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Episode Title: The 6-24 Hour Window: Screening, "Chat & Tap," and WorkflowHosts: Dr. Houman Khosravani (Stroke Neurologist) & Dr. Christine Hawkes (Stroke Neurologist & Neuro-Interventionist)Location: Stroke FM Studios, Toronto

The Original paper, ACT-FAST was a pre-hospital tool for detecting ELVO. This is now used in the ED as a first-pass clinical screen, that leads to acute CT/CTA Head and Neck.

In this episode of Stroke FM, we unpack the specific screening protocols for identifying stroke patients in the extended 6 to 24-hour window who may be eligible for Endovascular Thrombectomy (EVT). Unlike the standard "FAST" screen, this protocol aims to identify Large Vessel Occlusions (LVOs)—severe strokes caused by major clots that require mechanical removal.

We discuss the critical importance of accurate timestamps, how to clinically test for cortical signs (the "Chat and Tap"), and the essential workflow for emergency physicians to confirm candidacy before activating the regional stroke team.

• The Rule: The 6-24 hour window is calculated from when the patient was last seen completely normal, not when symptoms were discovered.

• Wake-Up Strokes: For patients waking up with symptoms, the clock starts when they went to sleep or were last seen well by family.

• No "Resets": Hearing a patient move or hearing a fall is not sufficient to reset the clock; there must be a confirmed interaction where the patient was at their neurological baseline. However, if the patient self-reports - definitely consider that.

Protocol for Emergency Physicians or Emergency Department Nurses - in a RN-led model:

The initial screening (using ACT-FAST or similar LVO tools) should be performed locally by the Emergency Physician. If the clinical screen is positive, the following workflow applies:

1. Local Imaging First: Order a CT Head and CTA (Angiogram) of the Head & Neck immediately at your site.

2. Confirm the LVO: Review the imaging to confirm the presence of a Large Vessel Occlusion.

Activate: Only once an LVO is confirmed on imaging should you call the Regional Stroke Centre or activate the "Code Stroke" transfer.

Note: In our network, once the call is made MD-to-MD and accepted, the transfer coordination is streamlined through a nursing-led model to expedite care.

Disclosures and Disclaimers

• Medical Education Only: This podcast is for educational purposes only. It does not constitute medical advice, create a physician-patient relationship, or establish a duty of care.

• Not a Substitute for Care: This content should not replace competent medical assessment, professional clinical judgment, or advice from a licensed physician.

• Views & Opinions: The views expressed are solely those of the hosts and guests and do not reflect the positions of their affiliated universities or hospitals.

• Patient Privacy: All cases discussed are fictionalized or significantly altered for educational purposes; no real-life patient data is used.

• Verification: While references are provided, the audience should independently verify all information and consult the primary literature for full details.

Intervals.icu is a Stellar platform to track your metrics, your fitness, whether you are a cyclist or love another sport.

In this episode, Mr. David Tinker, founder and primary developer of this platform shares some key insights. Knowledge is power and metrics are important. It is also important to be able to integrate data across different devices such as wearables. David shares his journey from a software developer to the creator of Intervals.icu, a platform designed for sport analytics. He discusses the importance of user feedback, the integration of AI, and the challenges of maintaining data accuracy. The conversation also touches on the growth of the cycling community, the significance of coaching, and the future of open-source hardware in fitness technology. David emphasizes the platform's commitment to user data accessibility and the ongoing development of features to enhance user experience.

Host: @neuroccm (X) @neuroccm (BlueSky)

Guest: @david_tinker (X) davidtinker.bsky.social (BlueSky)

Topic: Simulation Debrief – Airway Management in the CT Scanner

Host: Dr. Houman Khosravani

Guests: Dr. Nicole Kester-Greene, Lowyl Notario (APN), Miranda Lamb (Clinical Educator, now our *stellar* Patient Care Manager for our ED!)

• Patient: 67-year-old presenting with full Left MCA syndrome (Right hemiplegia/aphasia).

• History: Hypertension, Diabetes, on Ramipril (ACE Inhibitor).

• Initial Action: CT Head (Aspects 7, no hemorrhage) $\rightarrow$ tPA administered in the CT scanner.

• The Complication: Post-tPA, the patient developed hypoxia (sats low 90s) and significant tongue/lip swelling.

  • Note: Angioedema can be precipitated by the combination of tPA and ACE inhibitors.

The team discussed the critical decision-making process when a "Code Stroke" turns into a "Code Airway."

• Immediate Treatment:

  • Epinephrine: The team opted for 0.5 mg IM Epinephrine.

  • Debate: There was a discussion regarding IV vs. IM Epi. The consensus was to avoid IV bolus Epi in a stroke patient (due to hypertension risks) unless hypotensive, sticking to IM for the allergic reaction while monitoring BP.

  • Adjuncts: Methylprednisolone (125 mg) and Benadryl (50 mg).

• Airway Strategy:

  • The Challenge: Assessing whether to intubate immediately or observe. Given the progression, the decision was to intubate.

  • The Method: Awake Intubation (using Ketamine/Lidocaine/Phenylephrine) was chosen over RSI (Rapid Sequence Intubation) to avoid cardiovascular collapse and maintain spontaneous respiration in a difficult airway.

The debrief heavily focused on Human Factors and inter-departmental communication.

