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Speaker A: Welcome to the Huberman Lab podcast, where we discuss science and science based tools for everyday life. I'm Andrew Huberman and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. My guest today is Doctor Gary Steinberg. Doctor Gary Steinberg is a medical doctor, PhD, professor... |
Speaker B: Thank you Andrew. Pleasure to be here. |
Speaker A: I have a lot of questions. I know people are interested in keeping their brains healthy, and sadly, things happen to the brain, sometimes as a consequence of aging, sometimes as a consequence of certain activities. Maybe you could just explain for us right off the bat what is a stroke? What is an aneurysm? W... |
Speaker B: Sure. So a stroke is like a heart attack of the brain. It involves disruption of blood flow to the brain, either in the form of a blocked vessel or, less likely, a hemorrhage. About 87% of strokes are due to a clot, either forming in the brain artery itself or forming closer to the heart, in the heart or in ... |
Speaker A: How do we know if we have clots residing in our body that could be dislodged? I know that some people, when they fly, wear compression socks. I know that some people have genetic mutations that affect clotting. I'll raise my hand here and I'll do a disclosure. I did some genetic testing. I am a heterozygote ... |
Speaker B: Sure. Well, you might not know. In many cases, you don't know, and that's the problem. You can have a predisposition, as you say, due to certain genes that are mutated or represented that predispose to clots. And those clots can occur on the arterial side or the venous side. The arterial side is what general... |
Speaker A: Oh, good. In my case, that feels fortunate. |
Speaker B: Exactly. You can develop some venous problems in the brain, which can cause a venous type stroke. That's much less common. And the way that causes a stroke is not lack of blood flow being delivered to the brain, but by having a clot in an important vein, the blood can't get out of the brain. It backs up and ... |
Speaker A: What are some things that impact clotting or excessive bleeding? My understanding is these factor five Leiden mutations are one example. The other is, let's say somebody takes, say, a blood thinning agent, like baby aspirin, or I told, and I'll have to check this. I'm sure people will say in the YouTube comm... |
Speaker B: Sure. So different kinds of drugs thin the blood, and they can predispose you to having a larger hemorrhage than you would if something bursts or if you fall and have some traumatic injury to your brain or anywhere in the body. In general, they don't cause a hemorrhage because they're fairly safe. But if the... |
Speaker A: Interesting. |
Speaker B: So they have other beneficial properties. So, again, for my patients, I often recommend they take a statin, even if they don't have high cholesterol. |
Speaker A: Interesting. |
Speaker B: And then hypertension is another risk factor for developing clots and arterial disease. |
Speaker A: When you say that smoking dramatically increases the risk of stroke, is that because of nicotine per se? Is it the vasoconstriction and blood pressure elevation that comes from nicotine itself? Or is there something about smoking, maybe even vaping? I don't know that the contaminants, the other chemicals in ... |
Speaker B: It's not just nicotine. Nicotine is one of the factors, but it's the other products that are produced by smoking that can have an effect. |
Speaker A: So, given that so many fewer, at least Americans, and I think worldwide, people are smoking less, are we seeing less stroke? |
Speaker B: Yes. The incidence of stroke is actually decreasing. It may be in part due to decreased smoking, but it also is in part due to other modifiable factors. So hypertension is much better treated now than it used to be. People take better care of themselves in terms of other lifestyle factors, so people exercise... |
Speaker A: What is the relationship between heart health and brain health as it relates to stroke? I would imagine that anything that's good for our heart is probably good for our brain, given the enormous amounts of blood and glucose that the brain requires to function normally. |
Speaker B: Yeah, it's a good point. In general, the things that are good for the heart are good for the brain. There are differences between the heart and the brain, but they both depend very much on blood flow. The brain's unique, though, because the brain represents only 2% of the body weight, yet it. It draws 15% of... |
Speaker A: Yeah. You've spent some time in the landscape of the brain. Yeah. It's clear that of all the tissues in the body, if you had to pick one tissue to remove one cubic millimeter of that tissue, that your brain, and probably the neural retina would be your least favorite choice, just given the deficits that can ... |
Speaker B: Right. And, of course, the brain also is what makes us human. |
Speaker A: Right. Speaking of which, if we take a little departure into neurosurgery itself, your specialty of all the years of. Of doing brain surgery, can you recall maybe one of the most incredible moments or days that allowed for some insight into how the brain works by virtue of, let's say, stimulating a given bra... |
