In this episode of the Sarasota Neurology Podcast, Dr. Kassicieh, a recognized expert in stroke prevention, provides an overview of  current techniques for preventing and managing risk of stroke.

Stroke is the third leading cause of death in the United States. This combined with heart attacks and heart disease result in over 2 million deaths a year.

The common underlying cause is vascular disease or hardening of the arteries. Heart attack and stroke can be prevented with simple life style changes and medications. Treatment of high cholesterol, high blood pressure and stop smoking will significantly lower risk of suffering from these devastating conditions. This combined with supplements and simple medications, such as aspirin with have a dramatic impact in reducing risk for stroke and heart attack.

Listen to this report to find out how you can reduce your risk of suffering from a stroke, heart attack or other cardiovascular disease.

If you are concerned that you or someone you love may be at risk for stroke, please call (941) 955-5858 or click here to schedule your appointment today. If you’re outside the Sarasota area and unable to travel here, please locate a neurologist in your area.

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In this episode of the Sarasota Neurology Podcast, Dr. Kassicieh, a recognized expert  in clinical Botox, provides an overview of  current techniques for treating dystonia, muscle spasm (which may be associated with pain), spasticity from stroke or brain injury with Botox.



Botox was first FDA approved for medical use in 1989. Since then, Botox has found many medical uses to treat clinical conditions that were previously difficult to treat. Conditions such as cervical dystonia, blepharospasm, hemifacial spasm and spasticity such as that seen in cerebral palsy, stroke or spinal cord injuries have all been successfully managed with Botox.

Other similar products such as Dysport and Xeomin all have uses for cervical dystonia. Most recently, Botox was approved for use for treatment of chronic migraine headaches. Listen for more information on the clinical use of Botox and other similar products.

If you would like to learn more about the benefits of Botox, please call (941) 955-5858 or click here to schedule your appointment today. If you’re outside the Sarasota area and unable to travel here, please locate a neurologist in your area.

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Much has been said and written about caffeine over the past half century. There have been over 20,000 studies conducted looking at the various effects and benefits of caffeine over this period of time. Numerous studies have demonstrated the tremendous health benefits that can be derived from regular daily consumption of caffeine, most commonly delivered through the consumption of coffee or energy drinks such as Red Bull or similar beverage. All of these have a high caffeine content.  In almost any way that caffeine is consumed, there are certain health benefits that it delivers. Despite all the negative press that has been attributed to caffeine, there has never been a study that has shown that caffeine has long term negative health effects, quite the contrary. The vast majority of studies have shown some beneficial effect in the regular consumption of coffee and caffeine. In that sense, caffeine is truly one of nature’s own wonder drugs.

The use of caffeinated beverages  by humans is documented  since the 15th century. Over the past 100 years there has been an explosive growth in the manner that we get our daily “caffeine fix.” Coffee has been a staple beverage in most countries and cultures of the world. Prepared in various ways, it is all still derived from the humble coffee bean. There are many different types of coffee beans and many more ways to roast and grind the bean. The combination of these factors leads to preparation of coffee and related drinks. Caffeine is also added to various soft drinks and energy drinks, which gives these beverages the ability to make a person feel a “boost” in energy and alertness. In contrast to regular, black coffee – the healthiest of caffeinated beverage genre – many coffee preparations, soft drinks and any energy drink contain high quantities of sugar and/or fat. It is these ingredients that may contribute to the undeserved reputation that coffee or caffeine is not healthy. Of the regular, commercially available coffee, Starbucks has the highest caffeine content coffees.


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Vascular disease or “hardening of the arteries”, also known as atherosclerotic disease, is the number one cause of death in the United States. Contributing risk factors include diabetes, high blood pressure and high cholesterol. Diabetes is a major risk factor, equivalent to that of having had a heart attack. There is a direct association with high cholesterol and increased incidence of coronary artery disease. The most significant risk factor for stroke is high blood pressure. Both high blood pressure and high cholesterol are associated with a higher rate of vascular disease, stroke and heart attack.  Recent publications have indicated that coffee and tea may reduce the risk of having a stroke, stroke symptoms or other vascular events such as heart attack. The studies also indicate that individuals who consume coffee have a lower prevalence of diabetes, high blood pressure and heart disease.

