Podcasts about faan

What if the key to leading change isn't having all the answers, but knowing how to listen? In this episode, Sue Hassmiller, a nationally recognized nurse leader, leadership coach, and health care strategist, talks about the human side of leading teams through change and what it takes to build trust, psychological safety, and true ownership. She explains why deep listening and genuine relationships are more effective than simply telling people what to do. She also explores the difference between compliance and ownership, and how leaders can help teams take greater responsibility for improvement by connecting change to their values and giving them a voice. Finally, Sue shares how coaching, curiosity, and self-awareness can help leaders overcome judgment and better understand why teams may feel stuck, resistant, or exhausted. Tune in to learn how leaders can listen differently, build stronger connections, and create the conditions for meaningful, lasting change in health care! IHI Spotlight - Jesse McCall: In this IHI Spotlight, Jesse McCall, Senior Director at IHI, explains that sustainable healthcare improvement depends as much on people and culture as it does on technical methods. He emphasizes connecting frontline staff to a shared purpose, creating psychologically safe environments where people can speak up and test new ideas, and ensuring leaders close feedback loops so employees become partners in change rather than recipients of it. About Sue Hassmiller: Sue Hassmiller, PhD, RN, FAAN, is an executive and leadership coach for nurse executives and health care leaders. Across a distinguished career spanning frontline public health, nursing academia, high-level government policy, and 25 years leading national initiatives at the Robert Wood Johnson Foundation, she has dedicated her life to transforming health care systems from the inside out. An elected member of the National Academy of Medicine, recipient of the Florence Nightingale Medal, and recognized as a Living Legend by the American Academy of Nursing, Sue combines multi-sector expertise with certified coaching to help health care leaders navigate complex relationships, drive health equity, and champion compassionate care. She is also the author of Resetting: An Unplanned Journey of Love, Loss, and Living Again, which explores healing and the vital human element in modern health care. Things You'll Learn: Deep listening is essential for understanding how people experience and respond to change. Leaders build ownership by listening to their teams, acknowledging their perspectives, and connecting change to shared values. Psychological safety enables teams to contribute ideas, innovate, and perform at their best. Effective behavior change requires leaders to change their own behaviors by becoming more curious, self-aware, and less judgmental. Leaders can better support stuck or exhausted teams by asking questions and seeking to understand the underlying causes instead of making assumptions. Resources: Connect with and follow Sue Hassmiller on LinkedIn.

Sharon Pearce, DNP, CRNA, FAANA, FAAN has spent decades practicing, advocating, leading, mentoring, and telling the stories of nurse anesthesia. But behind the titles is a career shaped by formative mentors, difficult clinical days, unexpected opportunities, and a strong sense of responsibility to the profession. Nicolas and Kelsey have a great conversation with Sharon, not just a former AANA president and longtime voice in nurse anesthesia, but also a CRNA shaped by mentors, advocacy, hard clinical lessons, and a deep belief in giving back to the profession. She shares the stories behind her career, the people who helped build her confidence, what students can learn from difficult days, and why preserving the history of nurse anesthesia has become such an important part of her legacy. Here's some of what we discuss in this episode:

What is a nurse scientist, and what is the difference between one that is PhD-prepared versus DNP-prepared? Guest Dawn Aycock, PhD, RN, ANP-BC, FAHA, FPCNA, FAAN, shares about the importance of nurse engagement in research, and how to get involved, no matter your role or location.Related PCNA Resources:Presenting Your Work: Call for Abstracts: https://pcna.net/events-news/cardiovascular-nursing-symposium/call-for-abstracts/Empowering CV Nurses to Engage in Clinical Research (article): https://pcna.net/news/empowering-cardiovascular-nurses-to-engage-in-clinical-research/Clinical Research: Engaging with the Community (podcast): https://pcna.net/podcast/clinical-research-engaging-with-the-community/About Research and Evidence-Based Practice (article): https://pcna.net/health-topics/research-and-evidence-based-practice/See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Providence was the first health system in the United States to commit to becoming carbon negative by 2030, a goal that spans 51 hospitals, more than 1,000 clinics, and 120,000 caregivers across seven western states. In this Insight from Episode 104: Practicing Green Health, Beth Schenk, PhD, RN, FAAN, Chief Environmental Stewardship Officer at Providence, explains what it takes to make an operational rather than just aspirational commitment. She describes the WE ACT framework and scorecard that allows Providence to track resource use, cost, and carbon emissions month by month across every hospital, and explains her practical answer to the question she hears most from other hospitals: where to begin.   To listen to this Insight clip's full episode, visit the SEE YOU NOW Podcast Episode 104: Practicing Green Health on APPLE, SPOTIFY, YOUTUBE, or your favorite streaming platform.  Learn more about See You Now. Visit the ANA Innovation website for additional resources. https://www.nursingworld.org/practice-policy/innovation   Have questions or feedback for the SEE YOU NOW team? Future episode ideas? Contact us at hello@seeyounowpodcast.com. 

Obstructive sleep apnea affects approximately one in four adults and is especially common among patients with neurologic disorders, including stroke, Parkinson disease, dementia, epilepsy, and neuromuscular conditions. In this episode, Dr. Stephanie Stahl discusses why neurologists should routinely screen for OSA, highlights key symptoms and risk factors, reviews important considerations when interpreting sleep studies, and outlines current treatment options beyond CPAP. Learn how recognizing and treating sleep apnea can improve quality of life, optimize management of neurologic disease, and reduce long-term health risks. In this episode, Aaron L. Berkowitz, MD, PhD, FAAN, speaks with Stephanie M. Stahl, MD, FAASM, author of the article "Obstructive Sleep Apnea" in the Continuum® August 2026 Sleep Neurology 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. Stahl is an Associate Professor of Clinical Medicine and Sleep Medicine Fellowship Program Director at Indiana University School of Medicine in Indianapolis, Indiana, where she also serves as Sleep Laboratory Medical Director in the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine. Additional Resources Read the article: Obstructive Sleep Apnea 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: @AaronLBerkowitz  Full episode transcript available here Dr Berkowitz: Obstructive sleep apnea is very common. It can cause or contribute to common neurologic symptoms, such as headache and impaired cognition, and it's a risk factor for stroke. And yet, if you're like me, you may not know too much more about sleep apnea than that. Today, I have the pleasure of talking to sleep expert Dr. Stephanie Stahl to learn what every neurologist should know about OSA.  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. Today I'm interviewing Dr. Stephanie Stahl about her article on obstructive sleep apnea. This article appears in the 2026 Continuum issue on Neurology of Sleep. Welcome to the podcast, Dr. Stahl, and could you please introduce yourself to our audience?  Dr Stahl: Yeah. Thank you for having me. I'm a sleep medicine physician and neurologist and medical director of the Indianapolis Sleep Lab at Indiana University Health. I serve as the director of the Sleep Medicine Fellowship program. I'm faculty advisor for our very first student interest group in sleep medicine at Indiana University School of Medicine. I'm also actively involved in some national leadership roles, including the incoming chair of the American Academy of Sleep Medicine's Education Committee and co-chair of the Academy's Inter-Scorer Reliability Gold Standard Panel. So, I really appreciate this opportunity. I look forward to our discussion.  Dr Berkowitz: Me too, and we appreciate the opportunity too to get to talk to you. You have so much expertise in this area, and I certainly encourage our listeners to look at your article, which is very comprehensive and up to date, and I learned a ton from it. I didn't get much exposure to sleep neurology as a trainee, and I've always worked in academic centers where we have a sleep group and we can refer patients there. So, I have to admit, sleep may probably be the area of neurology I know the least about, and felt like I was learning something new from pretty much every line of your article, and I know our readers will too. So, your article has a lot of excellent detail for our readers on the diagnosis and treatment of this very common condition. But I'd like to keep our interview relatively high level today and focus on the essentials for the practicing general neurologist. So, to start, can you just give us a sense of what obstructive sleep apnea is, and what every neurologist should know about it?  Dr Stahl: Yeah. So obstructive sleep apnea is characterized by either partial or full obstructions in the upper airway. That may sound pretty simple, but this leads to a whole bunch of issues. It leads to oxygen desaturations, arousals from sleep, leading to sleep fragmentation. This can then lead to sympathetic nervous system activation, cerebral hypoperfusion, leading to a whole bunch of symptoms or neurologic conditions.  Dr Berkowitz: Great. And you mentioned this in your article, but just to emphasize, how common is obstructive sleep apnea in the general population?  Dr Stahl: Yeah. So, about a quarter of the general population have obstructive sleep apnea. Much more common in many neurologic conditions.  Dr Berkowitz: Yeah, so very common disorder. We are seeing patients with it quite frequently, whether that's the reason they are seeing us in neurology or not. And this leads to my next question, which is what neurologic symptoms or presenting concerns of a patient should make us think about OSA and the differential diagnosis, and what factors based on the history or the exam or the context would make you suspicious for OSA as the cause of a neurologic symptom? In other words, the patient's presenting with classic symptoms of OSA, and that's why they're seeing a neurologist or seeing a primary care doctor, but is coming for evaluation of, say, headache or other symptoms. And what symptoms would make you think of wanting to consider OSA, and then what aspects of the history or otherwise would make you want to evaluate the patient for OSA?  Dr Stahl: I think a really important takeaway is for neurologists to know that obstructive sleep apnea is very common in neurologic conditions and has that potential to worsen a lot of these conditions or their associated symptoms. And so, it should be on our radar. There are certainly some basic questions and signs and symptoms that we can ask patients about or, or take a look at on exam. And so particular symptoms include snoring. Anybody that snores loudly or frequently, that's a strong risk factor for obstructive sleep apnea. If someone's seeing them stop breathing in their sleep, if they are waking up a lot throughout the night. There are some other symptoms that we may not necessarily attribute upfront to obstructive sleep apnea, such as nocturia, nocturnal reflux, night sweats. There are some daytime symptoms, of course, too, like unrefreshing sleep, daytime sleepiness, morning headaches, an important one in neurology. And then we take a look at the patient's exam. And so, some things that neurologists might want to be thinking about are people with obesity are certainly at a risk for obstructive sleep apnea. But it's also very important to know that someone does not need to have obesity in order to have obstructive sleep apnea. We look at neck size, other morphologic characteristics, such as how much that we can see in the back of their mouth. Can we see their uvula? Does their tongue size appear large in their mouth? And then some other risk factors too, such as male gender, older age, family history, post-menopausal state in women. All that being said, though, sometimes in neurologic conditions, we don't have all of those symptoms or risk factors to be thinking about. And so, in certain neurologic conditions such as stroke where obstructive sleep apnea is very common and has the potential to increase the risk of another stroke, we may need to be thinking about testing these patients even with minimal symptoms or other risk factors.  Dr Berkowitz: That's very helpful. So, you mentioned their headache might be the presenting symptom, right, to a neurologist, and we should certainly be thinking about obstructive sleep apnea as a potential diagnosis, even the cause of the patient's headache, particularly you said patients with morning headache. I often try to think about in patients presenting with, for memory loss, or other cognitive concerns, and that may be due more to inattention from poor sleep, so asking about sleep and symptoms of sleep apnea in those contexts. Are there any other presenting neurologic symptoms not particularly related to sleep? I'm thinking of headache, memory loss, other symptoms that would make you think, "Oh, I should actually screen this patient for sleep apnea also."  Dr Stahl: Yeah, other symptoms to think about in pediatrics, hyperactivity, people that have impaired vigilance, as you alluded to, that poor attention. Sometimes people get misdiagnosed with ADHD, and it's actually just a manifestation of obstructive sleep apnea.  Dr Berkowitz: You alluded to this, Dr. Stahl, that stroke, for example, patients are at higher risk of developing sleep apnea as a result of stroke, and it's also a risk factor for stroke. What other neurologic conditions, primary neurologic diseases, put patients at a higher risk of OSA? And again, similar to the last question I asked you, what are some clues that we should evaluate for? We might be following a patient for their post-stroke care over time and not necessarily thinking about diagnosing a separate condition in them since we're following them for their stroke or their degenerative disease. What are the conditions that put patients at a higher risk of OSA as a result of the condition, and then when would you think about screening them for it?  Dr Stahl: Some particular neurologic conditions where obstructive sleep apnea are very common, in addition to stroke and, and TIA, include Parkinson disease. It can worsen a lot of the motor, cognitive symptoms, sleep disruption that we can see in Parkinson disease. Very common in all causes of dementia, but in particular Alzheimer disease and Lewy body dementia. Very common in neuromuscular conditions. We should definitely have obstructive sleep apnea and all forms of sleep-disordered breathing high on our radar. In conditions like myotonic dystrophy. Charcot-Marie-Tooth is another one where obstructive sleep apnea is very common. Myasthenia gravis, it can worsen the symptoms of that. In particular, a pearl is if somebody has morning weakness in myasthenia gravis, obstructive sleep apnea should be high on your radar. And also, as you mentioned, any forms of headaches. There are some other things too. If somebody has poor seizure control, especially nocturnal seizures, you might have obstructive sleep apnea on your radar as well.  Dr Berkowitz: So, I think you've covered essentially every category of neurologic disease, right? We have cerebrovascular, movement, neurodegenerative, neuromuscular, epilepsy, all conditions where either the disorder itself, such as stroke or the, correct me if I'm wrong, the neurodegenerative disease puts the patient at risk. Or the patient may be at risk for exacerbations of their disease, as you mentioned in myasthenia. I love that pearl. Not fatiguable at the end of the day, but if the patient with myasthenia is telling you they're feeling weaker at the beginning of the day, then think about obstructive sleep apnea and that obstructive sleep apnea worsening control of epilepsy due to poor sleep. So really a lot of bidirectional interactions with this common condition. Okay, so if we're concerned about obstructive sleep apnea, again, myself, a general neurologist speaking perhaps on behalf of other general neurologists, we see a patient with headache or reporting memory loss that we find to be impaired attention, or we see exacerbation of their underlying primary neurologic disease. As you mentioned, we think, "Oh, I've listened to this podcast. I've read Dr. Stahl's article. I should probably be thinking about OSA in this patient, and I should order a sleep study." Now, I admit when I get the sleep study back, I scroll to the bottom, I see they do have obstructive sleep apnea, I'm going to send them over to a sleep specialist. But for the general neurologist, what are some high-yield pearls and some pitfalls to be aware of when we get sleep studies for obstructive sleep apnea, and we are looking at the results? Dr Stahl: The first thing is to understand that there are two main types of sleep studies: in-lab polysomnography and home sleep apnea test. In-lab studies are typically what we consider the more accurate type of study. Main reason for that is that we have EEG, so we can see if someone is awake versus asleep. Most home sleep apnea tests do not utilize EEG, and so when we're looking at respiratory events, apneas or hypopneas, we're looking at over the total recording time rather than the total sleep time. So, we know we're going to capture some time where a person is awake, where we don't have sleep apnea events, and that can be a big amount of time in people with insomnia, poor sleep efficiency. And as a result of that, it can lead to an underestimation of the apnea-hypopnea index. That's really important for people to understand that that means we can end up with a false negative home sleep apnea test, or it can put them in a category of lower severity than what they actually have. And so, if you get a home sleep study report back that's negative for sleep apnea and you remain concerned, you need to go on to do an in-lab study, where about twenty to fifty percent of people will go on to have a positive in-lab study. You can also get false positives with home sleep apnea tests too, and so ideally, we should only be doing home sleep apnea tests in people that are at high risk of having obstructive sleep apnea to decrease our chance of false positive study. When we get that sleep study report, what's important to take a look at? So the main number that we look at currently is the apnea-hypopnea index. The number of apneas, which are full obstructions in that upper airway, or hypopneas, partial obstructions in the upper airway where either there's an oxygen desaturation or an arousal associated with that. Less than five is considered to be normal. Anything five or more gives them a diagnosis of obstructive sleep apnea, and then we stratify them based on the AHI. But it's important to take a look at more than just the apnea-hypopnea index. And while my eyes too on various reports like echocardiograms want to jump to the impression, it is important to take a look at that full report, see what their oxygen levels averaged and what they dipped down to. The arousal index, which is how many times a patient may have woken up briefly throughout the night. Take a look at the histogram, usually an image at the bottom of their report that shows what sleep fragmentation may have been like so that you can take that all in and make that decision. How important are these study findings, and is this a person that would benefit from treatment?  Dr Berkowitz: That's a fantastic overview of sleep studies and some of the highlights to look out for, even if we won't be understanding every detail as you would to know most importantly the caveats about home sleep testing having a fairly high percentage of false negative and false positive results. So being wary if our suspicion is high, and that test is normal or inconclusive to get an in-lab sleep study. And if our suspicion is low or maybe we haven't ordered the test and the patient has had it done elsewhere, and the history doesn't really match up to know that there are false positives on the home studies as well, and again, an in-lab study to settle the diagnosis. Is that right?  Dr Stahl: Yes.  Dr Berkowitz: Okay. Now, for most neurologists, probably if we diagnose OSA, we will be referring the patient to a sleep specialist like yourself for treatment. I think we're all familiar with CPAP and patients being on CPAP. Your article mentions a number of treatment modalities I admit I have not heard of before or maybe heard of in passing, acknowledging most general neurologists are not going to be prescribing or knowing with the nuance that you do as an expert how to decide which treatment a patient would most benefit from or most qualify for. So, can you just give us a broad overview, again, for the general neurologist acknowledging we might see a patient whose past medical history says OSA being treated with fill in the blank. What are the different treatment modalities, and how do you think, just so we can learn from you in broad brush strokes, about particular treatments for particular patients?  Dr Stahl: As you mentioned, most people are familiar with positive airway pressure or PAP therapy, and that does remain our most efficacious treatment. The way I explain it to patients is why PAP therapy is the most effective treatment is it's the only treatment that can take all of the tissues of that upper airway and open them up. Whereas all of our other treatments, we're going to target smaller spaces of that upper airway. So, our first option is if we can get somebody on PAP therapy, we know that that's going to be the best option for the majority. PAP therapy works by basically acting as an air splint to open up the air tissues. Know that masks are not interchangeable. There are masks that cover the nose and go over the nose and mouth and under the nose. Full face masks that cover the nose and mouth, they do typically require higher pressures, also tend to be less comfortable for a lot of patients as well. In addition to different PAP masks, there's different modalities of positive airway pressure therapy too. There are machines that auto-adjust, some that provide fixed pressure, bi-level PAP that provides a higher inspiratory pressure, lower expiratory pressure. Then outside of PAP therapy, there are, as you alluded to, a lot of options and more, continuing to come down the pipeline as well. Mandibular advancement devices or a form of oral appliances has been around for a while. This is device that somebody wears in their mouth. It's preferably customized for their teeth and titratable, meaning that they can make adjustments that pulls their mandible forward in relation to the maxilla in order to pull those tongue tissues further away from the back of the upper airway. That's ideally managed by a qualified sleep dentist or someone that specializes in oral appliance management. Other treatments include surgical options, including hypoglossal nerve stimulation, which is an implanted device that causes the tongue to protrude repetitively throughout their sleep period to hopefully open up the airspace. There's some other surgical options too that open up various places of the upper airway. There's a daytime treatment of obstructive sleep apnea, transoral neuromuscular electrical stimulation that changes the muscle fiber type of the tongue. And then there's some adjunctive treatments that can be helpful too, such as positional therapy, oral facial myofunctional therapy that helps a person breathe better through their nose and may help train the upper airway muscles.  Dr Berkowitz: Great. Well, that's a very helpful overview, and again, I refer our listeners to your article, which talks about all of those modalities in very comprehensive detail. So, Dr. Stahl, as we wrap up our conversation, you have a captive audience of neurologists and neurology trainees here. What would you like to leave us with that every neurologist should know about obstructive sleep apnea?  Dr Stahl: The most important, again, is for neurologists to know that obstructive sleep apnea is so common in your patient population, and it can have a significant negative impact on quality of life and health, including many neurologic conditions. And at the same time, obstructive sleep apnea is very treatable. We have so many options nowadays that we can usually get someone onto adequate treatment. And treatment has that potential to improve several neurologic symptoms and disorders, even at times when you don't think that there's an opportunity to improve symptoms such as say in, headache. So, neurologists really should be screening for signs and symptoms of obstructive sleep apnea, as well as considering testing in high-risk, potentially asymptomatic or minimally symptomatic patients.  Dr Berkowitz: That's a fantastic overview of some of the many pearls that you shared with us today, as well as in your article. So, thank you so much again. Today, I've been interviewing Dr. Stephanie Stahl about her article on obstructive sleep apnea. This article appears in the August 2026 Continuum issue on neurology of sleep. Be sure to check out Continuum Audio episodes from this and other issues. And thank you so much to our listeners for joining today, and thank you again, Dr. Stahl.  Dr Stahl: Thank you again 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.  

