Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And joining me today to highlight cryptogenic stroke in the young is Dr. Natalie Cheng. She's an Associate Attending Neurologist at New York-Presbyterian Hospital Weill Cornell Medical Center and an Assistant Professor of Clinical Neurology at Weill Cornell Medical College-Cornell University.

Dr. Cheng, thank you so much for joining us today. I'd like you to start for the listeners by explaining what a cryptogenic stroke is. How does it differ from the other types of strokes, hemorrhagic, ischemic? We hear about these names being bandied about. What does cryptogenic mean?

Dr. Natalie Cheng: Thanks for having me, Melanie. So, a stroke is by definition any interruption in blood flow to the nervous system, which includes the brain and the spinal cord. And for today, we're going to focus mainly on ischemic stroke, which is the most common type. It makes up 87% of strokes. The other type is hemorrhagic or bleeding types of strokes, and those make up about 13%.

When we talk about cryptogenic stroke, that means that it's an ischemic stroke whose cause has not been clearly identified despite completing a thorough stroke workup. And when we think about the potential causes of stroke, our diagnostic workup is guided by the most common causes, which we stroke neurologists think about in five different categories.

The first is large artery atherosclerosis, where there is buildup of plaque in a large artery that is significant enough to impair blood flow, and we can look for that through a few modalities. We can do an MR angiogram, a CT angiogram, or an ultrasound of the carotid arteries to look for any narrowings or blockages in the head or neck arteries.

The second category is cardioembolic, meaning a blood clot formed in the heart, and then that clot traveled to block blood flow to the brain. And when we look at the heart for a potential source of stroke, we will look at both the rhythm of the heart to look for an arrhythmia called atrial fibrillation. And we'll also do an echocardiogram, which is an ultrasound of the heart to look for any potential structural heart issues.

Next, the third category of stroke is called small vessel ischemia, when one of the very small branches of an artery gets blocked off due to buildup of plaque in those small arteries. And usually, folks who have high blood pressure, high cholesterol, or diabetes are at the highest risk for this. So in their workup, we'll also check a lipid panel and a hemoglobin A1c to see how well those risk factors are controlled.

And then, second to last is other determined causes. So, some people can have an ischemic stroke from a tear in the wall of an artery from an underlying blood clotting disorder or there's some complication during a surgery where the blood pressure drops very low. And that's a separate category.

And lastly, if a patient does not clearly have one of these above causes of stroke, then we'll categorize them as cryptogenic. And this makes up of about a third of all ischemic strokes.

Melanie Cole, MS: Well, that was an excellent explanation. What a great educator you are, Dr. Cheng. So, we think of strokes when we think of strokes, is an older population, over 60, over 65, people with risk factors, that sort of thing. But, you know, as our generations are getting older, how common are strokes? As we're talking about in the young, you mentioned it was 18 to 50 that we're kind of really concentrating on here in this episode. How common is this?

Dr. Natalie Cheng: Yeah. So, about 10-15% of all strokes occur in young patients in the age group of 18 to 50. And this has actually been shown to be increasing over the past couple of decades.

Melanie Cole, MS: Yikes. Why is that?

Dr. Natalie Cheng: There are a few thoughts. The prevalence of the traditional risk factors of high blood pressure, high cholesterol, and diabetes is unfortunately being diagnosed at younger ages. The use of tobacco, heavy alcohol use, physical inactivity, and poor sleep are also big risk factors. And we're seeing that also in younger people.

A specific population of the young that we don't often think about, but can definitely be a big risk factor is pregnant people. During pregnancy, you know, there are huge hormonal changes, big changes in blood flow, and these physiologic changes can also increase someone's risk for stroke.

Melanie Cole, MS: Wow. So, as we're seeing these lifestyle behaviors impact, as you said, diabetes, we're seeing that in younger and younger people and obesity. We're certainly seeing an epidemic of that in this country and sedentary lifestyle and higher stress, all of these things contributing. When we think of a stroke, we hear the moniker BEFAST, the acronym. Is that the same for cryptogenic strokes in younger populations? Is it going to be BEFAST? Tell us about symptoms.