Speaker B: Yeah. I mean, every patient is different, so I'm always learning, and that's why I still enjoy it, that it's a challenge. And you have to think quickly. It's nothing simply mechanical. But, for instance, a couple weeks ago, I had a patient who had a vascular malformation, which was located, we thought, right... |
Speaker A: Amazing. Yeah, it's remarkable to me how much can be done now with imaging, so visualizing the brain and being able to target a specific location. And you mentioned fiber optic cables. I've also heard of things like the gamma knife and lasers. So how much of neurosurgery nowadays is actually burrowing down t... |
Speaker B: Right. Neurosurgery is becoming much less invasive, and this is something that I really tried to push when I was chair of the department for 25 years at Stanford. So minimally invasive techniques include operating through the vessels. I don't do this myself, but my colleagues, some of whom are neurosurgeons,... |
Speaker A: Wow. |
Speaker B: Another form of noninvasive treatment that neurosurgeons use is called focused ultrasound. Again, you don't have to open the skull. It focuses sound waves on areas of the brain. We're using that to treat essential tremor or Parkinson's disease. It's starting to be used for treating tumors. So these are all a... |
Speaker A: Incredible. I should have asked this earlier, but TIA's transient ischemic attacks. I think most people assume or know that the symptoms of stroke include sudden weakness, maybe hemiparalysis of the face, confusion, slurring of the words. Of course, these symptoms can be the consequence of other things as we... |
Speaker B: Right. So a transient ischemic attack, or TIa, is a reversible stroke. It results in a temporary loss of function, such as inability to move, partial paralysis or complete paralysis. But then it resolves inability to speak, visual problems, double vision, blurred vision, loss of vision. It can cause slurred ... |
Speaker A: My understanding is that people can also have strokes in their spinal cord because spinal cord tissue is, after all, central nervous system tissue. I think most people don't realize this, but the tail end of the brain, the brainstem, as we were talking about before, essentially extends down the spinal column... |
Speaker B: Yeah, it's much less common than a stroke involving the brain, probably because there's less tissue involved. The spinal cord is supplied by an anterior spinal artery. That's an artery on this side and by two. |
Speaker A: So for those listening. Sorry. It would be on the stomach side. |
Speaker B: Of the body, and it's supplied by two arteries, posterior spinal, on the backside. So if there's an interruption to blood flow in any of those arteries, it can cause death of tissue in the spinal cord, and that would result in a neurologic deficit, depending on where it is. So if it occurred on the stomach s... |
Speaker A: I see, I should have asked this earlier, but is there any relationship between alcohol intake and the propensity for stroke or hemorrhage or any of these other things? |
Speaker B: Yeah, that's a good question. There is. The people who indulge or overindulge are at risk for developing stroke problems. So it's another contributory factor which can promote problems with the blood vessels clots, but also hemorrhage, so it can make the blood vessels more fragile. Another factor I see commo... |
Speaker A: And is that because those drugs tend to increase blood pressure during their use? |
Speaker B: It's because they damage the vessels and they also cause hypertension? Yes, it's both factors. So when I operate on these patients and looking at the vessels, they are rad, they're ragged, they're very thin, they're not normal vessels. They lack structural integrity. So it contributes to the development of p... |
Speaker A: So it sounds like the message is clear. Avoid cocaine use, avoid methamphetamine use, and avoid excessive alcohol intake if you want to avoid stroke. |
Speaker B: Right. And throw smoking in there, too. |
Speaker A: It's interesting because for a lot of years, there was so much discussion about red wine being good for heart health. Now it's debated. The moment I say that, people will send a bunch of studies that say yes. My stance on the more recent data is that if you had to pick, you'd drink less or not drink as oppos... |
Speaker B: Well, you know, this is interesting, and I'm always quite amazed at the way people change their behavior based on one study that comes out, even if it's a good study. So, yes, it used to be considered beneficial if you drank red wine. And then for a while, studies showed any wine was beneficial in moderation... |
Speaker A: Yeah, it's tricky. My read of the data, and here, I mean the data across multiple, certainly not every study, but multiple studies, is that zero to two drinks per week seems to be the range that everyone agrees is safe, at least for non alcoholic adults. And then once you get out past two drinks per week is ... |
Speaker B: Well, that was the prevailing theory until this year. And I don't know if you've kept up, but in the past few months, there have been several articles published saying, no alcohol is good. But then you have to balance that against the fact that alcohol, for many people, tends to relieve stress. If you're rel... |