As reported in Neurology Reviews, several independent studies have shown that daily consumption of black or green tea reduced the rate of stroke and number of people dying from stroke. These findings were reported at the 2009 International Stroke Conference. A summary of the findings of the numerous studies done show that tea consumption was associated with decreased brain volume injury from stroke with an increase in the number of brain cells that survive in a stroke. Retrospective analysis of the studies published, showed that 195,000 stroke patients were involved and the total number of strokes was 4,300. Dr. Lenore Arab, PhD reported this information and found that the consumption of three cups of tea daily was associated with an average stroke risk reduction of 21%. The exact mechanism of protection by tea in stroke risk reduction has not yet been completely determined. Dr. Arab’s findings were published in Stroke, 2009 February 19.

Coffee consumption has also been reported to reduce the prevalence of stroke. Information regarding coffee consumption and reduced stroke prevalence was also presented at the 2009 International Stroke Conference. This was published in Circulation, a well respected medical journal. It was reported that stroke and other vascular risk factors decreased the amount of daily coffee consumption increased. This finding was consistent even after considering and factoring out other high stroke risk factors such as smoking. Of the 9,384 patients in the study, for whom coffee consumption information was available, it was found that about 3000 had suffered stroke,TIA (transient ischemic attack) or stroke symptoms. The range of coffee consumption ranged from zero to 20 cups daily. Analysis of the data showed that in the individuals studied, those who drank no coffee had the highest prevalence of stroke. Drinking 1-2 cups daily had a stroke prevalence of 5%, 3-5 cups daily 3.5% stroke prevalence and greater than 6 cups daily 2.9% stroke prevalence. Other analysis of the data showed that there was an overall lowered prevalence of high blood pressure, diabetes and coronary artery disease with daily consumption of coffee, particularly in the higher daily coffee consumption group.

In conclusion, it is clear from the available data published in several medical journals, such as Stroke and Circulation, that there is a significant reduction in rate and prevalence of TIA, stroke and stroke symptoms with daily consumption of tea and/or coffee. Higher coffee consumption appears to be associated with a greater reduction in stroke prevalence. This in combination with a healthy diet, exercise of any kind and optimized medical therapy will provide individuals with the greatest protection against having a stroke and stroke prevention.

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Recent studies have suggested that qualifying Parkinson patients benefit from earlier treatment with deep brain stimulation, as reported in Clinical Neurology News. The study indicates that younger Parkinson disease patients are more likely to benefit from early brain stimulator treatment. There is information that may suggest that this therapy may have a protective effect in delaying the progression of Parkinson’s disease. Deep brain stimulation (DBS) was FDA approved in 2002 for treatment of Parkinson’s disease. Symptoms that are best controlled include tremor and dyskinesias although brain stimulation can also help reduce freezing and off time. Younger Parkinson patients develop motor complications such as dyskinesias, off time and freezing much earlier than older patients with Parkinson’s disease. As reported by Dr. David Charles, a Vanderbilt University Medical Center Parkinson neurologist, “No therapy…has bee shown to slow the progression of Parkinson’s.” The previous thinking was to wait until a patient had severe motor complications that could not be controlled with medications prior to considering DBS therapy. The new thinking, and research, is exploring benefits of DBS in earlier stages of Parkinson’s disease. In various reported cases, patients not only benefited from better control of their Parkinson motor symptoms but also had improved quality of life. Added advantages is that Parkinson patients treated earlier with DBS used less medications over an 18 month period, as shown in one small study. There are two studies currently looking at the benefits of early DBS therapy in Parkinson patients: EARLYSTIM is a French study and a smaller study at Vanderbilt University are in progress. It should be noted that Parkinson’s disease is a progressive neurodegenerative disorder. Even patients with DBS therapy do have progression of their symptoms. Memory loss can be a part of the Parkinson syndrome and is not helped by DBS therapy. DBS is not a substitute for optimal neurological and medication management of Parkinson symptoms. Dr. Kassicieh, at Sarasota Neurology, provides medical and neurological management for patients with Parkinson’s disease and brain stimulators. For more information click here.

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Many patients over the age of 65 complain of memory loss and are concerned they have dementia. Others attribute their memory loss to aging. While there is a very mild degree of memory loss associated with aging, it is usually not significant. For example, forgetting where you put your keys or where you parked your car. These are not serious memory problems. A more problematic degree of memory loss, while not dementia, is called Mild Cognitive Impairment (MCI). MCI is characterized by an increase level of forgetfulness. There are two primary types of MCI: (1) Amnestic MCI (2) Non-amnestic MCI. In patients affected with amnestic MCI, they have significant memory and recall difficulty. There is a stronger association with this type of MCI with Alzheimer’s disease. Non-amnestic MCI usually does not progress to Alzheimer’s disease but may go on to other types of dementia. The good news is that about fifty percent of all patient’s with MCI never progress to Alzheimer’s or any other dementia. MCI can also spontaneously improve and clear.