• The "CT Trap": The patient was isolated in the scanner. Managing an airway in the CT control room/scanner is dangerous due to lack of space and equipment.

• The Move: A critical decision was made to move back to the ED Resus room.

• Communication Gap: There was confusion regarding where the patient was going, highlighting the need for closed-loop communication before moving a critical patient.

• The Transition: The Stroke Team leader initially managed the code but recognized the need to hand over the airway to the EM physician.

• Explicit Handover: The importance of clearly stating, "I am handing over the airway to you," to avoid the "two cooks in the kitchen" scenario.

Dr. Kester-Greene introduced a specific communication framework to align the team during chaos:

1. Initial Summary: When the team arrives (Status, Diagnosis, Treatment so far).

2. Priority Summary: Mid-resuscitation (Re-evaluating what is most important right now).

3. Pre-Transfer Summary: Before moving the patient (Where are we going? Do we have the right equipment?).

• "Speaking Up": The nurse noted early signs of anaphylaxis but felt unheard initially.

• "Listening Up": Leaders must create space for team members to voice concerns (e.g., "Does anyone see anything I missed?").

The group established that for future cases involving angioedema in the scanner:

• Secure the Airway: If imminent failure, manage on-site (or immediate vicinity).

• Stable but Concerned: Transport immediately to the Resus room where equipment and space are optimized.

• Clear Terminology: Use "Airway Emergency" to trigger the correct mindset shift from "Stroke Protocol."

• Dr. Houman Khosravani – Stroke Physician

• Dr. Nicole Kester-Greene – Director of Emergency Dept Simulation

• Lowyl Notario – Advanced Practice Nurse / Patient Care Manager

• Miranda Lamb – Interim Clinical Educator--> Now our Stellar Patient Care Manager

A unique role - Code Stroke RNs - Critical Care-trained RNs coming to Code Stroke as part of a Stroke Program

2023 - In this episode of our Systems of Stroke Care series, Dr. Houman Khosravani sits down with Beth Linkewich, Director of Regional Stroke and Neurovascular Programs, to discuss a game-changing role in hyperacute stroke management: The Code Stroke Nurse.

As Endovascular Thrombectomy (EVT) volumes rise, hospitals face a critical bottleneck: the availability of anesthesia resources. Beth explains how her team bridged this gap by developing a specialized nursing role that allows patients to be safely transported to and monitored in the Angio Suite without an anesthesiologist present for every case. We dive into the "Huddle" decision-making process, the peri-procedural order sets, and the collaborative culture required to make this innovative model a success.

Key Takeaways:

• The Resource Gap: How the increasing demand for EVT created a need for alternative monitoring solutions when Anesthesia is not immediately available.

• The Role Defined: What a Code Stroke Nurse does—from the Emergency Department to the Angio Suite—focusing on airway management, conscious sedation, and hemodynamics.

• The "Huddle": The collaborative decision-making protocol between the Stroke Neurologist, the Code Stroke Nurse, and Anesthesia to determine if a patient needs an Anesthesiologist present immediately.

• Safety & Governance: How peri-procedural order sets and Critical Care (Level 3) training ensure patient safety during the transition of care.

• Collaboration: Why this model enhances, rather than replaces, the relationship with Anesthesia colleagues.

In this official Canadian Stroke Consortium (CSC) episode, we dive deep into the landmark ACT Trial (Alteplase Compared to Tenecteplase). Dr. Bijoy Menon, the trial's Principal Investigator, joins the show alongside Co-Principal Investigator Dr. Rick Swartz to discuss the design, execution, and practice-changing results of this pragmatic Phase 3 trial.

The ACT trial was a pragmatic, multicenter, open-label, registry-linked, randomized controlled non-inferiority trial.

• Scope: Conducted across 22 stroke centers in Canada.

• Timeline & Volume: Between December 2019 and January 2022, the trial enrolled 1,600 patients aged 18 or older with disabling acute ischemic stroke presenting within 4.5 hours of symptom onset.

• Randomization: Patients were randomized 1:1 to receive either:

  • Tenecteplase: 0.25 mg/kg (maximum 25 mg) as a single bolus.

  • Alteplase: 0.9 mg/kg (maximum 90 mg) as a bolus followed by a 60-minute infusion.

The study met its prespecified non-inferiority threshold, demonstrating that Tenecteplase is a reasonable alternative to Alteplase.

• Primary Outcome (Functional Independence): An mRS score of 0-1 at 90-120 days occurred in 36.9% of Tenecteplase patients versus 34.8% of Alteplase patients. This represents an unadjusted risk difference of 2.1%.

• Safety Profile: Safety outcomes were similar between the two groups:

  • Symptomatic Intracerebral Hemorrhage: 3.4% (TNK) vs 3.2% (tPA).

  • 90-day Mortality: 15.3% (TNK) vs 15.4% (tPA).

A prespecified secondary analysis examined 520 patients (33% of the trial population) with LVOs (including ICA, M1/M2-MCA, and basilar artery).

• Functional Outcomes: Among LVO patients, 32.7% in the Tenecteplase group achieved mRS 0-1 compared to 29.6% in the Alteplase group.

• Reperfusion Rates: For the 405 LVO patients who underwent thrombectomy, successful reperfusion was comparable on initial angiography (9.2% TNK vs 10.5% tPA) and final angiography (84.5% vs 88.9%).