Speaker A: Absolutely. I agree with you. I'm not heavy handed about the alcohol thing. I always just say, do as you wish, but know what you're doing. And I think many people who heard our podcast episode about alcohol, who stopped drinking alcohol or who elected to drink less, did, so I'm told, because they really didn... |
Speaker B: Exactly. |
Speaker A: I'd like to take a brief break and acknowledge our sponsor, ag one. By now, most of you have heard me tell my story about how I've been taking ag one once or twice a day every day since 2012. And indeed, that's true. I started taking ag one, and I still take ag one once or twice a day because it gives me vit... |
Speaker B: Yeah, it's a great question. And there's a lot of interesting concussion now. I got very involved in this back in the nineties cause I was the 49 ers neurosurgeon for a decade, from 1990 to 2000. |
Speaker A: How are they doing in that point? I remember the dynasty of the Eighties. The nineties are good. |
Speaker B: Oh, they were in super goal contention. In fact, I took care of Steve young. |
Speaker A: Yeah, he's a local guy. |
Speaker B: Yeah, Steve's a great guy and a really smart guy. In fact, he has a law degree from Brigham Young. Steve was quarterback then, and they were in Super bowl contention, and Steve had had some concussions. And I actually sent him back to play when he recovered. So you can examine someone and get a decent idea o... |
Speaker A: I see. To get a baseline? |
Speaker B: To get a baseline, of course, some of the players will game the system because they still don't want to be taken out. So they may try to perform not as well as they could on their eye tracking. Yeah, on their. |
Speaker A: I see. They throw the test. |
Speaker B: They throw the test. So their baseline is, I mean, you know, I don't think that's very common, but that's a way you can game the system. But as long as it's performed well, that's a very good way of detecting subtle problems with the brain. You're a vision scientist, so you understand how important all the c... |
Speaker A: Yeah. I'm always struck by when I see these newsreel highlights of a player goes down, they stay down and then they're helped up and everyone cheers and then they might hobble off, take a few moments, and then how are they gauging the decision to put the person back in? And the reason it's perplexing to me h... |
Speaker B: It is tricky, and I think we have better methods of. Even if you're talking about sports, on the sideline of doing testing, there are neurosurgeons there now who are part of the process. As far as recovering in general, it's good to not stress the brain, but total absence of sensory information, sensory depr... |
Speaker A: Just staying home in the dark with sunglasses on, also not a good idea. |
Speaker B: Exactly. So you want to make sure the brain still has input, but you don't want to overstress it when you're recovering from a concussion. |
Speaker A: Sounds like doing all the things to keep blood pressure relatively low, ldl cholesterol relatively low. So interesting what you said earlier, that statins might be vasculoprotective even in the absence of high cholesterol. |
Speaker B: Yeah, there's a lot of good evidence for that. In fact, some studies have suggested that taking statins reduces the risk of cognitive decline, including conditions like Alzheimer's. |
Speaker A: Interesting. I know that statins are a bit of a controversial topic among listeners because some people report, I think I have this right, that statins can give them a kind of a brain fog if they take the wrong one or excessive amount. Yeah, I'm not challenging what you're saying. |
Speaker B: No, no, no. It's. |
Speaker A: I just hear the shout in the comments section and I'm just, I don't take a statin, but my cholesterol is in check. But I'm hearing more and more about some of these benefits of statins. |
Speaker B: Yeah, yeah. And the information is still emerging for a traumatic brain injury in general, not a good idea to take an aspirin as opposed to a stroke or a. |
Speaker A: TIA, where you would want to take an aspirin. |
Speaker B: Right. Because if you have injuries, say you have a contusion to the brain and there's some traumatic damage, taking a blood thinner might cause that to worsen or cause a hemorrhage. |
Speaker A: What about caffeine? Is there any evidence that caffeine can increase stroke or ischemia? I like coffee and I like yerba mate tea, so I'd be reluctant to give it up, but I consume it in moderation. Is there any direct relationship there? |
Speaker B: I don't know any relationship unless you're taking so much that your blood pressure is sky high. |
Speaker A: My blood pressure tends to be lots. |
Speaker B: Of benefits, evidently, to caffeine. In terms of health. |
Speaker A: I agree with you there. I have a question about something that many people are starting to do now, which is to get exploratory MRI. I actually did one of these. I wasn't gifted one. I just decided to bite the bullet and pay for it is a whole body scan that put me in the tube, did an MRI. I get everything fro... |
Speaker B: Yeah. And people are getting total body scans. So I think there are benefits and risks involved. So the benefit is that you might pick up something that should be treated, like an early cancer or a large aneurysm in the brain, which would have a higher chance to bleed. But many times, and I see patients all ... |