In this episode, editor-in-chief Joseph E. Safdieh, MD, FAAN, highlights articles about a pilot American Board of Psychiatry and Neurology Academic Pathway, a study of the EpiWatch app, and a new approach to magnetic resonance scanning.

In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Karin G. Johnson, MD, FAAN, who served as the guest editor of the August 2026 Sleep Neurology issue. They provide a preview of the issue, which publishes on August 3, 2026. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Johnson is a Professor in the Department of Neurology at the University of Massachusetts Chan School of Medicine–Baystate and the Sleep Medicine Division Chief at Baystate Medical Center in Springfield, Massachusetts Additional Resources Read the issue: continuum.aan.com Subscribe to Continuum®: shop.lww.com/Continuum 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: @LyellJ Guest: @drsleepykarin  Full episode transcript available here 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 subscribing to the journal, listening to verbatim recordings of the articles, and exclusive access to interviews not featured on the podcast.  Dr Albin: All right, welcome all. For the first time ever in the history of Continuum Audio, we are coming to you live from Chicago here at the AAN annual meeting. And now over to your host, the one and only editor-in-chief, Dr. Lyell Jones.  Dr Jones: Welcome, everybody. My name is Lyell Jones, editor-in-chief of Continuum, and I'm here today with Dr. Karin Johnson, and we're interviewing Dr. Johnson for the upcoming and recently published issue of Continuum on Sleep Neurology. We have been doing Continuum Audio for a while, but we're doing something different this time. As our listeners online can tell, we are recording this for the first time ever with a live studio audience at the American Academy of Neurology annual meeting in Chicago, Illinois. So, this is a fun experience for us. I hope it's been fun so far for you, Dr. Johnson.  Dr Johnson: Great to be here.  Dr Jones: It's great to have you. So, before we get into the interview, I do wanna introduce our team here for the live recording of the podcast. You've already heard Dr. Casey Albin's voice. Dr. Casey Albin is an associate professor of neurology at Emory University. Also serves as one of our associate editors at the journal and one of our Continuum Audio interviewers. So, she's going to be working the crowd today. Let's have a round of applause for Dr. Albin. And our guest of honor today is Dr. Karin Johnson. Dr. Johnson is a professor of neurology at UMass Chan Medical School and, Baystate Medical Center in Massachusetts. She is a world-renowned expert in sleep neurology and is the guest editor for the most recent issue of Continuum on Sleep Neurology. Dr. Johnson, welcome. Why don't you introduce yourself to our audience?  Dr Johnson: You did a great introduction, but I'm a clinical sleep medicine specialist. Spend my days seeing patients, taking care of people with narcolepsy, sleep apnea, restless legs, everything that comes my way. And then I have a side interest in doing sleep medicine advocacy, especially for permanent standard time.  Dr Jones: And we may get to that. I mean, that might be part of our conversation today. So, you've now read all of the articles in this issue, and it's a really great issue. There's a lot of new developments in sleep neurology. There are some updates for clinicians, people who see patients with sleep disorders that I think are, are timely and important updates. You have this unique view because you have just read all of these articles, really good articles by expert authors. When you read through these, Dr. Johnson, what was the biggest, what was the biggest thing that surprised you?  Dr Johnson: I think the biggest surprise for me is just so many changes in, in all of these articles. I realized how easy it was for us to make a journal that is so different from a few years ago. Whether it's Dr. Stahl's obstructive sleep apnea and new ways to think about endotyping sleep apnea that is gonna have treatment implications or the new treatments that are out there like tirzepatide, the changes that we're having with restless leg treatment. I particularly wanted to have a chapter on circadian neurology that Dr. Abbott did a great job really highlighting how if we think about the timing of when we give meds, the timing of when we eat, how that really can help neurological health, brain health, overall health, as well as mental health and cognition, especially as the AAN thinks about brain health as a whole, not just treating our patients, but how we can treat the population of people by improving sleep. I like how we hit on all these different areas in this issue.  Dr Jones: And I don't know how you managed to do it. They're just a small number of articles. We cover a lot of existing territory with well-characterized diseases, with new advances. But there's a lot of new stuff in sleep, and so somehow, it's all packed in there. It's really impressive. One of the things I was gonna ask you about was an evolution, and this has been a number of years now in how we manage restless leg syndrome. When I was training, it was all about dopamine agonists, and that was your first line. And over time, the evidence has supported moving away from that, and now we have more recent guidelines that have come out, and it's really the alpha-two delta-one calcium channel antagonists. How is that transition going? Do you still see people in practice who come in on dopamine agonists? How is that going? How's the field responding to that?  Dr Johnson: That's one of my most frequent restless leg consults. So even though it's been years since I have really initiated dopamine agonists in my patient, every day we get in people often on very high doses of dopamine agonists, and their doctors have just been escalating and escalating these meds over the years, and they come in with horrible augmentation. Their symptoms are much worse than they used to be, happening earlier in the day. And so, trying to get these patients off of these meds that are addictive, the way I like to teach about it is these dopamine agonists are the Fioricets of the sleep world. We know they work great, but in the long run, the patients are gonna be worse overall. And so, it's so hard to get people off these dopamine agonists, just like it's so hard to convince a headache patient that they don't need their Fioricet and that they're gonna be better off if we can get them off of it. What I think has really changed is we have more options to use. So, the alpha-delta-like agonists like gabapentin are now considered first line, but there's a lot of patients who they just don't work well enough with or they don't tolerate. And so, what do you do in that case? It's easy when that works, but and, when that doesn't work, we are being much more aggressive these days with iron replacement, potentially even trying to push ferritin levels in refractory patients up to three hundred, and using IV iron rather than just oral iron to get over the absorption issues to get the brain levels high enough. Motor stimulators, little cuffs that kind of go around the leg and stimulate the peroneal nerve in a certain way that not only can give people immediate relief, but also some data that suggests that over time it actually lessens their restless legs. We have agents like dipyridamole that work on the adenosine system in a sort of new novel pathway at addressing restless legs. And then the opiates, often meds like methadone or Suboxone can be used in some patients. But as we're getting more of these other options, often we don't need to go to those levels because we do have more to work with.  Dr Jones: So, the key point is lots of options. We're not starting with dopamine agonists anymore. And I think the fact that you're still seeing a lot of patients who have been initiated on that probably tells us there's an education gap field that we need to work on. So, another thing that I noticed reading through the issue was, and this feels like a change over the last few years, is the availability and the tendency to use in-home sleep apnea testing as opposed to formal, traditional in-lab. And that feels like a great new option, and maybe that increases and improves availability for patients who need access to the test. But how do you work through that?  Dr Johnson: So, I love in-home testing. We've been using it for over a decade. Other parts of the country where insurances didn't sort of mandate it are now being more mandated. I think the real change happened for a lot of places over the pandemic when labs closed down. But I think it's good because it brings a lot more patients to us. They get tested, they get tested quicker. People who would say, "I would never go into a lab. Oh, I'll do a home study." So, it just does bring more people in, and it gets them to treatment that they need that can really be life-changing. But it's not for everybody. The biggest people are people that have other bad pulmonary issues. If you're on oxygen therapy, you should not be getting a home study. That really should be a group of people that come in the lab. Similarly, if you have bad COPD, you probably should be getting a full in-lab study, so we can get more monitoring. Central sleep apnea is an interesting one. It can be very hard in some cases to differentiate the centrals and obstructive nature as well on a home study. Doesn't mean you can't do a home. So, if it's a person that just can't get an in-lab study easily, maybe you start with the home. If it looks purely obstructive, and you're all set, then you got an answer, and you can move on. But if you get back a home study that looks questionably central, they're gonna need to come into that lab. So, if you already know they're high risk because they're on narcotics, cause they have congestive heart failure, it's usually worth going straight to the lab. But again, you may consider a home study based on the patient. Patients that really cannot use the equipment can also be an issue. So, if they've had a debilitating stroke and have no one to help them put on that device, or cognitively they just can't handle the device, they're gonna be someone who's gonna benefit from coming into the lab and getting the help from the techs. So, those are the big populations that you might go starting for a home. And then the other thing that confuses a lot of people, the home is only for diagnostics. It really isn't for treatment. So, I have patients that say, "Oh, like, you can just titrate my CPAP with a home study." No. So if it's a treatment decision where they're not doing well on treatment, or I need to figure out do they need CPAP or BiPAP or IVAPS or one of these more complicated treatments, those are people that are gonna need to come into the lab to get that treatment portion of the evaluation.  Dr Jones: What a great summary. That's like everything I needed to know about who do I need to bring into the lab and who do I think maybe could do an at-home study. Really great. And speaking of devices, I think all of us who see patients in the room here and our listeners out there online have experienced patients, and this feels like a very recent phenomenon to me, are coming in with their commercial at-home wearable device. And they have printouts sometimes, and they show me their phone, and they give me some numbers that I don't really know how to interpret. Reading through this issue, I learned a couple of great new words. I learned about orthosomnia, right? So, people who become so preoccupied with their sleep, it keeps them awake at night, literally, right? I mean, it's a complete paradox. I learned about nearables, so things that aren't necessarily wearables that are just in the room while the patient is sleeping that monitor proxies for sleep quality, sleep stage, and other things. And I frankly, I'm not really sure what to tell patients. So, what do you tell patients who come in with all the data? Like, or how do you tell patients to use these?  Dr Johnson: I think these devices can go both ways. So, I do kind of say the pros and cons of these devices. I think for a lot of patients, they're empowering. It's getting them to think about sleep, to wanna know how good their sleep is. Are they getting enough sleep? So, if it's used in those ways, it's gonna be very helpful. I actually had a patient last week, and they noted that they're having big desats all night and could show me essentially an overnight oximetry data rather than me having to order it, and I had days of data, which sometimes can be too much. But in this case, it's like, oh, when he was on his side that night, he looked a lot better, so I can use that to give advice to the patient about particular treatments. He actually went down to Mexico, and a doctor friend gave him oxygen therapy while he was there randomly. And we could see on the nights that he had the oxygen therapy, it did really help his central sleep apnea pattern. And so that pushed us towards saying, "Let's qualify you for that up here in the States." So, I think in some cases it can give really important data. Now, I saw a posting on social media the other day of someone saying, "Can I get advice on how to improve my REM sleep? My tracker says I have no REM sleep, and I need to do something about it." There's really not data to support needing to do something about it. And so, I do think it can get some people on these wild goose chases, trying to get to a certain percentage of sleep. And these trackers, they're good in a lot of ways, but they're not perfect. He could be getting REM sleep that the tracker on him does not show. You want to relate it to what symptoms are they having. I think they can be very good for trying something out. So, let's say someone, has their tracker telling them they get five hours of sleep, and they try this intervention, and that helps them show that they got the seven hours of sleep, or they went from no REM to REM and it goes in the right direction. It can help give them that positive feedback that something they're trying, is working. But the absolutes for any given patient, it's hard to over-- What does it mean if it says you've got a 50% score versus a 70% score? That may or may not be meaningful in any given person, but again, they can compare themselves to themselves. If they were a lower score and now they're a higher sleep score because they did something that was meaningful, and that goes along with them feeling better, that can help give them that positive feedback to do something good.  Dr Jones: So, a little bit of a mixed picture.  Dr Johnson: Yeah.  Dr Jones: Sometimes they help. Sometimes they distract. Hopefully- Dr Johnson: And as a provider, sometimes it can be overwhelming because they're like, "Come look at my year's worth of data." And you're like, "No."  Dr Jones: Yeah.  Dr Johnson: You know, let me see one page or two pages of data and be like, "Yep, okay, I get it." Dr Jones: Just show of hands in the audience, who in the room wears a sleep device at night, like a ring or a, some kind of sleep monitoring app? That's about half the audience.  Dr Johnson: This is why they're here.  Dr Jones: So that's really helpful, and I think it is. You want to be supported by the data. You want to be supported by evidence and high-quality biometric evidence. Another big trend, and this has been a number of years in the making, is the understanding, Dr. Johnson, of the relationship between sleep physiology and neurodegenerative disease. One of the things I love about neurology is there's still so much left to learn about the normal physiologic functioning of the brain. So glymphatics and other aspects of sleep physiology that we didn't know about a decade or two ago. When you think about how that relationship has developed, sleep physiology, maybe sleep disorders and neurodegenerative disease, how has that changed your approach to talking to patients? Do you counsel patients differently now because of what we understand better about that?  