Stroke 2023: A Change Has Come and Is Still Coming

Aug 26, 2023

Stroke 2023: A Change Has Come and Is Still Coming

For the non-neurologist, it may be hard to keep up with all the latest controversies, exciting advances, and paradigm shifts in the management of acute strokes – as chronicled in this week’s New York Times Magazine. In this Grand Rounds, Andy Josephson, chair of the UCSF Department of Neurology and award-winning neurology educator, will bring us up-to-date on the latest in treatments and secondary prevention strategies for patients with strokes and TIAs.

Speaker:
S. Andrew Josephson, MD, is chair of the Department of Neurology at UCSF where he specializes in neurovascular and other neurologic disorders, caring for general neurology and stroke patients in the hospital as well as in clinic. He is the founder of UCSF’s Neurohospitalist Program and specializes in difficult to diagnose inpatient neurologic conditions. As a go-to educator in the Department of Neurology, Andy has won numerous teaching awards from medical students and residents at UCSF including being selected to present the keynote address for the School of Medicine Commencement; the Henry J. Kaiser Award for Excellence in Teaching; the Academic Senate Distinction in Teaching Award, and the Robert Layzer Golden Toe Award for resident teaching. He also serves as the editor-in-chief of JAMA Neurology, a leading journal in the field.

Note: Closed captions will be available within 48-72 hours after posting.

Program
Bob Wachter: Introduction
00:02:10-00:52:17 – S. Andrew Josephson, MD, chair of the Department of Neurology at UCSF
00:52:22-1:00:33 Q\u0026A

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• February 23: Protecting the Legitimacy of Medical Expertise: Combating Misinformation in Medicine
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• February 16: Addressing the Crisis of Clinician Burnout — A Conversation with Tait Shanafelt
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See all UCSF Covid-19 grand rounds, which have been viewed over 3M times, at    • UCSF Department of Medicine Medical G…  .

Content

0.75 -> - Good afternoon. Welcome to Medical Grand Rounds.

2.91 -> I'm Bob Wachter, chair of the UCSF Department of Medicine.

6.69 -> We're just virtual today,

8.16 -> and so the usual ground rules are there

10.86 -> in terms of closed captioning.

13.59 -> If you have questions, put them in the Q&A,

15.57 -> and we are videoing this, and we'll put it up later,

20.04 -> and really looking forward to today's talk.

22.14 -> One of my favorite faculty members

24.75 -> and one of the great teachers at UCSF, Andy Josephson,

27.63 -> is going to teach us.

29.76 -> Andy, and the topic today is

31.327 -> "Stroke 2023: A Change Has Come and Is Still Coming."

34.29 -> Really amazing changes in the world of stroke

37.2 -> over the last several years,

38.34 -> and we will learn about them

39.48 -> from one of the world's experts.

41.34 -> Andy is a specialist in neurovascular, neurologic diseases.

45.15 -> He cares for patients with stroke

48.33 -> as well as general neurology patients.

50.07 -> He founded the neurohospitalist program at UCSF,

53.61 -> and really, nationally, has been a leader in that area.

57.63 -> He graduated from Stanford.

58.98 -> MD from WashU,

60.69 -> and then we were lucky enough

61.89 -> that he came for his internship in internal medicine

65.76 -> where I first got to know him

67.77 -> and then residency and neurology chief residency.

70.26 -> He did a fellowship in neurovascular neurology

73.35 -> and behavioral neurology

76.56 -> and has been a national leader since joining our faculty.

80.37 -> As I said, he's been a pioneer

81.84 -> in the neurohospitalist model of care

83.73 -> and has done research on inpatient neurology,

86.76 -> quality and safety in neurology,

88.74 -> and is editor-in-chief of "JAMA Neurology,"

91.17 -> which is the leading journal in the field.

93.84 -> He's won pretty much every teaching award

96.09 -> that exists at UCSF,

98.28 -> including the Henry J. Kaiser Award

100.11 -> for Excellence in Teaching,

101.04 -> the Academic Senate Distinction in Teaching Award,

103.8 -> the Robert Layzer Golden Toe Award, love that,

107.73 -> as well as has been the keynote speaker

110.73 -> at the School of Medicine commencement,

113.01 -> and I have to say our friendship and collaboration

117.75 -> as chairs of the two most important departments at UCSF

121.02 -> has been truly gratifying and is really a source of joy,

124.95 -> and we have wonderful collaborations

126.93 -> with Andy and his department,

128.25 -> and I prize them dearly,

129.54 -> so with that, let me turn it over to Andy Josephson.

132.24 -> Look forward to hearing it.

134.01 -> - Thanks, Bob. I really appreciate the invitation.

136.35 -> Let me see if I can share my slides and (indistinct) work.

140.85 -> There we go. Okay.

143.19 -> Thanks so much for having me.

144.57 -> I am (indistinct) talk about stroke here in 2023,

147.689 -> and as Bob indicated,

150.422 -> it's been quite a journey

152.61 -> since where we were couple decades ago,

154.77 -> but it feels like it's accelerated a fair amount

157.8 -> in the last 24 months or so,

160.17 -> so I think I'm gonna present

162.27 -> a lot of basics of stroke management,

164.58 -> also a lot of new data and new directions

167.7 -> where the field is going.

169.62 -> I'm gonna focus almost exclusively on ischemic stroke.

172.02 -> I'm not gonna mention hemorrhagic stroke that much

174.12 -> because we're a little far behind

175.89 -> in terms of our advances in that area,

177.93 -> but think there's much more of that to come as well,

180.48 -> and again, I just wanna thank everybody for having me here

184.17 -> in Department Medicine Grand Rounds.

185.82 -> I would say when I got this invitation,

187.86 -> I immediately was just deeply grateful.

190.95 -> I was, as Bob said,

192.3 -> part of this department now some 20-plus years ago.

196.05 -> We've had incredible partnerships

198.06 -> with the Department of Medicine

199.11 -> and in almost every subspecialty with neurology.

202.44 -> It's just a real honor to be here.

205.2 -> I think the second feeling I had was

206.67 -> I was utterly mystified as to why I would be invited

210.57 -> and why any of you would like to hear about stroke.

213.54 -> The list of great topics at this Grand Rounds

218.07 -> during the Covid pandemic and beyond

219.96 -> that Bob and Lakshmi and others have come up with

222.087 -> has just been tremendous,

223.23 -> and you get these, like, luminaries in the field

225.33 -> talking about important issues of public health

228.18 -> and important areas of infectious disease

230.04 -> and other parts of medicine,

230.94 -> and why you would want the neurologists

233.19 -> to roll in and talk about stroke, I really have no idea.

236.16 -> Maybe they knew the storm was coming,

237.99 -> and if the power goes out, then we don't miss that much,

241.23 -> but I am very grateful to be here,

243.36 -> so thank you very much.

245.07 -> I'm gonna begin by talking about, really,

248.28 -> the acute management of stroke,

250.38 -> and this is not something, I realize,

252.54 -> that many of you practice on a daily basis,

254.73 -> but it is important perspective

256.74 -> to hear where the field's going

258.03 -> and to be able to, if you're attending in the hospital,

260.49 -> if you're seeing patients in the clinic,

262.47 -> to really understand what we're doing in 2023

265.23 -> because it changes sort of the urgency

267.99 -> in which you approach these patients

270.33 -> and thinking about what our options are,

272.19 -> so I'll illustrate this with a series of cases,

274.65 -> but this is sort of the acute stroke case

276.84 -> that we'll start with.