The American Academy of Neurology published criteria for the diagnosis of MCI: (1) Individuals reporting their awareness of memory difficulty – preferably confirmed by a spouse or child; (2) Measurable memory loss greater than would be expected for age; (3) Normal general thinking and reasoning skills; (4) Ability to perform routine daily activities. Frequently patients with MCI have specific areas in which they are having memory trouble whereas patients affected with dementia have more global memory difficulties. Also quite frequently, patients with dementia are unaware of having any memory problem at all.

Risk factors for MCI and mild memory loss include such things as high blood pressure, lower educational levels, lack of physical and mental activities and vascular disease. Vascular dementia is seen in patients that have had multiple small strokes. Abnormally low blood pressure, particularly in patients with significant brain vascular disease (hardening of the arteries) can be a cause of reversible memory loss. Depression can cause a condition of memory loss known as pseudo-dementia syndrome of depression. Fortunately this is treatable and the “memory loss” is reversible in this condition.

In those patients affected with MCI, they can go on to develop dementia, usually Alzheimer’s disease. The true incidence is difficult to measure and ranges between 27-65% depending on which study one reads. Some studies have shown that the use of memory loss medications such as donzepil (Aricept®) can help improve memory function and potentially slow the progression of memory loss. It should be noted that in patients over the age of 70, approximately 12% will have some degree of memory difficulty. This is highly variable from patient to patient.

In summary, if you have a sense that you have memory difficulty, do not attribute it to normal aging. Consider seeing a neurologist trained in evaluating memory disorders and Alzheimer’s disease. You have everything to gain by improving your quality of life.

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Seizures are the manifestation of uncontrolled electrical activity in the brain. Affected individuals show clinical symptoms of seizures with twitching or jerking of one side or their entire body. With this they can make gasping noises, turn blue in the face, bite their tongue or lose control of their bladder. These symptoms are charateristic of a grand mal seizure. During an epileptic attacks, the person is not responsive or aware of what is going on around them. Fortunately there is excellent treatment available to control seizures and in many cases, keep patients seizure free.

It is estimated that there are 2-3 million individuals in the United States who suffer from recurrent seizures (epilepsy.) Many of these people are neurologically intact with the cause of their seizures being unknown. It is estimated that up to 10 percent of the population will suffer a single seizure in their life time. This does not mean that they will go on to have recurrent seizures or epilepsy. The average lifetime risk of having recurrent seizures is 3 percent.

Risk of developing seizures include prior head injuries, alcohol or drug abuse, stroke, meningitis or other brain infections. Brain damage from trauma, surgery or tumors can also predispose to seizures. For anyone who has even a single seizure, they should see a neurologist for a complete evaluation. A minimum of screening lab work, an EEG (electroencephalogram) and MRI brain scan should be done. Of course a complete history and physical (neurological) exam is also required. One important point to remember is that a normal EEG does not exclude the possibility that a patient suffers from seizures. In fact, approximately 70 percent of patients with recurrent seizures will have a normal EEG at all times other than during the time when they are having a seizure.

Fortunately there are several excellent seizure preventing medications (anticonvulsants) available. For decades, Dilantin, Tegretol and Depakote were the mainstay in seizure treatment. In the 1990s, several new anticonvulsants received FDA approval. These included Felbatol, Topamax, Lamictal, Neurontin, Keppra and Zonegran. In 2005, the FDA approved Lyrica for treatment of seizures. Although highly effective in controlling and stopping seizures, the newer anticonvulsants are overall no more effective than the older agents. One benefit of the newer agents is that they do not require as much lab monitoring as the older agents. Some anticonvulsants, such as Lamictal, Neurontin and Lyrica require no lab monitoring.

In summary, patient with recurrent seizures (epilepsy) or for those that have had a single seizure but are at high risk for further seizures, there are a number of therapeutic options available to control their seizures and improve their quality of life. Many patients can have complete control of their seizures, meaning seizure free, with appropriate evaluation and treatment. Most neurologically intact individuals can lead normal lives with specific seizure care by a neurologist. This fact has been shown through many studies on seizures and is the foundation of evidence based medicine for seizure control. It is critical that they see a neurologist as soon as possible, after their first attack, so that proper evaluation and treatment can be started.

