New ASA 2026 Stroke Ischemic Guidelines with Chair Dr. Shyam Prabhakaran

A stroke can feel like a lightning strike on the brain’s power grid—which is why the new 2026 AHA/ASA acute ischemic stroke guidelines focus on speed, clarity, and better systems at every step. We sit down with the chair of the writing group, Dr. Sean Pabakaron, to translate cutting-edge research into actions families, clinicians, and first responders can take right now. No jargon, no fluff—just the signals to watch, the questions to ask, and the processes that save brain.

We unpack what changed since the 2018–2019 updates and why more than 50 new trials reshaped the playbook for pre-hospital screening, ER imaging timelines, thrombolysis decision-making, and routing to thrombectomy-capable centers. You’ll learn how tools like FAST and the Cincinnati scale help paramedics identify strokes in the field, why regions now sometimes bypass closer hospitals, and how door-in, door-out time became a critical quality metric for transfers. Inside the ED, we outline the ideal sequence from stroke alert to scan within 25 minutes, to mixing tenecteplase or alteplase, to rapid consults for clot retrieval—because earlier treatment within extended windows still yields better outcomes.

We also spotlight a major breakthrough: meaningful guidance for pediatric stroke. Kids present differently, the data are thinner, and the stakes are high. Dr. Prabhakaran explains when thrombolysis and thrombectomy can be considered in expert centers and how causes shift from congenital factors to post-viral arteriopathy or trauma as children age. We close with practical prevention: midlife blood pressure control, access to primary care, and the simple steps that protect cognition and reduce stroke risk over decades.

If stroke touches your life—as a survivor, caregiver, clinician, or advocate—this conversation gives you a clear map for a faster, safer response. Listen, share with your circle, and help us spread actionable stroke knowledge. If you find this valuable, follow the show, leave a rating, and tell a friend who needs a smarter plan for brain health.

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Our beloved colleague, Dr. Davetrina Seles Gadson, passed away January 11, 2025. Dr. Gadson was an extraordinary speech-language pathologist and neuroscience researcher who devoted her energy to studying health disparities in aphasia recovery. She was a fierce advocate for improving services for individuals with aphasia, particularly Black Americans. Her research transformed our understanding of these health disparities and shed light on how we can address them. We were privileged to have Dr. Gadson as a cherished member of our lab community for four years, first as a postdoctoral fellow and then as an Instructor of Rehabilitation Medicine. She was still a close collaborator and friend to many of us at the time of her passing. Dr. Gadson was an incredible person—compassionate, inspiring, and full of life. Her dedication to advancing equity in aphasia recovery and her profound impact on our community will never be forgotten. ...

Transcript

Welcome, Mission, And Disclaimer

SPEAKER_02 0:09

Welcome to Brain Friends, where two neuronerds talk all things aphasia, language recovery, culture, and community. I am Dr. Datrina Celeste Gatson, a clinical speech language pathologist and neuroscientist.

SPEAKER_01 0:23

And I am Angie Cawthorn, stroke survivor and aphasia advocate.

SPEAKER_02 0:28

Welcome to our show. Welcome to Brain Friends. We want to thank all of our listeners for downloading the podcast. We appreciate everyone listening, so please tell a friend to tell a friend that we are here. And we are.

