Rania Habib, MD, DDS (Host): The CDC estimates that every 40 seconds, a person in the U.S. suffers a stroke. Long term disability is decreased when patients receive care within the first three hours of their first symptoms, so it's important for healthcare workers to stay up to date on acute strokes. Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm your host, Dr. Rania Habib. Joining me today is Dr. Russell Cerejo, an Interventional Neurologist at AHN Neurology. He is here to discuss acute stroke therapy, including the use of tenecteplase, expanding indications for large core strokes, and managing posterior circulation strokes.

He also delves into strokes in the young, covering spontaneous cervical arterial dissections and reversible cerebral vasoconstriction syndrome. Welcome to the podcast, Dr. Cerejo. It's an honor to have you with us today to discuss this very important topic.

Russell Cerejo, MD: It's a pleasure to be here.

Host: So let's begin with a short summary of the AHN Stroke Program.

Russell Cerejo, MD: So the AHN Stroke Program was developed and established and has been a comprehensive stroke center since 2012. We have the hub and a spoke system. The hub system is the flagship hospital, which is Allegheny General Hospital, and we have over 20 sites that are the spoke sites. We have 10 hospitals that are part of the AHN system, and we do partner with other hospitals that are not part of AHN, but do work with us through our telestroke program.

We provide both acute care as well as follow up care for stroke to the patients in the Western Pennsylvania region.

Host: That's fantastic. I love the fact that you have this big catch all system where you're able to treat all those acute stroke program patients, but then also you have followup for them, which is very important.

Russell Cerejo, MD: Yes, and we do follow up with not only our physicians, but we also have a stroke navigator program that follows all of our patients throughout their post acute phase and throughout their recovery.

Host: That's fantastic. Now we know that outcomes improve when care is provided within those first three to four and a half vital hours after the first stroke symptom. Could you provide updates on acute stroke therapy?

Russell Cerejo, MD: So acute stroke therapy has come a long way. Since the first positive trial for IV tPA, which was back in 1995, that was approved for three hours; there have been more studies since then that have shown that IV thrombolysis can be used up to four and a half hours with IV tPA.

There is also an increasing body of literature supporting mechanical thrombectomy or catheter directed procedures for acute stroke therapy. And the most recent update with stroke therapy has been with the use of tenecteplase.

Host: Now, as you mentioned, historically, tPA was the first medication of choice for IV thrombolysis for acute strokes. You did mention the new medication, tenecteplase. What is tenecteplase and what are the advantages of using it compared to tPA?

Russell Cerejo, MD: Tenecteplase is a modified version of tPA, or alteplase, and tenecteplase has a better affinity for fibrin and works a little bit longer in the body. The other advantage of tenecteplase is instead of a drip, it is given as an IV bolus. So patients can be transported easily from one hospital system to another. And the efficacy of tenecteplase is a little bit better than IV tPA.

Host: I know that we focused on the advantages. Are there any disadvantages of tenecteplase when compared to traditional tPA?

Russell Cerejo, MD: So in the studies, tenecteplase is shown to be non inferior to tPA and the bleeding risks are, almost equal or even lesser.

Host: Dr. Cerejo, when you're deciding which medication to put the patient on, how do you make that decision?

Russell Cerejo, MD: So currently the AHA guidelines state that we could use IV tPA for all patients and tenecteplase can be used in patients who have a large vessel occlusion, but as there is more and more growing evidence that tenecteplase is easier and very effective, most centers are going towards giving tenecteplase in place of tPA, and it's almost replacing tPA as time goes by.

Host: Okay. So I know that you said it's replacing tPA. When would you choose tPA then over tenecteplase? Is there really an indication or are most people switching to tenecteplase?

hmm,

Russell Cerejo, MD: I think most people are now switching to tenecteplase given the ease of administration and the efficacy of the medication but if you don't have tenecteplase or the institution does not have tenecteplase you can still use IV tPA.

