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Intracerebral hemorrhage carries high morbidity and mortality, but growing evidence highlights meaningful opportunities for prevention, risk reduction, and long-term recovery. This episode covers key strategies, including blood pressure management, interpretation of neuroimaging markers, and individualized decisions around antithrombotic therapy. It also emphasizes the prolonged recovery timeline and the importance of a holistic, patient-centered approach to improving outcomes.
In this episode, Casey S. Albin, MD, FAAN, speaks with Wendy C. Ziai, MD, and Vishank A. Shah, MD, coauthors of the article "Intracerebral Hemorrhage" in the Continuum® June 2026 Cerebrovascular Disease issue.
Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia.
Dr. Ziai is a professor of neurology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland.
Dr. Shah is an assistant professor of neurology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland.
Additional Resources
Read the article: Intracerebral Hemorrhage
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More about the American Academy of Neurology: aan.com
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Host: @caseyalbin
Guest: @VishankShah3
Full episode transcript available here
Dr Albin: A patient has suffered an intracerebral hemorrhage. They're taken to the neuro ICU, and they fortunately survive. But the journey does not end there. In fact, in some ways, the journey has just begun. Join us today as we unpack holistic care for ICH patients. 
Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. 
Dr Albin: Hello to our audience. This is Dr. Casey Albin. Today, I'm interviewing Dr. Wendy Ziai and Dr. Vishank Shah about their article on intracerebral hemorrhage. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast. I am so delighted that both of you are joining. To begin, let's just do a brief introduction of who you are and, and a little bit of how you got interested in the topic. 
Dr Ziai: Hi, I'm Wendy Ziai. Thank you for having me on this podcast. I am a professor of neurology at Johns Hopkins. I am a neurointensivist, and I think I got primarily interested in this topic through clinical trials that I have been a part of since my fellowship days. 
Dr Shah: Hi, everyone. I'm, uh, Vishank Shah. I am also, uh, very thankful for being invited to be a part of this podcast. I'm also a neurointensivist at Hopkins and the fellowship program director here for neurocritical care, and I'm interested in recovery after ICH, and that's why I'm a part of this work. 
Dr Albin: Welcome to you both. It is such a treat for me to get to interview fellow neurointensivist, particularly those who have such a wealth of experience. So, I am delighted to dive into this. All right. So, to set the stage for our audience, intracerebral hemorrhage has long been approached with pessimism. But your article really highlights that there are meaningful advantages in prevention and risk stratification and long-term recovery for these patients. Though you both are neurointensivist, this article really emphasizes primary prevention and the holistic long-term care for the survivors. And so, to begin, Dr. Shah, can you just lay out a little bit for our listeners the scope of intracerebral hemorrhage and its community impact? 
Dr Shah: Yeah. So, you know, ICH is the second most common type of stroke. There are more than three million new cases of ICH globally each year, and it accounts for thirty percent of all stroke types, but it is the one that has the highest mortality, with more than forty to fifty percent of the patients dying in the first thirty days, and then continued long-term impact on both functional as well as outcomes, as well as survivorship after the early period. And it also disproportionately impacts lower socioeconomic, and then minority races like Blacks, Asians, as well as Hispanic ethnicity. And so, there's a lot of work that needs to be done to reduce the burden of this disease. 
Dr Albin: Absolutely. I mean, these can really be devastating for families, and I really am appreciative of your highlighting that there's a lot of disparities, and there's a lot of work to be done to really increase equity to these patients. I think a lot of this goes into really the AAN's focus on brain health and trying to improve some of what we're doing to maintain brain health. And I really wanted to kind of drill down on this because for ICH, there's a lot that can be done upfront as we think about how do we counsel patients who may walk into the office about strategies to prevent ever becoming an intracerebral hemorrhage patient. So, Dr. Shah, can you walk us through a little bit about what neurologists in the community need to be doing to make sure that no one ends up with us in the neurointensive care unit? 
Dr Shah: Yeah, sure. So, I think, you know, one of the most important risk factors is, of course, hypertension and long-standing uncontrolled hypertension. And so really recognizing the need for early onset screening with regular blood pressure monitoring at a very early age, particularly in the races that I discussed earlier. And then I think another big part, obesity, metabolic syndrome, and type two diabetes. And I think there's a lot of interesting new work that with the GLP-1 agonist, you know, in a large multicenter cohort studies showing that patients receiving these had a significantly lower reduction risk of ICH. And so, this might be a really important part that, you know, clinicians need to start increasingly recognizing and using in their practice. And then, of course, other risk factors that are common include smoking, diet high in sodium, exposure to air pollution, both indoor as well as outdoor. And so, mitigating all of these risk factors can also reduce the burden of ICH. 
Dr Albin: Absolutely. And I really want to highlight that hypertension plays such an important role and that we as neurointensivist, as community neurologists, really need to be creative about ways that we can help people meet those blood pressure target and meeting people in the community where they are, making sure that they're not suffering from side effects from their medication that would prevent them from sticking with it long term. Dr. Ziai, anything else to add about what we can do in the community? 
Dr Ziai: So, we really want to emphasize, even in the acute phase, that patients moving forward need to have targeted interventions to reduce blood pressure, smoking, enhance their physical activity, have a diet that is high in fruits and vegetables and low in alcohol and salt, and then promoting weight loss, of course. 
Dr Albin: And Dr. Ziai, I'm gonna ask you a little bit about one of the things that maybe not all of our listeners have heard about is this APOE2, APOE4 genetic risk for intracerebral hemorrhage. What's going on there and, and should clinicians be testing for that?
Dr Ziai: That's a great question, and it is not one that we currently test people for at least acute ICH presentation. APOE2 and A4- E4 alleles, these give patients a two to three times higher risk of ICH by increasing cerebral amyloid deposition. And if you happen to have APOE2 carrier ship status, then along with other risk factors like white matter disease and vascular risk factors, these predict the onset of new microbleeds even during very short follow-up periods of about two years. And as we know, having cerebral microbleeds are associated with an increased risk of all strokes, ischemic and ICH, but they are one of many MRI markers of small vessel disease, which along with cortical superficial siderosis, does significantly increase future ICH risk. And so even in people who've never had an ICH, if they happen to have an MRI, it may be reasonable to look at the MRI and incorporate this burden of small vessel disease, and especially these hemorrhagic markers into, uh, decision-making about interventions. 
Dr Albin: That's a really excellent point. And so, I think that your article did a really beautiful job of thinking holistically about the patient, incorporating clinical markers of their risk for having ICH, but also those radiographic markers. I'm just gonna ask you to summarize those again one more time because not everyone will be familiar with these. So, when you're looking at an MRI, what are the things that you're particularly clued in on that would increase the patient's risk of future ICH? 
Dr Ziai: In the past, what we're looking for really is markers of cerebral amyloid angiopathy, which significantly increase a person's risk for lobar hemorrhage in particular. And so, we have a set of criteria called the Boston Criteria, and there's a new version of these, version 2.0. And these, um, incorporate a number of imaging markers that provide a very high sensitivity and specificity to diagnose CAA after an ICH. But even if someone's never had an ICH, and they evaluate that risk-benefit ratio for different cardiovascular prevention strategies. And so, the markers that we're specifically interested in are, of course, microbleeds. But not just having microbleeds, but are they lobar or are they deep? Lobar having a higher risk for lobar ICH. How many microbleeds are there? Is it greater than five, or is it just one or two? Also, cortical superficial siderosis is a marker, a hemorrhagic marker, that does portend a significant increased risk of recurrent ICH, along with having a lobar ICH. And now we have these new markers, which are the white matter hyperintensity multi spot pattern, which requires these hyperintensities on flare imaging in the subcortical area, having greater than at least ten of these multi spots, and also having enlarged perivascular spaces in the centrum semiovale, and having at least twenty of those. And finally, white matter hyperintensities, which can be measured with the physica score or just by visualizing them. We can look at white matter hyperintensities as well as being a measure of small vessel disease. 
Dr Albin: Got it. And so just to summarize, we're looking for small vessel disease markers because that puts our patients at higher risk of ongoing future bleeds. And then we're also looking for markers of particularly small vessel disease that's caused by cerebral amyloid angiopathy, which again, because it's having that protein deposition, that puts the patient at risk of those leptomeningeal very small vessels, putting the patient at risk of lobar ICH. Just confirming I've summarized this all correctly. 
Dr Ziai: Yes. That was perfect. 
Dr Albin: Amazing. Dr. Shah, I'm gonna go back to you. Let's say we have a patient. Let's say this is a sixty-five-year-old man who comes in and they want follow-up and they're... And you're trying to think about they've had an ICH in the past, and they are also at risk for ischemic disease. Let's say they, they have hypertension, they've had a smoking history. They have some risk for ischemic events. And you're trying to think about how do you balance those. Let's say the patient needs to be on aspirin but does have some of those high-risk features on their MRI. Is there any guidance on how we think through preventing them from having a recurrent bleed if they're a high-risk patient, also preventing them from having an ischemic event, which they might be at high risk for as well? 
Dr Shah: Yes. So, I think, you know, the first step is of course trying to understand what was the type of bleed. I think that has a very important role, like you mentioned. If it's a lobar hemorrhage versus a deep hemorrhage, the risk of recurrent ICH and ischemic events is very variable. So lobar hemorrhages, there's obviously a higher risk of recurrent hemorrhage events, whereas deep hemorrhage is actually at or behaves sort of like small vessel ischemic strokes and have a higher risk of recurrent arterial ischemic events. So that distinction in itself can help you gauge which patients would be safe and would benefit from these therapies. To begin, and of course, looking for some of these markers on MRI that were mentioned by Dr. Ziai for recurrence of hemorrhage risk. In terms of antiplatelet, the, there is a lot more data now to guide treatment, and we have the RESTART as well as the ESTART trial that showed that starting an, a single antiplatelet after intracerebral hemorrhage did not increase the risk of hemorrhage recurrence. They were very variable in the timing when aspirin was started, and so that remains still a question about what is the safest time point to start aspirin. For example, in the ESTART trial, they started them very early, within the first three days, whereas in  the RESTART it was all the way up to two months after the hemorrhage. And so... But in general, the risk of recurrent ICH was very low with a single antiplatelet agent. And so, if it's needed for ischemic prevention, it's relatively safe broadly across all types of hemorrhages. 
Dr Ziai: Yeah. I would just mention that there was also a subgroup analysis of the RESTART trial using MRI. And so, this more than likely included patients with CAA, since 40% of the hemorrhages were lobar in that study, and therefore seeing that there was no increased risk of recurrent ICH in RESTART, it is thought that putting patients back on their antiplatelet therapy is safe. 
Dr Albin: That's a really huge takeaway pearl for our listeners, that regardless of whether it's a lobar bleed or a deep bleed, if there is a strong indication, you know, this is not just, oh, because someone gave them aspirin 81, but truly that there is a reason that they need to be on a single antiplatelet agent, it probably benefits them to be on that agent, and there's good data that there's not a huge increase in risk. Summarizing all of that? 
Dr Ziai: Great. 
Dr Albin: Now, things are gonna get a little bit tricky here, because what if the patient, what if they need to be on dual antiplatelet therapy? Or what if they need to be on anticoagulation? Dr. Ziai, I'll, I'll throw that to you. How do you tackle that patient population? 
