Dr. Maxim Mokin discusses a new approach to acute stroke treatment. Listen in as he reviews available ischemic stroke treatments, discusses the evolution of stroke therapies and explains the role of effective recanalization in stroke.
Visit cme.tgh.org for other CME opportunities, including live webinars, on-demand videos, and local events offered to you by Tampa General Hospital.
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Makin Mokin, MD: Consultant for Medtronic and Steering (consulting) and Other financial or material support for EMBOLIZE trail (committee).
Target Audience: all physicians
Release Date: June 14th, 2022
Expiration Date: June 14th, 2023
Claim CME/CEU Credit for this episode here: https://cmetracker.net/USF/Publisher?page=pubOpen#/getCertificate/352829
Visit cme.tgh.org for other CME opportunities, including live webinars, on-demand videos and local events offered to you by Tampa General Hospital.
Selected Podcast
Emerging Interventional Approaches in Acute Stroke Treatment
Featuring:
Maxim Mokin, MD
Maxim Mokin, MD is an Associate Professor of Neurosurgery and Neurology, USF Health.
Transcription:
Scott Webb (Host): Strokes that result from large vessel occlusion or LVO can be challenging and require the expertise of a multidisciplinary team at a comprehensive stroke center to ensure the best outcomes for patients. And joining me today is Dr. Maxim Mokin. He's a Neurologist at Tampa General Hospital, and we're going to discuss emerging interventional approaches in acute stroke treatment.
I'm Scott Webb and welcome to MD cast by Tampa general hospital. I go to listening location for specialized physician to position content and a valuable learning tool for world-class healthcare. So doctor, thanks so much for your time today. We're speaking with other doctors, of course, and this is an interesting topic LVO or large vessel occlusion.
So as we get rolling here, what is a stroke from large vessel occlusion?
Maxim Mokin, MD (Guest): So, I'm a Neurologist by training and therefore this topic is very dear to my heart. When we talk about strokes, mainly we assume these are ischemic strokes, meaning that there is a cutoff of blood flow to the region in the brain. A large vessel occlusion stroke essentially implies that there is a major region in the brain that is occluded. So it's a large artery or a branch of a large artery that is blocked by a clot. Or sometimes we refer to this as an embolus.
Host: And Doctor, how do lVO strokes present?
Dr. Mokin: So strokes come in a variety of different clinical presentations. Typically to simplify it is that when symptoms of stroke are very severe or there are multiple symptoms present, in the same patient, we suspect that a large territory of the brain is being affected. I'll give you a couple of examples.
What do we call a mini stroke is something that comes and goes. A minor stroke would be someone who just is experiencing the facial droop, or maybe a little bit of a hand numbness. A major stroke from a large vessel occlusion is an emergency. It's a catastrophe. Somebody who collapses and is unable to move his or her right or left side of the body completely, or somebody who just stares at you and is unable to pronounce any words.
Another presentation in, in a stroke in the back of the brain is when the patient could go into a coma. So, these are very dramatic presentations and they imply that a large territory of the brain is suffering.
Host: Yeah, I see what you mean. And definitely emergency situations. Now let's have you go through, what are the latest treatment options for acute stroke?
Dr. Mokin: Let me try to summarize what scientists and doctors have been able to achieve over the last 25, 30 years or so. So, the first major breakthrough occurred in 1995. That is when, an NIH sponsored clinical trial was first published in the United States. And that led to approval of a blood medication that could be given through an IV, a clot-buster medication and it would dissolve clots. And since 1995, this treatment has been widely available and we still use it to this day. More recently, about seven or eight years ago, newer treatments called thrombectomy's also have proven to be highly effective. Unlike the intravenous medication that is just given through an IV, endovascular procedures are done by using small, soft catheters that are put through an artery in the arm or in the leg, and with the use of x-rays, these devices are carefully navigated all the way into the brain. The doctor is trying to visualize which vessel or which branch is occluded, and then try to capture and remove those clots to restore the blood flow. The main limitation of strokes with large clots is that the intravenous medications are not always effective.
