Selected Podcast
Endovascular Treatment of Ischemic Stroke
Hamed Farid, MD discusses the signs and symptoms of Stroke and the latest endovascular treatments available at Temecula Valley Hospital.
Featured Speaker:
Hamed Farid, MD, Neuroradiology Specialist
After completing his fellowship in Neurointerventional Radiology at UCSF, Dr. Farid set up his own practice in Orange County where he specialized in treating patients with blood vessel disorders of the brain, neck, and spine. Several years later, he resumed his education and earned a masters degree in Business Administration from UCLA, Anderson School of Business. Currently, Dr. Farid has always been interested in adapting technology to health care. Transcription:
Melanie Cole (Host): If you have a stroke, getting medical care as quickly as possible can help prevent death or minimize the lasting effects of a stroke. There’s a new treatment that’s proving to be very effective at removing large clots and in conjunction with TPA; it can lead to better outcome for stroke patients. My guest is Dr. Hamed Farid. He’s a neurointerventionalist and a member of the medical staff at Temecula Valley Hospital. Dr. Farid, tell us about the different types of strokes out there today.
Hamed Farid, MD, Neuroradiology Specialist (Guest): Sure. First of all, thank you so much for having me. The two types of strokes include ischemic and hemorrhagic. Now hemorrhagic is due to having blood in the brain. It could be secondary to a burst vessel such as an aneurysm or it could be due to a ruptured AV malformation or even small blood vessels secondary to very high blood pressures.
The other type of stroke which comprises approximately 87% of strokes, is called ischemic. And that’s when a clot from somewhere in the body travels into the blood vessels of the brain and prevents blood from going forward. Blood carries oxygen and therefore, there is a lack of oxygen going to the brain tissue.
Host: Who is at risk for ischemic stroke and does having one, put you at risk for another?
Dr. Farid: Sure. So, there are different risk factors for stroke. Age, as people get older, they are at higher risk of stroke. High blood pressure, diabetes, kidney disease, but then other conditions such as atrial fibrillation, coronary or carotid artery disease, build up of plaque; these are all risk factors for stroke. People who do have a stroke, are at a higher risk than the rest of the population of having additional strokes. So, if you do have symptoms of stroke; it’s important to find out exactly what the etiology is because you need to fix the etiology to prevent future strokes.
Host: So, let’s talk about symptoms because that’s a very important thing for people to note and as time is brain and it’s so important to get help immediately; tell us the symptoms of a stroke and how we can remember them.
Dr. Farid: Sure. An acronym that is pretty commonly used is FAST, F-A-S-T. And so, the letters stand for, the F stands for facial asymmetry. One side of the face looks abnormal compared to the other side, such as a facial droop. The A stands for arm, arm weakness. You can have either arm or leg weakness actually. And it’s any kind of weakness and usually the weakness is all of the sudden. So, it is a fast, all of the sudden there is weakness on one side of the body. The S stands for speech. There is sometimes problems with slurred speech. Sometimes difficulty getting words out. Sometimes even understanding words, something called aphasia. So, that’s what the S stands for and the T stands for it is time to call 9-1-1. Anytime we have symptoms like this that occur, especially if they occur all of the sudden; it is time to call 9-1-1 and get to a hospital as soon as possible because you might be suffering from a stroke.
Host: What happens at the ER, Doctor, and tell us about what people can expect from not only the EMS, if they are getting driven there in an ambulance; but what happens at the ER?
Dr. Farid: So, usually when the patient comes in, prior to getting to the emergency room, we get a call from the EMS and paramedics stating that they are bringing a patient to the hospital suspecting having a stroke. We go ahead and activate code STROKE overhead so that everyone is aware that there’s a stroke patient coming in. When the patient comes in, the patient is evaluated very quickly by an ER physician and a neurologist and taken immediately to CAT scan in imaging in order to take a look at the brain to determine whether there is – a non-contrasted CT, whether there is blood or not which excludes the possibility of a hemorrhagic stroke and then a CT angiogram and CT perfusion imaging. CT angiogram helps us in looking at the blood vessels of the brain to determine whether there’s a large vessel occlusion or a blockage in any of the blood vessels and the CT perfusion scan allows us to determine whether there is salvageable tissue for us to intervene on.