Dr Ziai: Yeah, the safety of dual antiplatelet therapy hasn't really been studied in patients who've had a prior ICH. Although, in people who've had previous strokes, putting them on dual antiplatelets doesn't seem to increase the risk of ICH, but it does increase extracranial hemorrhage. And so there may be other reasons not to put patients on dual antiplatelet agents. Patients who have cancer and also cardiovascular or cerebrovascular disease, putting them on dual antiplatelet therapy does seem to increase the risk for intracranial hemorrhage. So, I think there is enough of a bias against DAPT therapy in patients who have had an ICH that we would not recommend DAPT for patients with a prior ICH. 
Dr Albin: Absolutely. And, and then what about, let's say they have atrial fibrillation, and you know that they have a high CHA2DS2-VASc score, and they are at very high risk of ischemic events, but they've also had a prior intracerebral hemorrhage. Walk us through a little bit, how should we approach that patient? Dr. Ziai, I'm gonna start with you again. 
Dr Ziai: Sure. So again, looking at the MRI, which all patients with ICH should have nowadays. If patients do have these hemorrhagic findings, a lobar ICH, evidence of CSS, cortical superficial siderosis, especially if it's disseminated, and also lobar microbleeds, especially if there are greater than five, if they're multiple, then anticoagulation should really be avoided in those patients. 
Dr Albin: Absolutely. So, I'm really hearing that when we have a patient with ICH, it is just critically important that we understand is this a hypertensive bleed or is this a lobar bleed that is probably related to cerebral amyloid angiopathy? And getting to that distinction is going to play a major role in our deciding whether or not the patient can be on DAPT or can be on anticoagulation. And then what are some of the strategies for patients that you're referring them to if they really cannot tolerate being on anticoagulation, but they have atrial fibrillation, and they do need some sort of ischemic stroke prevention? 
Dr Shah: There's still a lot of controversy, even in non-lobar hemorrhages, about resuming anticoagulation and when that would be safe. HAF trial, there was a reduction in ischemic stroke recurrence, uh, but a significantly higher increase in hemorrhage recurrences. I think that trial included both deep and lobar hemorrhages. So, we still need more data, and I think the ASPIRE trial and maybe a meta-analysis would answer that eventually. But in the meantime, if a, specifically for lobar hemorrhages, which are, uh, thought to be CAA related, if they, uh, and the patient has AFib, you know, where anticoagulation would be contraindicated, a watchman device or, you know, AFib ablation may be some of the other strategies that can be looked into for those patients specifically. 
Dr Albin: Right. I think that's a really important point to emphasize, that we don't just don't give up and say, "Oh, you're not a candidate for anticoagulation," but we really reach out to our cardiovascular friends and say, "Hey, what other procedures can you offer that will minimize the risk of recurrence?" You know, we don't want them to have an ischemic event, but we also know long-term that there would be a real risk of anticoagulation. Just reminder to our listeners that there are new procedures, and our cardiology colleagues are always doing new trials and new devices, and so we should really leverage their expertise here. I am in the final minutes gonna just switch gears a little bit from talking about sort of the nitty-gritty of secondary ischemic prevention and secondary hemorrhagic stroke prevention and thinking about there has been this degree of pessimism around ICH patients, and that, you know, they have a much more severe outcome than our patients with ischemic strokes. I think that that is probably a myth that we need to do some debunking around, and I think maybe we need to reframe in terms of thinking about just the trajectory. So, Dr. Shah, walk us through a little bit about what we can expect about the recovery trajectory in ICH compared to those patients who have an ischemic stroke.
Dr Shah: Yes. From some newer data and studies, it is becoming clear that recovery after ICH is much slower than we expect. In general, for ischemic stroke, recovery is measured within the first few weeks to up to 90 days. But in ICH, we now know that patients can keep recovering all the way up to six months and even beyond. In general, from just a, a study of heart recovery that occurs after ischemic stroke, there's a steep recovery in the first seven days, and then sort of after that, patients still continue to recover, but it, it starts plateauing where up to 90 days. Whereas with ICH, there is not much recovery in the first 7 to 30 days, but after that, there is a recovery that occurs significantly between day 30 and day 180, and then some patients continue to recover all the way up to one year. The more severe the hemorrhage, the slower the recovery, but there's still some evidence to suggest that even severe hemorrhage patients can recover all the way up to one year out and beyond. This is, of course, in terms of functional recovery. 
Dr Albin: I think that's a really important point for our audience. Many of the listeners are residents, they're fellows, they're seeing these patients in the hospital, and they may not see a whole lot of improvement over even 30 days. But to keep in mind that just because the patient has not had a dramatic recovery within that first month that they may be in the ICU and then on the floor does not mean that that patient will never have recovery, and that we reset our expectations that recovery is possible, it's just gonna be slower. And I think that that's not only important for the healthcare team to take in mind, but also for patients and their families to know there is hope here. It's just gonna be slower. Dr. Ziai, looking ahead, what developments in this are you most excited about that you think will move the needle for care for the long-term outcomes and the prevention for these patients? What's ahead in, in ICH? 
Dr Ziai: Yeah, I think the research that's going on is very exciting at the moment. We just saw the presentation at the World Stroke Organization conference in the fall of the TRIDENT trial, Triple therapy prevention of Recurrent intracerebral Disease events, meaning strokes. And these investigators found that a single pill, a fixed dose of three blood pressure-lowering agents actually was successful in significantly reducing the risk of recurrent stroke in patients who have had a history of ICH and have just normal or low-grade hypertension. So rather than having patients on multiple antihypertensive agents, it may be possible to have them on a single pill, and may dramatically reduce their stroke risk. So that's exciting. There is also a trial ongoing, ASPIRING, testing whether antiplatelet monotherapy after 24 hours only can reduce the risk of all serious vascular events in ICH survivors. So very early antiplatelets. The SATURN trial, we didn't talk about statins yet, but it is comparing continuation versus discontinuation of statin therapy in ICH patients. And then we have ongoing epidemiological studies that are really needed to understand this interaction between the cardiovascular prevention strategies, the antithrombotic use, the blood pressure targets, and these high-risk neuroimaging markers for ICH. And I think that's gonna be key, personalizing the interventions for these patients. 
Dr Albin: So, I love that. And what I'm hearing is that it's really important to think about the personalized approach as well as how do we simplify things. We know that blood pressure control is critically important to the primary and secondary prevention of ICH, but we have to make it easy for patients to do so. Dr. Shah, I want to end with kind of understanding, you know, this was an unusual topic for neurointensivists to talk about. This was really about prevention. It was about long-term survivorship. It was about not what's happening in the neuro ICU. How did you guys get interested in sort of that aspect of care? 
Dr Shah: Yeah, so that's a great question. Dr. Ziai has been my mentor since I was in fellowship, so now about eight years that I've been working with her, and this was a project that I started in fellowship with under her mentorship, looking at long-term recovery in ICH patients, and specifically severe patients. Happy that work has received a lot of recognition. It was published in JAMA Neurology. We looked at patients with severe intracerebral and intraventricular hemorrhage, those that survived with an mRS of four and five at day 30, and what happened to them over the course of the year. There was really not much data on recovery after ICH. And we were very surprised to see that up to 40% of patients that were an mRS of four and five, so really, really severely disabled at day 30, recovered to an mRS of zero to three by one year. About one-third of that group that recovered actually achieved functional independence with an mRS of zero to two, which was very surprising, really breaking the myths around the pessimism with ICH. We found that a lot of the baseline comorbidities like diabetes, white matter disease, as well as what happens to them during the acute hospitalization, were adding all of that information to the severity of the hemorrhage significantly improved our ability to predict long-term recovery after ICH. And so that's kind of how we got interested in this work, looking at how factors in the care that we provide in the ICU, as well as what the patients come in with, how all of that could be modified to promote recovery in these patients that are often been forgotten. 
Dr Albin: I think that there's one takeaway to our listeners is that this is really a place where there's a lot of hope for recovery, and that the nihilism that has really surrounded ICH is a thing of the past, and we have to move forward with thinking about how do we proactively impact the recovery and counsel the patients and give them hope. Because just as your research shows, there really is the ability that they can attain that functional independence, which is absolutely astounding. It's really amazing. Again, today I've been interviewing Dr. Wendy Ziai and Dr. Vishank Shah about their article on intracerebral hemorrhage. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Please be sure to check out Continuum Audio episodes from this and other issues. Please go and check out. They have a wonderful article with lots of tables and figures, so much data. And again, thank you to our listeners for joining us today. Thank you, Dr. Ziai and Dr. Shah. 
Dr Ziai: Thanks very much. 
Dr Shah: Thank you.  
Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Stroke in children and younger adults differs significantly from adult stroke, with varied presentations and a broader range of underlying causes such as congenital heart disease and arteriopathies. This episode highlights key diagnostic considerations and evolving approaches to treatment in these younger populations.
In this episode, Aaron L. Berkowitz, MD, PhD, FAAN, speaks with Thalia S. Field, MD, FRCPC, MHSc, coauthor of the article "Stroke in Children and Younger Adults" in the Continuum® June 2026 Cerebrovascular Disease issue.
Dr. Berkowitz is a Continuum® Audio interviewer and a professor of neurology in the Department of Neurology at the University of California, San Francisco, in San Francisco, California.
Dr. Field is a professor at the University of British Columbia and the Sauder Family Heart and Stroke Professor of Stroke Research, and a stroke neurologist at the Vancouver Stroke Program, Vancouver Coastal Health in Vancouver, British Columbia, Canada.
Additional Resources
Read the article: Stroke in Children and Younger Adults
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Earn CME (available only to AAN members): continpub.com/AudioCME
Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud
More about the American Academy of Neurology: aan.com
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Host: @AaronLBerkowitz
Full episode transcript available here
Dr Berkowitz: Most neurologists are used to evaluating and treating adults with stroke since it's one of the most common neurologic conditions. But stroke can also occur in children, in infants, and even in utero. Today, I have the privilege of interviewing Dr. Thalia Field to talk about pediatric stroke. 
Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. 
Dr Berkowitz: This is Dr. Aaron Berkowitz, and today I'm interviewing Dr. Thalia Field about her article on stroke in children and younger adults. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast, Dr. Field, and could you please introduce yourself to our audience? 
Dr Field: Well, thanks so much. It's a pleasure to, uh, be speaking to you. I'm a stroke neurologist, and I treat adults generally. My wonderful colleague, Thivya Selvanathan, who's a neonatal neurologist, co-wrote the chapter with me. We do, unfortunately, have to treat some children with stroke collaboratively and I do advise on those cases. My practice is about one-quarter clinical, so I treat patients with acute stroke, look after them on the wards, see patients in stroke prevention clinic, and the rest of my time is mainly research and some administrative work and teaching. I run the clinical trials program for the Vancouver Stroke Program, and I do research of my own, mainly focused on stroke in younger adults. We previously did a trial and registry on cerebral venous thrombosis, and more recently, I've been running a national study looking at brain health in adults and children with congenital heart disease. 
