Stroke and Neurovascular Diseases: Expert Q&A

Neurovascular diseases include a wide variety of conditions that affect the blood vessels and circulation in the brain. When blood vessels to the brain are blocked, malformed, or begin to bleed, oxygen can no longer reach areas where it's needed. Our experts will discuss amazing treatments happening here at UChicago Medicine and take your questions live. That's coming up right now on At the Forefront Live.

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's start off by having each one of you introduce yourselves. Tell us a little bit about what you do here at UChicago Medicine. We have a full house today, but we were doing it in a very socially distant manner. So we have people scattered all over in back studios and basically any corner we could find where we could keep people apart.

Dr. Awad, we're going to start with you. You've been here for a while and you do some amazing work here at UChicago Medicine.

Yes, I am Issam Awad. I'm a neurosurgeon who specializes in bleeding in the brain and vascular problems in the brain. And as you said, I have been doing this for more than 30 years.

Fantastic. And Dr. Kass-Hout, you're over in another corner of the studio and we're going to have you introduce yourself. You're relatively new here at UChicago Medicine.

Yes, I joined the University of Chicago about eight months ago now. And I'm loving it here.

Fantastic.

I'm actually a urologist who is trained in stroke neurocritical care and minimally invasive surgery and mostly specialize in treating blood vessels in the brain and the spinal cord by means of catheters through very minimally invasive techniques, such as stroke, aneurysms, AVMs, and AV fistulas.

Fantastic. And let's go back to Studio B and we'll start with Dr. Coleman, you're up next.

Hi, I'm Sheva Coleman. I'm a vascular neurologist. So I do the medical end of taking care of patients with various types of strokes. I've been here at UT Chicago for almost exactly a year. I'm thrilled to be back here. I actually grew up in Hyde Park so that's a real homecoming for me to come and join the faculty here a year ago.

Oh, that's interesting. Fantastic. And we're going to go with Dr. Mendelson next, who is also back in Studio B. Dr. Mendelson.

Hi, I'm Scott Mendelson. I'm also a physician here at the University of Chicago. I'm also an alumnus of the Pritzker School of Medicine, so it's great to be back on faculty here. And I also specialize in acute stroke care, as well as some areas of pre-hospital care for stroke patients.

Great. And Dr. Mendelson, since we already got you up, we're just going to start with you with our first question. And basically, just if you can tell us, what is an acute stroke?

Sure. So we often think of a stroke as the clinical symptoms. What does the patient feel or experience when they're having a stroke? And usually, it's a sudden onset of neurologic symptoms.

And what do I mean by that is usually patients will experience some absence of the normal functioning of their brain. So this could present as a loss of vision sometimes or a facial droop. One side of their face looks different than the other.

Sometimes there's difficulty speaking or understanding the words that are spoken to you. And sometimes there's accompanying weakness on one side of the body and either an arm or a leg that might feel heavy or may not work at all. And when symptoms like that occur suddenly, we call that a stroke, and it's really important for patients or those who see that happening in others to seek medical attention right away.

Yeah, that's one of the things that we've heard many times when it comes to stroke. It's so important to get that attention quickly. And can you delve into that just a bit more?

Tell us why that's important. And what should people be aware of? What do they need to do if this happens?

Yeah, so we often teach the handy mnemonic FAST to both patients, their family members and the public. And FAST stands for face, arms, speech, and time. And that's just something to keep in mind. When you see symptoms, maybe a facial droop, someone having difficulty speaking, or you experience weakness on one side of the body to seek medical attention right away.

Call 911. Get to a hospital. Get to a physician right away because strokes happen quickly. And again, they usually occur, as you mentioned in the introduction, there's either by an interruption of blood flow to the brain or it's sometimes too much blood flow into the brain in the cases of hemorrhage. And all of those situations require emergent therapies or urgent care because with every minute that goes by, there's more damage that's accruing in the brain.