• Conclusion: Treatment outcomes were not modified by the baseline occlusion site, and rates of functional independence, hemorrhage, and mortality remained similar between groups.

A separate analysis highlighted that "time is brain" applies equally to both agents.

• Onset-to-Needle: Each 30-minute reduction in onset-to-needle time was associated with a 1.8% increase in the probability of achieving a good outcome (mRS 0-1).

• Door-to-Needle: Every 10-minute reduction in door-to-needle time was associated with a 0.2% increase in probability of a good outcome.

• Effect: The effect of time to treatment on clinical outcomes was similar regardless of which thrombolytic agent was used.

The investigators emphasized the practical advantages of Tenecteplase over Alteplase:

• Ease of Administration: The single-bolus administration of Tenecteplase (5-10 seconds) eliminates the need for a 60-minute infusion pump.

• Transport Efficiency: The single bolus facilitates rapid treatment and easier patient transfer for endovascular therapy when needed.

• Robust Evidence: The ACT trial's large sample size and pragmatic design provide the necessary evidence to support Tenecteplase as a standard of care for all patients meeting standard thrombolysis criteria.

• Dr. Bijoy Menon: Principal Investigator of the ACT Trial; Stroke Neurologist and Professor at the University of Calgary.

• Dr. Rick Swartz: Co-Principal Investigator; Stroke Neurologist at Sunnybrook Health Sciences Centre, University of Toronto.

Reference:Menon BK, et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke (ACT): a pragmatic, registry-linked, randomised, open-label, phase 3, non-inferiority trial. The Lancet. 2022.

Episode: The Clot Thickens – Integrating Stroke into Thrombosis Training

Host: Dr. Houman Khosravani (Stroke Specialist, Toronto)Guest: Dr. Stephanie Carlin (Assistant Professor, Medicine; Critical Care Pharmacist & Thrombosis Fellowship Graduate)

In this special episode of StrokeFM, Dr. Khosravani and Dr. Carlin discuss a manuscript they co-authored regarding the educational gap between stroke neurology and thrombosis medicine. They explore the results of a pilot project that integrated a formal stroke rotation into a thrombosis fellowship, highlighting how cross-pollination between these two disciplines leads to better patient outcomes and more comprehensive specialist training.

• The Genesis of the Project:

  • During her fellowship, Dr. Carlin noticed a high volume of consults involving stroke patients or patients with concurrent thromboembolic concerns.

  • Surveys of other Canadian and US thrombosis programs revealed that none offered a formal stroke rotation, prompting the creation of this pilot rotation.

• The Clinical Synergies:

  • There is a massive natural overlap between the two fields, specifically regarding:

    • Anticoagulation management (e.g., for Atrial Fibrillation).

    • Mechanical heart valves.

    • Prothrombotic states (e.g., malignancy, Antiphospholipid Syndrome).

    • Patent Foramen Ovale (PFO) management.

• Operationalizing the Integration:

  • Duration: A rotation of 4 to 8 weeks is ideal to cover necessary topics.

  • Alternative Models: For centers without dedicated rotations, integration can be achieved through joint case rounds, half-day presentations, or collaborative case conferences.

  • Scope: This model is applicable not just to pharmacy or internal medicine, but also to vascular medicine, hematology, and neurology trainees.

Dr. Carlin shares a compelling case study that illustrates the value of this integrated training:

• The Patient: A young woman in her early 20s on oral contraceptives presented with a large MCA stroke requiring TPA and thrombectomy.

• The Workup: Lab work revealed a prolonged PTT, raising suspicion for Antiphospholipid Syndrome (APS).

• The Learning Opportunity:

  • The Stroke Team educated the thrombosis fellow on TPA, EVT, and the timing of antithrombotics relative to hemorrhagic transformation risks.

  • The Thrombosis Fellow educated the stroke team on the nuances of APS testing (e.g., lupus anticoagulant interference) and appropriate contraceptive changes.

• Thrombosis Canada: A key resource for guidelines on anticoagulation and vascular health.

• Article: "The Clot Thickens: Integrating Stroke into Thrombosis Training" (The manuscript discussed in this episode).

Episode SummaryKey Discussion PointsClinical Spotlight: The Value of CollaborationResources Mentioned

Here are the show notes for the StrokeFM episode covering the SVIN 2021 meeting.

In this episode of StrokeFM, host Dr. Houman Khosravani sits down with Dr. Ameer Hassan, the President of the Society of Vascular and Interventional Neurology (SVIN), to discuss the major takeaways from the SVIN 2021 Annual Meeting in Phoenix, Arizona.

Dr. Hassan shares critical updates on clinical trials, his personal philosophy on bridging therapy versus direct-to-angio, and the nuance of managing intracranial atherosclerotic disease (ICAD).

Dr. Ameer Hassan, DO, FAHA, FSVIN

• Head of the Neuroscience Department at Valley Baptist Medical Center

• Professor of Neurology and Radiology at the University of Texas Rio Grande Valley

• President of SVIN

Dr. Hassan provided a rundown of the pivotal trials presented or discussed at the meeting:

• Subdural Hematoma Embolization: The SQUID trial (sponsored by Balt) and the EMBOLISE trial (sponsored by Medtronic) are investigating the embolization of the middle meningeal artery for chronic and acute-on-chronic subdurals.