Dr Berkowitz: Fantastic. Wow, that is a lot that you do, and we'll look forward to the results of some of those studies. So, when adults suffer a stroke, they typically present with sudden onset focal neurologic deficits, very common scenario we're consulted on.  And one thing you and your colleague talk about in the article is that strokes can present differently in infants and in young children. Can you talk a little bit about the differing clinical presentations of stroke in the youngest young as compared to our usual experience treating the older adults? 
Dr Field: Sure. So, you know, speaking about this as someone who doesn't see the children directly but has had the opportunity to discuss these patients with my colleagues and, like we all do, learn about it during our training, I think one of the distinctions, especially with neonates, is that it's generally not a presentation with focal neurologic deficits. Often these babies will have seizures or encephalopathy as their main presentation, and sometimes we're only finding out after the fact if they're presenting with developmental delay or early preference for handedness and hypotonia, things like that. So, in very young children, that's a distinction. And in older children, there can be sudden onset deficits and, and unfortunately, sometimes these are mistaken for other conditions that are more common in children, like seizures. But sometimes you can have a more indolent course, say, with something like a focal cerebral arteriopathy or something like that. So, it depends on the scenario, but the big difference primarily is in neonates, as far as I understand. 
Dr Berkowitz: Perfect. That's very helpful. So as an adult neurologist, when I think about causes of stroke or teach sort of the categories of causes of stroke to our residents and students, when we think about the evaluation of stroke, I divide them broadly into causes related to the heart, causes related to the blood vessels, and causes related to the blood with, in the adult world, the most common things, of course, being atrial fibrillation for the heart, atherosclerosis for the blood vessels, and then risk factors for atherosclerosis in the blood, diabetes, hyperlipidemia, very rarely picking up a hypercoagulable disorder in the blood column. And reading your article, it seems that, correct me if I'm wrong, stroke in young adults, stroke in the pediatric population can basically be organized into those same broad categories, heart, blood vessels, and blood, just that there's many more conditions on the differential diagnosis that you would consider in young adults to begin with and then children and then neonates as we get into the younger and younger population. So, I'd like to talk about each of these sort of buckets of etiology in turn and ask you about some of the causes we would consider in young adults and children in each of these, and then as they come up, probably ask you more questions about how frequently we find these sorts of things, how frequently they're the cause of stroke treatment, et cetera. So, let's start with the heart. As I said, in adults, we're mostly looking for rhythm disorders, right, atrial fibrillation. Sometimes we'll pick up a patent foramen ovale or PFO or other structural abnormalities, but mostly we're thinking about atrial fibrillation. But reading your paper, I was struck by the huge variety of conditions that you might be looking for in the heart in children or infants with stroke. So, can you tell us a little more about cardiac etiologies of stroke in the young? 
Dr Field: Yeah. So, I'd say unlike in older adults, where it tends more often to be a rhythm disorder, in children and adults who are younger, it's primarily a structural cause, and congenital heart disease being the most common. And it changes a little bit from younger adults shifting downwards in age to younger children in terms of the fact that often if we're seeing an adult with stroke related to congenital heart disease, it can be a paradoxical embolism from a previously undiagnosed PFO. Not in all cases, but fortunately this is improving over time. You know, generally people with diagnoses of more severe congenital heart disease are followed up from childhood and people are aware of the diagnosis, and hopefully they're being managed and watched for things like premature arrhythmias or depressed heart function or other things that can develop and require their own distinct antithrombotic management, for example. In young children, however, more severe causes of congenital heart disease tend to more frequently be associated with stroke. And in many cases, those strokes can be early on in life or associated, say, with perioperative complications or other iatrogenic-related causes in, in that way. Again, congenital heart disease can be associated with stroke at, at any point in the life course. But as adult neurologists, most frequently we're seeing very simple lesions like PFO with large shunts, and in children, it tends to be the more complex causes of congenital heart disease. 
Dr Berkowitz: Got it. So, let's move on to the blood vessels. Again, in adults, we're usually thinking about atherosclerotic disease, be that of the cervical arteries or of the intracranial arteries. But in your paper, a lot of discussion about the various vasculopathies, arteriopathies that can be cause of stroke in younger adults and in children. Could you talk a little bit more about some of the vasculopathies and vascular conditions that are causes of stroke in the younger population? 
Dr Field: Sure. Before I do that, I will say that especially in older younger adults, particularly over the age of thirty-five, and you know, kind of makes me shudder that that's an older younger adult. But, um, in, in any case, certainly conventional vascular risk factors are more common in this population with stroke, especially in those who don't have PFO-associated stroke. Like conventional atherosclerosis, you know, certainly is a cause of stroke in younger adults. But that being said, certainly other vascular causes and vasculopathy in particular is a much more common cause of stroke in younger adults and, and children than it is in older adults. In particular, dissection is an extremely common cause of stroke in younger adults. Generally cervical artery dissection from non-inflammatory vasculopathy, usually on, sometimes on the FMD fibromuscular dysplasia spectrum and, and sometimes, you know, provoked by minor trauma or something post-infectious that may make the vessels a little bit more susceptible. And in younger children, this inflammatory focal cerebral arteriopathy is a distinct cause that is a common cause of stroke in, in young children. There are other causes that can affect the blood vessels, you know, rarer things like vasculitis and vasculopathies that can develop in the context, say, of sickle cell anemia. But in general, as a bucket, vessels are still very important, but the pathology tends to shift. 
Dr Berkowitz: Got it. And you, um, alluded to a point that I wanted to ask you about. You mentioned the sort of, there's stroke in the young, and then where do you draw the line at young? Less than sixty, less than thirty-five, and then we've also talked about strokes as young as before the age of birth. Yeah, I'm remembering, is it the Helsinki study, one of the early large series of stroke in younger individuals? I think that, was it eighteen to forty-nine in that or fifty-nine? I don't remember the exact age, but being struck reading that paper as a resident and thinking about the workup for exotic causes we do, right, and when a young patient has a stroke. And correct me if I'm wrong, the most common etiologies of stroke in that series, and I'm curious the other large series yourself have been involved with, have still been vascular risk factors and arrhythmias and things that we, even common, quote unquote, common things in the young, such as dissection or hypercoagulable states. Uh, the things that we sort of tend to think about first are actually less common. But acknowledging that that paper has folks up to the late forties when the vascular risk factors may be, um, unfortunately kicking in earlier, uh, and earlier due to dietary and lifestyle factors. So is that true, or do you have sort of an age cutoff when it's, we say stroke in the young, people sort of think, "Oh, they'd work someone up differently if they're less than sixty, and they have no vascular risk factors or few vascular risk factors." When do we start getting into the kind of younger population where atherosclerosis and cardiac arrhythmias are not number one and two? 
Dr Field: I'd say first of all, you and I must have trained around the same time because I was also in my training, really struck by the results of the Helsinki study going, "Wow, I, I really didn't know how much of a role these conventional vascular risk factors still play." And I think we're seeing that information reiterated, unfortunately, like even with higher prevalences and more attributable risk in some of the newer series. There are newer European series looking at stroke in younger adults, and more recently, there's been one that we mentioned in the article from the Florida Stroke Registry. And it's true that generally the burden is in the older younger adults. But what I would say overall in terms of kind of how things guide the workup, you need to look at the patient and consider things. I mean, obviously you don't want to miss things that can be treated differently and identified by tests easily. You know, things like ruling out syphilis or antiphospholipid antibody disease in, in younger patients. You really want to make sure that that's not something that, that you'd miss because, you know, obviously your treatment is going to change. However, certainly we start with the basics for stroke workup in any patient that's coming in. At my center, CT angiography. Some centers it may be MR angiography and echocardiography. We take a careful history. We look at the blood work. We look at the vascular risk factor burden. We find out if there's kind of any worrisome personal history, family history, look at their general health context. I think that really helps to guide how far we go in a particular workup, and it also helps to direct the other investigations and types of follow-up we need to do. For example, if a patient has a fairly suspicious story for dissection, let's say they're getting over a cold, and they went to the gym, and, you know, there was a sudden movement that they did that really produced headache and neck pain, and there's an obvious cervical artery dissection. I'm not going to go too far down testing them for rare infections and doing advanced cardiac imaging unless something shows up on their initial echo, for example. But I will make an effort to do more detailed vascular imaging of the rest of their body, find out careful family history. If there's additional manifestations of a non-inflammatory vasculopathy elsewhere, say consider sending them to medical genetics, or obviously, if this is, you know, a second event, your flags raise even more. So, it really depends on the patient. If I find out that there's, you know, a family history of premature cardiac disease and things like that, you know, obviously we're gonna be keeping a close eye on their cholesterol, making sure that we're not identifying, for example, familial hypercholesterolemia, which is, you know, something that comes up not infrequently where we'll see an LDL in an untreated patient of more than five. I apologize, you're gonna have to do the conversion to American units on that. But there are things we identify and, you know, again, you don't want to fall solely on heuristics and your preconceived notion of, of the patient. You do have to consider the results of the investigations that you do order. But I think you can certainly be mindful in terms of how you direct your workup and in turn, how you direct your follow-up. 
Dr Berkowitz: That's great to hear your approach. Yeah, as you said, our approach always begins with the same, coming back to these three categories, right? Doing some type of structural imaging of the heart, rhythm monitoring for the heart, and then vascular imaging of the head and neck. And then I was going to ask you, and you sort of began to answer this question. Yeah. What's next and how far do you go? I think most people think the expanded stroke workup in the young is at a minimum, a TEE if there's been no signal thus far on the original workup. I just mentioned and you spoke about, and then probably hypercoagulable testing and only sending arterial side if there's no shunt and venous and arterial side if there's a shunt. Is that your second pass approach or did I miss anything, or are there other nuances there that are helpful to discuss? 
Dr Field: No, I think that's generally in keeping with what I do. I think with TEE being very important. I mean, the first pass are arterial stuff. Really, it's antiphospholipid antibodies and, and making sure there's no cancer. Like you said, only if there's a shunt do I pursue other venous hypercoagulability testing. Again, you [chuckles] kind of reiterate, go through with the history, make sure there's kind of no red flags. And sometimes, obviously, you do your best reasonable job with the first pass workup, and you will find out when someone presents with a second event that it's something very unexpected. Maybe first manifestation, someone with no obvious history and very initially normal-looking imaging, say with, with CATASL or something like Fabry's disease or something where you would consider it if there was kind of a more classical picture. But it wouldn't be something you would do kind of on your first or even second pass workup in the absence of any sort of clinical suspicion, family history, or something along those lines. 
Dr Berkowitz: I'm curious just as far as rough percentage. I feel like many of these patients we see it's a patient who's young and who's had a stroke, and the initial first pass has been unremarkable, and we do our TEE, and we do our hypercoagulable workup. Again, antiphospholipid antibodies only if it's-- there's no shunt. And if there's a shunt, adding on some of the venous hypercoagulability protein C, protein S, factor five, Leiden, et cetera. A lot of the times I feel like we don't find anything. What's your sort of general gestalt? Again, as a general neurologist who does a lot of inpatient neurology, I feel like when these cases come up, it's not that common that you say, "Oh, I actually diagnosed protein S deficiency." Or every once in a while, diagnose an antiphospholipid antibody, or you'll find a PFO on TEE. You didn't find on TT. I've maybe found one fibroelastoma in many years. How often do you find something? How often is it just as an adult a cryptogenic stroke in a young adult or child? 