Dr Johnson: Yeah, I mean, we are still limited with our data. We have so many studies that show the associations between whether it's not enough sleep, too much sleep, or having a sleep disorder like obstructive sleep apnea, and that being a risk factor for stroke or Alzheimer's or Parkinson's. But we still sort of lack the treatment trials that necessarily say, "If you treat obstructive sleep apnea, you're gonna have less dementia," or, "You're gonna be less likely to have that stroke." So, we have a lot of physiological studies, a lot of reasons why it makes sense, but we don't have that final, nail in the coffin to say, "If you do this, you'll definitely be better." So, we know certain groups are more at risk. If you have obstructive sleep apnea and you are symptomatic, you seem to have higher cardiovascular risk. If you have a person who's had a stroke and we find a milder case of sleep apnea, and they're someone that's totally asymptomatic. They say, "I sleep fine. I feel fine." There's not great data to say, "If you treat your sleep apnea, you're gonna be less likely to have a stroke." Now, if they come in and they're sleepy and their sleep apnea is really severe, and they have more hypoxic burden, which is also more connected with a lot of these risks, I'm going to say, "I think you are in the higher risk group of sleep apnea people who it's probably gonna be more likely to help your cardiovascular risk, your dementia risk." We can counsel them, and then it's really a personal decision. Some people are like, "No way. I'm never gonna use a CPAP machine, ever." And other people are like, "You know, my mom had a stroke. My dad had Alzheimer's. I want to do every possible thing I can to make it less likely that I have this outcome that I want to avoid." And so, you're going to take that in to, you know, do you want to try this treatment or not? It's a lot easier when you have outcomes that you can follow, like, "If I try CPAP, does my blood pressure get better? Do I stop having AFib attacks?" It's a lot harder when, will I or not get Alzheimer's ten years down the road or have that stroke?  Dr Jones: It's hard to get people to do things for kind of an abstract prevention down the road, but could be important. Are there trials going on that are going to assess this data?  Dr Johnson: Yeah. We currently have a big trial getting people right away, right after their stroke, on CPAP, and not only looking at prevention, but also looking at recovery outcome. It's been running for several years. Hopefully, we'll get enough data to close out the study coming up.  Dr Jones: We'll look forward to that.  Dr Johnson: Yeah.  Dr Jones: So, I'm really excited to get to our audience here, but before we do that, I do want to ask Dr. Johnson one more question. Dr. Johnson is famous for her advocacy for sleep in general, but specifically related to Standard Time. So, let's do a little experiment here. I didn't warn Dr. Johnson about this, so we'll see how she does. She does a ton of advocacy. She's a pro. So, pretend like we're in DC, and I'm a senator, and we just got in an elevator. You're going to give me your elevator pitch on what we should do.  Dr Johnson: So, you know, sleep is one of the few essential things in life. We need to eat, we need to drink, we need to have clean air, and we need to sleep and when we improve sleep, we can improve basically every outcome, whether it's academics, whether it's productivity, whether it's our physical health, our mental health. And the problem is we structure our lives in a way that really keep people, and especially our teenagers, from getting the sleep they need. And one of these structural things we do is permanent daylight savings time. Essentially, what you're doing is you're putting the sun out later, makes it harder to go to bed. I was just talking to someone, the sun's going down at 9:00, and you need to get your kid to sleep at 7:30, 8:00 so they can get the amount of sleep they need. That is almost an impossible task because their circadian rhythms are being pushed later, they can't fall asleep on time. Then you're setting their clocks an hour earlier, so when that alarm clock is going off at 6:00 AM in the morning, it's actually 5:00 AM in the morning. You're squeezing sleep from both sides, and it's basically impossible to get enough sleep. A lot of people think the only problem with daylight savings time is twice a year with the changes, and there are certainly harms related to that. So, a lot of people think if we went to permanent daylight savings time it would be better, and we got rid of those changes. What they don't realize is that permanent circadian misalignment by setting the sun more ahead, at 1:00 to 2:00 instead of at noon causes the sleep and circadian disruption all year round that leads to increased incidents of strokes, of heart attacks, of obesity, of cancer, of suicides, of depression, of worse academic grades. Again, pretty much every outcome you have there that relates to brain health, we have now data that shows that it's worse. And so, we can improve our lives if we can go to permanent Standard Time.  Dr Jones: You convinced me. How about that? If there were any skeptics in the room, I doubt there are any left. We only went to like the fifth floor there, and she... I'm like, "I'm voting for this. Whatever, whatever this bill is, I'm gonna vote for it." So, I'm excited to get to the audience here. Before we get to questions and answers, and we want you to get your questions ready for Dr. Johnson. I do have a couple of trivia questions. And we've been doing this for a little while now on the podcast. The first trivia question actually relates to arts and culture.  Dr Jones: What famous artist used transitions between sleep and wake states to inspire his art? Anybody know?  Guest Speaker 1: Is it Van Gogh?  Dr Jones: Not Van Gogh that I know of. There in the back.  Guest Speaker 2: Picasso.  Dr Jones: Picasso, not that I know of. Right here.  Guest Speaker 3: Salvador Dali.  Dr Jones: Salvador Dali. We have a winner. Thank you for your answer. So apparently, I read this. Salvador Dali would sit in a chair holding onto a metal key and wait until he fell asleep, and it would fall out of his hands and drop into a bowl, and it would wake him up. So, then he would pick it back up, and he would go in and out of sleep trying to generate hypnagogic hallucinations, basically, and he would use that to inspire his art. And you think about his art, maybe that kind of makes sense. All right, now I've got a neurology trivia question. Okay, so maybe we're a little more comfortable with the neurology trivia in here. What is the center in the brain that is responsible for REM sleep atonia?  Guest Speaker 4: The receptor is for erection in the lateral hypothalamus.  Dr Jones: That is not correct. REM sleep atonia. Right here.  Guest Speaker 4: Emilio Malgona, Hyannis, Massachusetts. Dorsal raphe nucleus.  Dr Jones: We'll give you credit for that. Very good. Excellent. So, the-  Dr Johnson: Well, no. That's actually the serotonin. He's talking about another one.  Dr Jones: Oh, I thought I heard, I thought I heard-  Dr Johnson: You heard dorsal  Dr Jones: ... I heard dorsolateral tegmental nucleus of the pod.  Dr Johnson: Not quite.  Dr Jones: You get a prize anyway, sir, just for, just for answering. Thank you very much. All right. So, we're all warmed up here. So, Dr. Albin, what do you think? Should we get some questions from the audience?  Dr Johnson: All right, we've got some questions.  Guest Speaker 5: I have a statement and a question.  Dr Jones: Please tell the podcast your name again, sir.  Guest Speaker 5: Steve Spar, New York City. The tyranny of the morning people. You don't want people, you don't want the sun to go down too late because it'll keep people up longer. I spent my whole life fighting people like you. I am a nighttime person. Why do I have to go to sleep earlier? I want to go to sleep later. I want to wake up later. I don't want to wake up at 7:00 in the morning. I want to wake up at 10:00. There's a certain tyranny that we must use circadian rhythms of the majority, and it persecutes people like me who are night people.  Dr Johnson: So that is a great question.  Guest Speaker 5: What say you?  Dr Johnson: What say me is actually the harms of daylight savings time are actually to the night owls, and don't really affect the morning people. I can still go to sleep on time and get up on time without that pressure of needing to go to work. The night owl people, they can't fall asleep until later. They want to sleep in earlier, but we're forcing them to get up an hour earlier for work and school. And because we're doing daylight savings time, you're not getting the morning light you need, you're getting too much light at night, and you are more sensitive to a delay in your circadian rhythm, which makes you even more of a night owl and increase the degree of social jet lag. So, we actually see that the harms and risks of things like depression, cardiovascular risks are much greater in night owls than they are in normal people or morning larks. And this is again why the risks are the highest for our teenagers, who are essentially all night owls. You're making it harder for them to fall asleep on time. You're making them more and more of a night owl that it becomes more out of line with our standard social schedule. So, what we can do for a night owl is say to our schools, say to life that we want to change our society norms of getting up early. But that has nothing to do with daylight savings time. That has to do with how we make our schedule Dr Jones: All right, next question. And introduce yourself to the audience.  Guest Speaker 6: Sure. I'm Sanjay Rathi from New Haven area, Neurology. Movement disorders, Parkinson's disease, sleep disruptions, sleep-regulating REM, RBD issues, what are your recommendations? And as things get worse, what additional intervention should we do?  Dr Johnson: Yeah, I think it's hard with a lot of our neurodegenerative disorders, it's a two-way sleep. The disorders themselves often worsen sleep quality, have decrease in their sort of circadian amplitudes, and so that can affect sleep ability. And so, trying to do the things that promote sleep, like getting lights down in the evening, keeping things dark and quiet, doing cognitive behavioral sort of therapies if that's needed can all be helpful. Very high incidence of obstructive sleep apnea or other sleep-disordered breathing, whether it's Parkinson's or other neurodegenerative disorders, so evaluating and treating that if need be. And some of these people, especially as they get later on, you may end up considering medication for insomnia because their underlying disorders was causing it and there's, and you're not going to CBTI your way out of it. We do have the new orexin antagonist sleep agents, which are more recommended for older people and probably safer agents than your Z drugs and some of the other sleep meds out there. So, some people should be on some of those meds if their sleep is so disrupted. I've seen some sleep studies where it's basically like wake, sleep, wake, sleep, wake, sleep all night long. And it's like, wow, you really cannot sustain sleep, and we think it's not just a behavioral thing. I think it is part of their underlying Parkinson's and underlying disorders that can really cause major sleep disruption.  Dr Jones: It's a great question. Before we get more from the audience here, Dr. Albin, I'm just curious, you know, you got some questions from online. Don't know if any of those stood out to you. And the other thing is, I think about your practice, Dr. Albin, as a neurointensivist, there's some great content in this issue on how to maintain an adequate sleep environment in the hospital and the importance of that for the acute episode, maybe for some long-term outcomes. When I was reading the article, I didn't really didn't think about the ICU setting. That must be-- what do you do in the ICU?  Dr Albin: Well, we happen to have a question about just that. Dr Jones: Well, there you go  Dr Albin: From Dr. Manners of Baltimore, Maryland. "What meds should I be giving patients in the ICU or the inpatient setting to preserve or recalibrate their sleep-wake cycles? Is there anything that we can do besides just getting them out of bed during the day?"  Dr Johnson: Meds are always hard cause as sleep doctors, we're usually the last one to recommend meds. But there are situations and scenarios where meds may be appropriate. I can't say what's one better than the other, and some of the meds we have probably aren't even available as options in the hospital. So, the, you know, again, the orexin antagonist may be a good class to try to use, but they may not be an option. There was a good study that looked at empowering the patient and whether or not the ICU patients are empowerable. But they give a card to the patients in the hospital and say, "Tell your nurse to turn off my TV and my lights. Do I need all the blood draws all throughout the night, or can it be put off to the morning?" And trying to empower the patient to ask for these things and do some of the behavioral things. And they found that doing that did improve the duration of sleep, did reduce some of the number of awakenings that people ended up having at night. So, I think the ICU is a very particular population where there's a lot of things you can't get rid of. But certainly, turning on the lights, turning off the lights, and trying to limit noises as much as you can, in those night hours, trying to give some sense of a 24-hour day. The other thing is feeding is really important to circadian rhythms. I had a patient that had a brain bleed and, after it, she just her circadian rhythms were just off, and part of it was she was getting tube feeds through the night. So, one of the very first interventions we did was to move her timing of her feeding so that it wasn't in sleep, and that really did help make a difference in getting her back on a pattern, along with light therapy and other behavioral techniques as well.  Dr Jones: It's a great question.  Dr Albin: Absolutely. I mean, I think that validates just that we spend a lot of time actually asking like, "Can we feed people during the day?" Or, "Can we, can we limit the amount of baths that are happening at 3:00 in the morning?" We also had another one from the audience that came from Dr. Lavina Singla of Mississippi, and I think a lot of our patients are asking this question. Is melatonin addictive?  Dr Johnson: Is melatonin safe? Is melatonin addictive? I think with any sleeping aid, people become addictive to what they perceive is the outcome. So, if they said, "This got me to sleep, and now I'm sleeping great, I don't want to come off of it." And so, you get this to meds that are truly addictive, but even meds that aren't felt to have that addiction, there is certainly a behavioral change. And that's a lot of what cognitive behavioral therapy is working with these patients on, is challenging that belief of maybe it isn't the med, maybe it's your internal belief and your worry about doing this. One thing about sleep is sleep happens when you are relaxed and calm and not worried. When you're worried about thinking that thing you're worried about is whether or not you're getting sleep, then you don't sleep. In terms of melatonin, if you don't need to use it, I wouldn't use it. If you are gonna use it, I'd try to use as low doses as possible. Do we know all the risks? We don't know. And especially I think there are potentially more risks in a growing child than, maybe someone who isn't having the same sort of hormonal, needs and growth needs. But then again, if you have, let's say, a kid with autism and melatonin helps him sleep, I'd much rather use melatonin than a lot of other agents, and if that really changes their functionality, that probably is very good for them and better than having them not get sleep. So, I think you have to weigh each individual situation and combine it, especially with the behavioral approaches so that hopefully this is not a long-term addictive thing you're on.  Dr Jones: So, it's complicated. Sounds like it.  Dr Albin: Not a straightforward answer.   Dr Jones: I thought that was gonna be just this hard no, but I guess it is something you have to think about. So, I want to really take a minute here to thank Dr. Karin Johnson, who has been our interviewee for this episode of the Continuum Audio Podcast sleep issue just came out. Really want to encourage our subscribers, our listeners, and our studio audience here to enjoy it. Thank you, Dr. Johnson, for joining us today. I want to give a big round of applause to Dr. Casey Albin for managing this crowd. Thank you to our listeners. Thank you to our subscribers. Thank you to you all for coming 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. Thank you for listening to Continuum Audio.   