The Lightning Strike Metaphor For Stroke

Global Reach And Tribute

Why The 2026 Guidelines Matter

True Or False Warmup

Meet The Guideline Chair

What Changed Since 2019

SPEAKER_01 0:48

Alright, so track with me. A stroke is like a single massive lightning strike hitting the central power grid of a city. In a flash, the lines are down. The supply of energy is severed, and block by block by block, the city inside your head starts to go dark. You can just you know what I'm talking about. The street lights are flickering out, the communication lines go dead, and the system that keeps everything running begins to fail. At that moment, recovery isn't about just waiting for the storm to pass. It's really about how fast the elite repair crews can get on site and re-route the power before the city takes on irrequitable damage and the blackout becomes permanent. That's what we're talking about today. Today we're just not talking about the storm, we're talking about the 2026 blueprints for the crews who saved the city. I'm Angie Cawthorne and welcome to Brain Friends the Podcast. This is a show where we take the complex world of aphasia, cognitive communication disorders, and life after stroke and turn them into language you can actually use. Alright, so quick disclaimer. Um we're here as an education uh and community conversation. This is not medical advice. If you think you or someone is having a stroke, you might want to cut off the podcast and uh go go call 911. Are you serious right now? I had to say that anyway. Before we get into the science of the power grid, I have to talk about the heart of this work. It is February 2026, and as the uh release of this podcast, as of this week, Brain France has listeners in over 90 countries. Uh that's global reach that matters because of the because of the legacy this month, the National Aphasia Association is holding its Ask the Expert webinar in memory of the great and brilliant Dave Trina Celeste Gadson. From this year forward, every February session of Ask the Expert will be held in her memory. Wonderful. A six-week summer research experience focused on stroke recovery. The links are in the bio, and that's in um in DC. So who doesn't love that? Okay, so the reason the reason today's episode is a lean-in moment is because the American Stroke Association reached out to share a massive update. The 2026 American Heart Association, American Stroke Association guideline for the early management of patients with acute ischemic stroke. Now, listen, clinical guidelines aren't like phone updates, they don't happen every year or while you're sleeping in the middle of the night, okay? When they change, it's because the science has moved so much that the old map is now obsolete. It's the new playbook that shapes how stroke is recognized, triaged, and treated in real time. I just finished recording with the chair of the writing group, and I said, wow, so many times during the edit, it was borderline embarrassing. He explains the care with a level of clarity that survivors and families actually actually use. So listen, um, I usually do an icebreaker with my guests, but I was a little nervous and I completely forgot. But we're gonna act like this was a professional pivot, and we're gonna do a quick true or false together, okay? Alright, so first one true or false. Most strokes are ischemic. Okay, see that's true, they're usually caused by a blood vessel and account for about 87% of all strokes. Okay, true or false, clinical guidelines are updated every year. Now you see that's false. See, I just told you that. If you were listening a minute ago, I just told you that they're only updated when evidence demands it, and then and it and and it's an intensive high-stakes process. Alright, last one. True or false. A clinical guideline is written by a few friends in a room and finished quickly. Now you see again, that was see, I was I was testing you to see if you were paying attention because I told you it's a vigorous multi-layered gauntlet of peer and expert review. Now, so those weren't see, I fooled you a little bit because those weren't trivia questions. Now I want to introduce today's guest properly, and I'm gonna do it by reading his bio exactly as it was provided to me. This matters and it tells you who he is, what he does, and why his perspective is worth your attention. Dr. Sean Pabakaron is an internationally recognized leader in vascular neurology and stroke research and treatment. He is the James Nelson and Anna Lewis Raymond professor and the chair of the Department of Neurology at the University of Chicago. Dr. Sham received his medical education at the Rutgers, New Jersey Medical School and completed his residency in neurology at New York Presbyterian Hospital, Will Cornell Medical College. He followed with his clinical fellowship in vascular neurology at New York Presbyterian Hospital, Columbia University Medical Center, and a Master's of Science degree in epidemiology at Columbia University under the mentorship of Ralph Suka. His scientific expertise includes stroke epidemiology, imaging, predictive analytics, and stroke services research. He has led multiple federal funded projects, including from PCORI, AHRQ, NI, NDS, and NHLBI. He is the PI, printable investigator, print of a Stroekneck Regional Coordinating Center in Chicago, and also an MPI of a multi-center cluster randomized trial targeting door-in, door out times for stroke transfers. Now, let me give you a quick practical reason that that last line matters because I want you listening with purpose. Door in, door out times refer to how long someone spends in the emergency department at a hospital before being transferred to another hospital for a higher level of stroke care. There's levels to the different different hospitals have different, you will hear about time-sensitive stroke care, what urgency actually looks like in a system, and why timing and treatment are so central to outcomes. And we will talk about communication, how clinicians can reduce language overload, and how patients and family can ask better questions and advocate for understanding. My goal today is that when you leave this episode, the outro music plays, you feel smarter, steadier, and more informed. Not alarmed, not overwhelmed, just a little smarter. Alright. Dr. Sean Pakeron, welcome to Brain Friends. For listeners meeting you for the first time, can you share what you do in vascular neurology and what your role was as chair of the writing group for the new guidelines from the American Heart and Stroke Association?