• Large Core Infarcts: The TESLA trial (PI Dr. Sam Zaidat) is moving forward, looking at thrombectomy in patients with large core infarcts, similar to the SELECT2 and IN EXTREMIS trials. The goal is to be more inclusive with mechanical thrombectomy.

• Bridging vs. Direct: The SWIFT DIRECT trial showed no statistical difference between direct-to-cath lab versus bridging lytics.

• AURORA Analysis: Confirmed that treating endovascular patients is safe, though the "number needed to treat" suggests patient selection (collaterals and salvageable tissue) remains vital.

Dr. Hassan advocates for individualized medicine rather than a blanket policy.

• Scenario A: If the angio suite is empty and the team is ready, he takes the patient straight to the cath lab.

• Scenario B: If there is a delay (e.g., room occupied) or the patient requires transfer, he utilizes IV thrombolytics (TNK or Alteplase).

• Rationale: "Time is brain." If you can't cut immediately, lytics provide a bridge.

Dr. Hassan discussed the risks of aggravating ulcerated plaque during acute interventions.

• Acute Stenting: Data suggests acute stenting is relatively safe, but Dr. Hassan prefers angioplasty first for ICAD.

• The "Wait and See" Approach: Based on the WEAVE registry data, waiting 5–7 days allows the "hot plaque" to cool down, significantly lowering stroke risk during stenting (from ~20% acute risk down to ~2-4% delayed risk).

• Hardware Selection:

  • Dissection/ICAD: Prefers self-expanding stents (e.g., Wingspan) or Enterprise stents if dissection is suspected.

  • Vertebral/Other Anatomy: May use balloon-mounted stents (e.g., Resolute Onyx) depending on distal vs. proximal diameters.

• AI Integration: Technologies like Viz.ai, Rapid, and Brainomix are essential for converting linear workflows (serial phone calls) into parallel processing (alerting the whole team simultaneously).

• Advanced Imaging: Moving toward advanced imaging (CTP) for the 6–24 hour window to identify salvageable tissue.

• New Journal: SVIN has launched a new journal titled Stroke: Vascular and Interventional Neurology.

SVIN 2021 Highlights: Trials, Stenting Strategies, and the Future of Thrombectomy with Dr. Ameer Hassan🎙️ Guest Profile📋 Key Clinical Trial Updates🧠 Clinical Pearls: Dr. Hassan’s Practice1. Bridging Lytics vs. Direct to Angio2. Intracranial Stenting and "Hot Plaque"🚀 The Future of Stroke Systems

StrokeFM: The Future of Neuroprotection & The Story of Nerinetide with Dr. Michael Hill

Episode S2_e07

Is neuroprotection finally moving from "déjà vu" failure to clinical reality? In this episode, host Dr. Homan sits down with Dr. Michael Hill (University of Calgary) to dissect the fascinating journey of Nerinetide, the landmark ESCAPE-NA1 trial, and the biological detective work that uncovered why a potential breakthrough drug clashed with standard thrombolytics.

• The History of Failure: Why previous neuroprotection trials failed, primarily due to the lack of human-analogous ischemia-reperfusion models in pre-clinical testing.

• The Molecule: How Nerinetide works intracellularly by interfering with the PSD-95 protein to stop toxic nitric oxide production without blocking critical synaptic signaling.

• ESCAPE-NA1 Results: A deep dive into the trial that showed an overall neutral result (2% difference) but uncovered a massive, statistically significant benefit (approx. 9.5% absolute risk difference) in patients who did not receive Alteplase (tPA).

• The Plot Twist (The Interaction): The biochemical discovery that Alteplase cleaves and inactivates Nerinetide in human plasma—an interaction that was not present in rat models due to species differences in plasminogen activation.

• Biological Plausibility: How the creation of a "D-enantiomer" (a mirror image of the molecule) proved resistant to Alteplase cleavage, confirming the interaction theory.

• The Future: A look at ESCAPE-NEXT, the upcoming trial designed to replicate the successful "No-Alteplase" arm of the previous study, and the FRONTIER trial, which looks at pre-hospital administration.

"We essentially have a true human ischemia-reperfusion model... This is the number one difference between the possibilities that exist now compared to what we had done in the past." — Dr. Michael Hill

"The trial was neutral... but when we looked at the two groups, we had a statistically relevant interaction... in the No-Alteplase group, the direction of effect was markedly positive." — Dr. Michael Hill

• The Trial: ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke)

• The Drug: Nerinetide (NA-1)

• Upcoming Trials: ESCAPE-NEXT and FRONTIER

In This Episode, We Discuss:Key Quotes:References & Further Reading:

In this episode Dr. Tess Fitzpatrick, and Dr. Katherine Sawicka

Episode Summary

In this episode, our guests discuss their recent publication regarding the real-world challenges of using Unfractionated Heparin (UFH) in acute stroke patients. The team explores the data behind the "hunch" that UFH often fails to achieve therapeutic levels quickly or consistently, and discusses the pragmatic shift toward Low Molecular Weight Heparin (LMWH).

The Clinical Problem

• Traditionally, IV Unfractionated Heparin (UFH) is the go-to for acute anticoagulation in stroke (e.g., for free-floating thrombi) because it has a short half-life and is reversible.

• However, achieving a therapeutic aPTT is difficult, often leading to patients being sub-therapeutic or supra-therapeutic for long periods.

