Talk with a Stroke Doc

Q: Are there any "outside of the box" trials being done (i.e., magnetic, electrical, or cannabis trials)? How do we find out about clinical trials?

A: We are part of the NIH-funded StrokeNet, and so we do offer many trials at the UUH – everything from acute treatments for hemorrhage to prevention trials to recovery studies of motor and cognitive outcomes. Some trials are only for patients who are currently experiencing a stroke, and so we offer them in the hospital. Others, such as the prevention and recovery trials, can often be found on our website (you can start here, a list of our actively enrolling trials). I am not aware of any cannabis trials, but you can always look online at https://www.researchmatch.org/ for additional trials. See also https://studiesforyou.utah.edu/ and https://www.trialstoday.org/guide.

Q: Did the number of strokes increase during the COVID-19 pandemic? Do the risks of stroke increase if a person had COVID?

A: The number of patients admitted for stroke actually decreased during the pandemic. However, the risk of stroke for someone with active COVID was increased. That’s a bit of a paradox that we think is mostly because persons with minor strokes stayed away from the hospital, and also because (1) face masking reduced the incidence of flu and (2) the reduced traffic dramatically improved air quality. (Both of these factors increase the risk of stroke.)

Q: Are studies still being done on lipoprotein(a)? What are the results and progress on understanding high cases?

A: We know that patients with high lipoprotein(a) are at increased risk of advanced atherosclerosis. We are still completing a trial that looks at lowering lipoprotein(a) in patients with histories of stroke or heart attack by using an investigational drug called pelacarsen. The overall goal is to reduce the risk of future major cardiovascular events (e.g., death, non-fatal heart attacks, and non-fatal strokes). The trial isn’t done yet, so we don’t yet know if it works.

Q: How do I make an appointment with someone experienced in stroke patient recovery and its related processes?

A: If you are looking for help with stroke recovery, I recommend you contact the UUH physical medicine and rehabilitation department at 801-646-8000 or visit https://healthcare.utah.edu/locations/neilsen-physical-rehab-hospital. There is also the University of Utah Health stroke support group (you can contact kara.tucker@hsc.utah.edu or collin.shepherd@hsc.utah.edu for more details).

Q: What about aspirin therapy? How long do I continue it after stroke?

A: The vast majority of patients after stroke require lifelong antithrombotic therapy, whether that is aspirin, another antiplatelet such as clopidogrel, or a stronger blood thinner (a “DOAC” or warfarin). Talk to your primary care provider or neurologist about which one you are supposed to be on.

Q: How can stroke survivors be advocates for stroke care?

A: Advocacy to our state and national lawmakers and policy makers is critical. Stroke survivors can be very helpful because you provide the voices of a lived experience. I’ve been advocating for 15+ years through both the American Heart Association (AHA) and the American Academy of Neurology, and both organizations have patient advocacy as well. You may not realize it, but our state and national policies affect stroke care.

A few of the things we’ve advocated for over the years include creating a Utah stroke registry to better understand our state’s stroke care, creating Utah policy to ensure ambulances take patients to certified stroke centers, nationally increasing NIH funding for innovative stroke research, and ensuring Medicare reimburses for TeleStroke services. We still need to do work to reduce drug prices and to increase access to rehab therapies, among other things.

There are endless ways you can get involved! You can donate your time or your money to organizations that will fight for stroke patients. You can write letters to the editor for your newspaper. You can speak at your church or other organizations about stroke signs and symptoms and the importance of calling 911 if you have a stroke. And you can educate your family so they can be your support too. Finally, your local American Heart group is always looking for volunteers for various heart and stroke activations.

You can also reach out to the team at UtahStrokeCenter@hsc.utah.edu if you’re interested in working with us on patient story opportunities. This might include writing about your experiences or agreeing to be videoed to help others understand what you went through.

Q: Are there any screening tests that can look at likelihood of stroke? I have a number of factors that put me at risk. I would like to get out in front of this if there is a way.

A: The best way to reduce risk of stroke is to make sure your vascular risk factors are controlled. I like to refer to the American Heart Association’s Life Simple 8, which highlights this. In particular, ensuring that your blood pressure is controlled to less than 130/80 is critical, as is not smoking. As we age, our blood pressure starts to climb, so just because it was good when we were younger doesn’t mean it’ll stay that way. So always ask at your doctor’s or at the pharmacy to get it checked.

In addition, AHA’s Health for Good is a great resource for creating good eating and exercise habits, and Know Your Numbers has a lot of valuable information on reducing risk for cardiovascular and stroke risk factors. There is also a podcast by Vascular Division members L. Dana DeWitt, MD, and Thomas Miller, MD, in which they discuss how to reduce your risk of stroke, and you can read about the Top 5 Steps for Preventing Stroke on the University of Utah Heath website.

Q: What is being done regarding research or how to address the mental health of patients who have had a stroke? And regarding the research being done on the recovery of stroke patients—are there any studies being done on patients who are further out from their stroke? What is being done to advance our neuroplasticity beyond two years?

A: We know that the earlier the rehabilitation, the better the outcome after stroke. But we also are increasingly aware that neuroplasticity can continue for many years after stroke. Most of the current NIH-funded studies are looking at the subacute period (i.e., the weeks to months after stroke) because they think there will be the most benefit in that period. That said, there are a few studies, such as the one here at the University focusing on couples after stroke that Dr. Alex Terrill, myself, and others are running, that do enroll patients further out from stroke. To find out more about that trial, contact ReStoreD@utah.edu or go to https://studiesforyou.utah.edu/trial_detail.php?trial_id=IRB_00142681.

Clearly more work needs to be done in the space of long-term rehabilitation therapies.

Q: Anticoagulation therapies are offered for Afib, but what are the stats telling us how much stroke truly is prevented? We use it, but what percentage does it actually prevent?

A: Anticoagulation therapies are very effective at preventing stroke in patients with atrial fibrillation. Without such therapy, the rate of stroke in patients with atrial fibrillation varies by various factors but is generally thought to be about 12% every 1–2 years. With anticoagulation therapy, that rate drops to 1–2% per year. Most patients are now treated with one of four “DOACs,” direct oral anticoagulants, but some (either due to cost or to specific contraindications) are required to be treated with warfarin, an older medication that requires frequent blood tests for monitoring.

Q: How can I help to get a TeleStroke program at my local hospital?

A: In Utah, we have worked very hard to extend top quality stroke care across the state. I think every hospital is now either a stroke center or is connected to a stroke center via TeleStroke (through the University of Utah, Intermountain Healthcare, or another program). You can find out if your hospital has one by calling their ER to ask.

Q: Is a cerebral angiogram more trustworthy than an MRI, or do they go hand in hand?

A: They study different things: cerebral angiograms look at blood vessels up close, while MRIs look at the structure of the brain. When an MRI looks at blood vessels, it’s called an MRA and it is not as detailed as a cerebral angiogram, but it has other advantages, including time, cost, and also the ability to see the vessel wall, which a cerebral angiogram cannot do.

Q: Is there much, if any, research ongoing about the relationship between frequent intense headaches following stroke?

A: That’s an interesting question, as one of our fellows is interested in studying just that, using something called sphenopalatine ganglion block; however, the study isn’t set up yet. Post-stroke headache is too common, but to my knowledge, we don’t have a specific treatment for it, and so try the usual headache medicines.