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Stroke occurs when a blood vessel in the brain becomes blocked or ruptures. The most common form of stroke is due to blockage of a blood vessel. Blood vessel blockage is caused by a condition known as
atherosclerosis, commonly known as “hardening of the arteries.” This is the most common type of stroke. Stroke is one of the three major leading causes of death in the United States. The other two are heart attack and cancer. Stroke is the leading cause of disability in the U.S. It is for this reason that it is much wiser to focus on stroke prevention in the first place rather than trying to limit the damage with stroke treatment after event has occurred. High blood pressure (hypertension) is the single biggest, treatable risk factor for stroke. In the 1970s, there was a push by the medical community to aggressively treat high blood pressure to lower the risk of stroke, premature heart disease and kidney failure. One cannot feel that their blood pressure is elevated but the damage to major body organs (heart, brain, kidneys) continues on. It is only when these organs start to fail or a stoke occurs, will it become apparent that a given individual may have hypertension. On occasion, patients with untreated hypertension may have headaches. Fortunately checking one’s own blood pressure is easy. This can be done at your doctor’s office, pharmacies or the local fire department. If you have high blood pressure with the top number greater than 150 or the lower number greater than 85, you need to see a physician for treatment. Fortunately there are many different types of medication to treat high blood pressure. Many patients can be successfully treated with a single drug, for mild hypertension. Individuals with moderate to more severe hypertension, multiple drug therapy may be necessary. With the aggressive push to treat high blood pressure, the rate of stroke in the United States has dropped dramatically over the past two decades. There is a class of blood pressure medication, the ACE inhibitors, that have been shown in well designed clinical studies to significantly reduce the risk of stroke independent of their ability to lower blood pressure. Current evidence based medicine strongly suggests that addition of an ACE inhibitor should be done in patients with high blood pressure, even if their blood pressure is adequately controlled on other agents. Ideal blood pressure range should be with the upper number (systolic) being less than 130 and the lower number (diastolic) less than 80.

It has been well known for several decades that aspirin thins out the blood. Cardiologists have used aspirin extensively for 30 years to lower the risk of having a heart attack. Aspirin slows down the formation of clots by blocking the clumping of platelets to form blood clots. In 1994 a hallmark study, the Antiplatelet Trialists’ Collaboration, was published demonstrating the clear benefit of aspirin in the prevention of stroke and transient ischemic attacks (TIA, “mini strokes”.) In 1998, the FDA approved labeling of aspirin for the prevention of TIA and stroke. Dosage recommendations in the range of 81-325 mg daily should be used. Unfortunately aspirin does not entirely prevent stroke or TIA from occurring. Other blood thinning agents can be used in patients who fail aspirin therapy. The other two agents are Plavix and Aggrenox. Either agent can be used in patients who have had a TIA or stroke while taking aspirin. In patients who have no history of heart disease, Aggrenox is the preferred agent. Plavix is preferred in those patients who have known coronary artery disease.

Lastly, high cholesterol has been implicated in the development of accelerated atherosclerosis. There have been studies that have shown some correlation of high cholesterol with the increased risk of having a stroke. Multiple, double-blind, placebo controlled studies have shown that the use of cholesterol lowering statin drugs for cholesterol reduction results in an average of a 27% overall secondary risk decrease in stroke. Studies are ongoing to show if statins may help in primary prevention of stroke and TIA. At this time, it is prudent to be on a statin drug, for cholesterol reduction. The currently available statins include: Lipitor, Zocor, Pravachol, Crestor or Mevacor if you have a cholesterol over 200. The marked benefit of this class of drugs on the reduction of stroke and cardiac events (35%) is dramatic and strongly supports more aggressive treatment for high cholesterol (hyperlipidemia.) The objective is to have a total cholesterol less than 180, good cholesterol (HDL) of greater than 50 and bad cholesterol (LDL) less than 100. A recent study published in the journal Stroke reported that discontinuing statin therapy in the year after a stroke is associated with a significant increase in the risk for death, even in the absence of heart disease.

Medications are not the only treatment for stroke prevention. Smoking is associated with a 2-3 times greater risk of stroke and bleeding in the brain. Smoking also contributes to the accelerated development of heart disease, emphysema and peripheral artery disease. Chantix is a new medication that received FDA approval to help stop smoking. Exercise is important in maintaining overall body conditioning and weight control. This in turn leads to an overall lowering of blood pressure and cholesterol. In summary, stroke prevention is much easier and cost effective than fixing the problem after someone has a stroke. This approach to stroke reduces mortality and disability for the entire United States population. The cost saving are in the hundreds of billions of dollars over stroke treatment. If you feel that you are at risk for stroke, contact a neurologist for evaluation and treatment.