Study Design & Indications

• The team conducted a retrospective study over three years, identifying stroke patients treated with UFH for specific cerebrovascular indications.

• Three main indications studied:

  1. Intraluminal thrombus (free-floating thrombus).

  2. Cerebral Venous Sinus Thrombosis (CVST).

  3. Cardiogenic indications (e.g., cardiac thrombus, low ejection fraction).

The Results: Confirming the Hunch

• Delayed Efficacy: For the first time the aPTT went over 70 seconds, 35% of the time it took between 12 and 24 hours to occur.

• Lack of Stability: 66% of patients never reached a "steady state" (defined as two consecutive therapeutic aPTT measurements).

• Overshoot: Patients spent 25% of the time in the supra-therapeutic range (too high), though major bleeding events were rare in this specific sample.

• Variability Causes: High variability is partly due to the non-specific binding of UFH to plasma proteins, monocytes, and endothelial cells, which are often elevated in acute phase reactants during stroke.

The Shift to Low Molecular Weight Heparin (LMWH)

• The center is moving away from UFH and toward LMWH for these indications.

• Benefits of LMWH: It offers a predictable dose-response relationship, greater stability, and higher bioavailability compared to UFH.

• The "Safety Blanket" Myth: While clinicians like UFH because of the reversal agent Protamine, the team notes that Protamine is rarely actually used in stroke settings (unlike in cardiac surgery). It often provides a "false sense of security."

Pragmatic Management

• Start Low: The team suggests starting LMWH at lower doses (e.g., roughly 2/3 dose) and titrating up, rather than immediately giving a full dose, to mimic the gradual onset of UFH without the instability.

• Exceptions: UFH may still be preferred for patients with severe renal failure or those requiring imminent surgery (within 4 hours).

There is a desperate need for randomized control trials (RCTs) specifically in the stroke population comparing Low Molecular Weight Heparin vs. Unfractionated Heparin to solidify these best practices.

🎙️ Meet the Guests🧠 Key Topics & Study Findings🏥 Clinical Implications & Practice Changes📚 Call to Action

CSC Dr. Bijoy Menon, University of Calgary

CSC Dr. Andrew Demchuk, University of Calgary

MR CLEAN-NO IV was a European multicenter RCT (Netherlands, Belgium, France) published in NEJM in November 2021.

Question: Is direct EVT superior or non-inferior to IV alteplase + EVT in anterior circulation LVO stroke patients presenting directly to thrombectomy-capable centers?

Design: PROBE design, 1:1 randomization, ~539 patients

Key Result: EVT alone was neither superior nor noninferior to intravenous alteplase followed by EVT with regard to disability outcome at 90 days after stroke. New England Journal of Medicine The incidence of symptomatic intracerebral hemorrhage was similar in the two groups. New England Journal of Medicine

Bottom line: Unlike the Asian trials (DIRECT-MT, DEVT) that showed non-inferiority for skipping tPA, MR CLEAN-NO IV couldn't confirm the same in European populations—so the bridging IVT + EVT paradigm remains standard for eligible patients at EVT-capable centers.

In this episode @neuroccm highlights three studies from #ISC2021 AHA's International Stroke Conference. We have the distinct privilege of having music by BreakMasterCylinder who has graciously contributed their compositions to our podcast focused on Stroke Education and awareness. We are most thankful - Please Follow @BrkmstrCylinder and contribute at Patreon. Click here to see the studies discussed in this episode.

AHA International Stroke Conference 2021

In this episode @neuroccm highlights three studies from #ISC2021 AHA's International Stroke Conference. We have the distinct privilege of having music by BreakMasterCylinder who has graciously contributed their compositions to our podcast focused on Stroke Education and awareness. We are most thankful - Please Follow @BrkmstrCylinder and contribute at Patreon.

Featured Studies:

ANGIO-CAT Study"Nonetheless this represents an extremely exciting time, and the message should not be lost that patients with large vessel occlusions can be screened to some degree of reliance clinically and imaged using a flat panel CT with what appears to be a safe modality, and then be taken to thrombectomy and not be denied thrombolysis if needed. This study shows a major speed-up effect in workflow processes. It is quite possible that future studies with higher number of patients, in a multicenter setting, could tease out outcome differences as well. Therefore overall, this is an incredibly positive step forward - Our tools are only as good as the people able to deliver them, and this workflow improvement study certainly opens the door to further optimization of hyperacute stroke care." excerpt from a news piece by @neuroccm for Neurodiem.
BEST-MSU Study"Taken together, 17% more patients were treated with TPA, the full 30% or more in the golden hour, with significantly improved patient-centered outcomes. There were 10% more patients with a modified Rankin score of 0 or 1 at 90 days. Overall, this is an important step forward in pushing the boundaries of bringing the treatment to the patient, and if this is ultimately found to be cost effective this represents yet another hyperacute innovation in acute stroke treatment. This may have specific relevance to both large, populated centers that are spread apart geographically, and certainly more austere environments as well." excerpt from a news piece by @neuroccm for Neurodiem.