SPEAKER_04 10:37

Sure. So I am again a vascular neurologist. That means I take care of patients with stroke, both in the hospital and in the clinic. My role and my honor was that I was asked to chair the writing group that we assembled for the 2026 American Heart Association Acute Ischemic Stroke Guidelines. That was a one and a half year process to get us to the publication last week.

SPEAKER_01 11:07

Wow. So how many people are involved in something like that?

SPEAKER_04 11:11

This group was over 30 people, not to mention the staff at the AHA also were included and very involved, and not to mention the peer review committee, which is a separate group of 20 or 30 individuals who also helped with reviewing the guidelines and shaping them to their final product.

SPEAKER_01 11:32

Okay, so when you change a guideline, what is new in these guidelines that was imperative to get the word out on?

How Evidence Becomes Recommendations

SPEAKER_04 11:42

Yeah, so the key thing here is that stroke care is not static. There's research being done in stroke care every day. And every month and every year that passes, there's new science and new studies that inform how we treat patients with acute ischemic stroke. Since the last guidelines, which were published in 2018 and updated in 2019, that has been a long period without a new guideline. And actually, probably upwards of 50 new trials have been completed in that space of time that are impactful and meaningful for what we do in terms of caring for stroke patients from the very beginning in the pre-hospital stage all the way into the hospital and managing complications from stroke. All of that has been informed by new data. And if we're still relying on the 2018-2019 guidelines, those are very outdated.

SPEAKER_01 12:45

So within the research that's being done, you were able to glean some information from that and then change the guidelines. Is that what we're pretty much saying?

SPEAKER_04 12:56

That's exactly what guideline writing groups are charged to do. They're charged to pull all the new research, read those papers, evaluate the quality of those papers. Are they high quality research studies? Are they not so high quality? And then form recommendations, uh, like that you read in those guidelines and give them a level of class of recommendation, strength of recommendation, as well as the evidence behind it. How good is the evidence behind it, the level of evidence? And that is really the job of our experts. Our experts are very uh much the leaders in their fields and knowledgeable and can analyze a paper and understand what's good about it and what was the weakness of it.

SPEAKER_01 13:42

So when you look at a paper that is a stronger paper versus a weaker paper, I'm assuming, and please correct me if I'm wrong, that would be how many participants they had, were the IRB guidelines maintained. What are the other things that make a research thing strong versus not so great?

When To Call 911

SPEAKER_04 14:04

Okay. You hit on a couple of really good features that we use to evaluate a paper. The size and sample size matters, which informs the power of that paper to compare one group versus another, because sometimes if you have two small of a group, you can't be certain that there are differences there. Whereas when you have large patient populations, you can be sure that one group is behaving differently than another group. The other thing that really matters is that we have a type of research that is considered the most definitive. That is called a clinical trial or randomized clinical trial. That tends to be the most definitive way of testing option A versus option B, or drug A versus drug B. And we look at that as a type of study that gets the highest weight compared to those that are non-randomized studies or not even prospective studies, meaning they're observing them over time. Some studies are done retrospectively, looking backwards at data. And so that's how we have a ladder of quality of research. And you mentioned that they're done rigorously with methods and safety and IRB regulations. That's also important. As well as finally the generalizability of the study. Is it only in one population that the study was done, or is it actually generalizable to all of the different types of patients that come and see doctors in hospitals? So we look at all of those things when we think about is that study a really high-quality study?

