Stroke FM

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: 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