Unruptured intracranial aneurysms and arteriovenous malformations are frequently discovered incidentally on neuroimaging, presenting complex decisions around monitoring, referral, and treatment. This episode highlights key risk factors for rupture, the role of imaging in evaluation, and practical approaches to triage and management, including when specialist intervention is warranted. In this episode, Gordon Smith, MD, FAAN, speaks with Edgar Samaniego, MD, FAAN, authors of the article "Unruptured Intracranial Aneurysms and Arteriovenous Malformations" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Smith is a Continuum® Audio interviewer and a professor and chair of neurology at Kenneth and Dianne Wright Distinguished Chair in Clinical and Translational Research at Virginia Commonwealth University in Richmond, Virginia. Dr. Samaniego is a professor of neurology, neurosurgery, and radiology and the director of the vascular neurology fellowship at the University of Iowa in Iowa City, Iowa. Additional Resources Read the article: Unruptured Intracranial Aneurysms and Arteriovenous Malformations 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: @GordonSmithMD Guest: @esamaniego Full episode transcript available here Dr Smith: Have you ever ordered an MRI of the brain and found a coincidental unruptured aneurysm or perhaps an arteriovenous malformation? If so, are you up to speed on how to manage this common situation, how to monitor, when to refer, and how to counsel your patients? If your answers to these two questions are yes and or no, then please keep listening.  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 Smith: This is Dr. Gordon Smith. Today, I'm interviewing Dr. Edgar Samaniego about his article on unruptured intracranial aneurysms and arteriovenous malformations. This article appears in the June two thousand twenty-six Continuum issue on cerebrovascular disease. Edgar, welcome to the podcast, and maybe you can briefly introduce yourself to our listeners.  Dr Samaniego: Yeah. Thank you, Gordon. So, I'm an interventional neurologist. I'm practicing at the University of Iowa. I've been in Iowa for the last ten years. I'm originally from Ecuador. Did my residency in Wisconsin, and then I went to Stanford for neuro critical care and stroke. And then I did my neurointerventional fellowship at the Baptist Cardiac and Vascular Institute in Miami.  Dr Smith: You're a triple threat in the world of vascular and critical care, which I want to get to later. But your article's really great. I'll admit one of the first things I do when I read an article for Continuum Audio is I see how long it is. I saw yours was as long as the rest, and I was a little surprised because this sounded like a simple topic. But having read it, it's anything but simple. This is really important and complex stuff. I wonder if maybe you can orient our listeners to the importance of this. We frequently find unruptured aneurysms or vascular malformations on brain imaging that we order for something else. I mean, how common is that, and why do you think our listeners need to be particularly attentive to our conversation today?  Dr Samaniego: It's pretty frequent that we see patients with unruptured brain aneurysms. A lot of times, you know, we do imaging like CT angiograms, or magnetic, resonance angiography. Patients come to the ER with headaches, and we find an unruptured aneurysm. And you know, the question always comes, "What should we do with this aneurysm that we found?" We know that a lot of these aneurysms will not rupture, but the caveat is that when they rupture, like fifty percent of these patients may die or have bad outcomes. So, it's always a puzzling question, you know. What should we do with the aneurysm?  Dr Smith: Well, thanks, Edgar. I mean, this is certainly something that I come across. I'm glad to hear that other people struggle with this as well. What actually is the prevalence of aneurysms in the general population? How common is this?  Dr Samaniego: It's more common than what we think, you know. The, the estimates talk about like one in every fifty people have a brain aneurysm, and about every eighteen minutes an aneurysm will rupture. In the United States, there's approximately thirty thousand ruptures per year. So, there's a significant number of, of patients affected by brain aneurysms. And, and the key thing is that affects usually younger patients who are in the most productive years of their lives. So that's why it shouldn't be ignored, and once we find an aneurysm, we have to have all the information for triaging and deciding on treatment of these aneurysms.  Dr Smith: Well, it's a great way to begin our conversation. I mean, this is not a rare problem. It's a common problem, and there's actually a really great section of the article I'll refer people to about medical malpractice and the importance of recognizing and dealing with this thoughtfully. It's an empowering section, not a scary one, but this is important for our listeners to know about. Pretty high-stakes stuff. Maybe you can orient listeners like me or maybe simple neuromuscular people. What different types of aneurysms are there?  Dr Samaniego: That's the interesting question because there's multiple types of aneurysms, and there is a whole spectrum of aneurysm. When we say aneurysm, you can be talking about a fusiform versus a saccular aneurysm. We tend to classify them based on shape, also location. But the two main classifications for brain aneurysms will be saccular, which, you know, has a sac kind of morphology shape, and then you have the fusiform aneurysms. Those are the main morphological classifications. Then on top of that, you have two other subtypes that you see quite often. The one that we see is mycotic aneurysms that is like a misnomer because it's not a fungal aneurysm. It's just an infectious aneurysm that most of the time we see on the setting of endocarditis. These behave a little bit different than the typical saccular or fusiform aneurysms. And then also you have other more rare types of aneurysms like blister aneurysms that are sometimes located in the anterior wall of the carotid artery. So, you know, within this spectrum, we have those main aneurysms. The typical aneurysms, which can be fusiform or saccular, and also the more atypical, which can be mycotic and also blister-like aneurysms.  Dr Smith: I wonder if you might comment a little bit on the relevance of the type of aneurysm, fusiform, saccular, blister, and then location on rupture risk or prognosis.You have a really great figure about anatomic classification in the article actually that I encourage everyone to check out when they hopefully read it. But what do these characteristics imply for risk?  Dr Samaniego: Yeah. This is very complex question because, you know, entails different characteristics of aneurysms such as shape, the location, morphology. So, we know that some locations, for example, the anterior communicating artery has a high risk of rupturing as opposed to patients such as the part of ophthalmic aneurysm, which are usually located at the origin of the ophthalmic artery in the internal carotid artery. So, by risk of rupturing, the highest risk is usually the anterior communicating. Then you have posterior communicating artery aneurysms, which are usually located in the internal carotid artery, but because of their proximity to the origin of the posterior communicating artery, they're called posterior communicating artery aneurysms. Then you have the posterior circulation aneurysms on top of risk of rupturing is the top of the basilar artery location. Those three are the highest risk for rupturing: ACOM, PCOM, and top of the basilar. In terms of morphology, I always tell my patients, you know, if it's like a nice-looking aneurysm that has this rounded shape is a benign morphology. If you have the aneurysm that's having these Mickey Mouse ears that has these blebs or daughter sacs, those are aneurysms that usually scare us because those are the ones that usually rupture. So that's another criteria, morphology. And then the other criteria would be size. There is this magnificent study called ISUIA, which was published several years ago, and basically what it demonstrated was that aneurysms that are seven millimeters or larger are more likely to rupture versus smaller aneurysms. So those are the three criteria that I'm looking into when talking to patients about morphology, location, size, and the, the shape or morphology of the aneurysm.  Dr Smith: So, let's say a general neurologist or comprehensive neurologist practicing in a community setting in a rural area orders a, let's just say a CT or CTA for a patient with a TIA and finds what looks like an aneurysm. What's the next step in terms of imaging? What's the best next step? I mean, there are a bunch of different imaging modalities. Do you get an MRA? Is it time-of-flight, contrasted? You know, when do you get a DSA and so forth?  Dr Samaniego: Yeah. The first thing to do is to better characterize the aneurysm. Order of more accurate imaging that we can obtain without being invasive with a diagnostic cerebral angiogram. The rest will be a magnetic resonance angiography with contrast that, you know, gives you really good detailed information about the aneurysm. Similar in terms of quality and precision will be a CT angiography. The caveat there is with CT angiography is that, you know, you use radiation, and the patient has to get iodine. And then under those two, you will have a time-of-flight magnetic resonance angiography, which doesn't use any contrast, but then you lose a little bit of quality in terms of the imaging and some morphological features you might miss. So usually what we do in my practice, I don't wanna do a diagnostic cerebral angiogram, and somebody has to refer an unruptured aneurysm. I try to do CT angiogram as a baseline, see how the aneurysm looks, and then for follow-up, I usually do magnetic resonance an- angiograms with with contrast. If there is a concern that the aneurysm has some dangerous features like it's irregular in shape, it's, it's larger, it's in one of these high-risk locations, might be better just to refer the, the patient to a specialist for a diagnostic cerebral angiography.  Dr Smith: So, you know, there are these scales that you talk about in the article. There's phases in the UIATS that are used to predict rupture risk and guide decision-making. Are these scales that general neurologists or non-vascular neurologists can use to guide care? I'm thinking of like Chad-Baskin, ASBAD, which, you know, all our residents know about. Should we all be familiar with these scores?  Dr Samaniego: I think they're very helpful in the sense that it will give us some guidance. Some of the characteristics of the scale might be up- outdated. For example, like ancestry. Although it's been described more in Japanese and Finnish populations, and North American, not as much as these two other populations. We do see a lot of aneurysms in people from North America and other backgrounds. For example, one of the biggest critiques for the phases is that doesn't take into account smoking history. Smoking that we know is a risk factor. And the other critiques for phases is that, for example, if you are older than seventy years old, you will score one point, which will increase your risk of aneurysm rupturing. Having said that, we do see like tons of aneurysms on younger patients, actually the most productive years of their lives that they rupture. So, it gives you some parameters like the presence of hypertension, the size, as I said, seven or larger, previous history of subarachnoid hemorrhage, and the location of the aneurysm. But it doesn't take into account other factors like smoking or morphological features of the aneurysm. Dr Smith: Now, you mentioned size. I'd like to maybe go back and talk about a case from your article, which I found really impactful. For our listeners, this is a sixty-four-year-old woman who had a five-millimeter ACOM aneurysm. She was imaged serially, didn't change over the time period, and then two years later ruptured with devastating consequence, right? And so that's a small aneurysm. Most aneurysms, I guess, are small aneurysms. I just wonder, when you see a patient like that, how do you handle the discussion regarding risk? And how do you decide when to refer them for an intervention?  Dr Samaniego: Yeah. It's always puzzling when we see these smaller aneurysms. And this example is a typical example of a patient that doesn't follow the rule of seven or larger aneurysm size for rupturing. We see that quite often on aneurysms located in the anterior communicating artery. Just this last week, I treated two patients with similar characteristics, with smaller aneurysms, like average size between four and five, that rupture, and both were located in the anterior communicating artery. So, we know that there is definitely a linear relationship between size and risk and rupture, but we do see a lot of patients that have smaller aneurysms, like three, four, five millimeters that rupture, and we don't really understand very well the, biology of these aneurysms. So, when we see these aneurysms, we try to maximize the characterization of the aneurysm with better imaging, try to see the morphology. And usually when an aneurysm is discovered, what we do for follow-up is a six-month follow-up with some type of imaging, CTA, MRA with contrast, and see if there's has been any change in, on the aneurysm.  Dr Smith: So, is it fair to say that a knowledgeable non-vascular neurologist can safely manage these patients, follow them over time using what they learned from reviewing your article, identify patients who have higher risk aneurysms based on the characteristics you summarize, and refer them to a tertiary center? When I get these, it's easy for me to have our vascular neurosurgeon see them or a vascular neurologist, right? But in a community where you may not have ready access to that subspecialist, is it still important to get all of these patients to a tertiary center? Are there select instances where a community-based general neurologist can follow them and then refer if there's change in size, for instance?  Dr Samaniego: Yeah. I think that everything else that we do in neurology, it's important to do some type of triage in referring some of these patients for further studying and  expert opinion. I think age and size of the aneurysm, age of the patient and size of the aneurysm are huge factors. For example, if we have an older patient in their nineties and has incidentally found two-millimeter aneurysm in a low-risk location like the parathalmic, that patient probably needs to be seen locally. I don't think merits a full workup. As opposed to a younger patient with a three-millimeter aneurysm located in the ACOM. I think that type of patient probably needs to be referred to a tertiary s-stroke center for workup. I mean, most of the time what's gonna happen is that if it's a small aneurysm with benign characteristics, you know, it's gonna be seen by the specialist and they're gonna determine some type of follow-up, which can be done locally.  Dr Smith: So maybe we can pivot a little bit and talk about AVMs, if that's okay. What's your approach to a coincidentally discovered AVM, right? I mean, presumably, we need to think about symptomatic AVMs a little differently, I would think. So maybe we can start with the same scenario we've been talking about. You get an imaging study for something else, and, well, we find an AVM. What's the approach to that situation?  Dr Samaniego: Yeah. AVMs are fascinating vascular lesions because they're very complex, they're very heterogeneous. If we're talking about the morphological features with aneurysms, this, in the case of AVMs, is way more complex in terms of location size. The complexity added to AVMs is that you have a feeding artery, you have a nidus, and then you have draining veins. So, all of these can be very heterogeneous. In case of AVMs, I think those definitely need to be referred to a tertiary center because the management of AVMs is multidisciplinary, even in the tertiary centers. You know, we don't have a magic wand that will say, you know, all these AVMs need to be treated this way. Sometimes they don't even need to be treated because we know from some studies that just watching them will be good enough.  Dr Smith: You raised management of AVMs. Maybe we can go back and talk a little bit about what's the latest in management of aneurysms. You manage aneurysms from soup to nuts and as an endovascular interventional neurologist. What's the latest in management of aneurysms?  Dr Samaniego: The latest is that, which falls within management, is that we have tools that they have not really been validated a hundred percent because we're still understanding the biology of some of these aneurysms. But high-resolution MRI will help us to define if there is some enhancement of the aneurysm. There is the thought that if there is enhancement after the administration of contrast, might be more of an inflammatory process. So that can be used for management, triage, and follow-up of some of these aneurysms. In terms of endovascular treatment, it has been really a revolution of how we treat these lesions. You know, we have a lot of new devices, better catheters to access the aneurysms.There is devices that you can place inside the aneurysm sac and it'll completely shut down flow into the aneurysm. There is other special stents called flow diverters that can take the flow away from the aneurysm and bypassing the aneurysm. So, all of these things have really revolutionized how we treat them. Having said that, you know, there's always a risk with any of these procedures, and that's why we gotta be mindful when we decide to treat these patients with unruptured incidentally found aneurysm.  Dr Smith: I've got just one more question, Edgar, which I kind of led with. You've got training as a vascular neurologist, a neurointensivist, and an interventional neurologist. And you know, Ralph Sacco, as you probably know, used to like to talk about the neurologist, and part of the neurologist was interventional. I wonder what wisdom you have to trainees that are listening to us right now who might be interested in pursuing a career as a neuroendovascular neurologist. What wisdom do you have for them about how to go about doing that?  Dr Samaniego: It has been really rewarding to be part of this process and evolution of treating a stroke and aneurysms and AVMs because I remember when I was a resident at the University of Wisconsin, we only had, like, thrombolysis and only one device for, retrieving some of these clots. But now we have, like, 10 different devices. We have two different indications or two, two different thrombolytics. So, my best advice for trainees that want to pursue neuroendovascular is to get engaged early on, understand very well the biology and the thought process because it's not only a technical field. You have to have really good judgment on when to do and when not to do the procedure, and try to find mentorship. You know, there is a lot of neurointerventional neurologists out there right now. Having a good mentor will really facilitate your career choices and getting into training.  Dr Smith: Well, Edgar, thanks so much. What an exciting conversation. It's just another great example of how exciting neurology is these days. Many exciting advances and innovations, and we just scratched the surface. I encourage all of our listeners to read the article. It's actually really, really informative. So, thank you very much.  Dr Samaniego: Thank you so much, Gordon.  Dr Smith: Again, today I've been interviewing Dr. Edgar Samaniego about his article on unruptured intracranial aneurysms and AVMs. This article appears in the June 2026 issue of Continuum on Cerebrovascular Disease. Be sure to check out other Continuum Audio episodes from this and other issues, and thanks to you, 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.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/NCPD/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/DYP865. CME/MOC/NCPD/AAPA/IPCE credit will be available until July 2, 2027.Charting a New Course for Alzheimer's: Adapting Clinical Practice to Evolving Patient Needs in the Era of Early Disease Detection and Modification In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Lilly.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/NCPD/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/DYP865. CME/MOC/NCPD/AAPA/IPCE credit will be available until July 2, 2027.Charting a New Course for Alzheimer's: Adapting Clinical Practice to Evolving Patient Needs in the Era of Early Disease Detection and Modification In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Lilly.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/NCPD/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/DYP865. CME/MOC/NCPD/AAPA/IPCE credit will be available until July 2, 2027.Charting a New Course for Alzheimer's: Adapting Clinical Practice to Evolving Patient Needs in the Era of Early Disease Detection and Modification In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Lilly.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/NCPD/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/DYP865. CME/MOC/NCPD/AAPA/IPCE credit will be available until July 2, 2027.Charting a New Course for Alzheimer's: Adapting Clinical Practice to Evolving Patient Needs in the Era of Early Disease Detection and Modification In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Lilly.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/NCPD/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/DYP865. CME/MOC/NCPD/AAPA/IPCE credit will be available until July 2, 2027.Charting a New Course for Alzheimer's: Adapting Clinical Practice to Evolving Patient Needs in the Era of Early Disease Detection and Modification In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Lilly.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/NCPD/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/DYP865. CME/MOC/NCPD/AAPA/IPCE credit will be available until July 2, 2027.Charting a New Course for Alzheimer's: Adapting Clinical Practice to Evolving Patient Needs in the Era of Early Disease Detection and Modification In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Lilly.Disclosure information is available at the beginning of the video presentation.