SPEAKER_01 15:45

So actually, before I forget, I do have another question. What's the difference between a clinical and a research project, like a clinical versus a research?

SPEAKER_04 15:57

Okay. So a clinical trial is a type of research that again is considered really the most definitive way to test whether something is better than another treatment. And that's because you really have created a way to avoid bias, which is a you know something that often we have when we think, oh, we want to test it in one group versus another, but we actually already were giving the drug to the people we thought it would help, and not giving it to the ones that it wouldn't help. And that's not randomized, that's biased. So what randomization does, it blinds us from that bias by flipping a coin and allowing a person to be in one group or the other, not determined by me as the doctor who has a bias. So randomized clinical trial is a type of research that's considered the most definitive way to answer a question around what's better than compared to another option. Other types of research could be non-randomized research. So it's still important that sometimes you're observing something in an epidemiological study, which is you follow people over, let's say, a year and you track how they did. Did they have another stroke? Did they um have a poor outcome? Did they pass away? Those are ways to get rates and numbers around how often does that happen? How common is something? That's still really important research. It's just not randomized, it's just observing people over time.

SPEAKER_01 17:31

From the guideline perspective, what symptoms should prompt an immediate 911 call, even if they're like subtle or they come and go? And when is it appropriate to actually wait and see? Because a lot of times they're like, call right away. Well, then they just send you home. And so now I feel like I've wasted my time, my family's up, it's three in the morning. Because it wasn't severe, they had me waiting in the waiting room for six hours. At what point can I make that decision?

Field Screening And FAST

Inside The ER Timeline

SPEAKER_04 18:02

Good question. I would say that the vast majority of acute, sudden symptoms that a person experiences that comes on like lightning. Like it's instantaneous. You mentioned earthquake. I've used lightning, I've used words like that that indicate that it's you know instantaneous. You go from feeling normal to something really not normal. And it's a neurological symptom. Your body is not feeling or working well, and we usually focus on a group of symptoms that are the most common. The acronym FAST is often used to educate the public because the face droop, the arm weakness, and the speech abnormality account for about 80% of stroke presentations. That's going to cover a lot of bases if you can remember fast. So a face droop that you're you're noticed or somebody notices on you that your arm is not working well and it's weak on one side, typically it's one side and not both together at the same time. And if your speech is either slurred or aphasic, saying the wrong words, mixing up words, or not understanding language, all of those, if they occurred suddenly, like out of the blue, is worrisome for an acute stroke and should warrant and should result in calling 911 because that's the quickest way to get in to the appropriate hospital, and they're able to stabilize you in case something worse could happen in the minutes after that, right? Some people start with that and then they could deteriorate quickly. And an ambulance is serviced by individuals who are trained, and they can stabilize, they can intubate, they can give medications. So that's really important. Now, there are symptoms that are more subtle, you mentioned the word subtle, that can still be a stroke and are not those three common symptoms. So what are they? Well, it might be a sudden loss of balance where you're leaning to one side. It might be a sudden loss of vision where one side of your vision or one eye sometimes is lost sight, or you're double. All of a sudden, whenever you're looking with two eyes open, your vision is double. Those are worrisome signs of stroke in the posterior circulation, the back of the brain. Whereas the FANS can be both the front part of the brain, the anterior circulation, or the back of the brain. So some of those subtle ones are important to recognize if, again, they came on suddenly out of the blue and you don't have any other explanation for it. Now, are there times where you could uh wait and see? I would say it's incredibly rare that we recommend that. I would say wait and see if it's a problem that you've had over and over in your life, if it's identical to other times where you felt this way, and it turned out it was a migraine attack or a feeling that you get when you sit in a certain position and you've known that about yourself. So in those instances, waiting and seeing is probably okay because you have in your mind a sense that, oh, this has happened to me before, and I don't think this is different from that. If it's different from that, you probably still should call 911. And so I would say it's infrequent that we would say, wait it out.