278.43 -> 65-year-old right-handed man,

280.5 -> history of high blood pressure,

281.49 -> shows up to the ED in a really a delayed fashion

284.25 -> after the sudden onset of right-sided weakness.

286.38 -> I've said it multiple times.

287.91 -> People have a twinge of chest pain

289.5 -> that's probably indigestion,

290.7 -> they run to the ED,

291.9 -> but somebody's arm goes weak,

293.67 -> and they wait around, see if it gets better,

296.31 -> and that's something

297.143 -> that we really need to get through to our population,

299.46 -> how important it is to call 911 and present urgently

303.36 -> if you have any neurologic symptoms

305.07 -> that are concerning for stroke.

306.81 -> On this patient's exam, expressive aphasia,

309.48 -> right face and arm weakness, a right visual field cut,

312.3 -> left gaze deviation, and here's the key:

315.33 -> so he was last seen normal at 1:00 in the afternoon,

318.72 -> and you're now seeing the patient at 10:45 at night,

322.02 -> some nine hours and 45 minutes later,

324.75 -> and it's really important to note the time,

327.3 -> as we'll talk about in a minute.

329.4 -> Like every patient who shows up with a suspected stroke,

333.09 -> we get a noncontrast head CT,

335.28 -> and the goal of this head CT

336.63 -> is not to see the ischemic stroke

339.03 -> because you actually,

340.17 -> usually the head CT in ischemic stroke early on

342.72 -> will be normal.

343.8 -> This is a normal scan that I'm illustrating here.

346.59 -> The reason we get this is that 15% of patients

349.83 -> with the exact same presentation

352.38 -> are going to have an intracerebral hemorrhage,

354.3 -> and even the best stroke neurologist cannot tell,

356.61 -> based on clinical signs, vitals, whatever you might do,

360.33 -> the difference between an ischemic stroke

361.917 -> and a hemorrhagic stroke,

362.997 -> and because, as we'll talk about,

364.74 -> we treat ischemic stroke by thinning the blood,

367.5 -> taking blood clots out.

369.36 -> You would not wanna do those things

371.1 -> for a hemorrhagic stroke,

372.42 -> so it's very important that this scan is done

375.9 -> merely to exclude the 15% of people

378.39 -> who are going to have a hemorrhage

379.233 -> with this same presentation.

382.41 -> Now, at UCSF we've done this for a long, long time

384.93 -> thanks to a number of folks who helped make this happen,

388.83 -> now some 20 years ago,

390.03 -> but this is now standard throughout the country

392.58 -> that in addition to a noncon CT,

394.59 -> we're gonna get a so-called stroke protocol CT

397.29 -> that'll include that noncontrast scan

399.96 -> but also CT angiography that goes from the top of the heart

404.55 -> all the way up to the top of the head.

406.56 -> There will be CT perfusion.

408.06 -> Occasionally, we will get a postcontrast study.

410.19 -> What I'm gonna try to convince you

412.08 -> is that where we are in 2023,

414.36 -> that the CT angiography and the CT perfusion

417.3 -> that are performed in acute stroke

419.22 -> are just as important as the noncontrast CT scan,

422.07 -> and their results determine what we are going to do next,

426.63 -> so in this case, here's the CT angiogram,

429.69 -> and in the CT angiogram,

431.76 -> the right middle cerebral artery fills normally,

434.79 -> but there is a big cutoff

436.56 -> in the left middle cerebral artery.

438.69 -> That is a sign that the patient has a so-called LVO,

441.57 -> or a large vessel occlusion.

443.16 -> There is a clot sitting in the left middle cerebral artery.

447.21 -> We also get CT perfusion,

449.4 -> and I'm gonna talk about this a number of times.

452.61 -> The technical aspects of it are actually quite interesting.

456.15 -> It involves how quickly

458.19 -> contrast gets to various parts of the brain,

460.5 -> and then does it ever finally get there?

462.54 -> Or does it never get there?

464.07 -> And through a variety of fun pieces of calculus,

468.51 -> we're able to determine CT perfusion

471.24 -> in various parts of the brain,

472.56 -> so look on the far right,

474.27 -> and what you see is a cartoon of the brain

477.72 -> that then superimposed has colored pieces, green and red.

481.83 -> Every single voxel that is colored there

484.86 -> is a part of the brain that is not functioning correctly.

488.43 -> The person is symptomatic from everything that's in color,

491.67 -> but there's two colors, right?

493.41 -> Areas in red are areas that are dead.

496.35 -> The contrast never gets there. It's dead tissue.

498.99 -> No matter what we do, that is infarction.

501.57 -> It is not going to get better,

503.73 -> but the areas in green are areas that are ischemic.

506.79 -> They're not yet infarcted,

508.17 -> and if we could revascularize that tissue,

510.57 -> we may be able to save the day here.

512.82 -> When you see a patient with stroke,

514.8 -> you have no idea, based on the clinical symptoms,

518.07 -> how much of those deficits are reversible

520.77 -> and how much is irreversible,

522.48 -> and CT perfusion allows us to figure that out.

525.81 -> We'll come back to that in great detail.

528.39 -> If there's one slide

529.77 -> that's the take-home slide from the talk

531.6 -> when it comes to acute stroke management, it's right here,

534.54 -> so we have, in neurology,

537.12 -> in acute stroke management, we have time windows,

540.51 -> and in those time windows,

542.16 -> the treatment for stroke is safe and effective,

545.01 -> and outside of those time windows,

546.96 -> it may not be safe and effective,

548.76 -> and it's very important to establish when the stroke began,

552.63 -> but we don't ask patients,

554.437 -> "When did you start having a stroke?"

556.157 -> 'Cause if somebody wake up at 8:00 a.m.

558.18 -> with right-sided weakness,

559.32 -> they'll say, "At 8:00 a.m. when I woke up,"

561.51 -> but we don't wanna misestimate these time windows,

564.21 -> so as a result, we ask a different question:

567.007 -> "When is the last time you were normal?"

569.64 -> And if the answer is at 8:00 p.m.

571.32 -> the night before when they went to bed

573.24 -> or at 3:00 a.m. when they got up to use the bathroom,

575.82 -> that's when we start the clock,

577.89 -> and in 2023, here's where we are.

580.92 -> From 0 to 4 1/2 hours,

583.05 -> we can give an intravenous thrombolytic.

585.703 -> IV t-PA is the one that's most commonly used

588.69 -> to lyse the blood clot.

589.98 -> I'll talk about these all more in some detail.

592.77 -> Between 0 and 6 hours,

594.93 -> we can put a catheter in the groin or in the radial artery,

598.14 -> our neurointerventional colleagues,

600.09 -> who can then slink it up to the brain

601.95 -> and literally pull out the clot, mechanical embolectomy.

606.18 -> I mean, within six hours,

607.71 -> everybody who has a large vessel occlusion,

611.22 -> we can take out their clot,

612.81 -> and as I'll show you, make them better.

615.45 -> Between 6 and 24 hours,

618.06 -> some people, we wanna take out their clots,

620.85 -> and some we do not,

622.05 -> and that is based on the perfusion data

624.18 -> that I showed you earlier,

625.32 -> so let's dig into these in a little bit more detail,

628.02 -> but here's the snapshot to look at.