MR CLEAN-NO-IV StudyDirect to EVT (early window) vs. Thrombolysis + EVT - designed as a superiority study. "They did not show superiorly nor non-inferiority of direct to EVT vs. combination treatment. There were no differences in symptomatic intracranial hemorrhage which is a particularly important finding, given that one could expect a higher rate with the TPA group. Dr. Yvo Roos, in a post-presentation interview with the AHA, suggest that hemorrhage rates may be more related to either delayed recanalization or simply that reperfusion itself is the main culprit for hemorrhage rather than onboard thrombolytic. This is provocative and needs further study and further details need to be reviewed. Certainly, there is biological plausibility and that patients are heterogeneous enough in their physiology and baseline neurovascular characteristics that reperfusion as a physiologic insult can result in such findings.

The important takeaway message here is that for patients that are eligible to receive thrombolysis – that thrombolysis should not be withheld in the era of thrombectomy, and thrombolysis should be delivered in a timely manner.

Taken together, there appears to be more science and understanding of criteria that are still necessary to be discovered with regards to which patient should go a stroke center capable of delivering thrombolysis versus directly to center that can provide comprehensive care with both modalities." excerpt from a news piece by @neuroccm for Neurodiem.

In this episode, two keen Resident MDs Drs. Ryan Muir (PGY4) and Jaime Cazes (PGY1) join us for an in-depth at how things are going! A recent look back from within the 2'nd wave of COVID (in Canada), which thankfully is subsiding. They provide insight into how COVID has impacted their residency training, what our program has done, and how new learning opportunities have manifested in the form of Virtual Care. #TakeCare Everyone and keep looking out for your #Wellness as we look forward to better days!

Don't miss the conclusion of the 2 part episode on Crisis Resource Management (CRM). Click here for the details on this episode.

Did you ask about thrombolysis? We are here to deliver anxiolysis! In this second of a two-part episode of 2021, we discuss "crisis resource management" (CRM) in acute stroke - a cognitive, mindfulness, and non-technical framework for optimizing clinical performance and working in high-performing teams. CRM is a tool to master four operational domains: that of the self, teamwork, our working environment, and of course, (care for) our patient. Using CRM principles helps make us better clinicians, work more effectively in teams, and maintain a calm sense of vigilance. We re-introduce the concept of a "zero point survey" (Reid et al. 2018) as a starting point before coming on-call for a code stroke and as a tool for better self-awareness and performance. High-performing teams support good clinical outcomes at the resuscitation phase and apply to all subsequent patient care settings. Central to a high-performing team are principles of CRM and their timely application to stroke care. We review our paper in Neurocritical Care titled: "Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care" with three of the authors: Rajendram, Notario, Khosravani - In this episode we conclude this talk on "how to be a bad-a$$ stroke" resus doc!

Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care by: Phavalan Rajendram, Lowyl Notario, Cliff Reid, Charles R. Wira, Jose I. Suarez, Scott D. Weingart & Houman Khosravani (Neurocritical Care, published in 2020) Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance Cliff's Great talk - Making Things Happen

In this first of a two-part episode, we discuss Crisis Resource Management (CRM) in acute stroke. Click here to learn more about high performing teams in hyperacute stroke care.

Did you ask about thrombolysis? We are here to deliver anxiolysis! In this first of a two-part episode of 2021, we discuss "crisis resource management" (CRM) in acute stroke - a cognitive, mindfulness, and non-technical framework for optimizing clinical performance and working in high-performing teams. CRM is a tool to master four operational domains: that of the self, teamwork, our working environment, and of course, (care for) our patient. Using CRM principles helps make us better clinicians, work more effectively in teams, and maintain a calm sense of vigilance. We re-introduce the concept of a "zero point survey" (Reid et al. 2018) as a starting point before coming on-call for a code stroke and as a tool for better self-awareness and performance. High-performing teams support good clinical outcomes at the resuscitation phase and apply to all subsequent patient care settings. Central to a high-performing team are principles of CRM and their timely application to stroke care. We review our paper in Neurocritical Care titled: "Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care" with three of the authors: Rajendram, Notario, Khosravani

Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care by: Phavalan Rajendram, Lowyl Notario, Cliff Reid, Charles R. Wira, Jose I. Suarez, Scott D. Weingart & Houman Khosravani (Neurocritical Care, published in 2020) Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance

Greetings Stroke FM listeners. We are back in 2021 with an exciting series of Podcasts, follow-up episodes, clinical and non-technical discussions and new future partnerships. Looking forward to releasing episodes as we record them this year and moving onwards! Take care + stay safe!

In this episode the hosts discuss the future of stroke. Click here to see the details.

Key Terms: Thrombolysis, endovascular therapy,

Hosts: Ryan Muir, Houman Khosravani

Summary:

In this episode the hosts discuss the future of stroke by exploring and proposing novel applied modern concepts of endovascular and thrombolytic therapies to innovative and creative ideas for the future.

• Endovascular therapy for distal vessels is discussed

• Improving geographic access to endovascular therapy (especially for wide spread countries like Canada)

• The role of the NIHSS score in the acute assessment of stroke in the future and the increasing reliance on imaging parameters to guide decision making

• The future of thrombolysis

• The future of neuroimaging: Evolving understanding of ASPECTS and MRI Brain (Solid state MRI in acute stroke assessments), and potential role for focused ultrasound

• Neuroprotection and extending time-windows

Tune in to hear the hosts talk about residency, mentorship, work-life balance and more. Click here to see the details.