Host: What’s the first line of defense? What is that intervention? What does that look like?
Dr. Farid: So, the first line of defense is going to be intravenous TPA. If you present with stroke symptoms, and you come in within four and a half hours of the last time the patient was seen normal; and you qualify for that medication because just like everything else, there are certain exclusion criteria. If you do qualify for this medication; you will get the intravenous TPA. Now, after that if the advanced imaging demonstrates that you do have a large vessel occlusion; you would be – and the perfusion scan shows that you do have salvageable tissue; then you are at a – have the opportunity to have mechanical thrombectomy performed. Which is a procedure where you go in through a small incision in the leg, into the artery and under x-ray, you thread a catheter up into the brain, inject contrast, find exactly where the clot is and actually go up to the face of clot and extract the clot out of the brain vessel.
Host: Wow, isn’t that amazing that you have the ability to do that? Now speak about the new treatment that’s proving to be very effective at removing large clots and in conjunction with TPA, it can lead to better outcome for stroke patients. So, tell us a little bit about mechanical thrombectomy.
Dr. Farid: So, mechanical thrombectomy is a procedure that has recently proven to be very beneficial at reversing some of the symptoms of stroke. If the patient comes in and demonstrates the large vessel occlusion on the CT angiogram and the perfusion scan demonstrates that there is salvageable tissue in the brain; what the procedure allows you to do is go in and actually remove the clot so that you have improved blood flow in the brain.
That procedure is done in a room called the Biplane room and it’s under x-ray. The procedure entails making a small incision in the femoral artery in the groin, on either the right side or the left side and then under x-ray, taking a catheter up into the carotid artery on the side where the blockage is. From there, there are other catheters that you put into that other catheter in the neck in order to be able to get to the brain to where the clot is. And once you get to the clot, you use devices such as either aspiration catheters that suck the clot or stent retrieval devices which actually get ahold of the clot and then what you do is you actually pull the clot out of the brain.
Host: Wow. That’s really cool. So, does this work in conjunction with TPA if TPA is first, then mechanical thrombectomy would be the next step?
Dr. Farid: Yeah, so usually if the patient can qualify for TPA, they get the TPA, but there’s a big group of people that first of all cannot get TPA because they are outside of that four-and-a-half-hour window and then the second thing is that not all clots can be broken down by TPA. It really depends on the length of the clot and the makeup of the clot. So, mechanical thrombectomy has shown that in the past, with TPA, we would give the patients TPA. It used to be three-hour window, now it’s been extended to a four-and-a-half-hour window, but that’s all that that population that TPA was capturing. The research that has been done with these mechanical thrombectomy devices has shown that some patients can be salvaged, their brain tissue can be salvaged up to 24 hours since the last time seen normal. So, the thrombectomy devices are giving us abilities to actually go up and take the clot out up to 24 hours of a clot being there again, if there is salvageable tissue in the brain.
Host: So, is that the patient selection criteria for mechanical thrombectomy? Are some people not candidates for this?
Dr. Farid: Correct. So, for mechanical thrombectomy there are those two criteria, the CT angiogram that demonstrates whether there is a large vessel occlusion or not and then the perfusion which shows whether there is salvageable tissue. There are some people that come in within maybe 6-10 hours and unfortunately, their stroke is complete. A lot of that has to do with collaterals and the way the vessels have been built in the brain. Some people can last longer. It’s just like for example if you were to submerge yourself under water, have two people submerge themselves under water; one person can tolerate being underwater a lot longer than another person. It’s the same issue with the brain. It’s the lack of oxygen. Some people can tolerate withstanding longer times without oxygen and other people’s brain tissue dies a lot faster. And that’s why we use that perfusion in order to determine because every patient is different.
Host: Is there a way to reduce our risk of stroke?