630.93 -> First of all, IV t-PA.

632.52 -> Not gonna talk about this in great detail

634.59 -> except to tell you IV t-PA really works for stroke,

638.16 -> but it only works very early in the course.

641.67 -> We say to 4 1/2 hours,

643.26 -> but as you can see here in the graph,

644.76 -> this is a long, very old snapshot

647.82 -> of looking at a meta-analysis

649.44 -> of all the important t-PA trials,

651.3 -> and what you see is that its success degrades over time,

655.56 -> so if you can get t-PA in the first hour,

658.59 -> then people do very, very well.

659.88 -> The risk of hemorrhage is low,

661.41 -> and the rate of success in terms of lysing the clot

663.867 -> and leading to better outcomes is very high,

666.39 -> but as you approach that 4 1/2-hour window,

669.51 -> you get to the point

670.5 -> where the error bars start to cross the null,

673.92 -> and at that point, it's no longer effective.

676.38 -> You have a higher risk of hemorrhage.

677.61 -> You have a lower rate of helping people out,

679.89 -> and there's broad success.

681.12 -> This works for old individuals, young individuals.

683.25 -> They work for people with large strokes, little strokes,

686.31 -> medium strokes, everything in between,

688.05 -> so we use thrombolysis

689.91 -> if somebody doesn't have any contraindications

692.31 -> and comes in with an acute ischemic stroke,

695.52 -> again, within the first 4 1/2 hours.

698.07 -> Have to have a CT scan first

699.63 -> 'cause we have to make sure they don't have a hemorrhage.

702.72 -> Now, speed really matters.

704.88 -> Just because we have 4 1/2 hours to administer this therapy

709.56 -> does not mean that we wanna take our time

711.99 -> because every single minute that goes by,

715.56 -> there's over a million neurons that are dying

718.47 -> in an ischemic brain,

719.79 -> and so the quicker we can revascularize these people

722.22 -> the better.

723.12 -> This is a favorite study of mine

724.74 -> that were done by some of our colleagues

726.3 -> looking at the Get With The Guidelines registry

729.06 -> of all hospitals

730.08 -> that take care of patients with acute stroke

732.15 -> in this country,

733.59 -> and they looked at a decade snapshot,

735.75 -> and they looked at almost 60,000 patients who got t-PA,

738.713 -> and the bottom line is the following:

741.3 -> For every 15 minutes earlier

745.02 -> that t-PA was given,

746.46 -> I'm talking about 2 1/2 hours versus 2:45,

749.34 -> 90 minutes versus 120 minutes, everywhere in that window,

753.84 -> for every 15 minutes earlier,

756.15 -> significantly less people died.

758.31 -> There were lower rates of intracerebral hemorrhage.

760.77 -> More people were significantly able to ambulate

763.53 -> when they left the hospital,

764.7 -> and more people were able to go home,

766.89 -> so hospitals like UCSF have incredible systems of care

771.57 -> where we're able to give t-PA very, very quickly.

774.33 -> We get prehospital notifications by EMFs

777.51 -> that we're bringing in a patient with stroke.

779.52 -> A stroke code goes out across multiple people,

783.03 -> including radiologists, neurointerventional radiologists,

785.64 -> stroke attendings, and most importantly, our residents,

788.67 -> who then run down to the emergency room,

790.8 -> meet the patient on the gurney

792.15 -> when they come out of the ambulance,

793.89 -> and start a process

795 -> that very quickly gets the patient a scan.

797.01 -> 'Member, we have a scanner in the ED

799.17 -> that we clear out for this scan to happen

802.11 -> and then administer a t-PA,

804.54 -> often in the scanner after the noncontrast CT scan.

808.08 -> We keep track of how long it takes

810.84 -> from the time we get the call

812.58 -> or the time the patient arrives

814.32 -> to the time we can get t-PA.

815.97 -> It's an important quality metric,

817.95 -> and we're very proud of how we've done,

819.96 -> mainly led by our fantastic house staff

822.51 -> here in the neurology department,

823.95 -> so it's a big deal that we have systems of care

826.98 -> that can give t-PA very, very quickly.

829.86 -> Now, there's been a twist in the last year.

832.17 -> This has been a big headline,

834.09 -> and that is should we use a different lytic agent?

836.82 -> Should we use tenecteplase, or TNK?

839.58 -> Our cardiology colleagues will say,

841.507 -> "Didn't we, like, determine this 20 years ago?"

843.99 -> I hear ya.

845.4 -> We haven't, so we're still t-PA, alteplase,

848.91 -> as the lytic agent of choice.

851.07 -> This is sort of a new alternative.

852.81 -> There have been multiple studies looking at this option.

855.78 -> Why would we care?

856.95 -> Well, the reason why we really care

859.17 -> is that intravenous t-PA for stroke is given as a bolus

863.13 -> and then a 60-minute infusion,

865.53 -> whereas TNK can be given as a single bolus.

868.98 -> That is really important

870.81 -> because if somebody is within those 60 minutes,

874.11 -> and they're still getting t-PA,

876.51 -> hospitals who are transferring patients to tertiary centers

880.47 -> so they can get something like an embolectomy

882.99 -> often either have to keep the patient at the hospital

886.23 -> or find a critical care transport,

888.93 -> and those can be very difficult to find,

890.85 -> as many of you know,

892.14 -> so TNK allows us that there's no infusion going

895.98 -> and just have our regular VLS transport

898.14 -> and transfer the patient to a referring facility,

900.33 -> so this can really transform our ability

904.02 -> to get patients quickly the treatment they need for stroke.

908.04 -> There was a recent large noninferiority study

910.38 -> of about 1,600 patients.

912.12 -> I've cited it here at "Lancet."

913.59 -> No different in an outcome or safety,

915.87 -> and it's not approved by the FDA for this,

918.36 -> but many hospital systems have now adopted TNK.

922.41 -> Every Kaiser hospital, for instance, in Northern California

925.32 -> now uses this as part of a sort of drip-and-ship scenario.

929.16 -> At UCSF, because we do everything here,

931.26 -> we go ahead and still use alteplase for now

934.02 -> because we're not transporting the patient,

935.88 -> so it's not a real big deal

937.53 -> if we're doing another hour infusion,

939.3 -> and the data still is much more robust for t-PA,

942.27 -> but I think this is an important thing

944.46 -> to think about going forward,

946.5 -> so prior to about 2015,

949.02 -> all we really had that was evidence-based

952.47 -> was giving people lytics.

954.03 -> Giving t-PA was the name of the game,

956.07 -> and then, sometime around that period,

959.88 -> a technological advance happened

962.58 -> where catheters that were being used

964.77 -> to go into the brain to take out blood clots

967.71 -> became much more effective,

969.72 -> and we now have these devices

971.52 -> that we refer to as stent retrievers, as pictured here.

975.45 -> It's essentially a catheter

976.8 -> that is taken into the vessel in the brain,

979.98 -> and then a stent is deployed.

982.29 -> It's sort of like a deploying

984.09 -> of a Chinese finger trap, if you will.

986.914 -> It is a lattice that captures the clot,

989.46 -> and then the entire device, the stent and the clot,

992.97 -> are removed from the body

994.77 -> through the groin or the radial artery.