And the things that we can do to help patients, the things that we can provide in terms of medicines and therapies, surgeries, and interventions really depend on us giving those therapies in a very timely fashion as soon as possible. So don't hesitate. Call 911. Get to a hospital as soon as possible so that we can help you.

I do want to remind our viewers that we will take your questions. So just type them in the comments section. We'll try to get to as many as possible over the next half hour. We already have a few coming in.

But Dr. Awad, I want to go to you next because one of the things we talked about before we started the program, and again I think this really sets us apart and this to me is, I think, one of the neatest things we do is this multidisciplinary style of care. And you even make a little joke, we were doing that long ago, long before other people started talking about doing that. Can you talk us through that?

Yes, that's true. So University of Chicago would have had the culture, it's almost in our DNA, that we get together and talk about the case and we do it among multiple specialists. So the neurologist, the interventionalist, and the surgeon from the very beginning look at the case together. And our goal is to deploy our expertise and tool for that individual case.

So we've been doing this long before it became sexy, but we'll call it multidisciplinary care in practice. We see patients in clinics together. We admit patients and care for them together. And we discuss patients in an educational conference every week to analyze what we have done and how we can all contribute to the case.

And to me, that just makes sense because you have multiple minds working on a problem, different viewpoints, different thoughts. And I would imagine that's just very helpful.

Absolutely. And all the time, we learn from each other, and sometimes we come up with solutions that we wouldn't have thought about from our own angle. They come across because of these hard-nosed discussions that we have together. I think it's very, very unique to our team.

Fantastic. Dr. Kass-Hout, I'm going to come to you for this next question. This is a question actually from a viewer, and we talked a little bit about this before the program just as far as the impact of COVID on patients. And are you seeing more patients that are impacted with strokes or ministrokes due to COVID?

Absolutely. Actually, we're still learning about COVID and its association with stroke, especially venous stroke or arterial stroke and we've been seeing a lot of cases of conflict here in University of Chicago. And we work together with Dr. Awad and Dr. Coleman and Dr. Mendelson about treating this patient, what's the best way. They're usually very difficult. They cause a large burden of thrombosis that sometimes might need medical therapy, intervention therapy, and a lot of time, surgical therapy too.

So Dr. Coleman, we're going to come back to the back studio with you again and ask you, talk to us about some of the causes for an acute stroke. Dr. Mendelson touched on this a little bit in his answer earlier, but I wonder if you could expound on that a little bit.

Sure. So in general, stroke is divided into two big categories. That's what we call ischemic strokes, which are strokes caused by a blockage of a blood vessel usually from a clot and hemorrhagic strokes, which are bleeding-type strokes. So I'll focus on the causes of the ischemic or clotting-type strokes, which are the far more common type. They make up about 85% of all strokes.

And the three big causes of those types of strokes are disease that involves the big blood vessels. So you think about the carotid arteries, those arteries that go up the front of your neck where you can feel a pulse. Getting plaque or blockages that build up in those arteries, and then in the large arteries up inside the brain itself, that's one big cause of stroke. Basically, little pieces of that plaque can break off and go lodged in the brain and cause a stroke. So that's number 1.

Number 2 is you can have stroke that is caused by disease in very tiny blood vessels. Blood vessels that are actually just the size about the diameter of a hair, that those vessels are very, very vulnerable to damage from a few things, but the biggest one is high blood pressure. And over time, high blood pressure can really damage those teeny-tiny blood vessels and those can cause strokes. They basically just give out.

And then the third big cause of stroke is strokes that can come from the heart. That for various reasons, the most common of which is an irregular heart rhythm called atrial fibrillation or AFib, but there are a number of other things that can cause clots to form in the heart. And those clots can form in the heart, and then get sent up to the brain where again, they'll lodge in one of the blood vessels up in the brain, block that blood vessel up, and cause a stroke and cause the various symptoms that Dr. Mendelson described in the beginning.

Very interesting. I do want to tell our viewers. I'm seeing several questions, and I'm going to get to all of them if I can. I'll just go down the list here in a minute. But there's a couple of things I want to do first.