Key Terms: Transition to residency, Work-life balance, Mentorship, Surviving PGY1

Hosts: Sydney Lee, Jaime Cazes and Houman Khosravani

Summary:

• First few days of residency

• Managing expectations

• Discovering the rewards of residency

• Going from off-service to on-service

• Balancing residency with lifestyle

• Mentorship

• Surviving call

• Three take home points

1. A positive attitude will take you far

2. Reach out to your fellow residents

3. Enjoy yourself as much as possible

In this episode the hosts discuss stroke orientation during the COVID-19 pandemic. Click here to see the details.

Key Terms: COVID-19, Stroke Orientation, NVU

Hosts: Jane Liao, Houman Khosravani

Summary:

• Purpose of modified procedures - Limit human-human interaction

• Handover in separate rooms

• Limit hand-off of items (pager, tools) and wipe down after doing so

• Virtual meeting apps (Zoom, Google Meet) for rounds/teaching when possible

• Have a moderator for meetings focused on keeping discussions concise

• Send residents home early if the day's tasks are complete and they are not needed

• Assign only one resident to go with the staff to stroke codes as opposed to the whole team

• https://www.codestroke.net/covid19

In this episode the hosts talk about Protected Code Stroke (PCS), which provides a framework for safely and efficiently delivering hyperacute stroke care.

Key Terms: Protected Code Stroke, COVID-19, Personal Protective Equipment

Hosts: Phavalan Rajendram, Jaime Cazes, Houman Khosravani

Summary:

• The COVID-19 pandemic poses unique challenges in delivering hyperacute stroke care

• The “Protected Code Stroke” (PCS) protocol provides a framework for safely and efficiently delivering hyperacute stroke care

• Know when to activate a PCS

• Always use PPE with correct donning & doffing techniques

• Always appoint a safety leader

• Use crisis resource management principles

This episode covers how COVID-19 has impacted healthcare and medical education from the viewpoints of a graduating 4th year medical student and a staff physician.

• Key Terms: COVID-19, PPE, Pandemic, medical education

• Hosts: Jaime Cazes, Houman Khosravani

• Summary:

• This episode covers how COVID-19 has impacted healthcare and medical education from the viewpoints of a graduating 4th year medical student and a staff physician.

In this episode the hosts discuss hemorrhagic strokes. Click here to see the details.

Key Terms: ICH, blood pressure control, spot sign

Hosts: Phavalan Rajendram, Neha Patel, Houman Khosravani

Summary:

• Hemorrhagic strokes (HS) account for ~15-20% of all strokes

• There is a significant morbidity and mortality associated with HS

• Early blood pressure control is key in the management of HS

• CTA can identify a spot sign (may indicate increased risk of hematoma expansion)

• Etiologies

• Find out if the patient is on anticoagulation so that it can be reversed

• Make sure the patient is stable before CT scan (may need anti-emetics, intubation, etc.)

• Early blood pressure control is key

• Blood pressure target < 140/90

  • See ATACH-2 and INTERACT trials on BP control in ICH

• Consult NSx early as surgical options may be available

  • See STICH-2 trial on surgical management of superficial ICH without IVH

• Prognostication can be aided with “ICH Score”

In this episode, we dive into the evidence behind Dual Antiplatelet Therapy (DAPT) for acute secondary prevention, specifically breaking down the landmark CHANCE trial. We also talk about the POINT trial. Here is more on CHANCE.

Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack

• The Question: Does early administration of Aspirin + Clopidogrel reduce the rate of subsequent strokes compared to Aspirin alone?

• The Population: 5,170 patients ($\ge$ 40 years) with minor ischemic stroke (NIHSS score $\le$ 3) or high-risk TIA (ABCD2 score $\ge$ 4).

• The Timing: Treatment started within 24 hours of symptom onset.

1. Primary Outcome (Stroke Recurrence at 90 days)

• DAPT Group: 8.2%

• Aspirin Monotherapy: 11.7%

• Result: A significant reduction in stroke risk (HR 0.68; P<0.001).

• NNT (Number Needed to Treat): 29

2. Safety (Bleeding Risk)

• DAPT Group: 2.3%

• Aspirin Monotherapy: 1.6%

• Result: No statistically significant increase in bleeding rates (P=0.09).

In patients with minor ischemic stroke or high-risk TIA, starting Aspirin + Clopidogrel within 24 hours significantly reduces the 90-day stroke incidence without increasing bleeding rates compared to aspirin monotherapy.

Reference:

Wang Y, et al. NEJM, 2013. 369(1):11-19.

(Infographic credit: Visualmed)

The Study: CHANCE (2013)Key FindingsBottom Line

Tune in to hear the hosts discuss feedback and communication. You can learn more about this episode by clicking here.

Key terms: Feedback, communication, competence by designHosts: Neha Patel, Phavalan Rajendram and Houman Khosravani

Summary:

• Feedback can feel uncomfortable

• More feedback at more time points is effective for resident growth

  • Competence by design

• Types of feedback

• Debriefing as a team after difficult and complex medical situations

• How to learn and grow from feedback as a resident

• Sandwich approach to feedback

• Be constructive, goal is to help person improve ultimately

In this episode the hosts touch on code stroke basics, anxiolysis and burnout prevention. Click here to see the details.