SPEAKER_01 21:27

I've never seen a guideline that says, you know what, you're good here.

SPEAKER_04 21:31

You'd rather you err on the side of error and being wrong and safe than being at home and then something terrible is happening and you don't get in fast enough to get blood thinner treatment that we've talked in the guidelines about connectoplase or altoplace, or the thrombectomy, which is really important if you're having a severe stroke and a blockage of a large vessel, those things will not be offered to you if you come in too late or not at all.

SPEAKER_01 22:01

I was actually told by Dr. Roy Hamilton at a pen. Yeah.

unknown 22:05

Yeah.

SPEAKER_01 22:06

Dr. Roy Hamilton is a friend to the room and And he was telling me that the thrombosis, you don't have to be at the hospital as soon now.

Transfers And Door-In Door-Out

SPEAKER_04 22:14

Yeah. So we have a larger window. I caution that just by saying the following that even though we have a longer window up to 24 hours for actually both the blood thinners in select patients, thrombectomy in select patients, there are still benefits of being treated earlier in that window. So even though you have until 24 hours to get the treatments, your chances of having a really good outcome are better if you came in in the earlier part of the window rather than the later part of the window. Time is money. Time is brain. The guidelines also try to address this. Our healthcare professionals, uh paramedics, tees, are fallible, meaning they make mistakes and we make mistakes. Everybody does. But we do need to do a good job of making sure they know what types of symptoms constitute a stroke and how to screen for a stroke. That's really emphasized as well, utilizing screening tools in the field. And those include FAST, actually, that's a common screening tool. There's others that are similar to it called a Cincinnati Pre-Hospital Hospital Stroke Scale. These are ways to just do a standardized assessment. So you're not just making a judgment one time and then using, you know, your guesstimate the next time. You're using something standardized. It's a score, and it should tell you if it's scored as a positive, your speech was abnormal or your face was abnormal. No matter what, that's a score positive for a possible stroke. And they should be acting as if it's a stroke at that point, no longer saying that it's, oh, I don't believe the scale. No, the scale is the scale.

SPEAKER_00 24:06

Right.

SPEAKER_04 24:07

So that is part of the guidelines, too, to reinforce that all of our system partners, from the pre-hospital to the hospital, need to have the highest level of education about stroke and the importance of screening tools in the field so that patients can get to the right hospital.

SPEAKER_01 24:26

Walk us through the ideal timeline from arrival in the emergency department to diagnosis and treatment, and where do the delays most often occur? And what does the guideline emphasize and look to address to reduce them?