And Dr. Awad, we've got a video that we're going to play in just a minute. But before we get into that video, can you tell us a little bit about arteriovenous fistula or malformations? That's what's going to happen in that video, but if you can describe what goes on there, and then we'll play the video.

Yes. So these patients are either born with a weakness in the blood vessel or develop it over time, and that blood vessel either weakens and is vulnerable to bleed or there are connections between the arteries and veins, and we call these arteriovenous malformation or AVM or fistula. So the connection causes high flow in the veins that normally do not see the arterial flow, so they get weakened and they can burst and bleed in the brain. So these are lesions that are often silent until they leak or bleed.

So the first symptom the patient has is a hemorrhage, and they were living their life not knowing that they have this problem up until that point. So we want to detect that very quickly. And we want to be sure the source is fixed before it bleeds again and causes a bigger disaster.

So that's very scary.

It is.

It is something that can be dealt with, and that's why we're going to show this video because this is a video of a young man that experienced that. John, let's go out and play that, and we'll talk about it when we come back y'all.

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- I sneezed and when I sneezed, my brain actually, technically, it was bleeding. And I felt right away when I sneezed, I blacked out for a second, lost feeling in my hands, my feet. And the next thing I knew I just couldn't really get back my vision.

- Sam Messina's life changed with a sneeze.

- He had a small blood vessel abnormality in his brain that had been there silent. And then when he sneezed, the thing ruptured and hemorrhaged in the brain. So he had actually a small stroke affecting the visual area of his brain.

- Sam had an arteriovenous malformation or AVM. It's a tangle of abnormal blood vessels in the brain that most people don't even realize they have until something bad happens.

- When you are 20 years old and college, playing hockey, the sky is the limit, and now you hear that you have hemorrhage in your brain and that is a lesion that bled that may re-bleed again, it changes your life.

- The toughest part was definitely just thinking, like, why is this happening or, like, why me?

- Sam's accident happened while he was away at college in Alabama. His father remembers getting the call from the campus doctor right before Sam was transferred to a Birmingham hospital.

- The doctor, she was phenomenal. She called right away, and she was, I think your son might have an aneurysm. And I-- complete panic attack obviously. I missed the flight, so I literally just jumped in my car and started driving.

- The doctor in Alabama told the family Sam would need radiation for three years and advised against surgery. A family friend suggested Sam's parents bring him to UChicago Medicine for a second opinion.

- University of Chicago was great. They got us in right away, and we met Dr. Awad. Pretty much, actually, the first day and by the time we got there, he had already read all the reports and wasn't delivering the best of news. But he was giving us the honest opinion that it needed to be fixed, and it was going to require the brain surgery.

- And he called me in the middle of class and he was, like, OK, the doctors here said, I need to get surgery. And I immediately started crying.

- Sam's friends and family didn't expect surgery, but Dr. Awad explained the procedure. He said, the surgery was a better and safer option than radiation and was something he had done with great success many times.

- A neurosurgeon, out in practice, might not see many of these cases. They might see two or three in a career while in our team, we see maybe one or two a week.

- Sam's father says he's grateful for the care his son received. And that Dr. Awad made them feel comfortable about the complex brain surgery.

- He knew everything about Sammy like he was his only patient. I keep telling people all the time, like it's very rare because he's a great doctor, obviously he's super busy, but he walked in and he was like he was the only patient every time.

- Sam says the AVM changed his life in a positive way. He's open to new challenges and appreciates his opportunities more.

- In a weird, weird way, I'm actually really glad it happened because I just think it made me realize a lot more about myself or like I've never had a life-threatening situation like that where it's like most people don't, which is great. I mean, I don't recommend it, but it's like if you have something like that where you have to think about everything you have and how lucky you are, it's like you'll just be more thankful.

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Well, first of all, Dr. Awad, nice work. But secondly, that you made an interesting point in that video that I think bears repeating. We're a center that does a lot of this work. And you said some neurologists may see one or two cases like that in their entire career. We see several a week, potentially.