997.2 -> These new devices

998.94 -> successfully open up vessels that have a clot,

1002.27 -> these large vessels that have a clot in them,

1005.12 -> 90-plus percent of the time,

1007.79 -> so we now have a very effective way to get the clot open,

1011.84 -> but does it actually work?

1013.88 -> Let's see, so this is what it looks like.

1016.28 -> This is a patient who comes in pretreatment

1018.29 -> who has a clot in their middle cerebral artery.

1020.3 -> This is the case that we started with,

1022.28 -> and sure enough, after the therapy,

1024.95 -> you can now see all the blood vessels stilling

1027.26 -> that previously were not,

1029.3 -> and in this way,

1030.466 -> we're able to really potentially help the patient,

1033.89 -> but let's think about whether it really works.

1036.17 -> While 2015 was the big revolution in care,

1039.41 -> five major trials looking at this technique, embolectomy,

1043.7 -> were all published in "The New England Journal of Medicine."

1046.01 -> All were different, a little bit, in their trial design,

1048.68 -> but they said the same thing, and they were all positive.

1050.84 -> They said, "We're gonna use these neurogeneration devices.

1054.177 -> "We're gonna use our CTA to see who has a blood clot,

1058.227 -> "and if they've got a blood clot,

1059.667 -> "we'll go in and take it out.

1060.807 -> "We're looking for an LVO or a large vessel occlusion."

1065.03 -> If people got t-PA, if they could get t-PA, no problem.

1068.36 -> They could get t-PA

1069.41 -> and then go to the embolectomy suite to take the clot out.

1073.34 -> They used a six-hour time window,

1076.28 -> so all of these trials said,

1077.577 -> "If you're within six hours, you can get this done.

1080.697 -> "You're within 4 1/2,

1081.837 -> "you can get t-PA if you're eligible and then get this done,

1085.347 -> "but no matter what,

1086.18 -> "within six hours, you can get the blood clot taken out.

1088.887 -> "No perfusion data needed.

1091.137 -> "It works in all patients,"

1093.78 -> and then, in 2018, something else happened:

1095.81 -> two major trials

1096.71 -> published in "The New England Journal of Medicine,"

1098.45 -> the DAWN and the DEFUSE trial.

1100.19 -> What these trials did is they set a 24-hour window,

1104.48 -> and they said, "Between 6 and 24 hours,

1107.637 -> "we're gonna select people based on their CT perfusion,

1111.147 -> "and if they have a lot of green tissue,

1113.247 -> "we're gonna go ahead and take the clot out.

1115.107 -> "If it's all a bunch of red,

1116.817 -> "going back to my analogy I started with,

1119.427 -> "it's all dead tissue.

1120.507 -> "We're not gonna bother.

1121.557 -> "All we could do is make things worse,"

1124.46 -> and this really led to a major examination

1127.94 -> that continues today of triage and ED protocols

1132.02 -> because now, if you come to a hospital

1134.06 -> that doesn't have the capability, as I'll talk about,

1136.76 -> to perform embolectomy,

1138.83 -> they can give t-PA, call us at UCSF,

1142.28 -> get the patient over here,

1143.597 -> and we can perform said embolectomy.

1146.48 -> That's a real advance,

1147.59 -> and now that there is a 24-hour window,

1150.47 -> as opposed to just a few hours,

1152.33 -> that allows our reach to be much greater, at least locally,

1155.87 -> at Northern California, Central Valley, and beyond,

1159.26 -> and I think it's really important

1160.49 -> to try to help as many patients as we can.

1163.19 -> Now, this all seems really complicated,

1165.59 -> trying to figure out what's green, what's red.

1168.77 -> When this first started,

1170.12 -> radiologists, typically neuroradiologists,

1172.79 -> had to do postprocessing perfusion,

1175.64 -> so the CT would be done,

1177.17 -> and then the radiologist had to get on a workstation,

1179.69 -> do a bunch of things, select a vessel, get some numbers,

1183.23 -> talk to us, make these fun maps.

1185.33 -> It would take an extended period of time.

1187.97 -> That's not what's going on in 2023.

1190.67 -> There is now automated software that we all have

1194.9 -> that does this immediately.

1197 -> Guys have had some great talks in medical Grand Rounds

1199.49 -> about AI and its potential for the future.

1202.91 -> This is the present, so right now on all of our cell phones,

1206.21 -> I actually got one of these

1207.44 -> about two minutes before we started.

1209.9 -> Bob and I were joking around, and it pops up on my phone.

1213.71 -> We now have automated software,

1215.6 -> so the moment the CT is complete,

1219.83 -> as soon as the patient has the last image done,

1223.67 -> we get a notification on our phone

1226.04 -> that a CT has been complete with perfusion,

1228.86 -> and it shows us

1229.693 -> these are a couple snapshots from a recent case.

1232.28 -> It will tell us if there's a large vessel occlusion.

1234.77 -> I will get an alert on my phone

1236.03 -> that there's a large vessel occlusion.

1237.95 -> I will get a e-mail

1239.39 -> that says there's a large vessel occlusion,

1241.13 -> and then we will get these colored perfusion maps

1244.52 -> that you see on the side within 30 seconds,

1248.27 -> and we no longer have to guess

1249.89 -> how much is green, how much is red?

1251.84 -> It quantifies it for us.

1253.67 -> It tells me the number of milliliters of dead tissue

1257.15 -> the number of milliliters of ischemic tissue,

1260.33 -> and based on those thresholds,

1262.04 -> we can very easily decide

1263.87 -> whether we want to proceed with embolectomy,

1266.03 -> so now this is done immediately,

1269.06 -> and our phones are set to go off immediately

1272.06 -> as soon as a scan is done.

1274.61 -> Nine times outta 10, you see the scan.

1276.13 -> It was someone who got a CT perfusion

1277.91 -> for, say, encephalopathy on the floor.

1280.04 -> It's totally normal, fine,

1281.63 -> but we're able to see that as a team.

1283.94 -> This software, our software that we use,

1286.91 -> currently allows the team members to also communicate,

1289.55 -> so this is software that the notification's going to be

1293.45 -> when I'm the stroke attending, the stroke fellow,

1295.52 -> the resident who's on call, the neuroradiologist,

1297.86 -> the neurointerventional radiologist,

1299.84 -> and we can use the application to message each other.

1303.26 -> Let's get the angio suite ready. We're ready to go.

1306.11 -> Here's the clinical history, et cetera.

1308.12 -> A very, very powerful, remarkable tool

1310.91 -> that has shortened our ability

1312.32 -> to be able to get help for these individuals,

1315.53 -> so what do we do given this data?

1317.03 -> Where are we in 2023? Very straightforward.

1319.97 -> Everybody who's eligible for t-PA,

1322.52 -> FDA approved at three hours,

1323.87 -> but everybody in this country uses it to 4 1/2

1326.45 -> based on data,

1327.59 -> and in many other countries, it's used to 4 1/2,

1330.05 -> and it's approved in those countries.

1331.73 -> Everybody should get IV t-PA, maybe it'll be TNK soon,

1335.45 -> as quickly as possible.

1337.07 -> A CT angiogram must be performed

1339.65 -> to see whether somebody has a large vessel occlusion.

1342.26 -> If they do, and it's under six hours,

1345.53 -> open up that vessel

1347.42 -> regardless of whether they got t-PA or not.