Dr. Natalie Cheng: Yeah. So, there isn't anything inherently different in terms of how a stroke looks like, whether it's in a young person or an older person. And I'm so glad that you brought up BEFAST, which is a nice acronym that we use to educate folks on identifying the signs and symptoms of a stroke. You know, just for folks who haven't heard it before, the B in BEFAST stands for any sudden change in balance, so if somebody isn't walking steadily. E is for eye or any vision changes. F is for a facial droop. A is for any drift in the arm. If you hold your arms up in front of you, kind of like Frankenstein and one droops down, that's a sign of arm weakness. S is for speech. So any speech changes, if somebody's speech is slurred or not making any sense, that's also a sign of stroke. And the T means time to call 911. Because as we'll talk about, time is brain and the earlier you get treated, the better your outcomes.

I will say that sometimes BEFAST in the younger population, it's still helpful, but I think most of us, like you said, think about stroke happening in older people. So, the diagnosis of stroke can be delayed in younger people because it's not at the top of our differential diagnosis or, you know, the list of diagnosis that we think about when someone comes to the emergency room. You know, if you see a 65-year-old coming in with sudden weakness on the left side or confusion, you're going to think stroke probably. But if it happens in a 25-year-old, you might think it's something else altogether just because they're so young.

Melanie Cole, MS: Yes. That's really important to note. So now, speak a little bit about, as you're diagnosing this, and you just mentioned that diagnostic criteria and things to think about, especially if they're younger, what do we do then? If you see someone having those symptoms, and even if they're 30, then do we drive them? Do we call 911? Because, obviously, Emergency can help more, right? They're better prepared now to take someone to a trauma center, a stroke center, a designated stroke center. Do we call 911? Is that what we do? And then, what happens at the emergency room?

Dr. Natalie Cheng: Yeah. I would say definitely call 911. You know, some people are like, "Oh, it's easier if I call a taxi or have a loved one drive me." But when you call 911, it gives you a few opportunities to do a few important things. Number one, the EMS folks on the ambulance can call the nearest stroke center to pre-notify the ER staff and the on call stroke neurologist that, "Hey, there's this potential stroke patient coming in, get ready. Clear the CAT scanner, and be on standby for this patient coming in."

And then secondly, when the patient arrives and the lights are flashing, the sirens going off, that really gets the attention of the ER. When people walk into the ER, you know, unfortunately, our ER colleagues are very busy. And so, when someone comes in by ambulance, they do get prompter attention, and the sooner you diagnose a stroke, the faster you can treat them. And the faster the treatment is, the better the functional outcomes in several months.

Melanie Cole, MS: Well, you did say earlier, "Time is brain." And that's really an important thing to think about when we're talking about stroke. So, what are the treatment options now? You know, it used to be just only tPA within the certain number of hours, but I'd like you to speak about all the treatment options that are out there today, and if there's anything different when you are dealing with somebody on the younger side, as opposed to an 80-year-old.

Dr. Natalie Cheng: Inherently, the treatment options aren't different between the different age groups. Like you mentioned, tPA, which is a type of blood clot-busting medicine. We have another one as well called tenecteplase, and we can give either one of those up to four and a half hours from when the patient was last seen normal.

Beyond that, the risk seems to outweigh the benefit. It's not like we're like, "Oh, we can give this up to four and a half hours." It's much better if you get it as soon as possible. We usually call it the golden hour, so within 60 minutes from when the patient was last seen normal. But in addition to the thrombolytic therapies, if we suspect and find a blood clot in a large artery, we can do a procedure called a mechanical thrombectomy where an interventional neuroradiologist will actually go into the artery and remove the clot. And in most patients, we can do that up to six hours. And in some select group of patients, we can even do that up to 24 hours from when the patient was last seen normal.