Most often they're not effective simply because the clot is so large, the medication is not able to lyse it in time, to break it down in time. So these newer approaches with catheters, they mechanically remove the clot. And when it's done very quickly and effectively, that provides the best chance for a patient to recover his or her function.
Host: Yeah. And I know time is of the essence, right? They say time is brain, right. And with heart time is, is heart. So when we're talking about the brain and strokes, you know, time is really of the essence. So, I want to have you talk about the differences between primary and comprehensive stroke centers.
Dr. Mokin: This is a concept that emerged quite a few years ago. And essentially there is tens of thousands of different hospitals in the United States alone, that can deal with stroke patients. It's the level of treatment and that these hospitals are able to provide and that implies having certain specialists, having certain equipment, having certain dedicated units. Treating stroke is a team effort. So imagine a patient with a major stroke comes to the hospital. In order, as you rightfully mentioned, to provide the best possible care in the timely fashion, goal number one is to diagnose and recognize stroke correctly. Very quickly. Make sure that the physicians know what type of stroke we're dealing with. So it requires the right imaging equipment. Second, you have to have the right specialist. So, it's a stroke neurologist who would give the intravenous medication. It's in your interventional team that sometimes includes a neurologist or radiologist or neurosurgeon or all of the above to treat those strokes. After the treatment is done, ideally, the patient needs to be observed in an intensive care unit with a neuro intensivist who specializes in dealing with these types of strokes. So, all of these are typically available in comprehensive stroke centers. That's why the name comprehensive comes from. The hospitals that are only capable of giving one type of treatment, mainly intravenous thromoblysis, these are typically primary stroke centers.
Host: And you mentioned this earlier. But maybe have you go back over, what are the benefits of ZOOM catheters?
Dr. Mokin: ZOOM catheter is one of the most recent types of thrombectomy devices that have become available. The two main types of treatments we use these days to extract these clots are either special types of stents that grab the clot and we remove the clot with a stent, thus the names stent retriever, and the second main type is using a large diameter. We call them large bore catheters that we try to advance all the way to the clot. In the past, this catheter it used to be rather stiff. So it was quite challenging for us to navigate those catheters all the way into the brain. Remember the vessels are very small. They make multiple turns. So, now we have catheters that are softer, easier for us to navigate. And frankly having devices that require less effort, that make it safer for a patient to perform the procedure, reduce time and more effectively capture the clot, lead to the better chance of having a fast and successful procedure, which is extremely important for a better chance of recovery.
So, the ZOOM aspiration catheter is just an example of one of the latest technological advances that we have currently at our hospital.
Host: Yeah, there have been so many advances. And as we wrap up here and this has been a really educational. What are your takeaways when it comes to LVO, the latest, you know, work that's being done at Tampa General Hospital and when you think it would be appropriate or when you'd like other physicians to refer to you and your team at Tampa General?
Dr. Mokin: We We treat a variety of patients, with different types of strokes at Tampa General Hospital. I think what distinguishes our teaching hospital from other surrounding places is that because we're a university based practice, we are able to offer a variety of breakthrough treatments that could be the most recent, the most advanced devices to extract clots, such as the ZOOM aspiration catheters.
There's a few other ones that we currently evaluate as a part of studies because we hope, we believe that these can lead to better outcomes. There is other treatments that we're able to offer that quite frankly, very few places in the country have available. Examples could be stem cell therapy for patients who already had a stroke or for patients who are having strokes.
We have capabilities of treating patients with what's called hemorrhagic stroke. So, when there is a rupture or leakage of blood from the brain, and we have several trials of minimal invasive approaches, for these patients. And these are typically available to everybody else years later. When hospital and the university like ours, have this studies completed, then it gets, approved by all the regulatory committees. So, this is a very time-consuming process. So, it allows us to offer those treatments when appropriate, of course, way ahead of other hospitals.
Host: Well Doctor, thanks so much for your time and expertise today. This has been really educational and I'm sure it has been for other physicians as well, discussing the benefits for patients, the benefits for providers to refer to Tampa General Hospital and all the benefits to Tampa General Hospital. So thanks so much. And you stay well.
