SEASON 1

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.”

• 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

Key terms: thrombolysis, door-to-needle, contraindications

Hosts: Neha Patel, Phavalan Rajendram, & Katherine Sawicka

Summary:

• 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

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?

  • 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 the Modified Rankin Scale (MRS) at 90 days).

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

  • MR. CLEAN

  • ESCAPE

  • REVASCAT

  • SWIFT PRIME

  • EXTEND IA

• 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

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

• Prevent burn-out

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

Key terms: DAPT, Minor stroke, TIA
Hosts: Tess Fitzpatrick, Katherine Sawicka, and Houman Khosravani

Summary:

• Monotherapy with antiplatelet

• Dual antiplatelet evidence critical appraisal

• CHANCE

• POINT

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”

• 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.

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

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

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

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