Correct.

That makes a difference.

It is a huge difference because often we recognize salient features of the case that really alter how we treat it. And we want to choose for each patient the best solution for that problem, and it is not unusual that they felt like they are the only patient because that's how they should feel. This is a life-altering event, and they need to know the whole team is mobilized to help them.

Fantastic. Dr. Mendelson, how can a person prevent stroke or can you prevent stroke?

So that's a really great question and a hard one to answer. We often talk about preventing strokes. Unfortunately, after the fact, we know that there are certain things that put patients at risk for stroke-- things like smoking cigarettes, so don't do that. Quit smoking.

And then beyond that, it's really blood pressure control, blood sugar and diabetes control, and trying to live heart healthy lifestyles and diets that can sometimes prevent strokes from occurring in the first place. After a patient has a stroke, then it really becomes dialing in on those risk factors, figuring out some other things that may put patients at risk. And really trying to keep those things in check whether it be, again, things that we do as part of lifestyle, as part of the aging process, or sometimes genetic risk factors or we have a predisposition to high cholesterol-- all things that we try to control for our patients.

So Dr. Kass-Hout, can you talk to us a little bit about brain aneurysms? And what is the difference between a brain aneurysm and a stroke? Is there a difference? And what kind of treatments do we provide for that?

Yes. So brain aneurysm is, in simple words, it's just a ballooning of a blood vessel in the brain, just because of a weakness of one part of the blood vessel. Over time, with high blood pressure, that continues to grow and grow. And the most immediate danger of that when it's ruptured or bleeds, that's what we call a hemorrhage in the brain and what we call a subarachnoid hemorrhage because of the unique position of the aneurysm in the space around the brain.

The way we treat aneurysms-- again, here in University of Chicago, we do it in a multidisciplinary way. We meet about every case together, and we provide either an open surgical by Dr. Awad and his colleagues from the Neurosurgery Department. Or we can treat it, if feasible, by minimally invasive through catheters, through small incisions in the wrist or the groin.

I remember my first aneurysm here in University of Chicago in my first week. This was a very complex aneurysm, was not actually hypertensive aneurysm. It was more like dissecting aneurysm because of a gunshot wound.

And I remember we had a conference in neurocritical care, myself, Dr. Awad, and Dr. Warnke, over the phone within two minutes. We had this meeting. We talked about the patient, and we made the decision to provide the patient with the new technology that we use nowadays called flow diverter stents. So these are the options to treat aneurysms and that the key part is to be in our Neuro ICU Unit when they bleed because it's a very complex disorder.

And again, I can't just stress how important, I think, that is obviously you do as well, just having that team approach. It just really make such a difference. And that's interesting to hear.

So I'm going to start going through viewer questions, because we've received so many, and I want to get to them. And I'm just going to go around the group, so if there's something you don't want to answer, I'm going to pass it to somebody else. It's like the lightning round. You just do that.

So I'm going to start off. This is from Monica and says, hi, Dr. Awad, you and Dr. Tsui in the pulmonary team treated my pulmonary AVMs and brain aneurysm. I'm doing well. Thank you very much. It's not a question, but it's nice.

I will ask you this next question though. And this is, can you still have a block in your artery that does not show in angiogram? That's a question from a viewer.

Yes, there are some weaknesses of the blood vessels that do not show up on an angiogram, but the good news is that they show up on MRI. So that is nothing that's totally hidden from today's medicine. So if it's there, again the risk of stroke. We usually will find it.

Fantastic. Dr. Coleman, we're up to you next, and another viewer question. Are there telling signs prior to an incident? Do you have any kind of warning when this is coming on?

So not always, but sometimes, some patients do. Some patients will have what's called a TIA, which stands for transient ischemic attack. So transient, meaning that the symptoms come and go, and go away on their own.