Dr. Mokin: All right. Thank you. It was a pleasure.
Host: That's Dr. Maxim Mokin. He's a Neurologist at Tampa General Hospital.
Scott Webb (Host): And thank you for listening to MD cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars on demand videos and local events offered by Tampa general hospital.
Please visit cme.tgh.org. Thanks for listening. I'm Scott Webb stay well.
Scott Webb (Host): Strokes that result from large vessel occlusion or LVO can be challenging and require the expertise of a multidisciplinary team at a comprehensive stroke center to ensure the best outcomes for patients. And joining me today is Dr. Maxim Mokin. He's a Neurologist at Tampa General Hospital, and we're going to discuss emerging interventional approaches in acute stroke treatment.
I'm Scott Webb and welcome to MD cast by Tampa general hospital. I go to listening location for specialized physician to position content and a valuable learning tool for world-class healthcare. So doctor, thanks so much for your time today. We're speaking with other doctors, of course, and this is an interesting topic LVO or large vessel occlusion.
So as we get rolling here, what is a stroke from large vessel occlusion?
Maxim Mokin, MD (Guest): So, I'm a Neurologist by training and therefore this topic is very dear to my heart. When we talk about strokes, mainly we assume these are ischemic strokes, meaning that there is a cutoff of blood flow to the region in the brain. A large vessel occlusion stroke essentially implies that there is a major region in the brain that is occluded. So it's a large artery or a branch of a large artery that is blocked by a clot. Or sometimes we refer to this as an embolus.
Host: And Doctor, how do lVO strokes present?
Dr. Mokin: So strokes come in a variety of different clinical presentations. Typically to simplify it is that when symptoms of stroke are very severe or there are multiple symptoms present, in the same patient, we suspect that a large territory of the brain is being affected. I'll give you a couple of examples.
What do we call a mini stroke is something that comes and goes. A minor stroke would be someone who just is experiencing the facial droop, or maybe a little bit of a hand numbness. A major stroke from a large vessel occlusion is an emergency. It's a catastrophe. Somebody who collapses and is unable to move his or her right or left side of the body completely, or somebody who just stares at you and is unable to pronounce any words.
Another presentation in, in a stroke in the back of the brain is when the patient could go into a coma. So, these are very dramatic presentations and they imply that a large territory of the brain is suffering.
Host: Yeah, I see what you mean. And definitely emergency situations. Now let's have you go through, what are the latest treatment options for acute stroke?
Dr. Mokin: Let me try to summarize what scientists and doctors have been able to achieve over the last 25, 30 years or so. So, the first major breakthrough occurred in 1995. That is when, an NIH sponsored clinical trial was first published in the United States. And that led to approval of a blood medication that could be given through an IV, a clot-buster medication and it would dissolve clots. And since 1995, this treatment has been widely available and we still use it to this day. More recently, about seven or eight years ago, newer treatments called thrombectomy's also have proven to be highly effective. Unlike the intravenous medication that is just given through an IV, endovascular procedures are done by using small, soft catheters that are put through an artery in the arm or in the leg, and with the use of x-rays, these devices are carefully navigated all the way into the brain. The doctor is trying to visualize which vessel or which branch is occluded, and then try to capture and remove those clots to restore the blood flow. The main limitation of strokes with large clots is that the intravenous medications are not always effective.
Most often they're not effective simply because the clot is so large, the medication is not able to lyse it in time, to break it down in time. So these newer approaches with catheters, they mechanically remove the clot. And when it's done very quickly and effectively, that provides the best chance for a patient to recover his or her function.
Host: Yeah. And I know time is of the essence, right? They say time is brain, right. And with heart time is, is heart. So when we're talking about the brain and strokes, you know, time is really of the essence. So, I want to have you talk about the differences between primary and comprehensive stroke centers.