Dr. Farid: Sure. In order to reduce your risk of stroke, obviously, you want to make sure – there are certain things that we can’t change, certain risk factors, such as getting older and family history of stroke. But there are other risk factors that we can change. Controlling our blood pressures better, controlling our diabetes better, better diet, exercise, also if you have heart conditions such as for example, atrial fibrillation; having that detected and being on medication and having your blood be thinned out enough to be able to not have a stroke and reduce your risks of having a stroke.
Host: Wrap it up for us Dr. Farid. You are a great educator and you explained the mechanical thrombectomy so well to us. You made it a very visual explanation so, thank you for that. Give us your best advice, what you would like people to know about the fact that time is brain and getting in for stroke treatment as soon as you recognize those symptoms is so important.
Dr. Farid: Yeah absolutely. So, thank you so much again. And I would just really focus on the acronym of FAST when it comes to stroke. If there’s something that occurs all of the sudden that’s something is wrong with your face, either arm or leg weakness, your speech, anything like that; just call 9-1-1. Because you could be having a stroke and time is of an essence. So, the sooner you get to a hospital that provides these services; the sooner you are able to hopefully get the help you need in order to open up the blood vessel, reperfuse the brain so that you can limit the injury or even completely reverse the injury that has occurred to the brain during this time. And the most important thing is if you do see a loved one having a stroke; making sure you find out exactly when was the last time you saw your loved one normal, because that’s when the clock starts. The clock does not start when you come into the emergency department. It starts when the patient was last seen normal. And so, that is also of an essence.
So, remembering those symptoms and what time those symptoms began and calling 9-1-1 is the most important thing that you can do. And also, if you do have symptoms of stroke, and those things go away, it’s something called a transient ischemic attack or a TIA. Definitely present to your physician. Just because you have a symptom and it goes away, doesn’t mean you don’t have a stroke that is brewing. You need to go to your primary care physician and found out exactly what the cause of this is so that once the cause is found; you can treat that cause to prevent the risk of a stroke.
Host: Wow. Thank you so much Dr. Farid for being on with us today and again, for really sharing your excellent expertise in this field and in this topic. Thank you for being with us. You’re listening to TVH Health Chat with Temecula Valley Hospital. For more information, please visit www.temeculavalleyhospital.com, that’s www.temeculavalleyhospital.com. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for tuning in.
Melanie Cole (Host): If you have a stroke, getting medical care as quickly as possible can help prevent death or minimize the lasting effects of a stroke. There’s a new treatment that’s proving to be very effective at removing large clots and in conjunction with TPA; it can lead to better outcome for stroke patients. My guest is Dr. Hamed Farid. He’s a neurointerventionalist and a member of the medical staff at Temecula Valley Hospital. Dr. Farid, tell us about the different types of strokes out there today.
Hamed Farid, MD, Neuroradiology Specialist (Guest): Sure. First of all, thank you so much for having me. The two types of strokes include ischemic and hemorrhagic. Now hemorrhagic is due to having blood in the brain. It could be secondary to a burst vessel such as an aneurysm or it could be due to a ruptured AV malformation or even small blood vessels secondary to very high blood pressures.
The other type of stroke which comprises approximately 87% of strokes, is called ischemic. And that’s when a clot from somewhere in the body travels into the blood vessels of the brain and prevents blood from going forward. Blood carries oxygen and therefore, there is a lack of oxygen going to the brain tissue.
Host: Who is at risk for ischemic stroke and does having one, put you at risk for another?
Dr. Farid: Sure. So, there are different risk factors for stroke. Age, as people get older, they are at higher risk of stroke. High blood pressure, diabetes, kidney disease, but then other conditions such as atrial fibrillation, coronary or carotid artery disease, build up of plaque; these are all risk factors for stroke. People who do have a stroke, are at a higher risk than the rest of the population of having additional strokes. So, if you do have symptoms of stroke; it’s important to find out exactly what the etiology is because you need to fix the etiology to prevent future strokes.