TIA symptoms are generally the same symptoms as stroke symptoms. So loss of ability to speak, face drooping, weakness on one side, sudden loss of vision-- all those same symptoms. But in a TIA, the symptoms will just go away on their own certainly within 24 hours, usually a lot shorter than that, usually 10 minutes, 30 minutes.

What's really, really important is to know that if you have those symptoms and then they go away on their own, that that needs to be taken very, very seriously. That you should really treat it just like a stroke where the symptoms don't go away and get to the hospital and get to medical attention immediately because having those TIAs can, in some cases, be a prelude to going on to have a big stroke. And that can be a warning that gives us the chance to find the underlying problem and maybe fix it and maybe prevent that stroke from happening.

Great advice. Dr. Mendelson, this one's going to be for you. As far as symptoms, what's the difference between Bell's palsy and a stroke? What does Bell's palsy treatment look like and is surgery required?

So that's a really good question because sometimes the two can look very much alike. So a Bell's palsy is usually a facial droop on one side. It tends to involve more of the face than some of the weakness that accompanies a stroke and facial weakness, but that's really hard to tell without a neurologist on board and without seeking a physician. So the first message is that if you experience a facial droop, don't assume that it's a Bell's palsy, but actually seek medical attention because sometimes, if the two can be confused for the other, we won't want to miss out on giving you therapies or getting help to a patient who's actually having a stroke, and it's not just a Bell's palsy.

Once a diagnosis of a Bell's is made, then the treatments are very different. And they can vary all the way from medication acutely to surgeries or procedures, but it's very individualized and very dependent upon how severe the symptoms are at the time. But again, the major take-home is that if you feel like your face is drooping on one side, don't assume it's just a Bell's. It's better to be safe than sorry and come and seek help first.

We have received some great questions from our viewers, which we always do, and I appreciate that so much. Dr. Kass-Hout, another question from a viewer. How do you know you have blood clots? And are there any signs?

So blood clots in the brain, usually they present with what Dr. Mendelson has spoke about stroke symptoms, which could be changes in vision, changes in the ability to move either the face or the arm or the leg, the ability to talk or communicate, and then we go back to our face, arm, and speech and time is to call 911 immediately. So these are usually the signs of having a blood clot in the brain.

Can you tell if you have blood clots elsewhere in the body that can impact you? I'm assuming, I mean, that's a very different thing obviously, but are there warning signs on that?

Of course, like blood clots in the lungs usually comes with shortness of breath and inability to breathe. Blood clots in the legs usually come with swelling in the legs and sometimes painful sensation. So it's different depending on the location.

And as always, go see your physician if you have any concerns in those areas. Dr. Awad, are statins really as valuable in stroke and heart attack prevention as they are being promoted to be?

Yes. So statins have two major effects, both of which can be greatly, greatly beneficial to blood vessels. The first effect is the cholesterol-lowering effect, which cholesterol is already a risk factor for stroke at building those plaques. So when you're on statin, you build the plaques a lot slower and maybe even high-dose statin can regress the plaque. It can actually be like Drano. It's like regress the plaque.

But the other effect of statin is actually stabilizes the blood vessel wall. So the blood vessel becomes more like a younger, more pliable vessel when it is on statin. So if one has aging blood vessels with buildup of plaque, statins are definitely very helpful. And they are a level 1 evidence, meaning we should use them when they are indicated.

Great. Dr. Coleman, this is a pretty general question, but it is a question from a viewer. I think, probably is on a lot of people's minds right now, particularly with COVID. Is it OK to get vaccines after having surgery?

After having surgery, I might let Dr. Awad take that part of it, but I would say that certainly after having a stroke, we would absolutely recommend that people go ahead and get vaccinated. It can be advisable to wait a short period of time if your body has undergone some major stressor that might cause you to have trouble mounting a normal immune response, but certainly after a couple of weeks from any event, we would recommend that you go ahead and have a vaccine.

And Dr. Awad, would--

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--anything to say about the surgery part?

Yeah, you would talk to a physician.