Recorded live from the IFNA World Congress in Australia, Sharon and special co-host Kevin Chem welcome Richard Henker, PhD, CRNA, FAANA, FAAN, whose work with the World Health Organization and the G4 Alliance is helping reshape global anesthesia through data. We'll explore ​how ​the ​Operative ​and ​Encounter ​Registry ​serves ​as ​a ​simple ​point ​of ​care ​tool ​that ​allows ​anesthesia ​providers ​to ​capture ​essential ​surgical ​and ​anesthesia ​data, ​making ​our ​care ​visible ​in ​ways ​it ​hasn't ​been ​before. Here's some of what you'll hear in this episode:

The period immediately after hospital discharge is a critical yet often overlooked phase in stroke recovery, marked by both heightened vulnerability and opportunities for rapid brain repair. This episode explores the concept of transitional stroke care, emphasizing early specialist follow up, coordinated multidisciplinary support, and targeted interventions to improve outcomes and reduce complications. In this episode, Katie Grouse, MD, FAAN, speaks with Mona N. Bahouth, MD, PhD, FAAN, author of the article "Transitional Stroke Care and the Road to Recovery" 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. Bahouth is the medical director of the Brain Rescue Unit and an associate professor of neurology at Johns Hopkins School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Transitional Stroke Care and the Road to Recovery 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: @MonaBahouth Full episode transcript available here Dr Grouse: A lot of attention has been paid to what happens within hours to days of a stroke, but are we missing an equally crucial time in our patient's recovery after their discharge? Today, I have the opportunity to interview Dr. Mona Bahouth about the latest issue of Continuum 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. Mona Bahouth about her article on transitional stroke care and the road to recovery. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast, and please introduce yourself to our audience.  Dr Bahouth: Thank you for having me. I'm Mona Bahouth. I'm a stroke neurologist in Baltimore, Maryland, and I'm the medical director of our brain rescue unit at the Johns Hopkins Hospital. Great to be with you.  Dr Grouse: Thank you so much. This was a very interesting article. I have to confess going into it, I really didn't know a lot about transitional stroke care and the growing sort of recognition of its importance for stroke recovery and improved outcomes. Can you tell me what the key message from this article is that you really hope that readers will take away after reading it and hopefully integrate into their own patient practices?  Dr Bahouth: Yeah. I would say if there's one overarching message, it is that stroke care has come so far over the last couple of decades. We do so much wonderful life-saving work in the first couple of hours and days after stroke, but we haven't really paid as much attention to what happens once a patient leaves the hospital with this devastating acute disease. And I would just like to say that this article allows us to shine a light on providing a little bit more of a system of care, a more structured system of care that could benefit the patient for the long term, then that will benefit a large population of patients who otherwise may have complications that could cause disability longer in life.  Dr Grouse: Now, Mona, could you tell us in a nutshell, what is transitional stroke care, and why are we needing to focus more of our attention on this to improve patient recovery?  Dr Bahouth: Yeah. Over the last few years, we've really done a wonderful job of reducing the time that a patient spends in a hospital after stroke care. But in parallel, we have not really changed anything about what we do in the outpatient setting. So, a patient tells us that they come to the hospital with this acute and very scary and disabling disease. They feel that they're the center of the universe at our stroke centers, where we're hustling around them in groups and in interprofessional teams. But then on the day of discharge, they feel that they leave the hospital, and in some of our focus groups, that they kind of go home to a, a dark bedroom where they have to process all of this sort of on their own. It's quite a transition for both patients and their care partners. And here we've been very systematic about how we structure our care in the hospital for stroke patients, but once they leave the hospital, it's been a sort of free-for-all, or the Wild West, as some of my colleagues say. So transitional stroke care is really a way to extend the care that we deliver in the stroke unit to the patient's home or to their next phase of care. We know that stroke patients have 11 handoffs from beginning to end, in average, that they experience through the course of their acute stroke. And so, what we're really trying to do is extend the, the stroke unit to the patient's home or to their next phase of care so that they feel a bit more extension of that specialty care that they were receiving in the hospital. So, it's really a structure, a system.  Dr Grouse: Now, it seems that when we're thinking about the transitional care period, that it really hinges on this idea of sort of the sensitive period of stroke recovery. What is that, and why is that so important, and why do we really need to focus on that specific time?  Dr Bahouth: There are really two reasons that this is a critical period for patients. One is that we know from work in animal models as well as other sort of human early studies that the brain really has its optimal period of efficient brain repair in the first few weeks after stroke, meaning that it's recovering after this injury and figuring out how to reroute some really important brain functions. I would say it's also a critical period because the time period after stroke is a period that all the comorbid conditions that sort of conspired to cause a stroke are sometimes destabilized. And we know that sort of just putting people back on standard regimens for their hypertension, their diabetes, their heart failure doesn't always equate to sort of long-term improved outcomes at a time that the brain itself is going through changes. So, for example, we know that blood flow is critical to the brain. That's what all the hustle is about in the hyperacute period. And for the next couple of weeks after a stroke, autoregulation remains disrupted, so typical treatments of hypertension could have negative consequences for a subpopulation of patients. This management of hypertension needs to continue for a couple of days and weeks after stroke, and therefore, if a patient is discharged from the hospital, really requires a bit more specialty input. We also know that as the brain is trying to repair during the sensitive period, this high period of efficiency, we really want to inject high-intensity, high-quality activities that really improve their recovery. But in our current system in the United States, our transition to the period of rehabilitation is really quite clunky and disrupted and doesn't often happen in a seamless way. So, a true transitional stroke care program really attempts to manage the stroke itself. The comorbid conditions that conspire to cause the stroke, and the expedition of, of rehabilitation that could really jumpstart the recovery period in a more meaningful way.  Dr Grouse: Now, you mentioned hypertension as being sort of a critical factor that can affect the patients during this transitional period or this sensitive period. What are some other factors that can really play a huge part in their long-term outcomes in this really sensitive time?  Dr Bahouth: In our transitional stroke program, in our interprofessional group, we often talk about all of the changes that a patient is required to make at the time of stroke. Typically, they stay in the hospital several days. The patient and their care partner will receive a bolus of instructions about what their new healthier life should look like, and then they're sort of sent off to sort of self-manage without really accepting that that wasn't the perfect time to teach these things. So really, it's all about sort of lifestyle improvement. How do we get into a system of medication adherence when medications are a central portion of a patient's care? It is about managing the cognitive changes that happen after stroke, whether we acknowledge them in the hospital as a main deficit or something that people realize once they get back into the groove of their usual life, and the emotional consequences of stroke for both the patient and their care partner, who are both adjusting to this very scary moment that resulted in a brain injury. So, I think that the things that are focused on are both medical in terms of, you know, what are we doing with the diabetes? Is our glucose at a target range? Have we started wearing our sleep apnea paraphernalia? Are we managing our smoking cessation as much as we should? How have we done with our low-fat diet? Are we taking our medications as prescribed, or was there some cognitive blip that caused a mistake? But also sort of the emotional support that sometimes paralyze patients into sort of saying they cannot handle this transition into a new healthier way of brain recovery.  Dr Grouse: Yes, and it sounds like when patients sort of hit that wall, they almost just give up, right? There's just so many things they have to manage. They're emotionally trying to cope, and then they may eventually get to their neurologist at some point for a follow-up, and not much has happened.  Dr Bahouth: That's a really well-put statement. Like I mentioned earlier, we had several focus groups to say, "How's our stroke center doing? How is our comprehensive stroke center doing?" And we realized that we were very comprehensive while the patient was with us, but then the experience of the patient going home was really opposite of receiving comprehensive care. You know, the patient in the hospital said they felt well-supported, surrounded, quite busy all the time, but then they did go home, and this sort of set in that they've had a stroke. And many patients told us, "I just laid in bed because I couldn't quite kind of get through the thought that this has happened to me." And so, in our prior state of our comprehensive stroke system where patients weren't seen for a couple of months after their discharge, patients would tell me, "Well, I'm fine now.  But those first couple of months, I sure wasn't. You know, I was laying in bed. I was crying. I wasn't taking my medicines. I had a lot of despair and fear." Care partners would say, "I wasn't sleeping myself. I was watching to see if another stroke was gonna happen every minute." So, there are a lot of elements that are going on in those first two weeks that really require a specialist to say, "This is normal. This requires more attention," and to really help people get through a lot of the changes that come with stroke and brain injury.  Dr Grouse: Now, your article gave a really great, I think, example, where you had a juxtaposition of a hypothetical patient with a stroke and two very different post-discharge courses, one where they really kind of fell into that vacuum, that post-discharge vacuum, where they didn't get support and had some very disappointing outcomes versus a patient who did have a transitional care program with a lot of support post-discharge, and a lot of obstacles were overcome and problems solved such that the patient could do a lot better. And I encourage our listeners to take a look at it. If you could design and run it, how would your ideal transitional post-stroke program be structured? Like, how would you design it so that it would optimally support these patients?  Dr Bahouth: Yeah, you know, we, um, tangle with this every day in our current transitional stroke program that we call the JSTEP program. We've had several chapters of what we think is ideal for a patient, and thank you for sort of acknowledging that, like, the way those cases were written were really to underscore that we can have a lot of influence for patients. And while they were sort of hypothetical juxtapositions of one another, these are things we literally see every single day for our stroke patients. And people say, "Oh, if only we had done this, we would've caught that, and we would've prevented such-and-so." Some of the indicators of success have been we've really reduced our readmission rates to the hospital. We have decreased our length of stay because the confidence people feel to go home because they're well supported. So there have been indicators of success. But if I could take our program even next level, I would probably include a few other things. So currently, some of the strengths of the program are that a stroke specialist sees a patient within days of their discharge from the hospital, a time where some of those questions are sort of raising for the patient. Maybe a complication is starting to pop up that we can address before it, uh, gets out of hand and requires a readmission. We can tackle some of the fears that patients are having to say, "I wonder if this is normal or not. I better just go to the hospital." So, some of that early touch point by a true stroke specialist is really critical. And that visit only happens because the seed is planted in the hospital, so there really has to be some initiation of the program at the time the patient is in the hospital to say, "This is what you can expect when you leave here. You have someone who's walking this with you. They're a stroke specialist. They're gonna know how to help you navigate." The second part of our program that is a success is our rapid connection to specialties. So, we know that stroke patients are gonna need connection to rehabilitation specialists, physiatrists, the therapists. We know they're gonna need connection to cardiology when atrial fibrillation or heart failure or something is really at an extreme.We know endocrinology might be a part of the patient's story going forward. And so, I think the second success of our program is really alliance with key stakeholders in a stroke patient's life and quick access to having the patient be connected to what it is they need in the moment that we realize that there is a situation at home. The third thing that I think has been really a success of our program is this interprofessional education that we schedule patients for at the time of their discharge, just as any other important healthcare visit. During this interprofessional education session, the patients get to meet dietician, pharmacist, nurse, therapist, where key discussions about healthy behaviors, avoidance of complications after stroke really happen in a group session where there can be a lot of interaction. You know, currently our education happens in a time where the brain is injured, the patient is not sleeping well in the hospital. We have a lot of stress and fear. It's not the perfect time for anyone to receive such important education. So, I think the third really most important thing has been this formalized interprofessional education to really bolster the education that started at the hospital. If I were to really take our program next level, and every day we're considering it, I really think we haven't done a couple of key things. One is we have not really found a way for the care partner to be supported, that the care partner is usually the brave one sitting there with a tight lip and nodding and very, you know, concerned about what's happening and taking close notes. But we really haven't done well to just manage the care partner's needs sort of independently of the patient themselves, sort of help them with the experience of going through this. I think that could benefit both the care partner and the patient by sort of bolstering their sort of emotional consequences of this. And they are really our key partner in the patient's success in the outpatient setting, getting the patient motivated, helping them get to appointments, helping them to adhere with medications. So, I think if we can focus a bit more on the care partner, that might really bolster the long-term effect for patients. And I think finally, behavior change is very complex. Sometimes we're taking a group of patients who may have never exercised and said, "You know, we really... You need to walk several minutes a day. You need to increase your aerobic capacity. We need you to stop smoking." And these are not behavior changes that can just happen with sort of a one-time visit. So, I think we really need to incorporate a lot more of exercise therapy and concepts of people who can sort of coach along the continuum for some of these behavior changes so that we can really promote wellness and a return to health. And I think one final thing that could be additive from a transitional stroke program is really a better way to truly measure recovery for stroke patients, some of those in between the line measures that we're not really getting by a three-month modified Rankin score. I think a transitional stroke care model would really allow us to both insert research and potential other therapies along this time period, but also measure the success of those in a more granular way.  Dr Grouse: Thank you so much for that, and also it was really helpful to get a good overview of, like, what the transitional care program really means, right? Like, what is the structure? What is happening with the patient? So, I think all of that's really helpful. But I can't help but think, listening to all of that, that sounds like while certainly in an ideal state, and I don't think anyone can argue with how helpful that sounds, is it always something that's practical? Can we implement things like this, especially where access is limited, resources are dwindling as far as what patients can get and what evaluations patients can get? Do you think that this is something that can actually be implemented in programs throughout the country? And what are strategies we can consider to try to improve getting some of these resources for our patients?  Dr Bahouth: I think this is such a critical topic. I think that we have, in the medical system, tried to force our healthcare practices into old models of care instead of sort of adopting new ones. And so, I think that, you know, while everyone says, "Wow, that sounds like a very resource-rich program," I would have to stop and push back and say, well, a very resource-rich situation is when a stroke patient, sometimes fifteen to twenty percent of the time, are readmitted to the hospital at a time where hospital beds are at a premium. Maybe we need to turn those dollars of savings of sort of these readmissions and extra length of stay into dollars that we put into sort of this transitional period where we help promote success. So, I think it really becomes more of a value proposition when you talk about it. But that said, of course, we have to make sure that we're a high-value, high-productivity system. So, our current transitional care program uses a telemedicine structure. We know that stroke patients cannot drive in most states after their stroke. We know that their care partners are trying to return to work and normalize. It is very difficult for patients with paralysis, cognitive changes to come back and forth to multiple appointments. In the past, we have tried to make this transitional care program an in-hospital program. I think using the technologies that we have available for telemedicine are critical, especially for this population who have barriers to getting to their appointments. So, I think with a very low resource investment, a transitional care program can be created once you really develop the skills of the, the stroke team to really reach beyond the hospital with the tools that we already have in the hospital and just extend that to the next chapter. It is an investment, most certainly, but I think it's one well worth the investment for the patient's success, their quality of life, as well as some of the value metrics that we judge our hospitals by.  Dr Grouse: Are some of the transitional care codes that CMS has put out in recent years helpful to get some reimbursement for these types of visits?  Dr Bahouth: Absolutely. So, I think that's been a really wonderful policy change that has happened, recognizing the importance of these transitional care models. There are billing codes that allow you to have higher billing than a usual neurology appointment when a patient is within a certain window, meeting certain criteria for their eligibility for such a visit.There are codes that have now been developed and are being more and more utilized to have visits with care partners and realize that the care partner is an important member of the equation of this patient's success. So, there are definitely codes that can be used. I think we're very good in healthcare of delivering a lot of free care, but that's not the nature of the beast these days. We have to really be very aware of our dollars and cents, and so utilizing some of these important codes that I hope only continue to expand to recognize the importance of the transitional period for patients.  Dr Grouse: Now, Mona, I wanted to ask, was there anything that you wish you could have included in this article that didn't make it in?  Dr Bahouth: You know, obviously, um, word limitations are always challenging. I think that the article, I think, does a good job going sort of from beginning to end. I think a deeper section, certainly we have commented on the sort of sociodemographic challenges of a program like this that also relies on a technology like telemedicine in many cases. But there are so many nuances to that conversation that I think that section could have definitely gone on for a much longer period of time to talk about some of the strategies, the strategic ways that we work hard to make sure that these type of transitional care programs are accessible to all, especially the vulnerable who may have challenges with accessing technology. But I will say it is possible. You know, we are in a urban city. We see a lot of patients with various insurance status and access to technologies, and we've had a very high show rate in our post-hospital transitional program, so it can be done with a thought and, uh, care to those vulnerable populations who may need more attention across the transition.  Dr Grouse: Well, I really appreciate all the work you've done in this area, and it sounds like it's an area that will continue to grow as we learn more and hopefully improve. And I really appreciate you taking the time out of your day to talk with us about your article.  Dr Bahouth: Well, thank you for having me, and it's a topic that's near and dear to us, so thanks again for highlighting its importance.  Dr Grouse: Again, today I've been interviewing Dr. Mona Bahouth about her article on transitional stroke care and the road to recovery. 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.

In this episode, editor-in-chief Joseph E. Safdieh, MD, FAAN, highlights articles about a blood test that could predict cognitive decline before pathological signs, the use of tirofiban after tenecteplase for stroke, and the role of artificial intelligence in peer review.

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 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: @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.

Looking for proven ways to end bullying in your unit? Join the co-hosts as they welcome expert Renee Thompson for a candid, practice-focused conversation on bullying in the nursing workforce. Renee will also be presenting the keynote presentation at the 2026 AMSN Convention in September.     To learn more about the 2026 AMSN Convention OR to register, visit: https://amsn.org/Events/AMSN-Convention   SPECIAL GUEST   Dr. Renee Thompson, DNP, RN, FAONL, FAAN, CSP is CEO & Founder of the Healthy Workforce Institute®. She is a sought-after speaker, bestselling author, consultant, and leading authority on creating healthy workforces by eliminating bullying and incivility. With over 30 years of experience as a clinical nurse, nurse educator, quality manager, and nurse executive, Dr. Thompson spends the majority of her time working with healthcare leaders who want to cultivate a healthy workforce. Renee is the CEO and Founder of the Healthy Workforce Institute and has been repeatedly published, interviewed, and awarded for her work to eradicate disruptive behaviors in healthcare. In 2020, Renee was invited by the Joint Commission to become a member of their Workplace Violence Technical Advisory Panel, has been published in numerous nursing journals, and is a frequent invited guest on radio, podcasts, webinars, and online social media platforms. In 2016, Renee received the Nursing Excellence award as a nurse entrepreneur, honoring her work to eliminate workplace bullying. She received the first Outstanding Nursing Alumni for Excellence in Leadership Award and Distinguished Alumni recognition from her alma mater, and was a finalist in the Healthcare Heroes Awards as a Healthcare Provider. Her blog has won numerous awards as a Top Nursing Blog "must-read" by the online nursing community, and her anti-bullying videos are viewed by healthcare organizations around the world. Renee is one of only 30 nurses in the world who have achieved the prestigious Certified Speaking Professional designation. In 2018, she was recognized as one of LinkedIn's Top Ten Voices in Healthcare for her contribution to their global online healthcare community and in 2022 was identified as one of the top 5 Nurse Influencers on LinkedIn. Also in 2022, Renee was inducted as a Fellow of the American Academy of Nursing for her work to eradicate disruptive behaviors in healthcare and in 2024 received the Safe Spaces award from the Florida Nurses Association. In March 2026, Renee will be inducted as a Fellow of the American Organization for Nursing Leadership for her sustained contributions to the specialty of nursing leadership, commitment to service and influence in shaping health care by addressing disruptive behaviors. Renee has a Master's degree in Nursing Education and a Doctorate of Nursing Practice from the University of Pittsburgh.   MEET OUR CO-HOSTS Kellye' McRae, MSN-Ed, RN is a dedicated Med-Surg Staff Nurse and Unit Based Educator based in South Georgia, with 12 years of invaluable nursing experience. She is passionate about mentoring new nurses, sharing her clinical wisdom to empower the next generation of nurses. Kellye' excels in bedside teaching, blending hands-on training with compassionate patient care to ensure both nurses and patients thrive. Her commitment to education and excellence makes her a cornerstone of her healthcare team.   Marcela Salcedo, RN, BSN is a Floatpool nightshift nurse in the Chicagoland area, specializing in step-down and medical-surgical care. A member of AMSN and the Hektoen Nurses, she combines her passion for nursing with the healing power of the arts and humanities. As a mother of four, Marcela is reigniting her passion for nursing by embracing the chaos of caregiving, fostering personal growth, and building meaningful connections that inspire her work. Hayley Sweetser, MSN, APRN, AGCNS-BC, MEDSURG-BC, CPHQ, WTA-C is a Clinical Nurse Specialist in Newark, Delaware who provides support to patients and caregivers within the Acute Medicine Service Line at ChristianaCare. She is working towards reducing overall patient harm events within the service line through collaboration with bedside nurses, physicians, and other specialties. Hayley has a strong passion for medical-surgical nursing and has spent her whole nursing career in this specialty. She strives to advance medical-surgical nursing practice by encouraging alignment with evidence-based practice.   Eric Torres, ADN, RN, CMSRN is a California native that has always dreamed of seeing the World, and when that didn't work out, he set his sights on nursing.  Eric is beyond excited to be joining the AMSN podcast and having a chance to share his stories and experiences of being a bedside medical-surgical nurse.   Sydney Wall, RN, BSN, CMSRN has been a med surg nurse for 5 years. After graduating from the University of Rhode Island in 2019, Sydney commissioned into the Navy and began her nursing career working on a cardiac/telemetry unit in Bethesda, Maryland.  Currently she is stationed overseas, providing care for service members and their families.  During her free time, she enjoys martial arts and traveling.  Trish West, DNP, MSN, CMSRN, PCCN, CEN, NEA-BC, FAMSN is a passionate nurse leader whose career reflects both expertise and a heartfelt commitment to advancing patient care. Trish's credentials include being a Certified Medical Surgical Registered Nurse, Progressive and Emergency Nursing, Nursing Executive Advanced, and most recently, induction as a Fellow in the Academy of Medical Surgical Nursing. She enjoys spending time with her husband Mark and their five children. Her favorite motto, "Never underestimate the difference you can make," truly captures the spirit with which Trish approaches both professional and personal endeavors.   