Host: Okay, wonderful. Now let's move on to endovascular therapy. Can you give us some updates on the advantages of endovascular therapy when compared to IV thrombolysis?

Russell Cerejo, MD: One of the drawbacks of IV thrombolysis is some of these large strokes which are caused by large blood vessels blocked in the brain, can be very hard to break off by the IV thrombolysis, either tenecteplase or tPA. And in those cases, doing mechanical thrombectomy may be beneficial in addition to the IV thrombolysis.

As we know, time is brain and the faster we can open up these blood vessels, the better it is. And even though IV tPA and tenecteplase are very effective in opening up these blood vessels, sometimes, some patients, it may not open up. And in those cases, especially using mechanical thrombectomy to open up these blood vessels can be beneficial.

Mechanical thrombectomy has also come a long way since its initial trials. Back in 2015, most of the trials showed positive outcomes. And since then, the field has expanded.

Host: How does endovascular therapy aid in the including the large core strokes?

Russell Cerejo, MD: So initial studies that looked at mechanical thrombectomy for acute strokes with large vessel occlusions only selected patients who had a small stroke and a large salvageable brain, or what we call penumbra, and it is definitely beneficial for those. And then as the technology has become standard of care, the scientific community has kind of tried to push the envelope to see how more can we help the patient.

And so in recent studies that were done using patients with a large core or a big stroke that is in its early phases, it's still forming; there's been benefit of doing thrombectomy compared to not doing thrombectomy in patients with these large cores. So there's a lot of benefit of doing this acute stroke therapy with catheter based procedures for the patients with even a large stroke.

Host: That's fantastic. Now let's also focus on posterior circulation strokes. When a patient suffers one of these, what is the ideal therapy? Is it endovascular therapy, IV thrombolysis, or is it a combination of both?

Russell Cerejo, MD: So usually it's a combination of both. IV thrombolysis has been approved for strokes of either the anterior and the posterior circulation. However, there was not much evidence supporting posterior circulation thrombectomies because most of the early studies focused on anterior circulation. However, there are now studies that have shown the benefit of endovascular therapy in posterior circulation strokes.

And these strokes can be very devastating because they can affect the basilar artery, the vertebral arteries, and even a small stroke in the posterior circulation can be very disabling. So these are almost one of the most feared kinds of strokes that someone can have in the brain. And so trying to help these patients the best we can with either IV thrombolysis and or mechanical thrombectomy is very beneficial.

Host: Absolutely. So when you're looking at a patient to decide whether or not they are a candidate for endovascular therapy, how do you make that determination?

Russell Cerejo, MD: We do take a few things into consideration. First is the time of onset. Most therapy with endovascular can be done up to 24 hours from the symptom onset of the last known well. However, there is always benefit of doing the therapy as soon as possible because the longer we wait, there is more brain damage going on every minute.

Having said that, we do assess to see how much of the brain is already affected and what is salvageable. But as we know, even with a decent size of the brain being affected, we are still able to help these patients with mechanical thrombectomy.

Host: And overall, when you look at outcome data of IV thrombolysis versus endovascular therapy, or the combination, what has the better outcomes and is it specific to the type of stroke that they have?

Russell Cerejo, MD: So for large vessel strokes or where these big blood vessels in the brain are blocked, IV thrombolysis has helped, but a combination of IV thrombolysis and mechanical thrombectomy is always much superior. And today it's almost standard of care to provide IV thrombolysis as well as mechanical thrombectomy for patients who are eligible with a large vessel occlusion.

Host: And I know a bunch of our listeners are probably wondering what is involved in the mechanical thrombolysis?

Russell Cerejo, MD: So in mechanical, we take catheters from the groin in a vessel or from the radial artery in the wrist and take these catheters and we snake the catheters from inside the blood vessel all the way up to the brain. And then we use different devices like a stent device on a wire, or we can just use a big bore catheter and connect it to a suction device and suck out the clot.