Yeah, I would agree. So basically, most of the time, the advantages of a vaccine are such that if you were to get COVID instead, you are in far worse situations. So all the concerns we have about the vaccine with what we are going through in almost every scenario, it is many, many folds better to be vaccinated than to get COVID.

So Dr. Mendelson, another question from a viewer. Are floaters in your eyesight a sign of stroke? Interesting question.

They typically are not. Usually, floaters are going to be restricted to that eye itself or some problem with the lens. The things we worry about with regard to stroke and vision is when patients report a complete loss of vision.

Sometimes patients will report feeling like a curtain is coming down or they'll see a black spot in the center part of their vision that expands out and often total vision loss. Those are times where I think it's important to seek medical attention right away. Floaters that can come and go might warrant a visit to an ophthalmologist, but are typically not a symptom of a stroke.

Great. Dr. Kass-Hout, I've had a shunt since 2004. This viewer asks, can it ever be removed?

I'll defer that to Dr. Awad as a neurosurgeon.

What do you think, Dr. Awad?

So shunts are usually put to divert spinal fluid and spinal fluid has built up in the brain, maybe after a stroke or after something else. So I think if it has been there for a long time and maybe the cause for which the shunt was put in has gone away, there are ways for us. We can tell whether we are dependent on the shunt or not. So I think you should follow up with the doctor who put the shunt in the first place. Often, living with the shunt is a lot better than trying to mess with it.

So Dr. Kass-Hout, I'm going to come back to you. We spoke a little bit before the program about some of your work. And I know you can't get into too many specifics, but you had seen a patient recently, and it just you did some work. And it's amazing the change that you can see in some of these patients like what we saw in the video a moment ago. Can you just tell us a little bit about what that-- that's going to be tremendously rewarding.

It is very rewarding every day. We work very hard and these small moments when we see the patients improving in front of our eyes after we do a procedure, it makes us feel very happy. And pretty much all the hard work and the tiredness vanished immediately when we see such result.

As the patient I treated yesterday who had had a left middle cerebral artery occlusion, which is a major vessel in the brain. And immediately, when he presented to us, he was not able to talk. He was not able to walk. He was not able to move the right side of his body.

We took him in immediately to the Angio Suite. Again, we used catheters with the plastic hollow tubes that we pushed from the groin all the way to the brain. We were able to put a stent and aspirated the clot within a few minutes.

And when I saw him this morning, he was thanking me. His family were in tears and thanking me that he's talking now, and he's able to move his right side in there. We're actually working to send him to a rehab facility. So these moments, we see a lot here in the University of Chicago, and we're very happy when-- as you mentioned, it's very rewarding when we see the results of our hard work.

And this is why I love doing these patient stories like the one we showed earlier because it's so neat to be able to talk to the patients, their family members, and see how their lives is almost a miracle really. I mean, it's really pretty exciting to see. We're about to run out of time. So I do want to give you the final word Dr. Awad, and if can you talk to us a little bit about the importance of a comprehensive stroke center because that makes a huge difference?

It is huge. So the comprehensive stroke center is a designation of an institution that has all the parts to take care of a complex stroke. So while some simple strokes can be handled in primary stroke centers out in many community hospitals, the pieces and machinations and the expertise to take care of the complex stuff like what Dr. Kass-Hout described or what Sam Messina had and others, those really need that complex high-level expertise. And we were the first center in Chicago to achieve this designation. We are very proud of it and we work very hard to try to apply all the guidelines and the standards of these comprehensive high-level centers.

Fantastic. And we probably could go for another half hour, but we ran out of time. Special thanks to our physicians for being with us today. You guys were fantastic. And a big thank you to those of you who watched and participated in the program today. Some really good questions.

Please remember to check out our Facebook page for a schedule of programs coming up in the future. And to make an appointment, go online to uchicagomedicine.org or you can give us a call at 888-882-0200. Thanks again for being with us today, and hope everyone has a great weekend.

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