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 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: @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.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME information, and to apply for credit, please visit us at PeerView.com/WNQ865. CME credit will be available until June 29, 2027.Spotlight on Seronegative Generalized Myasthenia Gravis: From Clinical Uncertainty to Personalized Treatment In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from argenx US, Inc.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME information, and to apply for credit, please visit us at PeerView.com/WNQ865. CME credit will be available until June 29, 2027.Spotlight on Seronegative Generalized Myasthenia Gravis: From Clinical Uncertainty to Personalized Treatment In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from argenx US, Inc.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME information, and to apply for credit, please visit us at PeerView.com/WNQ865. CME credit will be available until June 29, 2027.Spotlight on Seronegative Generalized Myasthenia Gravis: From Clinical Uncertainty to Personalized Treatment In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from argenx US, Inc.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME information, and to apply for credit, please visit us at PeerView.com/WNQ865. CME credit will be available until June 29, 2027.Spotlight on Seronegative Generalized Myasthenia Gravis: From Clinical Uncertainty to Personalized Treatment In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from argenx US, Inc.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME information, and to apply for credit, please visit us at PeerView.com/WNQ865. CME credit will be available until June 29, 2027.Spotlight on Seronegative Generalized Myasthenia Gravis: From Clinical Uncertainty to Personalized Treatment In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from argenx US, Inc.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME information, and to apply for credit, please visit us at PeerView.com/WNQ865. CME credit will be available until June 29, 2027.Spotlight on Seronegative Generalized Myasthenia Gravis: From Clinical Uncertainty to Personalized Treatment In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from argenx US, Inc.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME information, and to apply for credit, please visit us at PeerView.com/WNQ865. CME credit will be available until June 29, 2027.Spotlight on Seronegative Generalized Myasthenia Gravis: From Clinical Uncertainty to Personalized Treatment In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from argenx US, Inc.Disclosure information is available at the beginning of the video presentation.

In this episode, editor-in-chief Joseph E. Safdieh, MD, FAAN, highlights articles about asundexian reducing recurrent ischemic stroke, the link between the high-dose flu vaccine and Alzheimer's dementia incidence, and the evolving role of osteopathic medicine in neurology.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/PFX865. CME/MOC/AAPA/IPCE credit will be available until June 27, 2027.New Pathways, New Possibilities in Multiple Sclerosis: BTK Inhibition and the Future of Patient Care In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Genentech, a member of the Roche Group.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/PFX865. CME/MOC/AAPA/IPCE credit will be available until June 27, 2027.New Pathways, New Possibilities in Multiple Sclerosis: BTK Inhibition and the Future of Patient Care In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Genentech, a member of the Roche Group.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/PFX865. CME/MOC/AAPA/IPCE credit will be available until June 27, 2027.New Pathways, New Possibilities in Multiple Sclerosis: BTK Inhibition and the Future of Patient Care In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Genentech, a member of the Roche Group.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/PFX865. CME/MOC/AAPA/IPCE credit will be available until June 27, 2027.New Pathways, New Possibilities in Multiple Sclerosis: BTK Inhibition and the Future of Patient Care In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Genentech, a member of the Roche Group.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/PFX865. CME/MOC/AAPA/IPCE credit will be available until June 27, 2027.New Pathways, New Possibilities in Multiple Sclerosis: BTK Inhibition and the Future of Patient Care In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Genentech, a member of the Roche Group.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/PFX865. CME/MOC/AAPA/IPCE credit will be available until June 27, 2027.New Pathways, New Possibilities in Multiple Sclerosis: BTK Inhibition and the Future of Patient Care In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Genentech, a member of the Roche Group.Disclosure information is available at the beginning of the video presentation.

This content has been developed for healthcare professionals only. Patients who seek health information should consult with their physician or relevant patient advocacy groups.For the full presentation, downloadable Practice Aids, slides, and complete CME/MOC/AAPA/IPCE information, and to apply for credit, please visit us at PeerView.com/PFX865. CME/MOC/AAPA/IPCE credit will be available until June 27, 2027.New Pathways, New Possibilities in Multiple Sclerosis: BTK Inhibition and the Future of Patient Care In support of improving patient care, PVI, PeerView Institute for Medical Education, is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.SupportThis activity is supported by an educational grant from Genentech, a member of the Roche Group.Disclosure information is available at the beginning of the video presentation.

In this episode of the NCS Podcast Perspectives series, host Nicholas Morris, MD, and co-host Tom Lawson, PhD, ACNP-BC, FNCS, speak with Molly McNett, PhD, RN, CNRN, FNCS, FAAN, about her career in neurocritical care and the role of implementation science in translating research evidence into routine clinical practice. Dr. McNett reflects on her early experiences as an ICU nurse, the disconnect she observed between published evidence and bedside care and how those experiences shaped her work in research, guideline development and implementation science. The conversation explores the distinction between implementation science and quality improvement, common barriers to practice change and the importance of identifying local facilitators, workflows and organizational needs. Dr. McNett discusses examples such as automated pupillometry and fall-prevention practices, highlighting how implementation strategies and hybrid research designs can help healthcare teams adopt and sustain evidence-based care. The discussion also examines interdisciplinary collaboration, mentorship and opportunities for nurses and advanced practice providers interested in research. Dr. McNett shares practical advice for clinicians seeking to address evidence-to-practice gaps, including finding mentors, participating in research teams and developing a deeper understanding of individual and organizational behavior change. The views expressed on the NCS Podcast are solely those of the hosts and guests and do not necessarily reflect the opinions or official positions of the Neurocritical Care Society.

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. Additional Resources Read the article: Thrombolysis, Thrombectomy, and Antithrombotic Therapy for Acute Ischemic Stroke 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: @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.

Please visit answersincme.com/FAJ860 to participate, download slides and supporting materials, complete the post test, and get a certificate. Presented by Nancy L. Kuntz, MD; Vanessa Battista, DNP, MBA, CPNP-PC, CHPPN, FPCN, FAAN; and Ethan Hilgert. In this activity, experts in the management of spinal muscular atrophy (SMA) discuss the diagnosis and treatment of late-onset SMA (type 3b, 4) in adults. Upon completion of this activity, participants should be better able to: Recognize clinical features that are suggestive of SMA in adults; Review the evidence for approved disease-modifying therapies in adult patients with SMA; and Apply strategies that address barriers to achieving optimal clinical outcomes in adults with SMA.

In this episode, editor in chief Joseph E. Safdieh, MD, FAAN, highlights articles about appointment wait times for commercially insured patients, post-traumatic headache severity in children with a family history of migraine, and the FDA approval of a drug for Alzheimer's agitation.

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.

In our June episode, we celebrated the Year of the Brain, as new discoveries continue to deepen our understanding of how the brain works. Dr. Anna Hohler, Director of Neurology for Northwell Health's Westchester Region, joined us to share simple steps we can all take to support brain health. In this month's Key Note, Dr. Hohler focuses on migraines—a common and often debilitating condition affecting millions – explaining what they are, who's most at risk and how to treat and prevent them. The Takeaway We want to hear from you! Please complete our survey: 1199SEIUBenefits.org/member-feedback. Drop us a line at our social media channels: Facebook// Instagram // YouTube. Get started on your health journey by making an appointment with your primary care physician to know your numbers: 1199SEIUBenefits.org/healthyrelationships Get to know your numbers at 1199SEIUBenefits.org/healthyhearts. Relieve stress with mindfulness classes at 1199SEIUBenefits.org/healthyminds. Find healthy recipes and meal-prep tips at 1199SEIUBenefits.org/food-as-medicine. Visit the Healthy Living Resource Center for wellness tips, information and resources: 1199SEIUBenefits.org/healthyliving. Get inspired by fellow members through our Members' Voices series: 1199SEIUBenefits.org/healthyliving/membervoices. Stop by our Benefits Channel to join webinars on building healthy meals, managing stress and more: 1199SEIUBenefits.org/videos. Visit our YouTube channel to view a wide collection of healthy living videos: youtube.com/@1199SEIUBenefitFunds/playlists. Sample our wellness classes to exercise body and mind: 1199SEIUBenefits.org/wellnessevents.   Guest Bio Anna DePold Hohler, MD, FAAN, is a distinguished neurologist, researcher and educator who recently joined Northwell Health to lead and enhance neurology services for its Westchester Region, as well as launch a new virtual neurology program across the 28-hospital system. An internationally recognized expert in movement disorders, she is deeply involved in research furthering novel therapies to treat Parkinson's disease. Dr. Hohler began her career in the U.S. Army, serving for eight years and achieving the rank of major. 