Dr Field: So much of what we see is PFO-related, dissection-related, conventional vascular risk factor-related. We do send referrals to medical genetics. Sometimes we'll do testing for rare things like Fabry's or consider other diagnoses. But I mean, those tend to be the exceptions. About one in four to one in five young adults with stroke end up with this cryptogenic label. I like to keep them on my radar for a few reasons. I think, one, it produces tremendous anxiety for them to not have a cause of stroke identified and just to kind of have a generic approach to secondary prevention. So, I think just to kind of keep an eye on them, manage their anxieties each year, make sure there's kind of no updates in, in terms of general secondary preventionAnd sometimes just things dawn on you later or there are new conditions, say things like, you know, DADA2, this, you know, adenosine deaminase deficiency. You know, there are new diagnoses that, that come on the radar. And sometimes treatments change. You know, for example, when I was starting my early career, the evidence hadn't yet been in place for PFO closure, and then all of a sudden, the paradigm completely changed. And you want to make sure that you can get in touch with those patients to reconsider your approach at the time. So I realize that not everybody has the luxury of extended follow-up with their patients, but I think often you can kind of encourage them or their healthcare team or just, you know, patient themselves to keep in touch periodically just to make sure that there haven't been any changes in treatment paradigms or just with your own awareness of particular, you know, diagnoses or, or just kind of readdressing the situation, uh, a year after and seeing if there's anything that may have occurred to you in the interim. 
Dr Berkowitz: Perfect. Really illuminating to hear your approach to these challenging cases. And as you said here and then a couple of times, I think, in this interview is in many of these cases it's your first pass, maybe even your second pass, you haven't found anything. And the key is, unfortunately, as distressing as it may be for the patient as well as for us to not have an answer, to just keep following these patients. And sometimes you really can't sort it out until something else happens, either neurologically or systemically, where you say, "Oh, that's what this was." But there would've been no way to know it from the first presentation. So, we've talked a lot about the diagnosis of causes of stroke in younger adults and children. And in the last minute or two here, I just wanted to talk a little bit about treatment. You mentioned early on that you're involved in thrombectomy cases in children. What's the state of evidence or at least state of practice in terms of offering therapies like thrombolysis and thrombectomy in our patient population? I guess it would be under 18, right, who is not studied in the major trials. Do we have evidence and, or in the absence of evidence, what's sort of the, the expert guidance on treating young adults under 18 and children with some of these acute therapies? 
Dr Field: So, trying to keep up with the literature on this. You know, certainly the evidence has been more established in a small trial and pediatric registries for use of tPA, tissue plasminogen activator, in children just because, you know, it's been around much longer. In terms of tenecteplase, which I, I really think signifies a, a practice shift in adult stroke because of its, you know, non-inferior efficacy and ease of use and potentially better rates of recanalization over time. In children, to my knowledge, that evidence base is, is limited to case series and anecdotal shifts in availability of drug and, and different practices. So, the evidence base is not particularly strong for tenecteplase in children who are identified within a reasonable amount of time who are still otherwise candidates for thrombolysis, you know, thrombolysis in children. Children who are a little bit older, I think, can't remember the exact age, but generally very young, like neonates, children who are under the age of two, I believe. I would want to double-check that thrombolysis is less commonly used and just because the safety has not really been that well-established. And for thrombectomy, it's now recommended to use thrombectomy in otherwise eligible children in the newest AHA guidelines. It gets a little bit more controversial in very young children. Under the age of six, there's less of an evidence base and, and often it will depend on people's level of comfort in terms of the size of the arteries. It's my understanding that once you get to about age six, the artery diameter is similar to that in fully grown people. But in younger children, I think just because of the catheters, there can be risk of, of injury. So, it's more of a case-by-case conversation with your interventionalist for younger children. And again, the evidence to intervene is not there for very, very young babies, for example. 
Dr Berkowitz: That's very helpful to hear the current state of the evidence and the current state of practice, acknowledging, of course, there's not that much evidence, and these are relatively uncommon occurrences, fortunately, for children, but making it challenging for practitioners and practices may, um, vary based on different institutional protocols. So again, today I've been interviewing Dr. Thalia Field about her article on stroke in children and younger adults. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Be sure to check out Continuum Audio episodes from this and other issues. And thank you to our listeners for joining us today. 
Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Rapid advances in acute ischemic stroke care have expanded treatment windows and improved patient outcomes through thrombolysis, mechanical thrombectomy, and optimized antithrombotic strategies. This episode highlights evolving approaches to patient selection, the growing role of tenecteplase, and the importance of team-based systems of care in delivering timely, effective treatment.
In this episode, Casey S. Albin, MD, FAAN, speaks with Christopher R. Leon Guerrero, MD, author of the article "Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke" in the Continuum® June 2026 Cerebrovascular Disease issue.
Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia.
Dr. Leon Guerrero is an associate professor of neurology and the adult neurology residency program director at Atrium Health Carolinas Medical Center in Charlotte, North Carolina, where he also serves as outpatient stroke director.
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Read the article: Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke
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Host: @caseyalbin
Full episode transcript available here
Dr Albin: In stroke care, every minute kills nearly two million neurons. But today, we're going to unpack all the details about the latest treatments that can give those neurons back. 
Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. 
Dr Albin: Hello and welcome. This is Dr. Casey Albin. Today, I'm interviewing Dr. Christopher Leon-Guerrero about his article on Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast. I always like to start by just having you introduce yourself so our listeners know a little bit about you. 
Dr Leon-Guerrero: Thanks for the introduction, Dr. Albin. Really glad to be here today. My name is Chris Leon-Guerrero. I'm a vascular neurologist at Atrium Health in Charlotte, North Carolina, at Carolinas Medical Center. I'm an associate professor in the Department of Neurology. I serve as our Neurology Residency Program Director, and I also wear the hat of an outpatient stroke director in our clinics. 
Dr Albin: So, you are wearing a lot of hats and balancing a lot of things, and it's a really exciting time to be talking about this. For our listeners, we are recording this right after the launch of the American Heart Association, American Stroke Association just released their new guidelines on acute ischemic care. So, no better time to kind of dive into some of this. And really, when I think about acute ischemic stroke care, it's dramatically transformed in the last two to three decades. I mean, from lengthening time windows for IV thrombolysis to expanded thrombectomy eligibility, this is really, I think, some of the most exciting stuff in neurology. And your article did a fantastic job of distilling those rapid advancements and clarifying some of the evidence behind some of these new evolving treatment selections and imaging modalities, and it's exciting. So, let's just start with thrombolysis. Where are we now with IV thrombolytics and the time windows there? 
Dr Leon-Guerrero: So, a lot has changed in the last decade, since that initial trial with NINDS, nearly thirty years ago. We're still giving intravenous thrombolysis in the traditional time window up to 4.5 hours, and really emphasizing we should be selecting patients for treatment early and quickly as possible. In most of those cases, a non-con head CT is sufficient to rule out bleeding and initiate treatment as quickly as possible. Where things have gotten really exciting is using advanced neuroimaging to help select patients beyond that traditional 4.5 hour window, and we're able to treat patients even up to twenty-four hours from symptom onset. 
Dr Albin: Which is really exciting. It has really totally shifted the paradigm here. You know, I think most listeners are going to be pretty familiar with three to four and a half hours. Like, that's sort of our standard. What can you tell us about some of the advanced imaging we're using for that later selection period? 
Dr Leon-Guerrero: It's around the principle of you want to be able to, uh, rescue significant salvageable tissue without a lot of core. So, this large profusion deficit and small core is really how you're trying to select out these patients. And two types of modalities are used. One is going to be MRI, and a lot of those imaging protocols, you know, are outlined in the WAKE UP trial and basically are looking for patients with DWI hyperintense lesions and FLAIR negative lesions to suggest that patients in an early time window that's treatable for thrombolysis. And then in the other category, we'll be using profusion imaging, whether that's CT profusion or MR profusion, to look for patients with large salvageable tissue. 
Dr Albin: Yeah. And I think that this has been one of the things that, to me, has been really impactful is I think when WAKE UP came out, it was exciting. It was fun to sort of think about, "Hey, we're going to be able to use MRI." But MRI can be very challenging to get acutely, especially in community centers where they don't have the capabilities to get someone from the emergency department into an MRI rapidly enough to make thrombolysis decisions. So, to see some of that expand to CT profusion has been really exciting. How are you going about sort of counseling patients or thinking about their risk when you're using some of those, like, advanced imaging techniques? 
Dr Leon-Guerrero: Yeah. I think it's similar to the conversations we've had with patients even within the traditional 4.5 hour window. The risk for intravenous thrombolysis is hemorrhage, and counseling patients on the, you know, the risk and benefits of hemorrhage and the potential clinical benefit of receiving thrombolytics is important. And then providing patients with that information to make an informed decision, so that they can make the best decision for their own care. 
Dr Albin: Totally. And it's, again, time sensitive, but trying to give families enough information and enough time to sort of process those, especially when it's a little bit beyond the standard that we're so used to consenting for. The other big area that's really changed is that tenecteplase has become the star of the show. It's really gained momentum, so what should clinicians understand about this? 
Dr Leon-Guerrero: Yeah. There's been an explosion of data over the last decade on tenecteplase supporting its use for clinical practice. You know, there was recent updates even from the neurology journal with a large meta-analysis with all of the data showing good clinical outcomes and perhaps even lower risk of bleeding. And so, I think you're seeing a lot of centers across the country switching from alteplase to tenecteplase. There's some practical advantages. So tenecteplase is a one-time bolus dose. And then biologically, it seems to have better fibrin specificity, longer half-life, which may ultimately make it a more attractive drug and may make it even more effective. But I think the practical aspects of tenecteplase are not to be understated. I think there's a lot of advantages for speed and efficiency and for centers to make that switch. 
Dr Albin: Yeah. I remember when our health system made the pivot from alteplase to tenecteplase. Like any changes, that obviously created some adjustments with the new workflow. But, the fact that this could be given just as a one-time dose and not with the "we got to calculate the bolus, and now we got to get the infusion on board," like really simplified workflow. So, I think that's been pragmatically one of the nicest things we've done in stroke care. Really exciting. 
Dr Leon-Guerrero: Yeah. And, you know, it's a doable thing. I think you have to be, very deliberate about it at whatever center you're at to make sure that all stakeholders are aware of that change. I think that's helpful to get everybody involved and have a lot of planning to avoid wrong dosing errors or inadvertently dosing as alteplase versus tenecteplase. But it's certainly doable, and I think in the long term, centers that have switched have been pretty satisfied with tenecteplase. 
Dr Albin: And you know, initially when this came out, there really was sort of a debate about, is it gonna be 0.25? Was it gonna be 0.4? Where have we landed with that debate? 
Dr Leon-Guerrero: So, I think we found the correct dose is 0.25 milligrams per kilogram is the recommended dose with a max out of 25 milligrams. There's some within the American Heart Association guidelines that were just published. They mentioned even tier dosing based on 10 kilograms, so intervals. So, that may be an easier way for centers to do it. But that cap out dose of 25 milligrams at 0.25 milligrams per kilogram, I think, is the sweet spot. 