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Botox (botulinum toxin Type A) has been available in the United States for clinical use since 1989. At that time it was approved by the FDA for treatment of eye and facial muscle spasm disorders, blepharospasm and hemifacial spasm respectively. Then in 2000 the FDA approved Myobloc (botulinum toxin Type B) for treatment of cervical dystonia, a condition of involuntary neck muscle spasm. The dystonias, as a class of muscle spasm disorders, are characterized by involuntary muscle spasms involving the muscles in the neck, face and extremities. The cause of the majority of these conditions is unknown. In some individuals, spasticity (tight muscles which cannot be relaxed, a form of dystonia) can result from stroke, traumatic brain or spinal cord injury or cerebral palsy.

Prior to the use of Botox, it was very difficult to treat muscle spasm disorders. Medications had side effects and surgery had limited benefit associated with the risk of complications. Botox opened an entirely new avenue to treat spasticity. The drug works by causing a chemical relaxation of muscles that are injected. Botox is highly selective in that it remains in the muscles that it is injected into. Patients with cervical dystonia have difficulty with their head pulling to one side of the other. They may also have their head pulling backward or forward. Not only is this condition painful, it also causes patients to have functional difficulty with activities such as driving, playing sports or even eating. In patients with limb dystonia, there is involuntary spasm of an arm, leg or both. This can cause difficulty with dressing, walking or even personal hygiene (if their hand is fisted up.) Botox (or Myobloc) can provide excellent relief of these symptoms thereby improving patients’ quality of life. For patients with severe muscle spasticity from stroke, Botox provides relief of the tight muscles allowing for greater ease in certain activities. It is important to note that Botox (or Myobloc) will not restore function of any limb affected by the stroke. What the treatment will do is provide increased comfort due to reducing pain from spasm and allow for improved ease in doing some daily activities.

Blepharospasm is characterized by involuntary blinking which can result in forced eye closure and functional blindness. Affected individuals may have difficulty driving or watching a movie because of this. Botox has been shown to be the single most effective treatment for this condition. Of all the muscle conditions treated with Botox, none respond as well as those patients affected with hemifacial spasm. This condition affects one side of the face and is characterized by spasm the facial muscles on that side. This can also result in a degree of functional blindness. While most conditions treated with Botox (or Myobloc) have a therapeutic effect for 2-3 months before requiring retreatment, patients with hemifacial spasm may not need retreatment for anywhere from 3-6 months.

For any patient considering receiving Botox or Myobloc, it is important to see a physician familiar with diagnosing and treating these uncommon movement disorders. These individuals are familiar with administration of Botox or Myobloc which will help to obtain optimum results from each treatment

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High cholesterol and triglyceride levels are at epidemic proportions in the United States. It is estimated that there are 30 million affected individuals with this condition but only about 10% are treated with medications. This is an unfortunate fact considering that vascular disease (heart disease, stroke) combined is the leading cause of death in the United States. Multiple clinical studies have shown the dramatic beneficial effects of the main class of cholesterol lowering drugs, the statins. The summary of these studies is that they provide a 25-35% secondary risk reduction in ischemic vascular events. The class of statins include: Zocor, Lipitor, Pravachol, Crestor and Mevacor. While highly effective in lowering total cholesterol as well as “bad cholesterol” and raising “good cholesterol” (LDL and HDL, respectively, these medications require lab monitoring for liver and muscle problems. Fortunately the incidence of severe side effects is low. More commonly, patients treated with these drugs can have muscle and joint pains. With proper treatment and monitoring, patient’s experience an over all improvement in health and marked reduction in their risk for having a stroke or heart attack. For every 1 million patients treated with one of these agents, 10,000 stroke and heart attacks are prevented, annually. The economic and personal benefits of this are staggering.

There are other non-medication ways that individuals can lower their cholesterol. The American Heart Association lists the benefits of taking fish oil supplements in cholesterol reduction. Other nutritional aids can include flax seed and limiting sugar intake. Of course regular, daily exercise, stop smoking and a healthy, low-fat diet are all important in controlling cholesterol levels and blood pressure.

In summary, one cannot “feel” elevated cholesterol levels. It is an insidious disease that causes a slow death by gradually blocking off arteries that carry blood to the vital organs of the body. If you are overweight, have diabetes, smoke or have a family history of these or high cholesterol, you should see you health care professional for further evaluation.

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