Host: Let's move on to talk a little bit about strokes in the young. So the CDC now estimates that the older patients stroke risk is actually decreasing, but it's increasing in patients that are younger. Why is that trend occurring, do you think?

Russell Cerejo, MD: That is correct. And approximately 10 percent of all strokes occur in patients between 18 to 50 years of age. And the rates of hospitalization have doubled since 1995. One of the thought processes of this increase has been an increase in the prevalence of stroke risk factors, like hypertension, diabetes, hyperlipidemia, tobacco use, and then lack of diet and exercise. Also stress may play a part in this.

Host: When we talk about strokes in the young, we know that one of the causes is spontaneous cervical artery dissections. Could you elaborate on that?

Russell Cerejo, MD: Spontaneous cervical artery dissections are basically a tear in the inner layer of the blood vessel and this can present with stroke like symptoms or stroke as the presenting symptoms. Oftentimes, it may just present with, you know, a very bad headache, but there are a few patients who may present with acute stroke symptoms.

And these happen to occur mainly in the younger population and is a big cause of stroke in the young population.

Host: Is there any way to prevent cervical arterial dissection? I know in the name it's spontaneous, but is there any way that patients can help prevent it?

Russell Cerejo, MD: So there is no direct way to prevent a spontaneous dissection as the name suggests, it's spontaneous. However, there are certain risk factors that may make patients more prone to having spontaneous cervical artery dissections or vertebral artery dissections like fibromuscular dysplasia or some kind of connective tissue disorders.

And so I think kind of being aware of that is important. Sometimes for these patients who have these kind of risk factors, maybe avoiding neck manipulation, activities that would predispose them to injury of the blood vessels may be beneficial.

Host: Now another cause of stroke in the young is reversible cerebral vasoconstriction syndrome. Could you give our audience just an overview of what that is?

Russell Cerejo, MD: Yes, so reversible cerebral vasoconstriction syndrome or RCVS has been there for a while, but we've known a lot more about this disease condition over the last probably 20 years. And what we have understood is that we don't exactly know what brings this on. However, there are certain factors that can be associated with.

So it is commonly seen in patients after pregnancy, in the postpartum period, it can be associated with certain medications like nasal spray stimulants or stimulant medications like amphetamines or sometimes even antidepressant medications like selective serotonin reuptake inhibitors. And what these can, these patients may present with often is just a very bad headache, but oftentimes they can present with strokes or bleeding in the brain. And the stroke can be the first presenting symptom for these patients.

Host: Thank you for providing that overview. It's really important for us to understand that. Now, you've done a wonderful job of giving us a summary of the AHN Stroke Program, updating us on the acute stroke therapy, and then discussing strokes in the younger population. What take home message would you like to leave with the audience, Dr. Cerejo?

Russell Cerejo, MD: I think the biggest take home message is that time is brain. The earlier we can intervene for patients presenting with acute stroke, the better outcomes we can have. We also have to be very cognizant about the signs and symptoms of the stroke. And so a common acronym is BEFAST, which stands for B for balance, E for eyes, F for face, A for arm, S for speech. And so any issues with balance, eyes, speech, face, droopiness, or arm weakness, you want to call 911. And that's one of the things we always harp on that please call 911. Don't ask your loved ones to take you to the hospital because the triage EMS providers can basically take you to the closest stroke ready hospital. And that's the key part here.

Host: Absolutely. And obviously they want to take the patient to a stroke center like yours at AHN to make sure that they can have the correct follow up and care. So thank you for providing this wonderful overview.

Russell Cerejo, MD: Thank you for having me. It's a pleasure to be here.

Host: Once again, that was Dr. Russell Cerejo, an Interventional Neurologist at AHN Neurology. I'm your host, Dr. Rania Habib, wishing you well. Thank you for listening to this edition of AHN MedTalks. To learn more, or to refer a patient, please call 844-MD REFER. That's 844-M-D-R-E-F-E-R, or visit ahn.org.