SEASON 1
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. Our team of co-hosts are: Jaime Cazes, Ryan Muir, Phavalan Rajendram, Katherine Sawicka, Tess Fitzpatrick, Neha Patel, Sydney Lee, and Houman Khosravani. Ideas and opinions are our own and this podcast is not a substitute for expert medical advice.
In this episode the hosts discuss code stroke. Tune in to learn about the acute assessment of the patient presenting with a code stroke and thrombolysis. You can learn more about this episode by clicking here.
Key Terms: Code stroke, protocol, intravenous tPA risks, intravenous tPA contraindications, ASPECTS and stroke mimics
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 the Table 1 Adapted from the 2017 American Academy of Neurology Continuum Article titled, “Clinical Evaluation of the Patient with Acute Stroke.”
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
Tune in to hear the hosts discuss thrombolysis. You can learn more about this episode by clicking here.
Key terms: thrombolysis, door-to-needle, contraindications
Hosts: Neha Patel, Phavalan Rajendram, & Katherine Sawicka
Summary:
What is tPA?
Indications for tPA
Does time matter?
TNK
Contraindications for tPA
tPA and EVT
Door-to-needle time tips
Post tPA care
In this episodes the hosts review the evidence for the role of endovascular therapy for acute ischemic stroke. Click here to see the details.
Key Terms: Endovascular therapy (EVT), Mechanical Thrombectomy, Large Vessel Occlusion, CT-Perfusion, Perfusion Mismatch
Hosts: Ryan Muir, Tess Fitzpatrick, Houman Khosravani
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?
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 the Modified Rankin Scale (MRS) at 90 days).
These trials were summarized in a meta-analysis performed by the HERMES in collaboration in 2016.
In the HERMES pooled analysis the number 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 - the THRACE trial
These trials led to the 2015 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 beyond 6 hours and up to 24 hours in select patients.
o DAWN
o DEFUSE 3
As a result of DAWN and DEFUSE 3, the 2019 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 thrombectomy is 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
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
Do some reading ahead of time
Prevent burn-out
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 design
Hosts: 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 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
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”
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 talk about Protected Code Stroke (PCS), which provides a framework for safely and efficiently delivering hyperacute stroke care. Click here to see the details.
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
Know when to activate a PCS
Always use PPE with correct donning & doffing techniques
Always appoint a safety leader
Use crisis resource management principles
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
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
A positive attitude will take you far
Reach out to your fellow residents
Enjoy yourself as much as possible
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
Written and performed by Jaime Cazes