Melanie Cole, MS: Wow. I mean, it really is an exciting time in your field. There's so much happening and moving so quickly. If somebody younger has a stroke, Dr. Cheng, how important is the multidisciplinary management? Tell us who's involved. What does stroke rehab look like for somebody who's had a stroke as a younger person, the risk of having another one, the rehab and recovery, which if someone is 85, my dad was 95, he had a stroke, but he was really great afterwards. But still, it's different when someone is younger and their bodily functions are stronger. Tell us a little bit about the difference in recovery and rehab, what that looks like.

Dr. Natalie Cheng: It really depends in terms of somebody's stroke rehab how severe their neurologic symptoms are in terms of how we can predict they're going to recover. But in general, most younger patients are in better baseline functional status. So, most of them are able to take care of themselves before they had their stroke. And that's a big prognostic factor in trying to decide if they're going to be able to take care of themselves again after their stroke. And just physiologically, younger people do have more neuroplasticity, meaning although the part of the brain that was damaged by the stroke is not going to grow back, other healthy parts of the brain can take over. And that's where the multidisciplinary rehabilitation comes in. So, you have physical therapy, which typically focuses on things like regaining the ability to walk. There's also the occupational therapists who help with activities of daily living, meaning how to use your hands to get dressed or brush your teeth, prepare a meal, things like that. And just as importantly, our speech and language pathologists, they're the ones who help the folks who have trouble with their speech whether it's understanding other's speech or language or the clarity of their speech and the fluency of it. And they can also help with folks who develop trouble with swallowing after a stroke. So, all three of these different rehab modalities are super important.

Most of the recovery will happen in the first three to four months after a stroke, which is why we really try to get patients if they need it, the most aggressive type of rehabilitation, because it's kind of a dose-dependent thing where the more rehab you get earlier on, the better your outcomes are. Now, people still definitely can recover beyond a year or even two years out after their stroke. And we want to definitely support patients through that process.

Melanie Cole, MS: Yes, it's so important. And if you had to offer your best bit of advice to families who know someone or love someone who is on the younger side, under the age of 50, that's had a stroke, a cryptogenic stroke, what would you like them to know about decreasing their risk of another stroke, getting support, resources, help from families. Give us your best advice here.

Dr. Natalie Cheng: There's so much that loved ones can help young patients with after a stroke. I think the most important thing is to really be a cheerleader for your loved one. At baseline, a lot of patients, no matter if they're young or old, can develop depression after a stroke. Anywhere from 20-40% of patients. And you can imagine, it's a huge life change for some of these people. And just being able to encourage their loved ones to really, you know, commit their best to doing their rehabilitation, to keep going even though it's a very long process is probably the number one thing that they could do.

The second thing that loved ones can do is attend doctor's appointments with their loved ones. You know, some people do develop some cognitive deficits after stroke, and it's not easy to remember all the medical terminology that doctors sometimes use to explain why they think the patient had a stroke and what tests they're going to do. It's good to have that second set of ears to just confirm with the patient, like, "Oh yeah, Dr. So and so said this," or to just even take notes, just because the brain is undergoing so much recovery that to also take on that cognitive load by yourself is a lot.

And then, thirdly, I think that one unique thing about young patients with stroke is a lot of times they're early in their career, in the middle of their career. Some of them are parents of young children. They have a lot of multitasking to already do before they even had their stroke. And now, they are not able to function in the same capacity as they were before the stroke. So, just helping out with some basic chores, right? Like if you can help babysit the kids once in a while, go grocery shopping for the patient, doing things like meal prep. Caregiver burnout is a real issue, and a lot of times this falls on the spouse of the patient who had the stroke. And so, there's only so much one person can do. So if you're able to be an extra layer of support, that can be extremely helpful.

Melanie Cole, MS: Great advice, Dr. Cheng. That really is so important for all of us to hear, and especially about the caregiver burnout. That's really a big issue today. And thank you for explaining everything so clearly for us. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, iHeart, and Pandora. And for more health tips, go to weillcornell.org and search podcast. We have so many great ones on there. And parents, don't forget to check out our Kids Health Cast. So much great advice there. I'm Melanie Cole. Thanks so much for joining us today.

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