Key terms: Stroke rotation survival guide, NIHSS tips, Burnout prevention

Hosts: Katherine Sawicka, Tess Fitzpatrick, and Houman Khosravani

Summary:

• Code stroke basics

  • Establish roles within the team – history-taker, examiner

  • Clarify history from EMS, family, bystanders (ie: last seen well)

  • Know your NIHSS

• Anxiolysis

  • Useful apps

    • NIHSS score & stroke tools

    • Neuro toolkit

  • Do some reading ahead of time

    • Canadian Best Practices guidelines are a great resource

    • Learn ASPECTS, the CT Scan scoring system for stroke developed in Alberta, Canada

• Prevent burn-out

Co-Hosts: Ryan Muir, Tess Fitzpatrick, Houman Khosravani

Key Terms: Endovascular therapy (EVT), Mechanical Thrombectomy, Large Vessel Occlusion, CT-Perfusion, Perfusion Mismatch

Summary:

In this episode the hosts review the past 15 years of evidence for the role of endovascular therapy for acute ischemic stroke and trace its evolution to present day guidelines for the acute treatment of stroke.

• What is endovascular therapy?

• What were the early trials of EVT – what did we learn from them?

  • MULTI – MERCI

  • PENUMBRA PIVOTAL

  • IMS-III

  • MR. RESCUE

• These early trials facilitated the development of later trials done between December 2010 and December 2014, that outlined a reduction in mortality and stroke disability (as measured by theModified Rankin Scale (MRS) at 90 days).

• These trials were summarized in a meta-analysis performed by theHERMESin collaboration in 2016.

  • MR. CLEAN

  • ESCAPE

  • REVASCAT

  • SWIFT PRIME

  • EXTEND IA

• In the HERMES pooled analysis thenumber needed to treat with EVT was 2.6 persons to reduce MRS by 1 point.

• One trial was done later also favoured EVT, but was not included in the HERMES meta-analysis - theTHRACE trial

• These trials led to the2015 AHA/ASA focused update and recommendation that endovascular treatment should be offered to patients with acute ischemic stroke when:

  • Pre-stroke mRS score 0 to 1

  • Even in those patients receiving IV r-tPA within 4.5 hours of onset

  • Causative occlusion of ICA or proximal MCA (M1)

  • NIHSS score of ≥6 and ASPECTS ≥6

  • Presenting within 6-hrs of symptom onset

• While the above trials demonstrated benefit of endovascular therapy performed within 6 hours of symptom onset (although REVASCAT demonstrated a benefit within 8 hours) in the context of acute ischemic stroke, two trials were recently published that demonstrate benefit beyond6 hours and up to 24 hours in select patients.

oDAWN

oDEFUSE 3

• As a result of DAWN and DEFUSE 3, the2019 AHA/ASA Guidelines now suggest:

  • Within 0 – 6 hours of symptom onset:Direct aspiration thrombectomy as a first pass or mechanical thrombectomy with a stent retriever should be done if the following criteria are met: (i) prestroke MRS of 0 – 1 (ii) causative occlusion of the internal carotid artery or MCA segment 1 (M1) (iii) age >18 years (4) NIHSS ≥ 6

  • Within 6 – 24 hours of symptom onset

    • In selected patients with acute ischemic stroke within 6 – 16 hours of last known normal who have a large vessel occlusion in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomyis recommended

    • In selected patients with acute ischemic stroke within 6 – 24 hours of last known normal who have a large vessel occlusion in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable

Co-Hosts: Neha Patel, Phavalan Rajendram, & Katherine SawickaSummary: Great Episode on Thrombolysis - we will have a future episode on TNK as well.-What is tPA?-Indications for tPA-Does time matter?-NINDS -ECAS III -TNK-TEMPO2 -Contraindications for tPA-tPA and EVT -SWIFT DIRECT -Door-to-needle time tips -Post tPA care

Co-Hosts: Ryan Muir, Tess Fitzpatrick, Houman Khosravani

Summary:

In this episode the hosts discuss the approach to the acute assessment of a patient presenting as a code stroke. This episode also reviews the indications, relative contraindications and absolute contraindications to thrombolysis.

• Defining roles within the Code Stroke Team: splitting the team into MD1 and MD2.

• Assess patient stability.Airway,Breathing, Circulation,Glucose. Ask yourself is this the type of patient who needs intubation or ICU? Is this the type of patient you may need help from the ER doctor managing vitals?

• Examination and NIHSS performed by MD1 while MD2 is collecting collateral information (don’t delay the scan for the full NIHSS, this can be completed later).

• Before travelling to the scanner, be prepared: thrombolysis kit and anti-hypertensives

• Be on the lookout for “STROKE MIMICS.”Some common stroke mimics are depicted below in theTable 1Adapted from the 2017 American Academy of Neurology Continuum Article titled,“Clinical Evaluation of the Patient with Acute Stroke.”

• ASPECTS score

• MD2 to review indications and contraindications to thrombolysis and endovascular therapy

• Risks of thrombolysis: hemorrhage, angioedema

• Documenting the discussion of consent for thrombolysis and endovascular therapy

You've heard of thrombolysis? We are here to deliver anxiolysis when it comes to learning about stroke. This Stroke-focused podcast is developed by a keen group of doctors who are in the Neurology program in Toronto. It is geared towards residents and medical students with a keen interest in stroke and stroke-related topics. Ideas and opinions are our own and this podcast is not a substitute for expert medical advice. We are the official podcast of the Canadian Stroke Consortium. Follow us on X.com @strokefm