Choosing Hospitals And Bypass Policies

SPEAKER_04 24:45

Yes, good question. So we know that when a person comes in through the emergency room, that hospitals are now set up to have protocols to call a stroke alert. That's the first step that usually happens when somebody says, I think this person's having a stroke. They've had a screen for it in triage, and the person looks like they're having a stroke. They'll call a stroke alert page. And typically on that page, there's going to be members of the stroke team that are activated. Those might include a stroke neurologist, a vascular neurologist like myself, or it might also include more advanced providers who are either interventional neurosurgeons or neuroradiologists or neurologists. Those are people who might be needed if it's going to escalate all the way to doing that thrombectomy procedure. So they're all being activated. And then the first step at that point is getting assessed for stroke by one of those team members, typically the stroke neurologist, and getting the patient to a scanner, a CT scan or an MRI scan in some of the advanced centers that can do an MRI quickly. It still has to be done quickly. So within 25 minutes, you need to have that scan completed and beginning to be reviewed by the team, the radiologist, but also the stroke neurologists and surgeons and interventionalists. And if that scan is completed and we have information about whether there is a stroke already present, that would tell us whether there's treatment options. The biggest barrier right now, once you've hit the emergency room, is in that early window of triage where people still need to use their screening tools. The nurses, the emergency room doctors have to be thinking stroke when somebody comes in with maybe vague symptoms, maybe they're subtle. Their radar has to be on and they have to be thinking about stroke. So that activation time to getting that stroke team involved is sometimes a barrier if it's not obvious, if it's not an obvious stroke. And then imaging time, getting patients quickly imaged. We set a goal of 25 in the guidelines, 25 minutes. It should be, it could be even shorter in places that are really doing it well. It could be within 10 minutes that their imaging is done, because that's a first step in getting you to a diagnosis. And then the challenge becomes delivering treatments that work. So if you're eligible for thrombolysis based on that initial assessment and that scan, how quickly can the drug be prepared and given to you in that emergency room? That's processes that we need to improve at many hospitals. That means the pharmacist might need to be called. That means the nurse has to pick up the tinectoplase or the altoplase and mix it. And then somebody has to push it. And there's also ensuring that they're safe to be given because they want to do a checklist of contraindications or reasons they shouldn't get a blood thinner.

SPEAKER_02 27:42

Right.

Thrombectomy Tech And Timing

Pediatric Stroke Breakthroughs

SPEAKER_04 27:42

So they have to do that all very quickly. So those could all add up to time and delays. The next big barrier to treatment and the big problem that a lot of patients face is when they need to have the most advanced treatment for acute ischemic stroke, and that's thrombectomy. Thrombectomy isn't offered at every hospital because it requires a specialized team and equipment. So that is offered at thrombectomy stroke centers, or what's also the next level, the comprehensive stroke centers. So those centers are far less frequent in our communities than your primary stroke centers or acute stroke-ready small hospitals. When you're getting taken to a closest stroke center, it may not be a center that has thrombectomy available at that center. So the guidelines do talk about when that is a possibility, and you have a high enough suspicion in the ambulance or in the field that this person's having a severe stroke or a large vessel occlusion stroke, taking them to the comprehensive or thrombectomy center if it's within a reasonable distance, because they'll need to be transferred to the comprehensive stroke center for the highest type of level of care. And in that scenario, when they actually go to one hospital and have to be transferred, the time delay, the transfer delay to getting to that next hospital sometimes can be in the order of hours. Oh my God. So that is brain tissue dying and of course time ticking that is irreversible. You're losing all that tissue. And we know that's a big barrier. So this concept of transfer delay is something we focus on, and we talked about in the guidelines, especially as a quality metric, to tell hospitals how do you reduce that? What can you do? One of the metrics that we emphasize in the guidelines is called door in, door out. Oh. It's called DDo, door in, door out. It is basically the time when you hit the door of your emergency room and the time when you leave the emergency room, the door out, to go to that second hospital where you're going to go for that thrombectomy. We need that to be as short as possible, if you think about it, because you ultimately need to get to that other hospital where they can pull the clot out. So if you can reduce that time to 90 minutes, 60 minutes, those are the kinds of targets that we're going to have to start to look at in our stroke systems of care.

SPEAKER_01 30:29

Wow. That is so one of my questions was actually if I'm at home and my husband's going to drive me, and I it looks like maybe it might be we're assuming it's a stroke, right? Or even if I'm in the ambulance and I know that this hospital is closer to me, but the hospital across the bridge is actually Penn Medicine in my particular case. Shout out to Penn. So should I take that extra ride to Penn, that extra 20 minutes, or should I go to the closest hospital and how we know?