Dr. Mokin: This is a concept that emerged quite a few years ago. And essentially there is tens of thousands of different hospitals in the United States alone, that can deal with stroke patients. It's the level of treatment and that these hospitals are able to provide and that implies having certain specialists, having certain equipment, having certain dedicated units. Treating stroke is a team effort. So imagine a patient with a major stroke comes to the hospital. In order, as you rightfully mentioned, to provide the best possible care in the timely fashion, goal number one is to diagnose and recognize stroke correctly. Very quickly. Make sure that the physicians know what type of stroke we're dealing with. So it requires the right imaging equipment. Second, you have to have the right specialist. So, it's a stroke neurologist who would give the intravenous medication. It's in your interventional team that sometimes includes a neurologist or radiologist or neurosurgeon or all of the above to treat those strokes. After the treatment is done, ideally, the patient needs to be observed in an intensive care unit with a neuro intensivist who specializes in dealing with these types of strokes. So, all of these are typically available in comprehensive stroke centers. That's why the name comprehensive comes from. The hospitals that are only capable of giving one type of treatment, mainly intravenous thromoblysis, these are typically primary stroke centers.
Host: And you mentioned this earlier. But maybe have you go back over, what are the benefits of ZOOM catheters?
Dr. Mokin: ZOOM catheter is one of the most recent types of thrombectomy devices that have become available. The two main types of treatments we use these days to extract these clots are either special types of stents that grab the clot and we remove the clot with a stent, thus the names stent retriever, and the second main type is using a large diameter. We call them large bore catheters that we try to advance all the way to the clot. In the past, this catheter it used to be rather stiff. So it was quite challenging for us to navigate those catheters all the way into the brain. Remember the vessels are very small. They make multiple turns. So, now we have catheters that are softer, easier for us to navigate. And frankly having devices that require less effort, that make it safer for a patient to perform the procedure, reduce time and more effectively capture the clot, lead to the better chance of having a fast and successful procedure, which is extremely important for a better chance of recovery.
So, the ZOOM aspiration catheter is just an example of one of the latest technological advances that we have currently at our hospital.
Host: Yeah, there have been so many advances. And as we wrap up here and this has been a really educational. What are your takeaways when it comes to LVO, the latest, you know, work that's being done at Tampa General Hospital and when you think it would be appropriate or when you'd like other physicians to refer to you and your team at Tampa General?
Dr. Mokin: We We treat a variety of patients, with different types of strokes at Tampa General Hospital. I think what distinguishes our teaching hospital from other surrounding places is that because we're a university based practice, we are able to offer a variety of breakthrough treatments that could be the most recent, the most advanced devices to extract clots, such as the ZOOM aspiration catheters.
There's a few other ones that we currently evaluate as a part of studies because we hope, we believe that these can lead to better outcomes. There is other treatments that we're able to offer that quite frankly, very few places in the country have available. Examples could be stem cell therapy for patients who already had a stroke or for patients who are having strokes.
We have capabilities of treating patients with what's called hemorrhagic stroke. So, when there is a rupture or leakage of blood from the brain, and we have several trials of minimal invasive approaches, for these patients. And these are typically available to everybody else years later. When hospital and the university like ours, have this studies completed, then it gets, approved by all the regulatory committees. So, this is a very time-consuming process. So, it allows us to offer those treatments when appropriate, of course, way ahead of other hospitals.
Host: Well Doctor, thanks so much for your time and expertise today. This has been really educational and I'm sure it has been for other physicians as well, discussing the benefits for patients, the benefits for providers to refer to Tampa General Hospital and all the benefits to Tampa General Hospital. So thanks so much. And you stay well.
Dr. Mokin: All right. Thank you. It was a pleasure.
Host: That's Dr. Maxim Mokin. He's a Neurologist at Tampa General Hospital.
Scott Webb (Host): And thank you for listening to MD cast by Tampa general hospital, which is available on all major streaming services for free to collect your CME. Please click on the link in the description for other CME opportunities, including live webinars on demand videos and local events offered by Tampa general hospital.
Please visit cme.tgh.org. Thanks for listening. I'm Scott Webb stay well.