Dr Albin: Yeah. That's great, and I think that that has helped, you know, say, "This is what we're doing. There's not a debate that's happening anymore." And that really just got codified in the new ASA guidelines, so really exciting there. So, there is a lot of guidance for these patients, but I think one of the things that your article really tackled is the fact that there are some special populations, where we really still don't have a lot of guidance. And so, I think just to kind of distill those for the listeners, thinking about our pregnant patients, thinking about children, how are we approaching thrombolysis decisions in these special populations? 
Dr Leon-Guerrero: These are always tough cases. For example, for pregnant women, they've often been excluded in the thrombolytic trials. But there's still evidence. You know, there's some inference based on the evidence we do have, and there's a lot of registry and case reports suggesting potential safe treatment for pregnant women. And I think when you're approaching those cases, again, it's gonna be patient-centered and really should be multidisciplinary. These are the types of cases you really need to lean on your maternal fetal medicine colleagues, your high-risk OBGYNs, your obstetricians to help with that decision-making. And I think, a multidisciplinary approach is the way to go for these cases. It's the same thing with the pediatric population. We had some data. There was one trial, randomized control trial, called TIPS trial that looked at using intravenous alteplase for acute ischemic stroke in patients under the age of 18. It had difficulty with enrollment. But I think most experts would argue that patients with pediatric stroke should be considered for intravenous thrombolysis if appropriate. Again, same thing. You want to make it a multidisciplinary approach, really getting your pediatric neurologists, your pediatricians involved early to make the best decision for the patient. 
Dr Albin: Yeah. That's just really an important takeaway, just thinking about this as a multidisciplinary decision, because there are going to be other stakeholders to the patient's care who may have some different information than what we as neurologists are bringing to the approach. And obviously, our perspective really matters. But trying to work in everyone's unique vantage point of the patient really helps to make the most effective decision. When we talk about acute ischemic stroke care, I really don't think that you could do justice to the topic without pivoting to mechanical thrombectomy, which, you know, as we think about how the medical field as a whole, not just neurology, how the medical field has evolved. I mean, there's probably no bigger impact than mechanical thrombectomy has made in terms of reducing not just morbidity, but mortality from stroke. I mean both. So, thrombectomy has been around for a while, but just walk our listeners through what's the core that we for sure know that these are the patients that this works for? 
Dr Leon-Guerrero: The types of patients we should be selecting for intervention are patients with large vessel occlusions. And those initial trials that were published in 2015 really demonstrated that this is a quite an effective treatment for patients with large vessel occlusion ischemic strokes in the anterior circulation. When that smattering of publications occurred in 2015, the general consensus, we should be treating all patients up to six hours from symptom onset if they do have a large vessel occlusion. And then, Dr. Albin, as you know, the, the windows continue to expand. So, we were using advanced neuroimaging with MR selection and perfusion selection based on DAWN and DEFUSE 3 trial protocols to select patients all the way out to the 24 window, and it's even expanded beyond that over the last few years. 
Dr Albin: I think that when we think about trials that really, totally, changed the game, when we think about DAWN and DEFUSE 3, and we switched from that time-based window to more of that, like we talked about for thrombolysis, that tissue-based clock and, like, looking at what is salvageable and where can we make an impact on salvageable tissue, truly moved the needle in terms of just bringing this therapy for people who, you know, it's hard to get in within six hours. When we moved the needle to 24, it made a huge difference. But people were still coming in with a lot of ischemic damage already done, and they would have traditionally been excluded from being enrolled in thrombectomy trials. But that's changing too. So where are we there? 
Dr Leon-Guerrero: Yeah. I think there were lessons learned from DEFUSE and DAWN that we were probably over-selecting. Perhaps too stringent. You know, we had number needed to treat in the range of two to three for good outcome based on those trials. And so, I think those were lessons learned to move forward, and we, and, and people started looking at large core infarctions. And in the last few years, we've seen a multitude of randomized control trials examining large core infarctions. These are patients with ASPECT scores all the way down to zeros. A lot of the trials relied on three to six as their score, but there was at least one large core study that looked at ASPECT scores down to zero to two, and all of these studies showing benefit. 
Dr Albin: Yeah. And we've really moved into if there's some tissue to spare there, probably getting clot out really makes a big difference in impact. You know, it was really surprising to me as a neurointensivist looking at these trials, that the trials had such low rates of hemorrhage, and pretty low rates of dramatic cerebral edema after thrombectomy. I don't know that we've seen all of that in sort of real world applications, but again, we are still seeing some of these patients come in, that really would've been devastated having some amount of functional recovery regained, which is incredible. In terms of another patient population that I think gives a lot of people pause or stickiness, is those basilar artery occlusions, right? Another large vessel, but one that we've had a little bit harder of a time enrolling in trials and having well-selected trials. Where are we now on whether or not basilar artery occlusion should go to mechanical thrombectomy? 
Dr Leon-Guerrero: So, a lot of excitement in this area, too. There's at least two studies that were published in the last five years that were showing benefit in doing thrombectomy for patients with basilar artery occlusion up to 24 hours, and these were patients with moderate to severe deficits with NIH Stroke Scale scores greater than 10. And then making sure that they don't have large core, so using a newer scoring algorithm on the CAT scan called PC ASPECT, so basically a posterior circulation ASPECT score, to kind of make sure that patients don't have large core infarctions that are being considered for thrombectomy. All of those things collectively in those two recent studies, the ATTENTION trial and the BAOCHI trial, I think is what ended up making those studies positive, is that we were selecting the right types of patients, uh, without large core, early core, and patients with moderate to severe deficits that made the difference from previous trials. 
Dr Albin: Yeah. I think that that's so important. Those trials to me, and like how long it took to get those enrolled, really emphasized to me that there really was a selection bias. Like, we believed this worked, which made it hard to then do a trial. But I'm so glad to hear that we have the data now to support moving forward in a more rigorous way. 
Dr Leon-Guerrero: You're absolutely right. I think that was some of the challenges with the initial trials. In fact, the authors had commented on that. There's a lot of difficulties with lack of clinical equipoise, or experts wanting to take these patients anyways out of clinical trial and treat them, and so that's always been an issue. And then, you know, we all remember basilar artery occlusion cases. They can be severe, devastating cases in our career, but the reality is they're not that common. So, if you look at large vessel occlusions, they only account for about 10%, and if you look at all stroke patients presenting to most centers, they represent about 1% of cases. So really hard clinical trials to do just because there's thankfully not a lot of patients walking around with basilar artery occlusions, but certainly makes for challenges when you're trying to conduct randomized controlled trials on this subset of patients. 
Dr Albin: Absolutely. But we did it, and I think that, like, really if, if the listeners take nothing else, it's that the field of vascular neurology is really moving forward with evidence-based, doing very rigorously controlled clinical trials, which is, I think, is what makes this field so exciting. Finally, closing out, cause we could talk all day, but we don't have all day. You know, it seems to me that more and more we are just using dual antiplatelet therapy all the time. And maybe that is, uh, a little bit of a hyperbole, cause I don't think it's all the time, but let's walk through— when is there good evidence for dual antiplatelet therapy? 
Dr Leon-Guerrero: Yeah. So, there's strong evidence for early initiation of dual antiplatelet therapy or DAPT in patients with minor stroke or high-risk TIAs, and it's been studied using both clopidogrel as an add-on to aspirin and ticagrelor. Both seem like they're viable options in patients. I think one of the key things is the duration of therapy. So, in these cases with minor stroke and high-risk TIAs, we really should be confining the treatment of early DAPT for 21 days. The risk profile changes, so the risk of recurrent stroke starts to decline with time, and that risk of hemorrhage complications increases with time. And so that sweet spot of 21 days, or even some centers will do 30 days for just practical purposes, you know, really is what we should be doing in most of those cases. Other instances where DAPT can be considered, is in patients with intracranial atherosclerosis that's symptomatic, extrapolating from the SAMMPRIS trial that in the, in the medical management arm alone, used dual antiplatelet therapy with aspirin and clopidogrel for up to 90 days. So, you'll see that as well in clinical practice. Some people will opt for a 90-day duration for those patients with symptomatic intracranial atherosclerosis and stroke. 
Dr Albin: Just so I emphasize, this is not set it and forget it. You can stay on DAPT forever. It is you're going to have a definitive time course, 21 days, 90 days. We have directed instructions where we're doing more benefit than harm because of that risk of hemorrhage. 
Dr Leon-Guerrero: That's correct. In most cases, we really should be confining the duration of DAPT either to 21 days or 90 days. This is a challenging clinical practice. Centers really have been making an emphasis on stroke follow-up, so making sure these patients get appropriate and timely stroke follow-up to address these issues and to make sure that DAPT is discontinued if appropriate. 
Dr Albin: Yeah. I love that, and I want to pull on that a little bit because you as someone who is helping direct a stroke center– A lot of this really does rely on systems of care. When we think about early lysis decisions or mechanical thrombectomy, it's how do we get the patient to one of those capable centers as quickly as possible? And then on the back end, when you're discharging a patient, how do you make sure that they are getting follow-up, making sure that they're getting their Holter monitor if they need it? You know, all the stuff that goes into kind of figuring out, why did the stroke happen? What are some of the things that you, in your role, are really excited about, that will move the needle over the next five or 10 years? 
Dr Leon-Guerrero: Yeah. I think a lot of centers are doing it just like we're doing it. It really has to be a team-based approach, and you really want to reach the patient where they are in terms of the continuum of care. And so making sure if it's the in the field that you've reached out to your EMS and first responders to make sure they understand triage protocols to get patients where they need to be, to get the acute treatments that they need for the type of stroke that they're presenting with, to the actual centers that you work at, making sure your whole team, nurses, emergency physicians, APPs that are involved in care are all aware of the stroke protocols and how we're selecting these patients, making sure that your imaging protocols are up to date, and so that it's seamless when patients come in, that we're not adding on perfusion if we should have gotten that up front– We already know, have made decisions before that patient gets there. And then thinking about the patient after that hospital stay, I think, is critical. We really want to reduce their risk of recurrence, making sure that we're leveraging transitions of care, getting those patients seen in our stroke clinics for follow-up, and then make sure we're passing that baton to the long term. All of their long-term comorbidities that may be increasing their risk of stroke are managed and reduced as best as possible. 
Dr Albin: From the Continuum journal to the continuum of stroke care. 
Dr Leon-Guerrero: That's right. 
Dr Albin: I mean, we have it all. I think that that really is so important. I'll just close with what's one thing that is your favorite part about being a vascular neurologist? 
Dr Leon-Guerrero: I think it's what attracted to me to this field. As a medical student at that time, all we had was intravenous thrombolysis, and there was so much promise. There was so much promise that there was going to be widespread advancements in acute stroke, and here we are. There's been a tremendous amount of advancements and improvements for patients. I'm really excited to see what unfolds in the next few years, and I'm really excited that we've been able to increase the number of patients we're able to treat with acute ischemic stroke. I hope that we continue to expand the time window, the inclusion criteria, all of those things that we can treat more stroke patients effectively. 