SPEAKER_04 31:04

So here's again, you know, the the challenge. The challenge is to give people the advice that they should just do it on their own with their car or their family or Uber, that can be quite dangerous because what if you worsen in the car? What if you now become unconscious in the car? That you don't have anybody to help you in that situation. So if you're having a stroke, we still think calling 911 is the right thing to do. The system that you live in has to set up policies to make that choice that you just mentioned for you. So that if you're calling 911, hopefully in the Penn region, they already have a system in place where they would escalate you to that second hospital, bypassing the first hospital, because they have a screening tool to do that. We do in Chicago. So we have a system where if you call 911 in the city of Chicago, depending on the severity of your symptoms in the assessment by the paramedics, they can go to a slightly more distant hospital because it's the most advanced one that could potentially treat a large vessel occlusion, a blockage of a brain artery that couldn't be done at the first hospital that was closer.

SPEAKER_01 32:21

So they have a system already set up. When did those type of differences come about?

Causes Of Stroke In Kids

SPEAKER_04 32:28

I would say in the last five to ten years, many regions have started to implement these policies. They happen to be policies because there's often a municipality that oversees fire departments and they have to introduce them and approve them. So it's often under the governance of a city or a county or a state, and they will then develop those policies and implement and train their paramedics to know that now the policy and the protocol is that if you assess somebody and they're having a more severe type of stroke based on your assessment, your options are actually to escalate them to a further away but still appropriate comprehensive or thrombectomy center. There are really great technologies for pulling clots out in the brain. We can actually achieve that now with 90% confidence. What will be removed? But again, the earlier you can get to that clot, the better. And so we have better technology to get clots out of the brain than ever before, but we need more patients to get to those centers and get to them quickly.

SPEAKER_01 33:39

Oh, wow. Okay. All right. Actually, within the other questions, I do have one more pediatric question to close. Okay. How often do strokes occur in children? Why are they commonly missed? And how do the new guidelines help to reduce this misdiagnosis of the babies? We got to take care of the babies.

Midlife Risk And Brain Health

SPEAKER_04 34:03

Yeah. So this was a real step forward of these guidelines. Never before have we tackled pediatric stroke in these guidelines. They were always called adult ischemic stroke guidelines. And so we decided that we would try to do that. We realized, as you said, that is a population that is not being treated with the same degree of standardization and wanting to get people to kind of at least approach it in similar ways while we continue to advance the science, because that is the missing link compared to adult stroke, is that there are not that many studies in pediatric stroke to tell us that this is better than that option. Those types of rigorous, high-quality studies that we talked about at the beginning have thousands of patients in it. So you can say that we know one is better than another. We don't have that kind of data in pediatric stroke. It's rarer. That's good news. It doesn't happen that often compared to adult ischemic stroke. And there are differences in the way they present. I mentioned the classic signs of stroke in adults, face arm speech. Actually, in children, it might be more varied. They might actually have both sides of their body be affected. They might actually lose consciousness. They might actually have a seizure as their first presentation because the brain of a child is very different and less fully developed than the brain of an adult. So there are nuances to stroke detection and diagnosis in children. And then the treatment options that are available, we have less data about them than in adults. Nevertheless, the guidelines took the position that when possible, we wanted to be able to include them in the guidelines and make recommendations. For instance, around the safety of blood thinners in children over one month of age, up to 18, that we think they can be done in the right setting, in the right place, as well as pulling clots out, thrombectomy, in children who are coming in with big syndromes, big stroke symptoms, and the blockage is found on imaging of the brain. And so there are some things we think should be considered in children in the right center, in the right hands, because those experts need to be there to make those types of decisions. Because we're talking about babies and children here. We want to make sure whatever's being done is done by the best people and that they're doing it with the best knowledge and best data available to make those decisions.

SPEAKER_01 36:41

That is absolutely amazing. I have so many questions about the children having strokes and how you said like zero months.

SPEAKER_04 36:52

What causes it? It changes depending on the age group. In the very young, it could be a congenital problem, could be something they're born with, and that's the cause of their stroke. As they age, sometimes it's due to what's called focal angiopathy or focal narrowing that's often thought to be post-viral. Some patients will get a bad illness, and then they get inflammation that attacks those arteries and causes them to narrow suddenly and close. And then in other people, it's traumatic. As children get more active, they might injure an artery in their neck, and that can cause the artery to tear and cause a stroke. So these are less common, but they're more unusual to the causes.