Speaker A: Maybe we can talk about lifestyle factors, because I think anyone listening to this is going to think, I don't want a stroke. I don't want transient ischemic attack. I don't want hemorrhage, I don't want any of this stuff. And we already discussed a little bit about how what's good for your heart generally i... |
Speaker B: Well, I think it has to be individualized to some extent. And over time, the standards and the guidelines have changed. It used to be if your systolic blood pressure, that's the upper number, was under 100, 3130 or under, that was considered normal and would not lead to problems. Now, the guidelines suggest ... |
Speaker A: Like, I shouldn't have been overdoing exercise or overdoing everything. |
Speaker B: I was in my. |
Speaker A: I was a Stanford faculty member that does something. That was a joke, that among Stanford. |
Speaker B: I was 56, and I operated all day in two operating rooms. I got done early, it was in the spring, and I took a run up to the dish, and then I took a red eye to Houston for a meeting, and I emailed on the flight, got an hour or two asleep, went to the meeting, I was fine. It was a stroke meeting with a bunch o... |
Speaker A: That's clearly the bedrock of health. |
Speaker B: So I increased. I used to get three to 5 hours sleep a night. Now I get seven to nine if I can do it, cut back on coffee, on caffeine, and I don't push myself to exercise like I used to. If I'm feeling a little fatigued, I'm on an antihypertensive agent. But I actually don't take it every day because for me ... |
Speaker A: I'm learning. I mean, this is very interesting. I tend to have low blood pressure. It sort of runs in my family to have low blood pressure. I can definitely relate to the hard driving ambition phenotype. I think it's worth people hearing this because it's characteristic of a lot of people in high intensity p... |
Speaker B: Well, I would recommend they take their blood pressure. So you want to try to correlate any symptoms you're having with vital signs that you modify. So take your blood pressure if you're feeling faint, if it's low, one thing you can do easily is to hydrate. That was something else. I used to not drink much. ... |
Speaker A: I can imagine that'd be pretty uncomfortable. I don't want to be the patient that you're operating on when you have to go use the bathroom. |
Speaker B: Yeah. So now and then I'll reveal that I had a kidney stone, which is common among surgeons. This was a decade ago, and since then, I hydrate all the time. So I hydrate to the point that my urine is crystal clear all the. |
Speaker A: Time, and that helps with some of the brain clarity. So, interesting. I've done a little bit of work with people in the special operations community, and I think people hear about them and they think, oh, you know, what's the magic potion that they're taking? What are they doing? And they do a number of very... |
Speaker B: I'm skeptical. And I used to dehydrate. I felt better dehydrated and fit. But as I've matured, I think it's very, very important for your blood pressure, for your general health, and for your kidneys. |
Speaker A: Yeah, you mentioned sleep. Is there a relationship between sleep deprivation and stroke risk? |
Speaker B: That's a great question. There's, interestingly, strokes occur more commonly during sleep. It's not known why. One theory is that it's related to circadian rhythms. I don't know if there's a relationship between sleep deprivation and stroke. |
Speaker A: I'd like to take a brief break and acknowledge one of our sponsors element. Element is an electrolyte drink that has everything you need. That means the electrolyte, sodium, magnesium and potassium in the correct amounts and ratios and nothing you dont which means no sugar. Now, I and others on this podcast ... |
Speaker B: Ended up with a dissection of her artery. |
Speaker A: Right. And something had happened, and she had essentially a stroke. And so I share both these stories to make very clear that I have nothing against chiropractors. But I think, like any health practitioners, they come in a range of talents. And this was really, like, for me, an alarm. And I decided at that ... |
Speaker B: It's a dissection of an artery, either the vertebral artery in the back or the carotid artery up closer in the front. |
Speaker A: So no cutting. When you say dissection, they're basically making an adjustment. |
Speaker B: Yeah, well, what happens is, and I agree with. We're on the same page, I recommend patients, if they're gonna have chiropractory, not to have manipulation of their neck. Cause that's what occurs. It's not common, but I see it. We see it. What happens is the artery is damaged. The manipulation of moving the b... |
Speaker A: Yikes. And there's no way to know whether or not this is going to happen. |
Speaker B: No. That's why I recommend not having neck manipulation by a chiropractor, even if it's rare. It's so devastating when it occurs that, personally, I would avoid that. |
Speaker A: Yes. I tell the chiropractor, stay away from anything above the shoulders, please. And then the back work has been beneficial. Again, these exercises, perhaps the most beneficial thing about it, as long as we're there. I realize it's a bit of a niche condition, but what about hanging upside down? I had one o... |
Speaker B: No evidence that it's bad. |
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