Dr Albin: It is really a very exciting time to be a vascular neurologist. Again, today, I've been interviewing Dr. Christopher Leon-Guerrero about his article on Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke. This article appears in the April 2026 Continuum issue on cerebrovascular disease. Be sure to check out Continuum Audio episodes from this and other issues, and thank you again, Dr. Leon Guerrero and our listeners for joining today. 
Dr Leon-Guerrero: Thanks for having me. 
Dr Monteith: This is Dr. Teshamae Monteith, associate editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Pregnancy and the postpartum period are critical windows of increased stroke risk, driven by physiologic changes such as hypercoagulability and blood pressure fluctuations. This episode highlights key warning signs, including headache and hypertension, along with practical guidance on evaluation, management, and risk reduction to improve outcomes for pregnant and postpartum patients.
In this episode, Kait Nevel, MD, speaks with Michelle H. Leppert, MD, author of the article "Pregnancy and Stroke Risk" in the Continuum® June 2026 Cerebrovascular Disease issue.
Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana.
Dr. Leppert is an associate professor of neurology at Tufts Medical Center in Boston, Massachusetts.
Additional Resources
Read the article: Pregnancy and Stroke Risk
Subscribe to Continuum®: shop.lww.com/Continuum
Earn CME (available only to AAN members): continpub.com/AudioCME
Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud
More about the American Academy of Neurology: aan.com
Social Media
facebook.com/continuumcme
@ContinuumAAN
Host: @IUneurodocmom
Guest: @humich
Full episode transcript available here
Dr Nevel: The time during and around pregnancy is often thought of as a very joyful time, full of hope. But for some, medical complications such as stroke can lead to devastating disability and sometimes even death. Today, we're going to learn about pregnancy and postpartum stroke, including stroke risk evaluation and best practices in management and risk reduction to help our pregnant and peripartum patients reduce stroke risk and achieve best possible outcomes. 
Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. 
Dr Nevel: Hello, this is Dr. Kait Nevel. Today, I'm interviewing Dr. Michelle Leppert about her article on pregnancy and stroke risk. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Michelle, welcome to the podcast, and please introduce yourself to the audience. 
Dr Leppert: My name is Michelle Leppert. I'm a stroke neurologist, and I currently work at the Tufts Medical Center in Boston, Massachusetts. 
Dr Nevel: Thank you so much for being here, Michelle, and I'm looking forward to talking to you about your article. I always love starting with the question, what's the most important takeaway from your article for the practicing neurologist? 
Dr Leppert: I think in this article, I'm trying to highlight that during pregnancy and especially postpartum, there's a heightened risk of stroke for women, and that's important for clinical neurologists to understand that this is a particularly vulnerable time for the population that we take care of. I think that one of the few of the things that could be informing this heightened stroke risk are the physiological changes that women undergo during pregnancy. So, that includes coagability, where there's an increased likelihood of clotting, and also the cardiovascular adaptations, including increased cardiac output and having an increased cardiac volume. And all of these mechanisms all contribute to the increased risk of strokes around pregnancy and postpartum. 
Dr Nevel: Great. Thanks for that. What are some of the unique aspects of stroke types in etiology in pregnancy that we should be aware of? 
Dr Leppert: When we think of strokes overall, generally the majority of our strokes are ischemic. So, for the overall population, about eighty-seven percent of strokes are ischemic, while the remainder are hemorrhagic. However, interestingly, during pregnancy, what we're seeing is about half of our strokes become hemorrhagic strokes, and now only a half of our strokes are ischemic, and this is in contrast to what we see in the overall population. One of the reasons is because pregnancy is associated with preeclampsia, and preeclampsia increases the risk of hemorrhagic stroke during pregnancy. 
Dr Nevel: Can you tell us just more about headache in general in pregnancy and association of headache with secondary causes of headache and how that relates to stroke risk in this patient population? It seems like in this patient population that when somebody has a headache, we need to be very careful in our headache questions and evaluation. 
Dr Leppert: Yeah. And I think the most concerning symptom that we're finding in this population is headaches, and the reason is because headaches is one of the clinical signs of having preeclampsia, which dramatically increases your risk of having a stroke, and especially a hemorrhagic stroke. So just to back up, we can talk about blood pressure for a little bit and some of the pathophysiologic changes during pregnancy. What most people may not know is that there's a dramatic vascular expansion that occurs during pregnancy. And somewhere during the second trimester, your blood pressure is actually the lowest. So, it can drop below pre-pregnancy levels and make your blood pressure appear low for the baseline. However, during the third trimester, as the baby is growing, there is increased vascular volume. The blood pressure starts to increase. We're seeing some of the highest prevalence of blood pressures, which is a sign for preeclampsia, and headaches develop during that third trimester, and particularly during the time around delivery and postpartum. And one of the most concerning signs, the most common sign of preeclampsia is having a headache. So, I think that with any patient that's presenting with a headache, especially during the third trimester or after delivery, that we really need to pay attention and take their blood pressure. That's one of the easiest clinical indicators that something could be going very wrong. Some of the other red flags clinically that we look for in headaches is that acute onset of a severe headache. That headache quality is different from what they usually have. Any woman with focal neurological symptoms associated with their headache, kind of excessive nausea and vomiting that's not characteristic for them. Not getting any relief with medications, and then lastly, checking that blood pressure is very important. 
Dr Nevel: And what are the thoughts on blood pressure management in this patient population? I know that there is a little bit of difference in guidance in some of the obstetric societies on how we should manage blood pressure in this patient population. And then, is there anything beyond blood pressure management that we should be thinking about doing for this patient population to reduce their stroke risk? 
Dr Leppert: I think that's a good question, and I hadn't really understood that this could be an area of controversy, cause my practice is mostly in stroke, and for most of adult population, the guidelines for blood pressure is very clear. We treat everybody over 130/80. If you're elderly, then your blood pressure limit might be a little higher. However, there's disagreement in the OBGYN guidelines from the American guidelines to the European guidelines. So, what the current American guidelines suggests is that if you have a history of chronic hypertension, then we would want your blood pressure treated during pregnancy below 140/90. However, if you don't have a history of chronic hypertension, then we allow the blood pressure to be higher and then it's an acute intervention if it's anything over 160. One of the issues with this strategy that is concerning is we had just mentioned that the pathophysiology of a pregnancy where you have the lowest blood pressure in that second trimester, and so your blood pressure may be abnormally good. [laughs] And it appears that it's better than your baseline. And so, by the OBGYN definition, any gestational blood hypertension is considered at 20 weeks and later. Sometimes these blood pressures are masked in some women who are pregnant. I think regardless of the controversy and what the practice should be, the focus is that most of the strokes are happening actually peripartum and postpartum, right? So, the woman's no longer pregnant. It is these time periods of the highest risk that we wanna make sure that the blood pressure is controlled. So, after the woman delivers the baby, we're no longer, you know, hampered by the whatever is chronic or gestational. We should be treating that blood pressure to 140/90. I think that not focusing on the controversy until the science catches up is probably what we should do. But like, really, the message here is that we should be checking women around the time of delivery and also postpartum, that we can't forget about their blood pressures postpartum, cause it actually doesn't peak until day five after they deliver the baby. 
Dr Nevel: Does knowing that, that blood pressure peaks around day five, do you think that that should impact how we counsel patients in checking their blood pressure at home? Cause most women at day five are home. They're not still in the hospital. 
Dr Leppert: Yeah, I think that's a really good point. One of the best interventions has been having a blood pressure at home for pregnant women. So even during their pregnancy and then postpartum, allow them to check their blood pressures, cause there's... Most of the cases, to be honest, that I've seen of preeclampsia and intracranial hemorrhage has happened postpartum. And I think what's unfortunate is that the woman is at home, they're distracted cause they have a newborn baby. They have a headache. They're just taking some Tylenol. And then if you have that blood pressure cuff readily accessible, that's a, a really easy way for them to check and notice that, hey, the blood pressure's too high, they have to go into the hospital. 
Dr Nevel: Yeah, absolutely, and it's not just like a headache because you're sleep deprived and have a newborn. It's a headache that you need to pay attention to. Okay, maybe we could talk a little bit now about evaluation when we are suspicious of potential stroke. What do we need to know about imaging modalities and safety considerations of imaging in this patient population? 
Dr Leppert: Yeah, that's a great question. I think when I was training, it was fairly controversial to give a pregnant woman MR contrast with gadolinium during their pregnancy. And as I was researching for this article, actually there's not definitive evidence that that is harmful for the fetus. However, in general, for the acute evaluation of patients during pregnancy, we're recommending using the CAT scan and then a CT angiogram. And then if the acute evaluation is not necessary, then an MRI. And if we need vessel imaging, you can employ an MRA time-of-flight study. That doesn't require the gadolinium contrast. However, one thing that I learned from this article that I thought was really interesting was the use of abdominal shielding. So, you're scanning someone's brain. I always thought, "Hey, doesn't it make sense to put a lead shield over the abdomen?" It turns out the lead shield actually interferes with the automatic calibration of the CT machine, so studies have found that actually increases the dose of radiation that the fetus is exposed to. So, it's much better when we're doing acute evaluations to not shield the abdomen, and really the only thing that can help reduce the radiation dose is the duration of the study. So, what we would recommend is if you want a rapid CT angiogram, rapid CT head, go ahead and obtain it. But if you don't need extra sequences, like a delayed phase of the CT angiogram, then to avoid that and reduce the exposure.
Dr Nevel: I'm so glad that you talked about that because I was shocked when I read that in your article that we shouldn't be using abdominal shielding in pregnant women. I had no clue. I thought that that was, like, something that we absolutely should do. So, I found that really interesting. Thank you for that. So, any special considerations for acute stroke intervention or management in pregnancy in the postpartum phase, especially things like thrombolysis and thrombectomy? 
Dr Leppert: Yeah. So, I think that as our evidence is getting better for thrombectomy, I would be more judicious about using IV thrombolysis, especially around the time of delivery, cause there is some evidence that it can be associated with postpartum hemorrhage. Patient selection, I think, is key here. So, women who have disability associated with their stroke, and then women who aren't candidates for thrombectomies are still candidates for IV thrombolysis. But understanding that this is a little bit of an unchartered territory for us, and only using IV thrombolytics when we think that there is a big benefit to be had. 
Dr Nevel: Can you talk a little bit more about RCVS and PRESS in pregnancy and some of the overlap that we see in this patient population and its relationship to preeclampsia? It seems like there's a lot of interconnections there, and I thought that that was pretty interesting in your article. 
Dr Leppert: Right now, the thinking is that RCVS and PRESS are on the same spectrum of pathology, and we think that it has something to do with the autoregulation of vascular resistance in the posterior circulation of the brain. We're not sure what triggers this, but there is something about pregnancy that classically we'll see this postpartum RCVS phenomenon. It likely has to do also with blood pressure that we're seeing. So really classically we think of this, like, thunderclap headache. You see vasospasms on imaging that is transient, that are kind of the classical signs of RCVS. But I think that we're still not completely sure what triggers it, but it's a very well-described clinical phenomenon. 
Dr Nevel: Great. Thank you. Could you share a little bit about migraines in pregnancy and stroke risk? [laughs] I also thought that this also a segment of your article that caught my attention because migraines are so common. What's the association of migraine, pregnancy, and stroke risk? 