Host: So, let’s talk about symptoms because that’s a very important thing for people to note and as time is brain and it’s so important to get help immediately; tell us the symptoms of a stroke and how we can remember them.
Dr. Farid: Sure. An acronym that is pretty commonly used is FAST, F-A-S-T. And so, the letters stand for, the F stands for facial asymmetry. One side of the face looks abnormal compared to the other side, such as a facial droop. The A stands for arm, arm weakness. You can have either arm or leg weakness actually. And it’s any kind of weakness and usually the weakness is all of the sudden. So, it is a fast, all of the sudden there is weakness on one side of the body. The S stands for speech. There is sometimes problems with slurred speech. Sometimes difficulty getting words out. Sometimes even understanding words, something called aphasia. So, that’s what the S stands for and the T stands for it is time to call 9-1-1. Anytime we have symptoms like this that occur, especially if they occur all of the sudden; it is time to call 9-1-1 and get to a hospital as soon as possible because you might be suffering from a stroke.
Host: What happens at the ER, Doctor, and tell us about what people can expect from not only the EMS, if they are getting driven there in an ambulance; but what happens at the ER?
Dr. Farid: So, usually when the patient comes in, prior to getting to the emergency room, we get a call from the EMS and paramedics stating that they are bringing a patient to the hospital suspecting having a stroke. We go ahead and activate code STROKE overhead so that everyone is aware that there’s a stroke patient coming in. When the patient comes in, the patient is evaluated very quickly by an ER physician and a neurologist and taken immediately to CAT scan in imaging in order to take a look at the brain to determine whether there is – a non-contrasted CT, whether there is blood or not which excludes the possibility of a hemorrhagic stroke and then a CT angiogram and CT perfusion imaging. CT angiogram helps us in looking at the blood vessels of the brain to determine whether there’s a large vessel occlusion or a blockage in any of the blood vessels and the CT perfusion scan allows us to determine whether there is salvageable tissue for us to intervene on.
Host: What’s the first line of defense? What is that intervention? What does that look like?
Dr. Farid: So, the first line of defense is going to be intravenous TPA. If you present with stroke symptoms, and you come in within four and a half hours of the last time the patient was seen normal; and you qualify for that medication because just like everything else, there are certain exclusion criteria. If you do qualify for this medication; you will get the intravenous TPA. Now, after that if the advanced imaging demonstrates that you do have a large vessel occlusion; you would be – and the perfusion scan shows that you do have salvageable tissue; then you are at a – have the opportunity to have mechanical thrombectomy performed. Which is a procedure where you go in through a small incision in the leg, into the artery and under x-ray, you thread a catheter up into the brain, inject contrast, find exactly where the clot is and actually go up to the face of clot and extract the clot out of the brain vessel.
Host: Wow, isn’t that amazing that you have the ability to do that? Now speak about the new treatment that’s proving to be very effective at removing large clots and in conjunction with TPA, it can lead to better outcome for stroke patients. So, tell us a little bit about mechanical thrombectomy.
Dr. Farid: So, mechanical thrombectomy is a procedure that has recently proven to be very beneficial at reversing some of the symptoms of stroke. If the patient comes in and demonstrates the large vessel occlusion on the CT angiogram and the perfusion scan demonstrates that there is salvageable tissue in the brain; what the procedure allows you to do is go in and actually remove the clot so that you have improved blood flow in the brain.
That procedure is done in a room called the Biplane room and it’s under x-ray. The procedure entails making a small incision in the femoral artery in the groin, on either the right side or the left side and then under x-ray, taking a catheter up into the carotid artery on the side where the blockage is. From there, there are other catheters that you put into that other catheter in the neck in order to be able to get to the brain to where the clot is. And once you get to the clot, you use devices such as either aspiration catheters that suck the clot or stent retrieval devices which actually get ahold of the clot and then what you do is you actually pull the clot out of the brain.
Host: Wow. That’s really cool. So, does this work in conjunction with TPA if TPA is first, then mechanical thrombectomy would be the next step?
