much for joining us today and sharing some more information about stroke, and different types of causes, and what we're all working towards, hopeful prevention, with our listeners.

Dr. Sarah Song:
Well, thank you so much for having me. I really enjoyed the conversation.

Dr. Daniel Correa:
Thank you again for joining us today on the Brain & Life podcast. Follow and subscribe to this podcast so you don't miss our weekly episodes. You can also sign up to receive the Brain & Life magazine for free at Brainandlife.org, and even get the Espanol version. For each episode you can find out how to connect with our team and our guests along with great resources in our show notes. We love it when we hear your ideas or questions. You can send these in by email to BLPodcast@brainandlife.org and leave us a message at 612-928-6206. You can also follow the Brain and Life Magazine and me on any of your preferred social media channels.
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Peloton Instructor Bradley Rose on Returning to Life After Stroke

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