1350.09 -> If it's greater than six hours, though,

1352.61 -> we need to use our perfusion

1355.34 -> to select those individuals

1357.35 -> who should and should not be receiving endovascular therapy.

1361.58 -> That's the key,

1363.02 -> and here's an important piece

1365.27 -> that I'm gonna spend a few minutes on

1367.19 -> is that all of these parameters

1369.56 -> were chosen for trials, basically,

1373.04 -> and they may or may not include

1375.11 -> all patients who can benefit.

1377.21 -> My colleague Wade Smith,

1378.56 -> who's the division chief of our neurovascular division,

1382.13 -> has been saying for many years,

1384.087 -> "Do we ever hurt anybody by opening up the vessel?

1386.997 -> "Is there really data that somebody can be injured?"

1390.95 -> And I used to think he was wrong about this,

1394.01 -> but I'm gonna show you some data

1395.36 -> that's come out in the last six months

1396.95 -> that might suggest that Wade's right,

1399.47 -> that we should just think

1400.64 -> about opening up the vessel on everyone,

1402.38 -> but I'll come to that.

1403.61 -> It is a major emphasis of current research.

1406.13 -> Many of you may have seen,

1407.15 -> in "The New York Times" just a few days ago,

1410.21 -> this really neat article

1412.13 -> talking about large vessel occlusions

1414.74 -> opening up vessels in an angiography suite.

1417.05 -> Remember, neurointerventional radiologist, NIR,

1420.08 -> you can get there through a neurology residency,

1422.42 -> a radiology residency, or a neurosurgery residency,

1424.94 -> so this is really a multidisciplinary group of folks,

1428.48 -> and this article talks about how effective this therapy is,

1432.5 -> but how there's just not enough of these people

1435.02 -> across much of the country,

1436.43 -> so in rural areas,

1438.11 -> even in places you wouldn't think is that rural,

1440.15 -> for instance, up in Tahoe,

1442.1 -> there's just not folks and hospitals

1444.38 -> that have the capability to do this,

1446.45 -> so this article talked about the process

1448.64 -> of transferring patients to hospitals,

1450.8 -> how long it can take

1452.24 -> getting people to get the stroke treatment they deserve.

1454.64 -> Ultimately, we need more hospitals that can do this.

1457.49 -> There are multiple different,

1459.26 -> there are multiple different designations

1461.09 -> for hospitals as stroke centers.

1463.31 -> Primary stroke centers,

1464.54 -> and these names have changed a little bit,

1466.13 -> but I'll use the old parlance.

1468.56 -> Primary stroke centers are stroke centers that can give t-PA

1471.92 -> and provide good care to patients.

1474.41 -> Patients who are at comprehensive stroke centers like UCSF,

1478.82 -> these clots can be removed

1480.11 -> by people who are on call 24 hours a day to do so.

1482.69 -> By the way, when I say UCSF, Moffitt, ZSFG, the VA,

1486.68 -> all three have this capability covered by the same team

1489.77 -> of fantastic neurointerventionalists,

1491.99 -> so I think this is an important public health concern

1495.17 -> because when I'm traveling to places,

1496.85 -> I wanna know, like, where's the closest stroke center

1499.64 -> if I need this to be done?

1501.41 -> I don't want it to be a 12-hour plane flight,

1504.74 -> drive with an ambulance, helicopter ride, et cetera.

1508.07 -> Very, very important going forward.

1509.78 -> Now, I wanna take everybody back for just a second

1512.3 -> to the year 2008, 15 years ago.

1515.33 -> In 2008, the space shuttle Atlantis was still flying.

1520.13 -> There was the last episode of "The Sopranos."

1523.923 -> LeBron and the Spurs were fighting it out

1526.79 -> for the NBA championship.

1529.01 -> Bob and Niraj were writing articles

1530.96 -> about the color of wristbands

1532.43 -> that needed to be done to be DNR.

1534.02 -> I mean, a lot of, like,

1535.34 -> totally antiquated, meaningless things,

1538.88 -> but I gave Grand Rounds in the Department of Medicine

1542.57 -> for the first time on stroke,

1545.09 -> so I was invited to give Grand Rounds on stroke.

1547.79 -> I wanna show you the star here suggested from 2008.

1551.51 -> I'll show you two slides that I said back then

1554.03 -> just to show you how not smart I am

1556.67 -> at figuring things out for the future.

1558.56 -> I said, "Listen. New things are coming.

1560.577 -> "We're gonna be able to open the vessel with these devices,"

1564.02 -> which were not yet happening at all.

1566.21 -> Good, but I also said that we were going to be able

1569.42 -> to (indistinct) medicines, neuroprotective medicines,

1574.34 -> that would protect this ischemic tissue

1577.34 -> and keep it from dying

1578.99 -> as we're getting ready to open up the vessel

1581.75 -> or just because we want these neurons not to die.

1586.07 -> Multiple over 20 trials of neuroprotective agents in stroke,

1590.24 -> they've all failed,

1591.26 -> so we do not have a drug, as I predicted we would,

1594.38 -> to be able to stop folks from their neurons dying

1599.09 -> as we're waiting to get these treatments.

1601.19 -> Hence, how important it is to rapidly

1604.28 -> and rapidly get people to centers

1606.38 -> where they can get the treatment they deserve.

1608.54 -> I also said CT perfusion is coming,

1610.64 -> but then made a statement on the next slide

1613.13 -> that we were going to be moving from a time-based window

1616.4 -> where all these things had time frames,

1618.89 -> to a pure tissue-based window where all we care about is

1622.67 -> whether or not there's a lot of green or a lot of red.

1626.78 -> That turned out to not be true either,

1629.36 -> and I'm gonna explain that over the next few slides

1631.73 -> talking about a few new advances,

1633.2 -> so first of all, should we ignore this time window?

1636.62 -> 24 hours was arbitrarily chosen,

1640.25 -> and in our journal, "JAMA Neurology,"

1641.78 -> there's been a number of these studies

1643.34 -> looking at very late endovascular cases,

1646.04 -> so these are people who were, like, 36 hours out.

1649.1 -> I think the mean was about 33 hours,

1651.74 -> but they still had favorable perfusion.

1653.66 -> They had a lot of green and very little red,

1656.15 -> and when their clots were taken out, they still had benefit.

1659.99 -> Not as much benefit if you would've gotten them early,

1662.39 -> but still had benefit,

1664.01 -> so I'm gonna mention three advances in the last few months.

1667.01 -> Here's number one.

1668.24 -> Maybe we will start ignoring these time windows completely

1671.93 -> and saying, "If the perfusion looks good,

1674.397 -> "we're in good shape."

1675.44 -> That's that tissue-based window that I predicted.

1678.68 -> What about this?

1679.76 -> It turns out that a variety of studies, this is one,

1682.52 -> probably the most important

1683.45 -> that was published in "The New England Journal" last year

1685.19 -> say, "If you've got an endovascular suite ready,

1688.797 -> "if you've got a neurointerventionalist

1690.777 -> "sitting there ready to go, should you mess with t-PA?

1694.497 -> "Or should you just go to the suite

1695.997 -> "and get the clot taken out?"

1697.61 -> And the answer right now is give t-PA if you can,

1701.36 -> but this was a large European trial

1702.98 -> where they said, "We're ready to do the embolectomy.

1706.347 -> "Should we just forget the t-PA?"

1708.68 -> And they couldn't show a difference

1710.03 -> by giving those patients t-PA.