Dr Leppert: Yeah. So that's a very complicated association. So, we know that migraines are associated independently with strokes, and especially people with migraines with aura. However, migraines are also highly associated with PFOs, right? And during pregnancy, what we see is that there is a hypercoagulability state, and so we see lots more DVTs, we see more PEs associated with women during pregnancy. So potentially, because migraineurs also are more likely to have PFOs, they could be presenting with more cardioembolic, kind of paradoxical emboli from these thrombus. But I'm not quite sure that we know why migraines in and of itself, especially with migraines with aura, lead to strokes. And especially during pregnancy, I'm not sure because we have very little understanding about pathophysiology of pregnancy while having migraines with aura also leads to more strokes, or that risk is really just associated with PFOs. So, I think that we need to think about that a lot more. The recommendation is a baby aspirin if you have some of these risk factors for preeclampsia, any vascular risk factors, and including migraines with aura during pregnancy. And we think that baby aspirin is relatively safe, especially starting around the 12 to 16-week period. 
Dr Nevel: So just to clarify, in a woman who's pregnant, who's 12 weeks or beyond in their pregnancy and who has migraine with aura, is that a patient that we should consider aspirin for them to reduce their stroke risk? 
Dr Leppert: I think you can. I am not sure that there is a specific recommendation. I think that, like, a conversation with your OBGYN is, you know, a good idea. But we do recommend that baby aspirin for women, um, above 35 years old because it's considered advanced maternal age. And then we recommend baby aspirin with women with a history of hypertension, multiple gestations, diabetes, renal disease, autoimmune disease. So, I definitely think that is something to consider. 
Dr Nevel: Yeah. Interesting. Okay, great. Thank you for that. When someone has a stroke and they're pregnant again, what are some strategies for secondary stroke prevention? And you mentioned some of the primary risk reduction, but are there any others that you haven't mentioned yet other than aspirin and blood pressure control for primary prevention?
Dr Leppert: Yeah, absolutely. So, I think that it's important to plan ahead. So, for women who are thinking about getting pregnant after they've had a stroke, one of the tenets of stroke neurology is trying to figure out why the first stroke happened. So, I feel like before getting pregnant, it's great to have a very thorough stroke workup so that you understand what the risk factors were and that those risk factors are controlled. One of the interventions, one of the only interventions that's, has evidence in young people with strokes is PFO closure. So, if you do have a stroke from a PFO, we recommend you get that closed prior to your pregnancy because then hopefully even given the hypercoagulability of pregnancy, there's some protection against another embolic stroke. 
Dr Nevel: Another really interesting part of your article that I did not know before I read it was about the risk of cardiovascular disease long term in women who have had stroke during pregnancy. Could you talk a little bit more about that? 
Dr Leppert: What we understand is that gestational diabetes and gestational hypertension sets you up for having diabetes and hypertension later on in life, and it's really developing the actual diabetes to the hypertension that increases your risk of strokes. So, what's really an important takeaway for providers is that after women develop gestational diabetes or they have gestational hypertension or they develop preeclampsia, it's very important for their primary or their neurologist to be very vigilant of these risk factors developing so that they can be modified before the women are at higher risk for strokes. And the reason why we think this happens is because pregnancy is like a stress test for your body. And so, the fact that you've developed the gestational diabetes or the gestational hypertension kind of already suggests that you're more likely and more vulnerable to developing these traditional risk factors later on. 
Dr Nevel: That makes sense. Thank you for that. What do you think is a common misconception about stroke in pregnancy? 
Dr Leppert: When I was earlier in my training, it kind of felt like having a stroke during pregnancy was being struck by lightning. It was really random. There was nothing you could do. It just happened to people. And I think as I learned more in my career, and especially researching for this article, I'm kind of shocked and disturbed by how much of the strokes in pregnancy we can actually prevent. Through management and monitoring of blood pressure for women. And so, I do think that it does our patients a disservice if we think that these are rogue events. But really, it might be a sign of the failure of our health system where we're not taking care of women around their delivery and postpartum and being more vigilant about their blood pressure and more vigilant about the clinical signs that they're developing. 
Dr Nevel: Yeah, I really got that from your article, how important it is to monitor for blood pressure and other risk factors, and that that continues after the baby's born. Thank you so much for that, and thank you for talking with me today about your article about stroke and pregnancy. Again, today I've been interviewing Dr. Michelle Leppert about her article on pregnancy and stroke risk. This article appears in the June 2026 Continuum issue on cerebral vascular disease. Please be sure to check out Continuum Audio episodes from this and other issues. And thank you so much to our listeners for joining us today. 
Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal which is full of in depth, and clinically relevant information, important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members– you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Primary stroke prevention is a critical opportunity for neurologists, with most stroke risk driven by modifiable factors such as hypertension and lifestyle behaviors. This episode highlights practical tools and strategies, including Life's Essential 8 and contemporary risk calculators, while also exploring evolving approaches to shared decision making and secondary prevention.
In this episode, Katie Grouse, MD, FAAN, speaks with Mitchell S. Elkind, MD, MS, FAAN, author of the article "Stroke Prevention" in the Continuum® June 2026 Cerebrovascular Disease issue.
Dr. Grouse is a Continuum® Audio interviewer and a clinical assistant professor at the University of California, San Francisco in San Francisco, California.
Dr. Elkind is the Chief Science Officer for Brain Health and Stroke at the American Heart Association in Dallas, Texas, and a professor of neurology and epidemiology at Columbia University in New York, New York.
Additional Resources
Read the article: Stroke Prevention
Subscribe to Continuum®: shop.lww.com/Continuum
Earn CME (available only to AAN members): continpub.com/AudioCME
Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud
More about the American Academy of Neurology: aan.com
Social Media
facebook.com/continuumcme
@ContinuumAAN
Guest: @MitchElkind
Full episode transcript available here
Dr Grouse: Neurologists have generally been more involved in secondary stroke prevention, but primary stroke prevention is increasingly recognized as an important topic of discussion for neurologists. Today, I have the opportunity to interview Dr. Mitchell Elkind, who wrote the article on stroke prevention in the newest Continuum issue on cerebrovascular disease. 
Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. 
Dr Grouse: This is Dr. Katie Grouse. Today, I'm interviewing Dr. Mitchell Elkind about his article on stroke prevention. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast, and please introduce yourself to the audience. 
Dr Elkind: Thank you so much, Katie. So, my name is Mitch Elkind, and I'm the Chief Science Officer for Brain Health and Stroke at the American Heart Association and a stroke neurologist by background. 
Dr Grouse: Well, I just want to start by saying that I really enjoyed reading this article. I think this is just a really wonderful article I recommend strongly. Such a high yield, an important topic for a lot of us who see patients who are interested in learning about their stroke risks or need help with, uh, stroke prevention after having a stroke. So, I wanted to start. What's changed in the last couple of years? You know, what are some big highlights that you really want to stress that are different from maybe the last time we reviewed this topic? 
Dr Elkind: Sure. Well, there's been a lot of development in the field of secondary stroke prevention, for one thing. But even beyond that, I think we increasingly appreciate how important it is to control what we call the social drivers of health on the earlier side, primordial or primary prevention. And that has been a big advance, I'd say. And I would also say, I think it's really important for neurologists to understand some of those questions about primordial and primary prevention. You know, we tend to get involved with patients after they've had a stroke or maybe a TIA, some kind of event. But sometimes we find people who are following for, you know, non-stroke related conditions who have risk factors also. And we can really play an important role in identifying those risk factors and helping to prevent a first stroke or vascular event as well. So, I think it's real important for us to be doctors even before we're neurologists. So, you know, Katie, about ninety percent of stroke risk is modifiable, so we can do a great job as neurologists in preventing stroke. And one of the most important things that we can do is to identify and treat high blood pressure. And recently, actually, the American Heart Association, American College of Cardiology guidelines on the management of hypertension have said that treatment of high blood pressure not only prevents stroke, but it can also help to prevent cognitive decline and dementia. And this is the first time that we've had a class of recommendation one and level of evidence A, the highest level of recommendation we give for the use of blood pressure treatment to prevent dementia. And that's largely based on the results of some large trials that have come out recently showing that you can prevent dementia with blood pressure control. So that's a really exciting link, I think, between cardiovascular risk factor control and subsequent brain health. It just illustrates the role that neurologists can play in, so many conditions outside of stroke as well. 
Dr Grouse: That's a really great point, and I want to get a little more into the idea of primordial stroke prevention. Can you tell us a little bit more about what that might be? 
Dr Elkind: So primordial prevention refers to addressing how we can prevent risk factors from occurring in the first place, and how can we improve the environments in which people live. You know, we know that only about twenty percent of health outcomes is dependent on what happens between the patient and their doctor in the office. About eighty percent of it is due to what happens in the environments in which we live, work, pray, and play. And so that's what we mean when we refer to the social drivers of health. What is the neighborhood like where somebody lives? Do they have access to healthy food? Do they have places where they can go to exercise? Is there air pollution in the area that may affect their health? You know, one really interesting fact that's become apparent in the last few years is that air pollution is a major risk factor for stroke. Something like a sixth of all strokes can be attributed to the quality of air. And so, what are the things we can do at the broader public policy, community level to reduce the risk of risk factors like high blood pressure and diabetes even before somebody has an event that brings them to the attention of the doctor? So that's what we're thinking about with regard to primordial prevention. It's the earliest stage in prevention. 
Dr Grouse: And that's really fascinating. You know, I think an area that we haven't, as neurologists, really put a lot of our time thinking about, but clearly a very important thing. I really appreciated reading your article about how you incorporated the fact that, you know, a lot of these risk factors overlap very, very closely with all the risk factors for various types of cardiovascular events. And I would imagine that the work you've done as the Chief Clinical Science Officer for the American Heart Association has informed a lot of the way you've thought about-Trying to bring all these risks together and think a little bit more holistically about the whole thing. Could you tell us a little bit more about that and the work that you've done on the American Heart Association's Life's Essential 8 score? 
Dr Elkind: Sure. I can't take credit for it. It's really work that was done by others at the Heart Association, particularly a cardiologist and epidemiologist named Don Lloyd-Jones. But many other volunteers participated. Life's Essential 8 is our approach to primary stroke prevention and cardiovascular prevention more broadly. We say Life's Essential 8 because it includes four health behaviors and four health factors that people can observe to reduce their risk of cardiovascular disease. The four factors are kind of things like know your numbers, your blood pressure, your blood sugar, your body mass index, right, which is a combination of weight and height, and your cholesterol level. So, know those numbers and keep them within the recommended ranges, and talk to your doctor if they're not. And then four lifestyle behaviors. So, one of them is to eat a healthy diet, and typically that means the Mediterranean diet. It means getting regular exercise, and we recommend 150 minutes a week of moderate to vigorous physical activity. Of course, it means abstinence from smoking or other tobacco products. And the last one, the eighth one, which I was so excited about when we added this, is sleep, recommending at least seven hours of sleep a night. So, I was really excited about this because we used to talk about Life's Simple 7, and then the last iteration of our recommendations included this recommendation for adequate sleep because of the mounting evidence of the importance of sleep to cardiovascular health. But sleep is really a brain function, right? And so, it was really the first, in a way, specific brain function that was added to our recommendations. So that's Life's Essential 8. People can read about it online at heart.org and recommend it to your patients as a simple way for people to understand the best approach to reducing their risk of cardiovascular disease, including stroke. 