This episode explores how translational research bridges the gap between scientific discovery and real-world patient care, and highlights the nurse's pivotal role in clinical trials. Tune in to guests Brittany Butts, PhD, RN, and Erin Ferranti, PhD, MPH, RN, FAHA, FPCNA, FAAN, to learn how you can champion research, from participation to publication, and drive meaningful change in healthcare.Link to the Cardiovascular Nursing Certificate here: https://pcna.net/career-development/cardiovascular-nursing-certificate/See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Social determinants of health, including housing, food access, insurance status, and structural inequities, significantly influence stroke prevention, recovery, and long term outcomes. These factors affect biological risk, treatment adherence, and disparities in care, even when traditional clinical measures are addressed. This episode highlights practical strategies for integrating screening, leveraging multidisciplinary teams, and identifying opportunities for advocacy to improve patient outcomes. In this episode, Teshamae Monteith, MD, FAAN, speaks with Nneka L. Ifejika, MD, MPH, author of the article "Social Determinants of Health and Their Impacts on Stroke Prevention and Outcomes" in the Continuum® June 2026 Cerebrovascular Disease issue. Dr. Monteith is the associate editor of Continuum® Audio and an associate professor of clinical neurology at the University of Miami Miller School of Medicine in Miami, Florida. Dr. Ifejika is an adjunct professor of physical medicine and rehabilitation at UT Southwestern Medical Center in Dallas, Texas, and the chief scientific officer of the Division of Academics at Ochsner Health System in New Orleans, Louisiana. Additional Resources Read the article: Social Determinants of Health and Their Impacts on Stroke Prevention and Outcomes 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: @headacheMD Full episode transcript available here Dr Monteith: Two patients have the same stroke, but when they return, they have very different outcomes. We can look into some of their comorbidities, but something we don't spend enough time talking about is the social determinants of health. Stay tuned to this discussion. I promise you, you'll become a better neurologist. 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 Monteith: This is Dr. Teshamae Monteith. Today I'm interviewing Dr. Nneka Ifejika about her article on social determinants of health and their impacts on stroke prevention and outcomes. This article appears in the June 2026 Continuum issue on cerebrovascular disease. How are you? Welcome to our podcast. Dr Ifejika: Thanks for having me. I'm doing great. Dr Monteith: Great. So, can you introduce yourself to our audience? Dr Ifejika: Sure. I'm Dr. Nneka Ifejika. I am the Chief Scientific Officer of Ochsner Health System in New Orleans, Louisiana. But I'm also a cerebrovascular rehabilitation doctor. I've been practicing for about nineteen years, and am happy and honored to be a contributor to this Continuum Neurology article. It's a really important topic. Dr Monteith: Great. So, what got you into this field, first of all? Dr Ifejika: Well, I was deciding between PM&R and neurology, and I was putting in both match lists. And I thought about it and I leaned toward PM&R, but stroke still had a grasp on my heart and my mind. And so, after I finished my residency, I joined the UT Houston stroke team, and I did a, thankfully did a two-year fellowship and became cross-trained in stroke as well as physical medicine rehab. So, I am a jack of both trades. Dr Monteith: So, you got your way in a way. Dr Ifejika: I did. Dr Monteith: You know, we have a lot of learners that are listening, so it's always, uh, nice for them to be inspired, I think, by people's career paths. So why don't we talk about the objectives of your article? Dr Ifejika: Sure. So, one of the most important things that we wanted to do was make sure that medical students, residents, faculty, and fellows understood the impact of social determinants of health on stroke recovery and stroke rehabilitation. It's not as simple as you have hypertension, hyperlipidemia, we're going to manage your stroke risk factors. Oh, you had an ischemic stroke. You presented in time for the window. We're going to give you endovascular therapy and then modified Rankin scale at hospital discharge in ninety days. No, no, no. The stroke survivor and their caregivers and their family have a lot more to deal with outside of what we look at during the acute stroke hospitalization and post-acute rehabilitation. Things like, can they afford the medication that we're prescribing? Antiplatelet agents or anticoagulation can be extremely expensive. Do they have housing insecurity? Is there food insecurity? What's going on behind the scenes that we are not addressing that can directly impact the admission rate and the readmission rate after we take care of a stroke survivor? Dr Monteith: I love the article because you took a real deep dive into social determinants of health, what they are, why they matter, and what we can do about them. And so why don't we talk a little bit about the NINDS framework for social determinants of health? I think many of us might not be familiar with the framework per se. Dr Ifejika: So, the framework consists of multiple domains specifically that relate to social determinants of health that were published in Neurology a couple of years ago. So, I do hope that people who are hearing this recording actually read them. There are interpersonal domains, there are classic medical domains, there are indeterminate domains, and there are six total domains. And health domains are the last domain. So, things like when it comes to housing insecurity, food insecurity, that's a domain of social determinants of health. When it comes to chronic racism, when it comes to biases that patients experience, those actually impact outcomes. So, there are six separate indices that we're going to get into in detail and how we address them as clinicians, whether it be at the medical student level, resident level, faculty level, to integrate the social determinants of health in our care plans, because we could be doing a much better job. And I think it'll be really important from the interpersonal perspective when we really relate to our patients and their families that we ask these questions. For example, if we're prescribing someone to have treatment for their diabetes mellitus and ha- and, and be taking insulin, if they have housing insecurity and they're in a homeless shelter, they have to leave the homeless shelter during the day. So, what happens to the insulin that we prescribe? These are variables that we are not considering on a regular basis, but they directly relate to compliance. Dr Monteith: Great. So that was one thing I wanted to bring up. We're very good at measuring blood pressure and trying to determine, uh, the association between stroke outcomes and things that we can measure, glucose, lipids, blood pressure. What is the evidence for social determinants of health and stroke outcome? Dr Ifejika: The evidence is growing, and there have been many publications that have come out that are, are going to be highlighted in this article related to structural determinants of health inequities, like structural racism, as well as disparities related to ethnicity and race. There's geographical disparities. For example, a lot of patients are, are primarily concerned about rural versus urban, whether you have access to different post-acute rehabilitation, whether you have access to secondary stroke prevention because you simply don't have the transportation from a, a rural area to get to a drugstore to get things available to you. Social status. There are actually publication related to socioeconomic status and the concerns when it comes to air pollution. So particulate matter 2.5, we know that that has a direct impact on stroke outcomes and health overall, but we don't really think about it as a structural determinant of health inequity. There's several multiple layers of research that have gone on specifically that have been cited in the literature that relate directly to social determinants of health and how we can address them moving forward. Dr Monteith: And what I found interesting in your article in that you gave at least a few examples where social factors like income, education were controlled for, and maybe in large part it is, but even when you control for some of these very obvious social risk factors, you still have inequities. Dr Ifejika: Absolutely. And I think it was really important to show that we had strong peer review evidence behind this, as it wasn't just something that we were creating or hypothesizing about. There have been studies that have been done over this over decades of time, showing the impacts of social determinants of health on outcomes. But the question and concern that we have is we know this growing body of literature continues to expand. What are we doing about it when it comes to education of the future generations of providers who will be caring for this population? Dr Monteith: Before we get into how, you know, what we're going to do about that, let's just kind of put that link, cause the evidence is there. How does it drive biology? Dr Ifejika: It's a great question. So, for example, particulate matter 2.5 in air pollution has been shown to have an existing impact on hypertension, raising your blood pressure. So that's a direct effect of a social determinant of health related to socioeconomic status because people who live in areas with higher air pollution are... They're not green spaces. They live near highways. Those are areas that unfortunately are also impacted by food deserts. Food deserts, if you're not able to get fresh fruits, vegetables, whole foods, increases your risk of developing diabetes, hyperlipidemia, also increases your sodium intake, again, increasing hypertension. These things are all connected to biological determinants. It's just that we're not asking about them necessarily within the social history when we're taking people into the hospital, but they have direct effects. Dr Monteith: Great. Neurologists tend to be busy and, you know, we're... have all of these things that we're being asked to do and chart and click and all of that stuff. And so how can we more readily integrate screening for social determinants of health and that conversation into the work we do? We recognize it's important. We recognize it's an important risk factor. There's a lot of these determinants. So, what is a good way to do so? And I, I know that in the paper you've, you've given different roles to different team players, so I want you to talk about that too, but just kind of even a regular routine office visit. Walk us through a way we can more easily integrate that kind of conversation. Dr Ifejika: It's an excellent question, and what I've recommended that we do in a standard office visit is utilize the time before the visit to send out screeners. So, for example, usually with an electronic medical record, you can send documents before the visit even starts, where people can check off whether they have any concerns regarding housing, food insecurity. They can check out their location of where they live, whether they live near a highway or not near a highway. It's specifically related to socioeconomic status. We can ask about insurance status, whether they have insurance, insured versus uninsured, but then also types of insurance, whether they have Medicaid insurance versus Medicare insurance. Then even drilling even further, type of Medicare insurance, Medicare Advantage versus traditional Medicare, cause all of those things actually play a role in this. Dr Ifejika: And evaluate these things and don't take time during your office visit. Send these screeners out beforehand. Have them be assimilated by your medical staff. Make sure you're utilizing every resource that you have at your disposal to help streamline things, so by the time the person comes in for the visit, you've primed the pump. You have this information already in your hands at your fingertips cause it was sent out in advance, and you have your medical staff already have an understanding of. If they didn't fill it out electronically, give it to them in the lobby. Make sure they have a handwritten copy in the lobby so that when they come into the office visit, you have the information at your fingertips. Dr Monteith: Are there any particular resources that you recommend for those types of screeners? Dr Ifejika: What I've used in the past, if you have patient-reported outcomes, so the PROMIS instruments, that's a good start. It doesn't get into the details of housing insecurity, food insecurity, but it's a good start to help prime questions and to start the conversation during your office visit. In my clinics, I do a PROMIS 27 on every patient, as well as a PHQ-9 for depression on everyone. And then I collect data longitudinally, and I can always drill down on factors that I noticed that could become a problem moving forward. Dr Monteith: Yeah. And then also in your article, you spoke a bit about this impact from the acute presentation in the hospital to rehab. Dr Ifejika: Yeah. Dr Monteith: So why don't you talk about these different entry points where we can really engage our patients and try and help reduce their burden? Dr Ifejika: Sure. So, healthcare can be quite fragmented, and the stroke patient, stroke survivor, and their family member have no grasp of that. They've had a stroke, and they may be going from the ER to the ICU to the stroke unit to the floor to the rehab unit, and we see it as multiple levels of care, multiple types of providers. They see it as one hospital. And the concern that we have is, at those branch points, things get dropped, and we have the opportunity to pick things up at those branch points. So, during the acute care hospitalization-Primarily, that's the establishment of what has happened, how we're gonna treat it, what are the variables that we can control for right now to address those determinants of health moving forward, and to specifically looking at whether they were taking medications before, whether they could afford medications before, what that looks like at hospital discharge. Is there any duplication of medications? If a person is taking Coreg and you prescribe metoprolol, but they still have the Coreg at home, should we have really prescribed the metoprolol? We're just spending money that they may have concerns when it comes to access to care and the cost of these prescriptions. So, it's the responsibility of the acute care physician to kind of look at that. Those are subtle things that we think are subtle, but they add up quickly for the family when it comes to having one group of medications that's the same class and having to buy another type. When it comes to post-acute rehabilitation, it's really an important time to screen for whether the caregiver can handle what's occurring. So specifically, if the caregiver is already burning out and the average length of stay for a stroke patient is five days and they've come to rehab for two weeks, what's gonna happen in the next two years or the next four years? So, during the post-acute rehabilitation phase, it's time to kind of look at that and drill down on those kind of questions. Also, the levels of care, Dr Ifejika: it's really important to look at other levels of rehabilitation, so skilled nursing facilities, making sure people have access to that if they need to, if the caregiver is burned out and they don't have the ability to go straight home. Because acute inpatient rehab, the goal of it afterwards, is to go straight home. It's not to go to another facility. So, you need to have that screener in place when it comes to whether the family can take care of this person, and whether the family can do it in an effective way to prevent them being readmitted. Dr Monteith: Great. I also like that you spoke about kind of the team approach and different roles, both for screening and for intervention, both being very important, especially the intervention. And so why don't you give us a few examples how the team could break up the responsibility and how also for the intervention component that can be done. Dr Ifejika: Sure. So, I broke up the team into several levels. So, the team medically is the medical student, resident, and faculty physician. However, the team also includes the support staff, so your case manager, your social worker, the therapist, physical therapy, occupational therapy, speech therapy, the pastoral services, all these members of the team. You know, sometimes as physicians, we don't read those notes. There's a lot of information in the notes from social work, care coordination, and the therapist. They get down to subtleties cause they're asking questions, for example, "What kind of equipment do you have at home? How many stairs do you have at home? What level of house do you have, one story, two story? If you live in an apartment, do you have an elevator access?" That's important for someone with hemiparesis. When it comes to medications, when it comes to insurance status, when it comes to your ability to have the mechanisms to pay for care as an outpatient, social workers are required to ask these questions cause they have to figure out resources for the patient and their family to help facilitate improved outcomes. So, they have to ask questions regarding these tasks. The concerns are, do we read what they're saying? So, it's really important to interact with them, and if it's not something that you're looking at in the chart, cause we're all so tied to our computers, find where they are in the hospital. Walk by their office and have a chat. Run your list with them, especially for people who you're concerned have vulnerabilities, and make sure that you're setting an example for your medical students with your faculty doing so. If you're looking at it from the medical student, resident, faculty perspective, medical students, listen. This is your opportunity to really contribute to the team as well as learn about social determinants of health and research in their fields. You are the boots on the ground for the medical team. You are the ones who should be priming the pump and asking these questions of the family members. We're sending you into the rooms to do a history and physical. Social determinants of health should be a part of your history and physical, and you should be taking what we're saying in this article and asking these questions and tying it into your resident. Now, the resident is the work person of the hospital. We all know this. Things run through the resident. Things run through the fellow. It's really important that they have this information in a manner that is negotiable. The list keeps getting longer, and a resident doesn't need to be overburdened. It needs to be synthesized in a manner that can help facilitate the resident being able to act as well as communicate any concerns to the faculty. And at the faculty level, we are the voices that can affect change. So, if there's any concerns when it comes to advocacy, research, making sure that people are accessing care in a way that makes sense, particularly when it comes to the ability for us to galvanize change on a national level, that's kind of our job. Dr Monteith: Great, and so let's talk about intervention. What are things that, let's say, the neurologist can do to deal with some of these social factors? Dr Ifejika: From the neurology perspective, I think it's really important to identify missed opportunities and making sure that we address them. For example, the conversations around the ability to have access to care related to insurance versus no insurance. There are many, many ways that neurologists are able to advocate for a person being able to get to Medicare insurance, particularly in the outpatient setting. When we see patients in clinic, it takes two years, them, to qualify for Medicare, two years at a minimum. But there's a gap there that can be filled by us making sure that we document what's happened, contact their providers, facilitate communication with their employers, if they're employees, they can get some short-term disability benefits to help bridge that gap prior to receiving Medicare insurance. It behooves us to do this because if we do not, they fall into the gap and they get readmitted and they're back on service anyway. So, what's important is the outpatient that we really kind of focus on things that we can impact and things like insurance and getting people transitioned from having employer-based insurance versus getting to Medicare is a really important way that we can effect change in a, in a way that's viable and, and replicable. So, in the outpatient setting, neurologists have a wonderful opportunity to effect change in social determinants of health. When it comes to employed persons, who had a stroke transitioning to Medicare, it takes two years to do so. So, in the outpatient clinic, if you have an employed person, make sure that you fill out their short-term disability benefits forms, their long-term disability benefits form. Bridge the gap. Get that information to their employer so they can maintain constant coverage. Because if they do not, if they have to choose between refilling medications and putting food on the table, they're going to choose putting food on the table, and that's going to directly impact their outcomes if they're not taking the medication that we recommend. Dr Monteith: I think that's a great point. I mean, there's a lot that we can do, and in some ways, it may not take that much to document and to be able to ask the questions and to include some of that information into the assessment and plan is really a, a great idea. Dr Ifejika: And you know, if we don't bring these things up and have these conversations, it doesn't get addressed. And that's why I'm very, very thankful that I had the opportunity to do so, cause this is a part of what I do all day. I think that if I wasn't integrating these kind of conversations into my practice, I wouldn't have the ability to share these tips and these abilities to move things forward in a manner that will be constructive for our field overall and for our patients. Dr Monteith: And towards the end of the article, you brought up something I think we don't see in many articles, and that's the role of advocacy and getting involved in health policy. So, can you talk a little bit about that? Dr Ifejika: You know, it's really important to facilitate change when you see that there are things that need to be changed. And the best way to do that is through advocacy at the local or state or federal level. A lot of these variables that we're dealing with can be addressed through legal changes. I'll give you an example. End-stage renal disease, if you have immediate hemodialysis and you have that requirement upon hospital discharge, you qualify for Medicare immediately. Immediately. Before you even leave the hospital. Why wouldn't something be similar for a stroke? Well, the reason why is because there was a level of advocacy that came around end-stage renal disease and a member of Congress's wife had hemodialysis requirements. And so, a law was passed to make sure Medicare covered it immediately after hospital discharge. So, it requires advocacy in some significant ways to get things done, but we have the bandwidth to do this. We take care of a population that has some of the highest rates of preventable disability. That's not going away. We need to make sure that we're effecting change for this group to make sure that they have the best possible outcomes they can experience. Dr Monteith: So, any final messages for our listeners? Dr Ifejika: I look forward to hearing everyone's feedback about our issue. I am thankful for the opportunity to talk about, address, and write about this important topic, and look forward to everyone's feedback. Dr Monteith: Well, thank you so much for being on our podcast. It was a really wonderful summary and we had a very thorough conversation, but you didn't give away too much, so I think they're going to have to read the article. Dr Ifejika: You're going to have to read the article. And we want medical students, residents, fellows, faculty, all of our ancillary staff within the hospitals, please read this article. We really appreciate it. Dr Monteith: Again today, I've been interviewing Dr. Nneka Ifejika about her article on social determinants of health and their impacts on stroke prevention and outcomes. 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.

DescriptionIn this episode of Perfect Prey, I'm joined by Ann Burgess, pioneering forensic nurse, researcher, educator, and author of Expert Witness. Ann's groundbreaking work transformed how professionals understand trauma, victimization, sexual violence, and offender behavior. Her research has influenced criminal investigations, forensic psychology, victim advocacy, and some of the most well-known criminal cases in modern history.Together, we explore the long-term impact of trauma, why victims are so often disbelieved, and how systems continue to fail those who come forward. Ann shares insights from decades of work studying victims, offenders, serial violence, child abuse, and the psychology of coercion and control. We also discuss institutional betrayal, trauma responses in children and adults, family court failures, pornography, grooming, and what it takes to create meaningful change within systems that were never designed to fully protect victims.What we coverAnn Burgess's pioneering work in victimology and forensic nursingHow trauma impacts behavior across the lifespanWhy victims are often disbelieved by systems and institutionsInstitutional betrayal and systemic failuresCoercive control, fear, and psychological abuseTrauma responses in children and adolescentsChild sexual abuse and delayed disclosureFamily court, victim credibility, and expert testimonyThe role of pornography and grooming in abusive behaviorThe Menendez case and evolving understandings of traumaWhy trauma-informed education is critical for professionalsHow offender thinking patterns develop and escalateWhy listenIf you are a survivor, clinician, attorney, advocate, educator, or protective parent, this episode offers a rare opportunity to hear from one of the most influential voices in trauma and victim research.Ann Burgess's work helped shape how we understand trauma today. Her insights illuminate why victims respond the way they do, why systems often misunderstand those responses, and why meaningful reform requires us to listen more closely to survivors' experiences.Guest BioAnn Burgess, DNSc, APRN, FAAN is an internationally recognized forensic nurse, researcher, educator, and author. She is a professor at Boston College and has spent decades studying trauma, victimization, sexual violence, serial offenders, and forensic mental health.Ann's groundbreaking research on rape trauma syndrome helped transform the understanding of victim responses to sexual assault. She has consulted with the FBI's Behavioral Science Unit, contributed to offender profiling research, and served as an expert witness in numerous high-profile cases.She is the author of several books, including Expert Witness, which chronicles her work at the intersection of trauma, criminal behavior, and justice.Connect with Ann BurgessBook: Expert Witnesshttps://www.amazon.com/stores/Ann-W.-Burgess/author/B0H13DQXPP?ref=sr_ntt_srch_lnk_3&qid=1780604748&sr=1-3&shoppingPortalEnabled=true&ccs_id=9489809f-1ae4-4998-b8db-a0cbcc536d23Boston College Faculty Profile: https://www.bc.eduConnect with Dr. ChristineProtective Parenting Program: https://www.coercivecontrolconsulting.com/services/for-parents/Dr. C's Community: https://go.drcocchiola.com/innercirclecommunityOfficial site: https://www.coercivecontrolconsulting.com/YouTube: https://www.youtube.com/@DrCocchiola-coercivecontrol/videosTikTok: https://www.tiktok.com/@dr.c_coercivecontrolInstagram: https://www.instagram.com/dr.cocchiola_coercivecontrol/TEDxTalks: https://www.youtube.com/watch?v=gp2qByKOue4&t=24sBooks:https://url-shortener.me/c/FramedBookhttps://url-shortener.me/c/EveryMomentOfEveryDayIf this episode landed for you, please share it with someone who needs to hear it, subscribe for more trauma-informed conversations, and consider leaving a review — it helps other survivors find validation and safety.— Dr. Christine Cocchiola & Ann Burgess

Could you imagine working in a rural location where access is truly a lifeline for people? Today's guest is April Erickson, DNP, CRNA, an ​Alaska ​based ​nurse ​anesthesiologist ​and ​anesthesia ​medical ​director ​with ​more ​than ​15 ​years ​of ​experience ​in ​rural ​independent ​practice. Sharon and guest host Jackie Rowles, DNP, MBA, MA, CRNA, ANP-BC, NSPM-C, FNAP, FAANA, FAAN, sit down with April to discuss frontier medicine, independent practice, leadership, and what it truly means to provide care where access is critical but not guaranteed. Here's some of what you'll hear in this episode:

In this episode, editor in chief Joseph E. Safdieh, MD, FAAN, highlights articles about a link between higher meat and slower cognitive decline in APOE34/44 carriers, the geographic distribution of research funding, and how artificial intelligence is reshaping neurology.