1712.22 -> Now, what might happen

1713.33 -> is that if there is not a suite immediately available,

1716.54 -> you're being transferred in,

1717.86 -> or it's the middle of the night,

1718.82 -> and the neurointerventionalist

1719.72 -> has to come in from their home,

1721.34 -> then maybe we would give t-PA,

1724.19 -> but if you're at a center like ours

1726.08 -> where we've got people ready 24 hours a day

1727.75 -> to take the clot out,

1729.85 -> we may be getting the point where we say,

1731.247 -> "Forget the t-PA; just get the clout out.

1733.557 -> "If it's gonna take any extra time to give t-PA,

1736.167 -> "don't bother,"

1737.99 -> and then, the third one,

1738.89 -> there are two trials that came out just a few weeks ago

1741.92 -> in "The New England Journal of Medicine."

1743.84 -> One of the things that we do

1745.13 -> when we think of perfusion imaging is

1746.99 -> we say, "If the actual infarct,

1748.707 -> "the amount of dead tissue is too big,

1751.707 -> "we don't take the clot out

1753.147 -> "because it won't help the patient,

1754.527 -> "and it's just gonna lead to more hemorrhage,"

1756.92 -> but these two trials,

1758.18 -> which were published early view

1759.5 -> in "The New England Journal,"

1760.97 -> basically looked at very large infarcts

1764.174 -> and showed that, you know what?

1767.12 -> These people still benefited a little bit

1769.4 -> from getting their clot taken out.

1771.35 -> In one trial,

1772.183 -> there was a little bit more hemorrhage in the brain.

1774.5 -> In another one, there were a few more groin complications

1777.02 -> than in the group that didn't get it taken out,

1779.09 -> but the bottom line is

1781.01 -> we're probably moving to the point

1782.84 -> where even this tissue window may be thrown out the door

1786.98 -> and we just say, "Just get the clot,"

1790.1 -> and this is much more akin

1791.42 -> to what we're thinking in cardiology

1793.01 -> which is that if there's a STEMI, you know,

1794.75 -> we don't say, "When did it happen?

1796.677 -> "How long ago has it been? Is it six hours or eight hours?"

1799.79 -> We don't say, "Well, let's look at myocardial perfusion

1802.137 -> "to see how much tissue is to save."

1803.66 -> We say, "Let's revascularize the patient.

1806.337 -> "Let's get that vessel open."

1809.06 -> That may be where we're moving in the world of neurology,

1813.32 -> so that's what I wanted to say about acute stroke therapy,

1816.14 -> and I think it gives you some flavor,

1818.12 -> even if you're not dealing with these issues

1820.19 -> on a daily basis as to where we are,

1822.05 -> so let's go to some more practical issues

1823.993 -> that everybody who takes care of medicine patients,

1826.85 -> neurology patients will encounter,

1829.34 -> so here's a 65-year-old guy

1830.9 -> with a history of high blood pressure.

1832.46 -> It takes him three days to come in

1834.59 -> with right-sided weakness,

1835.94 -> and again, I would say

1837.56 -> if there's one thing we can do for our patients,

1839.183 -> it's to encourage them that stroke's an emergency.

1841.7 -> You need to present quickly to the hospital.

1843.95 -> Time is brain, so on the exam, there's a pronator drift.

1847.31 -> There's weakness in the right side

1849.02 -> in a pyramidal distribution.

1850.58 -> The patient's taking a baby aspirin a day

1852.92 -> as well as hydrochlorothiazide for his blood pressure.

1856.55 -> Now, we've been talking about CTs.

1858.77 -> MRIs are often not needed in acute stroke

1861.65 -> because it's a clinical diagnosis,

1863.96 -> but if you're wondering if somebody actually has a stroke,

1867.08 -> it turns out that good old-fashioned MRs of the brain

1869.75 -> with diffusion-weighted imaging

1871.31 -> will tell you with great certainty if somebody has a stroke,

1874.85 -> and they'll also help you age the stroke.

1876.95 -> DWI, or diffusion-weighted imaging.

1878.96 -> You don't have to be a neural radiologist

1880.46 -> to see the big white blob on that side,

1882.77 -> which is the acute stroke.

1884.3 -> Diffusion-weighted imaging turns positive

1886.61 -> within seconds after a stroke

1888.83 -> and stays bright for about seven days or so,

1892.25 -> so it can definitively tell you if a stroke has occurred.

1895.49 -> This is often helpful for a patient

1897.11 -> who maybe had an old stroke and had left-sided weakness.

1900.44 -> It got better, but it's worse today.

1902.57 -> Is that a new stroke? Or is that a urinary tract infection?

1905.51 -> We need the recrudescence.

1907.25 -> A diffusion-weighted MRI can help you,

1909.38 -> so this patient has a stroke.

1911.36 -> How do we work out why the stroke occurred?

1913.88 -> And how do we prevent another one?

1915.44 -> Well, we think of things from the bottom up.

1918.71 -> Is it a cardioembolic event from AFib?

1921.923 -> From a clot sitting in a chamber?

1923.75 -> From a paradoxical embolus through a right-to-left shunt?

1926.42 -> We can figure that out with tele for AFib,

1929.03 -> some sort of echo with a bubble study.

1931.37 -> We really think of the aortic arch

1933.26 -> as a place where plaque can form

1934.85 -> and then shoot off, go downstream, and cause a stroke.

1937.52 -> We could look at that in a variety of ways.

1939.74 -> We're really concerned about the carotid arteries,

1941.84 -> as you know, many different ways to look at the carotids.

1944.45 -> In fact, there's a plethora,

1947.3 -> four different ways to look at the carotid arteries.

1949.46 -> I'll come to that in a second,

1950.84 -> and then, finally, the intracranial vessels

1952.73 -> where people can get atherosclerosis

1955.01 -> in a proximal intracranial vessel like an MCA.

1958.34 -> They can then break off, go downstream, and cause a stroke,

1961.91 -> so this is the workup that we want to do.

1964.34 -> You're also gonna evaluate stroke risk factors

1966.98 -> like you would at somebody who has an MI.

1969.02 -> You wanna know their blood pressure.

1970.07 -> You wanna know their cholesterol, etc.

1971.21 -> Would go on and on.

1972.65 -> What's neat about our CT angiography that starts here

1975.977 -> and goes up to the top of the head,

1978.11 -> is that immediately, the arch has been evaluated,

1980.81 -> the carotids have been evaluated,

1982.217 -> and the intracranial vessels have been evaluated,

1984.53 -> so right when the person presents,

1987.38 -> you've got everything done

1988.79 -> except exploring whether there's a cardioembolic source

1992.18 -> through telemetry and some sort of echo,

1995.09 -> and speaking of some sort of echo,

1997.04 -> we typically get a surface echo for a bubble here

2000.07 -> with a bubble here at UCSF,

2001.78 -> but there is data to suggest that TEE

2005.41 -> is a better way to investigate people who have stroke

2009.88 -> that increases the yield

2011.86 -> of things that you would do something about.

2014.173 -> Now, TEE's obviously invasive.

2016.72 -> It requires, you know, a lot more of a lift

2020.14 -> than a surface echo,

2021.07 -> but our cardiology service,

2022.51 -> our echo service has been such a wonderful partner of ours

2025.93 -> working together to figure out

2027.61 -> which patients do we need a TEE in?