SPEAKER_01 37:36

Right.

SPEAKER_04 37:36

It could be a congenital problem, a traumatic problem, or an infectious problem.

SPEAKER_01 37:44

That is absolutely amazing. And that is always just so scary when you know you're dealing with children and how they present and they don't know. They're like, oh, my neck hurts. My arms, oh look, I'm like a robot. I don't have arms. You're like, no, that's that's a stroke, son.

SPEAKER_03 38:00

And they'll joke about it or they won't know what it is. They think their bodies is changing.

Gratitude, Resources, And Closing

SPEAKER_01 38:05

Yeah, how could they? So I'm gonna close with this. We have a smart cookie uh question that I ask every guest. And what is one piece of advice you would give to help people protect their brain health? What is the one piece of advice that you tell your favorite auntie about brain health?

SPEAKER_04 38:25

Well, that's a great one. Now, there was a nice recent piece in the New York Times about brain health for the first week of January. I saw that. I contributed to one of the days. And the message I put out there, and I think was well received, was the importance of the midlife control of risk factors. If you aren't aware of them, you should get assessed for. And the most common one in midlife that we need to take care of to avoid cognitive problems later in life is blood pressure. Blood pressure control. So the blood pressure is doing damage to organs when it's very high and untreated. And it can do it silently, meaning you don't notice it's doing this damage because it's just a number to you and you're not feeling anything. There's no symptoms until there are. So my message to people is know your risk factors in midlife, early life, so that you're seeing your doctor and you're checking your blood pressure, for instance, or checking lab work to understand if you're diabetic. Start controlling those risk factors with either diet, exercise, or medications if needed, and really take a proactive role in midlife. Because if you don't do it then and you wait and wait and wait, either something bad happens to you or the damage is already done, and you're cognitively and your brain health is impaired later on in life.

SPEAKER_01 39:51

What is midlife? What numbers are we talking about?

SPEAKER_04 39:54

Say 40 to 50. Okay. So when you've grown up, you're right.

SPEAKER_01 39:59

Right. When you're worried about your credit score and uh that these loans are prospering a little bit. No, I get it.

SPEAKER_04 40:05

You're a big big boy or girl. You know that you have to take care of other people and your health matters. You start, it's an important message. We need more people to take their health as seriously as they can. We need to help people get access to primary care doctors, access and affordable medicines. This is all part of it, is that we need to solve for those problems because otherwise we're really setting people up for bad health in their older years.

SPEAKER_01 40:32

Dr. P, I thank you so much for joining me today. The guidelines are available on the American Stroke and Heart Association website. I thank you for your time.

SPEAKER_04 40:44

Of course, um, again, I want this to be focused on the guidelines and getting people most educated as they can be about what the importance of these guidelines are.

SPEAKER_01 40:54

I appreciate you so much.

SPEAKER_04 40:56

Hey, Kierangie.

SPEAKER_01 40:57

Thank you so much. Bye bye. This was a good episode. See, I told y'all y'all want to learn something. Absolutely, absolutely. Dr. P, thank you for joining me and for breaking down a highly technical guideline in a way that the public can actually use and understand. And that absolutely matters. It really matters, it really does make a difference. So thank you for that. And to the American Stroke Association, I want to give a shout out to the team that made this conversation happen. Thank you for your coordination and your support and your commitment to public education. This is what it looks like when science leaves page and reaches the people it's meant to serve. So thank you for listening to this episode of Brain Friends. Again, my name is Angie Cawthorn. This is Brain Friends. So until next time, take care of your brain, take care of your body, and take care of each other. Peace, y'all.

SPEAKER_02 42:10

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