In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Cheryl Bushnell, MD, MHS, who served as the guest editor of the June 2026 Cerebrovascular Disease issue. They provide a preview of the issue, which publishes on June 3, 2026. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Bushnell is a Professor of Neurology and Director of the Center for Transformative Stroke Care at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Additional Resources Read the issue: continuum.aan.com Subscribe to Continuum®: shop.lww.com/Continuum 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: @LyellJ Guest: @CBushnellMD  Full episode transcript available here Dr Jones: One of the core tenets of our field is that we learn neurology one stroke at a time. But what do we have to learn about preventing them altogether? The science of stroke prevention, acute treatment, and recovery are evolving rapidly, and it's hard to keep up. Today, we're speaking with Dr. Cheryl Bushnell, guest editor of our latest Continuum issue on Cerebrovascular Disease, to discuss these topics and much more.  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 subscribing to the journal, listening to verbatim recordings of the articles, and exclusive access to interviews not featured on the podcast.  Dr Jones: This is Dr. Lyell Jones, editor-in-chief of Continuum: Lifelong Learning in Neurology. Today, I'm interviewing Dr. Cheryl Bushnell, who is Continuum's guest editor for our latest issue on Cerebrovascular Disease. Dr. Bushnell is a professor of neurology and the director of the Center for Transformative Stroke Care at the Wake Forest University School of Medicine in Winston-Salem, North Carolina, where she specializes in the care of stroke patients and their social and functional determinants of recovery and health, and is an internationally recognized expert on those topics. Dr. Bushnell, welcome. Thank you for joining us today. Why don't you introduce yourself to our listeners?  Dr Bushnell: Absolutely. Thank you for the invitation. It's really an honor to be here. So, as you mentioned, I am the director of the Center for Transformative Stroke Care at Wake Forest. It's a really fun transition for me to be involved with different care models for stroke, and I think a lot of the Continuum topics are directly relevant to some of the things that I'm doing now as an administrator and sort of a facilitator of new research. So, thanks again for having me.  Dr Jones: Yeah, and, and you have a wonderful perspective, and we're gonna pull that out today in our interview questions, and I'm looking forward to sharing that with our listeners. But before we get to the questions, we're gonna start off today's podcast with another Continuum Audio trivia question for our listeners. Anticoagulation has played a critical role in secondary ischemic stroke prevention for a long time now. While direct oral anticoagulants have taken on a greater role in the treatment of prevention of stroke, there are still some use cases for vitamin K antagonists like warfarin. The trivia question for our listeners is this: How was warfarin discovered, and how did it get its name? Stick around and we'll share the answer to that question toward the end of our interview today. So, Dr. Bushnell, let's get right to it. You alluded to your various roles, and your leadership in the field has been exemplary. The interventions for acute ischemic stroke have really exploded over the last decade or so, and they get a lot of attention and discussion, but prevention and recovery are just as important in the care of these patients. Tell us a little more about how you approached this issue, about the article topics you chose, etc.  Dr Bushnell: Well, once I was chosen to lead the guest editorship, I wanted to come up with a group of topics that were maybe a little bit different from previous issues. So, I kind of looked at the previous issues and saw, as you said, an emphasis on acute stroke, and that's really important because it has been evolving. But my thought was, how about what happens to patients after they get the intervention and they're discharged home? And because a lot of trainees may not get to see these patients ever again, or it's months before they might see them, or if they're readmitted, which is what we don't want to see, but that certainly is a lot of the exposure is in the inpatient setting. So, I thought I would kind of transport the education into the outpatient and transitional setting, as well as prevention, not only secondary, but primary prevention, with an emphasis on brain health. Some of the populations that may not get as much attention. So, sex differences, stroke in women, pregnancy, the transitions of care, and also the emphasis on holistic view of patients and their challenges, which includes the non-medical factors that drive health, otherwise known as social determinants of health.  Dr Jones: I appreciate that perspective, and obviously th-this is an area of your deep expertise, and it's great to have an issue that really digs into some of those topics a little more deeply. As an educator, I'm really glad you mentioned that about the trainee's perspective. You know, especially junior neurology trainees that are in the hospital all the time. They're seeing patients in the middle of a cerebrovascular catastrophe. But there's a long tail of recovery, right? And they'll get to see that in continuity clinic, but it's a good message to share from an evidence and, um, experiential perspective in the issue. So, appreciate that perspective. You've just read all these articles and edited them. Was there anything that you ran across that was a surprise to you?  Dr Bushnell: Well, I personally chose a lot of the authors based on my knowledge of their work. So, I wouldn't say that it was completely surprising, but I do think that I was just genuinely impressed with the quality of the writing and the synthesis of information. I just was incredibly proud of the work that these co-authors have put together. I'd say that that was-- it wasn't surprising so much as just a sense of pride that I had with the product that's coming out. But of course, there have been some new trials that had to be incorporated at the last minute, some of which were presented at the International Stroke Conference just a few weeks ago.  Dr Jones: Yeah. We try to be as up-to-date as we can, and I will completely agree with you. We have some really good writers in our field, and it's really just a pleasure when you read an article that's by an expert, and it's a joy to read. I can tell you it's one of the best parts of this job, and you get to learn a lot. I think one of the more challenging scenarios that I hear about from colleagues in recent years has been optimal management of patients with asymptomatic extracranial atherosclerosis. The pivotal trials that inform how we manage those patients were from a long time ago, decades ago, predating a lot of the more intensive medical management tools that we have today. In that scenario, Dr. Bushnell, what's the latest on that, and what should our listeners know?  Dr Bushnell: Well, obviously, the CREST 2 trial has been long awaited. It's been going on for over ten years, I believe. Of course, it's, uh, two different trials all in one, the carotid stenting and angioplasty versus intensive medical management. And of course, each of the carotid vascularization arms of the trial also had intensive medical management. And then the other trial is the carotid endarterectomy as the form of revascularization. And it interestingly did not show any benefit of carotid endarterectomy compared to intensive medical management. But of course, the somewhat surprising result was that carotid angioplasty and stenting truly was superior, although it was a small number of events in the trial overall. But that stenting plus intensive medical management was somewhat better than intensive medical management alone. And I think stenting has come a long way in terms of safety, and so I think that's been part of the evolution of the field. I do wanna say that I'm a huge fan of the intensive medical management, and I think that what the protocol does in terms of blood pressure management, cholesterol management is very much above and beyond what's done in private practice even. And the health coaching for all the other things related to diabetes and weight loss and smoking cessation and physical activity, that is what we need to be doing to actually decrease the risk of stroke, and I think that it's very effective. I can't say enough about the design of the study for that reason, that everyone gets the intensive medical management, and then you just layer on the type of revascularization on top of it. So, I wouldn't have been surprised if this was a completely negative trial overall. They just happened to have some better outcomes in the stenting arm.  Dr Jones: I recall a few years ago when the series of endovascular therapy trials for acute stroke came out, and I think there was a, a period of time where the field had to adapt to that. I wonder what you think about with the CREST 2 findings on stenting. I mean, is that gonna be a big change? Because obviously atherosclerosis is highly prevalent. Is that gonna be a big change? Is the field ready for that? How much adjustment do we have in store?  Dr Bushnell: I'm not sure it's gonna be a really big change. If you read the editorial that accompanied the trial in the New England Journal, just a few patients in either direction would have changed the outcome. I kind of look at it as an absolute difference that's relatively small. So, I'm not sure that it will have a huge impact on the field. I do think that the specialists who insert the stents may have some differences of opinion of who should be stented and who shouldn't. Because I think, you know, all of the specialists who do procedures were involved with the trial. But I would say there's a larger percentage of vascular surgeons who were involved, and so I'd say they may have a change of their practice. And neurologists may not even get involved at all.  Dr Jones: Right.  Dr Bushnell: That was one of the challenges for getting patients in the trial is that, you know, not all of us see the asymptomatic carotid stenosis, that they tend to get referred to vascular surgery. So, I think maybe in a corner of the practices of vascular surgeons is where you might see the differences.  Dr Jones: Your point about the way the trial was designed or the trials were designed, that intensive medical management is really important, and we have huge gaps in that. In our specialty, it's, you know, we have probably an opportunity in primary care even to address that. And that leads me to my next question. You know, given your perspective and your expertise, what do you think is the biggest practice gap in the care of patients with stroke or with cerebrovascular disease of any kind?  Dr Bushnell: I think by far the biggest gap is transitions of care and access to follow-up in a specialty clinic after discharge and continuous secondary prevention. We only call it secondary prevention because it happened to come after a stroke, but I really feel like we should just focus on prevention and call it that. There are a lot of people who are trying to kind of, get us away from primary versus secondary prevention. And, and Mitch Elkind is phenomenal and had a beautiful chapter weaving in prevention and brain health. So, I highly recommend that people, if they don't read any other chapters of the Continuum to read his, because I think that it's getting to your point about where the gaps are, and I think prevention is the biggest one. I think we could do so much more in models of care to ensure that there is a pathway once patients are discharged. We have no quality metrics. We have no measurement of how well people are doing after they're discharged. We have all of these fancy things and sophisticated acute treatments, but all of those are for naught if somebody goes home and they fall and they have a severe head injury or hip fracture because they weren't properly supervised or they didn't have the help that they needed at home. So, you got me on my soapbox here for a second, but that is definitely what I see as the gap.  Dr Jones: That's an important soapbox, an important gap, and obviously, if it was a simple problem, we could solve it. But it's obviously something that education is a valuable tool for that, and that's part of why we are including so much content in this issue of Continuum. So, if we put that aside as a gap that we would love to close, when you look into the near future or distant future, Dr. Bushnell, and what's the next big thing on the horizon? New interventions, new prevention tools, or something else entirely? What do you think?  Dr Bushnell: There are two things that I would mention. One is sort of the new category of anticoagulants, antithrombotics, the factor XIa inhibitors. We had an amazing presentation of the oceanic stroke trial at the International Stroke Conference, and this is probably going to be a game changer for the arsenal of antithrombotic therapies that we can offer to patients that do not have a reason for anticoagulation. So, they, they don't have atrial fibrillation, for example, or something else that requires anticoagulation. And so, the factor XI, asundexian, is the drug that they used in that trial. The safety profile is pretty amazing. There was very little bleeding complications and a great benefit in those patients with some degree of atherosclerosis, but, you know, of course, not enough to require carotid revascularization, but then also, um, small vessel disease and cryptogenic stroke. I think those are the three categories of patients, and that's a lot of the strokes that we see all benefited from this new drug. So, I think that's gonna be exciting. There, of course, it has to go through the FDA approval process, and so it might take a little bit of time before that's on the market, and we don't know how much it's gonna cost, but I think it is a, a major breakthrough. And of course, there are other similar medications in that category that are coming. And then I think the other thing is the emphasis on brain health and lifestyle factors and the things that we can do to prevent stroke and dementia because they are the same, essentially. Those are really important. And when we have someone in the hospital with a stroke or a TIA in particular, it's a great teaching opportunity for those patients to say, "Hey, here's what you can do to protect your brain." These are things that we always tell people to prevent a stroke, but just think about it as protecting your brain and keeping your brain as healthy as possible.  Dr Jones: That's a great message, and one that you get to share with patients directly. You're joining us today for this interview. You're on stroke service, so you're actively involved in caring for patients with stroke. What in your practice is the most rewarding aspect of caring for these patients? What is it that you find most rewarding?  Dr Bushnell: I've been involved in a clinical trial that has focused on managing blood pressure and also coaching and other aspects of stroke recovery. I think that has probably been the most rewarding aspect of my career. Until I was involved with this trial, I didn't necessarily do intensive blood pressure monitoring, but I'm seeing the benefits of having data from home, what those blood pressures are over a span of time. I see the immediate or intermediate effects of the blood pressure medication changes that I've made, and I see how the patients respond. So, I have to say that this is not part of usual practice, but I think it should be. And I think it's been incredible from the perspective of a neurologist who is really intensively trying to make the patients' lives better. And it's not just what I do, it's what the health coaches do as part of this intervention. And again, very similar to intensive medical management. So, I, I feel like I've been living it in a slightly different setting than in the CREST 2 trials. But there are other trials that have used the intensive medical management as approach as well. But I would say that's the most rewarding. I've seen people who've lost weight, who are physically fit, who are able to get off of blood pressure medications practically by the end of six months, and that's amazing. And then they continue doing it because they see the benefits.  Dr Jones: You've had a front row seat to a lot of that. That's really got to feel rewarding.  Dr Bushnell: It is, absolutely.  Dr Jones: You know, when you put it that way, it makes me want to go home and check my blood pressure, which I haven't done in a while. But I think that's a message to all of our listeners that we do have plenty of opportunity for risk factor optimization and following the evidence that has been generated and is being generated. Huge opportunity, not only at the population level, but I think the, um, individual patient level too. Okay, so now we're back to our Continuum Audio trivia question, and I'll repeat it for our listeners. How was warfarin discovered, and how did it get its name? Dr. Bushnell and I were talking about this earlier, so I'll just go ahead and share the answer. So, in the early 20th century in the U.S. Midwest, there were epidemics of a hemorrhagic disease in cattle, of all places, and this was eventually traced to moldy cattle feed that was made from sweet clover. And in 1940, researchers at the University of Wisconsin discovered that the anticoagulant in the sweet clover was a compound that was later synthesized for therapeutic use in 1954 as warfarin. And the name came from, uh, the support for the research. The research support came from the Wisconsin Alumni Research Foundation, or WARF, and the end of the word came from the underlying compound, which was coumarin. So that was a little bit of trivia that I had never heard. It's not in the issue, everyone, so you're getting something extra here on the podcast. But been using the drug forever. It still has its uses, even though it's become less advantageous than some of the newer agents. But-- And of course, Dr. Bushnell already knew that when I brought it up, but I just thought that was an interesting bit of history. Well, Dr. Bushnell, thank you for joining us. Thank you for such a great conversation about the latest in cerebrovascular disease. I learned a lot today. I learned a lot in reading these wonderful articles. I hope our listeners learned a lot today as well. I'm really grateful for your hard work on the issue, which I think will come in handy for junior readers and subscribers, as well as our more experienced neurologists as well. Sometimes it's hard to keep up with a rapidly changing subspecialty of our field. So, thank you for joining us today.  Dr Bushnell: Thank you for having me. It's been my pleasure.  Dr Jones: Again, today we've been speaking with Dr. Cheryl Bushnell, guest editor of Continuum's most recent issue on cerebrovascular disease. Please check it out, 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. Thank you for listening to Continuum Audio.

In this episode of HPNA Palliative Perspective, we're joined by Betty Ferrell—Editor of the Journal of Hospice & Palliative Nursing (JHPN), nurse, and internationally recognized researcher. As the leader of the End-of-Life Nursing Education Consortium, she brings a unique perspective shaped by decades of connection with hospice and palliative care nurses across the U.S. and around the world.  Now in her 49th year in nursing—beginning in oncology and entering hospice as it emerged in the United States—Dr. Ferrell reflects on the remarkable growth of the field and where we stand today.  At the heart of this conversation is the idea of a “professional home.” Drawing on the foundational work of pioneers like Florence Wald and Cicely Saunders, she highlights the enduring importance of interprofessional, whole-person care—and the need to stay grounded in those values as the field evolves.  In a time that can feel complex and demanding, this episode offers a clear message: you don't have to do this work alone. Finding your people, building community, and staying connected—through colleagues and organizations like the Hospice and Palliative Nurses Association—are essential to sustaining both practice and purpose.  A thoughtful and reassuring conversation about belonging, connection, and the future of hospice and palliative nursing.      Betty Ferrell, RN, PhD, MA, CHPN®, FAAN, FPCN® Betty Ferrell, RN, PhD, MA, CHPN®, FAAN, FPCN® has been in nursing for 48 years and has focused her clinical expertise and research in pain management, quality of life, and palliative care. Dr. Ferrell is the Director of Nursing Research & Education and a Professor at the City of Hope Medical Center in Duarte, California. She is a Fellow of the American Academy of Nursing and she has over 500 publications in peer-reviewed journals and texts. She is Principal Investigator of the “End-of-Life Nursing Education Consortium (ELNEC)” project. She directs several other funded projects related to palliative care in cancer centers and QOL issues. Dr. Ferrell was Co-Chairperson of the National Consensus Project for Quality Palliative Care. Dr. Ferrell completed a Masters degree in Theology, Ethics and Culture from Claremont Graduate University in 2007. She has authored 12 books including the Oxford Textbook of Palliative Nursing (5th Edition, 2019) published by Oxford University Press. She is co-author of the text, The Nature of Suffering and the Goals of Nursing published by Oxford University Press (2nd Ed, 2023) and Making Health Care Whole: Integrating Spirituality into Patient Care (Templeton Press, 2010). In 2013 Dr. Ferrell was named one of the 30 Visionaries in the field by the American Academy of Hospice and Palliative Medicine. In 2019 she was elected a member of the National Academy of Medicine. In 2021 Dr. Ferrell received the Oncology Nursing Society Lifetime Achievement Award and she was inducted as a “Living Legend” by the American Academy of Nursing   Brett Snodgrass, DNP, FNP-C, ACHPN®, FAANP Dr. Brett Snodgrass has been a registered nurse for 28 years and a Family Nurse Practitioner for 18 years, practicing in multiple settings, including family practice, urgent care, emergency departments, administration, chronic pain and palliative medicine. She is currently the Operations Director for Palliative Medicine at Baptist Health Systems in Memphis, TN. She is board certified with the American Academy of Nurse Practitioners. She is also a Fellow of the American Association of Nurse Practitioners and an Advanced Certified Hospice and Palliative Nurse. She completed a Doctorate of Nursing Practice at the University of Alabama – Huntsville. She is a nationally recognized nurse practitioner speaker and teacher. Brett is a chronic pain expert, working for more than 20 years with chronic pain and palliative patients in a variety of settings. She is honored to be the HPNA 2025 podcast host. She is married with two daughters, two son in laws, one grandson, and now an empty nest cat. She and her family are actively involved in their church and she is an avid reader.

When blood collects in the skull outside the brain and below the outermost layer of tissue surrounding the brain (dura), a subdural hematoma results. This may occur due to head trauma when it is called an acute subdural hematoma. Chronic subdural hematomas may occur due to aging and the increased fragility of blood vessels. The pooled blood may resolve on its own or may require surgical intervention as development of a subdural hematoma can be a life-threatening condition. Symptoms of subdural hematoma can include headache, confusion, change in behavior, dizziness, nausea and vomiting, lethargy or excessive drowsiness, weakness, apathy, and seizures. Subdural hematomas are generally diagnosed by CT scan or MRI imaging. Ashkan Mowla, MD, FAHA, FAAN, is neuro-interventional surgeon at the Pacific Neuroscience Institute® (PNI). He specializes in minimally invasive endovascular procedures to treat conditions and diseases of the brain and spine, including stroke, brain aneurysm, brain and spine arteriovenous malformation and fistula and carotid and intracranial disease. Accepting new patients: 424-212-5361

In this episode, Jill Hoggard Green, PhD, RN, FAAN, Trustee for The Joint Commision, Joint Commision International and Health Catalyst, discusses the lasting impact of COVID-19, the importance of balancing financial priorities with clinical innovation, and strategies for supporting and developing the next generation of healthcare leaders and caregivers.