2029.98 -> And which can we get by with a surface echo?

2032.53 -> We know TEE's better

2034.15 -> for looking at the left atrial appendage.

2035.68 -> It's probably a better bubble study in some patients,

2037.99 -> and it's the only one of these echoes

2039.37 -> that gives you a good look at the aortic arch.

2041.86 -> It changes findings probably,

2044.35 -> changes management probably about 10% of the time.

2047.59 -> We reserve TEEs

2049.36 -> for people whose workup is otherwise negative

2052.78 -> or in people who are less than 55.

2055.51 -> People less than 55, we usually go straight to a TEE

2058.6 -> rather than a surface echo.

2060.58 -> There's not great evidence to support what I just said,

2063.07 -> but that's kind of our evidence-based truce, if you will,

2066.67 -> thinking about the best use of echocardiography resources.

2071.68 -> Now, the other big headline in the world of stroke

2074.834 -> is how we figure out if someone's got atrial fibrillation,

2077.14 -> and the way we used to do this is simply doing an EKG

2079.69 -> and monitoring them with telemetry

2081.37 -> for about 48 hours in the hospital,

2083.44 -> but we're about a decade past a series of great studies

2087.94 -> that show that if when somebody leaves the hospital

2090.82 -> you do the whole workup,

2091.84 -> you look at their carotids, the intracranial vessels,

2093.85 -> the aortic arch, the echo, the telemetry,

2097.06 -> and we don't know why they had a stroke,

2099.01 -> that if those patients are put on at least 21 to 30 days

2103.72 -> of continuous cardiac monitoring on discharge,

2107.23 -> about 20% of them are gonna have atrial fibrillation.

2110.59 -> It's a huge number.

2111.64 -> One in five for otherwise unexplained stroke,

2114.13 -> even after you've done the whole workup,

2115.9 -> so it's now standard of care

2117.16 -> that somebody has a embolic-looking stroke,

2119.44 -> when they're discharged from the hospital,

2121.21 -> we put them on a long-term monitor.

2123.7 -> Data is at least 21, probably at least 30 days,

2127.21 -> looking for atrial fibrillation.

2129.448 -> (indistinct) changes management

2130.63 -> 'cause we're gonna anticoagulate those patients,

2132.43 -> as I mentioned admitted,

2133.69 -> and it's probably certainly cost effective.

2136.36 -> The big headline in the last year

2137.92 -> is, like, really long-term monitoring,

2140.92 -> including a series of randomized trials

2143.17 -> that basically said, "Well, if that doesn't work,

2145.907 -> "and you still don't know what caused it,

2148.097 -> "put in an implantable cardiac monitor

2150.737 -> "looking for AFib for at least a year,"

2153.61 -> and when that happens,

2154.477 -> and this is a study of about 500 patients aged 60

2157.99 -> or could be younger with a couple stroke risk factors

2160.84 -> who had a stroke within 10 days

2162.46 -> and they randomized people

2164.17 -> to doing this versus not doing this,

2166.42 -> they found a lot of people have atrial fibrillation

2168.76 -> that would've been otherwise missed

2170.14 -> with just doing telemetry or just doing a 30-day monitor.

2174.07 -> Interestingly, this is increasingly commonly used,

2177.19 -> but we don't have great outcome data yet,

2179.59 -> but I think this is very tantalizing,

2181.21 -> and we've begun to really put in long-term monitors

2184.18 -> in people who we don't know why they had a stroke

2186.73 -> because the incidence

2187.69 -> of atrial fibrillation in those patients is so darn high,

2191.17 -> so my general approach to stroke treatment is to say,

2193.397 -> "One, is this someone

2194.897 -> "who could get that acute stroke therapy?"

2197.02 -> Are they eligible for t-PA?

2198.007 -> Are they eligible for embolectomy?

2200.59 -> The answer's yes, then do it.

2202.12 -> If the answer's no,

2203.2 -> then you think about secondary prevention,

2205.3 -> and the first thing I say is,

2206.867 -> "Should they be anticoagulated?"

2209.57 -> And if the answer's no to that,

2210.76 -> everybody gets antiplatelets.

2212.2 -> Let's talk about anticoagulants for a second.

2214.27 -> I would've given this talk two decades ago.

2216.73 -> Everybody who had a stroke we put on then warfarin,

2220.18 -> and multiple studies since then have demonstrated

2223.66 -> that in almost every case

2226.33 -> antiplatelets are just as good

2227.86 -> if not better than anticoagulants,

2230.11 -> so when would we give an anticoagulant?

2232.45 -> Well, AFib and AFlutter,

2234.58 -> and if all you remember is Andy said after stroke,

2237.31 -> if they have AFib, we give them anticoagulants,

2239.77 -> and if they don't, we don't,

2241.57 -> that's directionally correct.

2242.98 -> You're gonna be 99.9% right.

2245.83 -> Sure there's some other things.

2247.18 -> If there's a thrombus seen in the heart, then LV thrombus,

2250.99 -> you're definitely gonna anticoagulate that person.

2253.6 -> Okay, but what if they have

2255.19 -> a big, baggy dilated cardiomyopathy?

2258.58 -> An EF less than 35%?

2261.04 -> Lot of times you'll see those patients anticoagulated,

2263.29 -> but in our randomized trials in stroke,

2265.39 -> including the WARCEF trial, which is now a decade old,

2268.06 -> we have not been able to demonstrate

2269.71 -> that anticoagulants are better than antiplatelets

2272.02 -> for secondary stroke prevention.

2274.21 -> I'll talk about PFO in a minute,

2275.86 -> but I'll just tell you that if you're not gonna fix the PFP,

2278.65 -> there is no advantage

2279.97 -> to anticoagulants over antiplatelets.

2283.99 -> What about a dissection?

2285.46 -> Common cause of stroke in young people,

2287.47 -> younger than the age of 50,

2289.54 -> but it turns out that we have good data

2291.49 -> that says you can treat those people with antiplatelets

2294.67 -> just as well as you can treat them with anticoagulants.

2297.64 -> Maybe a rare hypercoagulable state,

2299.95 -> antiphospholipid antibody syndrome's probably the only one

2302.38 -> where there's probably some evidence

2303.43 -> that anticoagulation is better,

2304.96 -> but all of this has really fallen by the wayside,

2308.665 -> and again, AFib, anticoagulate,

2311.8 -> everything else, probably not.

2314.35 -> Let me talk a little bit about PFO for stroke. It's a mess.

2317.23 -> I think it's gotten a lot better

2320.29 -> thanks to some wonderful data

2321.76 -> that our cardiology colleagues have generated.

2323.83 -> Remember, about one in five, one out four of us have a PFO,

2326.68 -> so one out of five or one out of four of our stroke patients

2330.19 -> are gonna have a PFO,

2331.48 -> and PFO alone is not necessarily associated

2334.81 -> with an increased risk of stroke,

2336.13 -> but if a patient has a very large PFO,

2339.37 -> perhaps if they're younger,

2340.75 -> if the PFO is illustrated up in the corner,

2343.09 -> has a pouching of the interatrial septal,

2346.69 -> so-called an atrial septal aneurysm,

2349.66 -> those patients are at high risk for secondary stroke,

2351.91 -> but until recently, we didn't know how to deal with them.

2355.12 -> They ran big trials around 2015

2357.85 -> trying to say, "Should we close that hole or not?"