Dr Grouse: I checked it out myself after reading the article. It's very accessible to patients. It's a great education tool. And they can, you know, see their own score and use that in their own way to, to think about what their risks are and how they can help mitigate and then rescore themselves down the line. There's also, though, on the kind of more the clinician side, the PREVENT calculator as well. Could you tell us a little bit more about how we could use that in approaching this patient population? 
Dr Elkind: Yeah. So, I think of Life's Essential 8 as being a patient-focused tool that people can use. PREVENT is really more for clinicians. Anybody can look it up online and enter your data into it. There's a risk calculator online. But the basic idea behind PREVENT and other similar risk calculators is that it's a way to estimate somebody's risk of having a cardiovascular event like stroke or a heart attack or even heart failure by entering information about your health. And we used to think, we used to use something called the ASCVD, atherosclerotic cardiovascular disease risk calculator, or the Framingham score. Framingham Heart Score, for example, was another one. PREVENT is the latest version, and it has several advantages over those earlier types of risk predictors. For one thing, it predicts risk at younger ages as well. It goes down to age 30. It predicts risk over a longer duration of time, so over 30, 10 or 30 years. It eliminates the use of race as an item to put into the calculator and substitutes for that socioeconomic status, so it's not a race base, but a measure of social disadvantage. And it also includes kidney elements, kidney measures. It includes renal function, for example, that weren't included in prior measures, and it can also be used to predict heart failure, which was not part of the original calculators. Another major advantage of the PREVENT study is that it was based on real-world data from about three million patients, many, many more than the 50,000 or so that the earlier risk calculators were based on. So, it has a much more robust data set and therefore allows a bit more precision in the ability to predict future risk of events. And typically, primary care doctors would enter their patient's data, calculate a risk, and then based on the results of the risk calculator, they can make recommendations about what type of medications a person should take or what other strategies they could use to reduce their risk. And so that's the role that PREVENT plays, is really being focused more for the clinician than the patient. 
Dr Grouse: Really great tool for us to be aware of. You earlier alluded to the fact that neurologists are in the situation where we sometimes are helping patients with this primary prevention. But you also make a case for why it's in the patient's best interest for us to be involved in, in these conversations when we can, when we have the opportunity. Can you tell us more about that? 
Dr Elkind: Shared decision-making is really important because we know that people aren't going to lead the healthiest possible lives if they're not invested in their care. And so, a doctor telling somebody what to do if the patient doesn't want to do it is gonna have limited benefit.So we emphasize the importance of shared decision-making as much as possible. And I think that where this comes up a lot is actually in the situation of, for example, atrial fibrillation, where patients will often be put on a blood thinner. And many people are fearful of blood thinners. They worry about the risk of bleeding. Maybe they know a relative who's had a bleeding complication from a blood thinner, and so they may be disinclined to try it. And so, it's really important to have these discussions about the risks and the benefits of medication and engage the patient in thinking about this. And there are even tools and visual aids that people can look to to help explain some of these complicated concepts to patients. So, these are the kinds of things that reflect implementation science as a way to improve adherence. We know what works in a clinical trial setting often, but the challenge is translating that into the real world and getting our patients to use the medications that we believe scientifically have been shown to be of benefit. I've actually been surprised sometimes at conversations I've had with people, in some cases, healthcare professionals who resist going on blood thinners because of their fear of the complications. And I feel like the evidence is there. Why don't they believe me? And that's why it's really important to have the conversation. Even our peers and colleagues can sometimes question the evidence, and it's important for us to be aware of that. 
Dr Grouse: Absolutely. I think that sounds very reasonable to me, and hopefully these tools will help us with making some of these decisions with our patients. Now, turning our attention a little bit to secondary prevention. So, you know, someone's already had a stroke or a TIA, sort of thinking about what we can do to optimize their risk factors for further strokes. You know, I think there has been some changes that have happened, I think, in the last few years that might be affecting some of the decisions we're making and some of the advice we're giving our patients. I wanted to talk a little bit about GLP-1 receptor agonist medications. Is the data there to support use of this either in secondary prevention or even in primary prevention in the case of stroke? 
Dr Elkind: There is evidence that supports the use of GLP-1s for stroke prevention. We need more data, though. We need trials that focus only on patients with stroke, for example, there have been studies in patients with cardiovascular disease broadly that include stroke patients. But if you look at the subcategory just of stroke patients alone, the data in that subgroup alone don't always show a benefit. And so, we need more data that's focused on stroke patients alone. So, I think the data are continuing to emerge, but we need more still. 
Dr Grouse: Is there any development in the thought about whether we should be putting patients on antiplatelet therapies for incidental, incidentally identified strokes? For instance, if you got an MRI for migraine or for other reasons and you found one, no history of any stroke-like symptoms. Should we be putting these patients on aspirin or any other types of therapies? 
Dr Elkind: That's a really great question. And again, it's an area where there's some controversy and really, there's really no definitive data that would support using antiplatelet therapy in people with incidentally discovered infarcts or what we call, you know, whispering strokes or silent strokes. Many stroke neurologists will use antiplatelet agents. This is one of those areas where it's so important to identify the risk factors. As we were saying before, patients who have other neurological disorders like migraine or epilepsy may turn out to have cardiovascular risk factors like diabetes and high blood pressure. That's why it's so important for neurologists to be able to treat those patients or refer them to specialists who can. Patients who have incidentally discovered lesions similarly are a group where we should be looking for risk factors. So, I don't think of it only in terms of do we put them on an antiplatelet or not, but really more holistically, can we identify their other risk factors and address those? Should the patient's information be entered into a risk calculator like PREVENT, for example, so that we can come up with a more global or holistic measure of their cardiovascular risk and address that as appropriate? Because if they are at risk for stroke, they're also at risk for cardiac events, including heart attack, heart failure, sudden cardiac arrest, and so forth. So, I think of it as a, as a great kind of teachable moment or an opportunity to catch somebody and bring them into the healthcare system more broadly and address those other potential risk factors. 
Dr Grouse: Speaking of, of risk factors that we often like to think about and work up when possible, in cases where it seems certainly possible the patient had an embolic stroke, but perhaps we've done a few weeks or four weeks of cardiac monitoring, have not found any evidence of atrial fibrillation. What's new and what's the current recommendations for doing further monitoring when there's high suspicion for cardioembolic stroke? 
Dr Elkind: This is a really active area of investigation, and guidelines suggest that we should do some cardiac monitoring for atrial fibrillation after an unexplained stroke, but it's not clear how much we should do. Studies generally show that the longer you follow somebody on a cardiac monitor after stroke, the more likely you are to detect atrial fibrillation. It could be as high as thirty percent after a few years. And that's great. And if you detect atrial fibrillation, people usually end up being recommended for a blood thinner. But how extensively we should monitor remains unknown. And I think a lot of the investigation recently has been around the question of, are there other ways to get that information rather than waiting six months or a year for the person to develop atrial fibrillation?It's a little bit funny logically to think a person has a stroke today, a year later you discover atrial fibrillation on the monitor, and you say, "Oh, now I know what caused your stroke a year ago." Right? The temporality, the causality perhaps is off in that case. And so, wouldn't it be better if we could tell what somebody's risk of having another cardioembolic stroke is, or the likelihood that they have atrial fibrillation is at the time that you first see them for the stroke, you know, in the hospital, for example. And so, there's some really new technologies that have evolved like AI or artificial intelligence interpretation of EKGs that can give a really good indication of which people are gonna go on to develop atrial fibrillation. And so, I think we need some more trials in that area to demonstrate that we can detect the risk of AFib and treat that even before it appears on one of those delayed monitors. That's an area that I think is very exciting right now. There's also a further question with regard to how to treat these patients, which is that sometimes atrial fibrillation is a consequence of the stroke itself. So, we can think about what people call known AF, meaning atrial fibrillation that's known about before the stroke even occurs, versus AF that's detected after a stroke, or AF-DAS, people will say. Those may have very different implications for the risk of recurrence and what the person's cardiovascular status is. So, I think what we've learned over the last few years is that atrial fibrillation, it used to be like the slam dunk for a stroke neurologist. It was the easy thing. You know, you had a stroke, you have AFib, you should be on a blood thinner. Now we know that there's lots of different kinds of AFib. There's AFib before stroke, there's AFib after stroke, there's burden of atrial fibrillation. So, some people may have 30 seconds of AFib, some people may have several hours, some people may be in it continuously. It comes and goes, and that can make it challenging to manage. So, we have a lot more work to do to understand this problem better. 
Dr Grouse: That also gets me into some other interesting areas that I think there's still some question, you know, how aggressive should you be? How often is it a case of is this correlated or is this causative? For instance, when a patent foramen ovale is, is discovered in patients with cryptogenic stroke. Are there any tools or new developments to help us understand whether these PFOs should be closed in these cases? 
Dr Elkind: PFO and stroke is a great story that's been going on for decades. And again, we've made tremendous progress in the last several years. So, it's true that about 20% or so of people have a PFO, and because of that, it can be really hard to say with any certainty whether an individual patient sitting in front of you, that the PFO was the cause of their stroke. Rarely we can have a really high degree of certainty. You know, if somebody has, uh, a DVT, for example, and shortly after that maybe they have pulmonary embolism and then a stroke, and we can say, "Oh, clearly this was a paradoxical embolism," went to the lungs and then some crossed over and went to the brain. That happens really infrequently. Most of the time you're faced with a patient who has a PFO and a stroke, and they may have some other risk factors. There are some tools that we can use to help figure out the likelihood that a PFO is related to a stroke. One of those is called the ROPE score or the risk of paradoxical embolism score that was developed by David Thaler and, uh, David Kent from Tufts and a group of other investigators as well. That score allows one to say what the likelihood is that the PFO was causative of the stroke, and it's based on a person's risk factors such that the younger you are, the more likely it is the PFO caused the stroke. And the absence of risk factors make it more likely that the PFO caused the stroke. So, the higher your ROPE score indicating the fewer other reasons you have a stroke, the more likely the PFO is to be causative. So that can be helpful in identifying patients who may have had a stroke due to their PFO. There are other features that are identified in something called the PASCAL score, which is a way of assessing the degree of shunting and whether or not there's an atrial septal aneurysm that can be used as additional factors that lead to the likelihood that a PFO was causative rather than just incidental. So, by putting this kind of information together, we can kind of do precision neurology or precision prevention by identifying which patients with a PFO are really the ones we need to worry about and do procedures like closure. 
Dr Grouse: I look forward to hearing more and learning more as more advances are made in these areas.
Dr Elkind: Thank you.  
Dr Grouse: And thank you so much for joining us today to talk about your article.  
Dr Elkind: Oh, I appreciate it. Thank you for giving me the opportunity. I really enjoyed it. 
Dr Grouse: Again, today I've been interviewing Dr. Mitchell Elkind about his article on stroke prevention. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today. 
Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.