Dr. Farid: Yeah, so usually if the patient can qualify for TPA, they get the TPA, but there’s a big group of people that first of all cannot get TPA because they are outside of that four-and-a-half-hour window and then the second thing is that not all clots can be broken down by TPA. It really depends on the length of the clot and the makeup of the clot. So, mechanical thrombectomy has shown that in the past, with TPA, we would give the patients TPA. It used to be three-hour window, now it’s been extended to a four-and-a-half-hour window, but that’s all that that population that TPA was capturing. The research that has been done with these mechanical thrombectomy devices has shown that some patients can be salvaged, their brain tissue can be salvaged up to 24 hours since the last time seen normal. So, the thrombectomy devices are giving us abilities to actually go up and take the clot out up to 24 hours of a clot being there again, if there is salvageable tissue in the brain.
Host: So, is that the patient selection criteria for mechanical thrombectomy? Are some people not candidates for this?
Dr. Farid: Correct. So, for mechanical thrombectomy there are those two criteria, the CT angiogram that demonstrates whether there is a large vessel occlusion or not and then the perfusion which shows whether there is salvageable tissue. There are some people that come in within maybe 6-10 hours and unfortunately, their stroke is complete. A lot of that has to do with collaterals and the way the vessels have been built in the brain. Some people can last longer. It’s just like for example if you were to submerge yourself under water, have two people submerge themselves under water; one person can tolerate being underwater a lot longer than another person. It’s the same issue with the brain. It’s the lack of oxygen. Some people can tolerate withstanding longer times without oxygen and other people’s brain tissue dies a lot faster. And that’s why we use that perfusion in order to determine because every patient is different.
Host: Is there a way to reduce our risk of stroke?
Dr. Farid: Sure. In order to reduce your risk of stroke, obviously, you want to make sure – there are certain things that we can’t change, certain risk factors, such as getting older and family history of stroke. But there are other risk factors that we can change. Controlling our blood pressures better, controlling our diabetes better, better diet, exercise, also if you have heart conditions such as for example, atrial fibrillation; having that detected and being on medication and having your blood be thinned out enough to be able to not have a stroke and reduce your risks of having a stroke.
Host: Wrap it up for us Dr. Farid. You are a great educator and you explained the mechanical thrombectomy so well to us. You made it a very visual explanation so, thank you for that. Give us your best advice, what you would like people to know about the fact that time is brain and getting in for stroke treatment as soon as you recognize those symptoms is so important.
Dr. Farid: Yeah absolutely. So, thank you so much again. And I would just really focus on the acronym of FAST when it comes to stroke. If there’s something that occurs all of the sudden that’s something is wrong with your face, either arm or leg weakness, your speech, anything like that; just call 9-1-1. Because you could be having a stroke and time is of an essence. So, the sooner you get to a hospital that provides these services; the sooner you are able to hopefully get the help you need in order to open up the blood vessel, reperfuse the brain so that you can limit the injury or even completely reverse the injury that has occurred to the brain during this time. And the most important thing is if you do see a loved one having a stroke; making sure you find out exactly when was the last time you saw your loved one normal, because that’s when the clock starts. The clock does not start when you come into the emergency department. It starts when the patient was last seen normal. And so, that is also of an essence.
So, remembering those symptoms and what time those symptoms began and calling 9-1-1 is the most important thing that you can do. And also, if you do have symptoms of stroke, and those things go away, it’s something called a transient ischemic attack or a TIA. Definitely present to your physician. Just because you have a symptom and it goes away, doesn’t mean you don’t have a stroke that is brewing. You need to go to your primary care physician and found out exactly what the cause of this is so that once the cause is found; you can treat that cause to prevent the risk of a stroke.
Host: Wow. Thank you so much Dr. Farid for being on with us today and again, for really sharing your excellent expertise in this field and in this topic. Thank you for being with us. You’re listening to TVH Health Chat with Temecula Valley Hospital. For more information, please visit www.temeculavalleyhospital.com, that’s www.temeculavalleyhospital.com. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for tuning in.