2360.58 -> None of these trials demonstrated

2362.26 -> that closing the hole worked,

2364.24 -> and then, in 2017, these trials were repeated,

2369.1 -> published in "The New England Journal of Medicine,"

2371.89 -> and all three trials sort of sliced and diced the population

2375.46 -> trying to find a group of patients with PFO and stroke

2378.73 -> who would benefit from PFO closure

2381.67 -> through an endovascular approach,

2384.19 -> and thankfully, these were all positive trials,

2386.86 -> so where we are in 2023 is

2389.08 -> we don't close all PFOs in stroke,

2391.99 -> but we do screen patients for PFO,

2394.87 -> discuss with our cardiologists the rules of the road,

2398.38 -> and then, for some patients,

2400.03 -> this is a very, very effective and important tool

2404.14 -> for secondary stroke prevention.

2406.03 -> Here's what the data says.

2407.44 -> Close the PFO if the patient's younger than 60.

2412 -> They're older than 60,

2413.08 -> there's really no data to close PFOs in those patients,

2416.65 -> and you can be sure that the PFO is the cause of stroke.

2420.13 -> If they also have atrial fibrillation

2421.69 -> or have a very tight carotid,

2423.04 -> then I pause whether the PFO is really involved.

2426.55 -> The qualifying event has to be a stroke, not a TIA.

2428.7 -> It has to look embolic, not like a lacunar stroke,

2431.68 -> and likely we concentrate on larger PFOs.

2434.83 -> Smaller PFOs were excluded from the trial,

2437.53 -> so they're mainly moderate or large PFOs,

2439.627 -> and we rely on our echocardiogram people

2442.09 -> to tell us how many bubbles are going through?

2444.31 -> Is it a medium PFO?

2445.143 -> Is it a small PFO? Is it a large PFO?

2447.52 -> So that's where we are

2449.05 -> in terms of secondary prevention with PFO.

2452.59 -> I mentioned that some people, like with atrial fibrillation,

2454.81 -> will be anticoagulated.

2457.12 -> Tracy and a lot of my friends

2458.98 -> who think about this a lot in the medicine department

2461.17 -> always remind me to say, "What does that mean?

2463.817 -> "Do we just start a DOAC?

2465.617 -> "Do we bridge somebody with heparin

2467.327 -> "and then start warfarin?"

2468.34 -> We use DOACs more often than not,

2470.71 -> but it turns out that should we give heparin in acute stroke

2474.61 -> in somebody, for instance, who has AFib,

2476.757 -> I think the answer is definitively not.

2478.87 -> Large trials that have randomized people

2481.12 -> and looked at large groups of folks

2483.64 -> who have or have not had a stroke

2487.6 -> and people who have a stroke

2489.13 -> who are randomized to heparin versus no bridging,

2491.59 -> it turns out can find no benefit, none whatsoever,

2494.89 -> to bridging heparin in stroke,

2496.39 -> so it is probably, even if people are really high risk

2499.27 -> or have a low risk of bleeding that's perceived,

2501.28 -> so it's probably unwise

2503.05 -> to think that we can magically find a group

2505.63 -> that benefits from heparin and we know better.

2508.93 -> In general, just don't use heparin in acute stroke.

2513.25 -> I think that's directionally correct.

2517.03 -> Let's talk about this case.

2518.26 -> 70-year-old woman, history of diabetes,

2520.72 -> 10 hours after the onset of slurred speech

2522.97 -> and right arm and leg weakness,

2524.5 -> taking a baby aspirin a day,

2526 -> and there's a little teeny stroke,

2527.56 -> a little lacunar stroke there,

2529.45 -> but there was no large vessel occlusion,

2531.7 -> so this patient is not eligible,

2533.8 -> not eligible for acute stroke therapy,

2536.65 -> and they're not within 4 1/2 hours,

2538.9 -> so they can't get t-PA.

2540.04 -> They can't get TMK, so we anticoagulates.

2542.98 -> Let's say we do the whole workup.

2544.3 -> No AFib, no reason to anticoagulate the patient,

2547.63 -> so the question is

2548.65 -> is this somebody who gets an antiplatelet?

2551.74 -> Everybody gets an antiplatelet, so yes.

2554.53 -> What do we treat them with?

2556 -> Well, we got three major options in stroke.

2558.22 -> We have good old-fashioned aspirin,

2560.11 -> and it turns out that 50 milligrams

2562 -> all the way to 1 1/2 grams, same thing,

2564.73 -> so you can give a baby aspirin or a full dose aspirin.

2566.92 -> Makes no difference.

2568.06 -> We usually treat people with just a baby aspirin.

2570.64 -> Nobody uses Aggrenox anymore, but it's an effective therapy,

2573.7 -> and it's a little bit better than aspirin.

2575.89 -> Baby aspirin combined with extended release dipyridamole

2579.1 -> that's given twice a day.

2580.57 -> About 30% of people have to stop it

2582.49 -> because they get a headache,

2583.99 -> and then, a lot of us use clopidogrel,

2586.51 -> but the thing to remember is that multiple trials

2589.12 -> show that the combination of clopidogrel and aspirin

2592.6 -> is no better than one by itself,

2595.99 -> so long-term combination therapy with dual antiplatelets,

2600.7 -> that doesn't work particularly well,

2602.68 -> so what we do in 2023,

2604.81 -> if they weren't taking any medicine,

2607.03 -> you could start them on aspirin after their stroke or TIA,

2610.12 -> or you could start them on clopidogrel.

2611.8 -> Clopidogrel's a little better,

2613.39 -> but aspirin is so easy to tolerate

2616 -> that we generally start aspirin,

2617.56 -> but many of our patients have a stroke or TIA

2619.6 -> while they're on aspirin,

2621.34 -> and then it's really mandated

2622.84 -> to switch them over to clopidogrel or perhaps Aggrenox.

2626.83 -> If they're already on Plavix or Aggrenox,

2628.72 -> I have no idea what to do.

2631.03 -> We often switch to the other one.

2632.74 -> What I do know

2633.61 -> is that those patients should not be anticoagulated

2636.25 -> just because they've failed antiplatelet medicines

2639.04 -> unless they're proven to have atrial fibrillation

2641.29 -> or some other reason why they should be anticoagulated.

2645.19 -> Now, one of the big advances in the last few years

2647.35 -> has been trying to figure out

2648.4 -> if there's ever a role for dual antiplatelets

2650.78 -> with, for instance, clopidogrel and aspirin.

2653.86 -> Is it ever a winning combination,

2655.72 -> like this combination reflex hammer and stethoscope

2659.53 -> up in the right-hand corner, which seems delightful.

2662.41 -> The POINT trial was published

2663.73 -> in "The New England Journal of Medicine,"

2664.96 -> and what they tried to do is they said, "Listen, we know,"

2667.78 -> and this was based by Clay Johnston

2669.7 -> when he was based here at UCSF

2671.01 -> as a large international trial (indistinct) to say,

2674.023 -> "Can we identify a subgroup of patients

2676.667 -> "who would benefit from both aspirin and clopidogrel?"

2680.41 -> And the way to do it

2681.37 -> is to find patients who don't have much risk of bleeding.

2684.73 -> They have a tiny stroke or no stroke

2687.76 -> and use it for only a short period of time

2690.55 -> when we know that the higher risk of recurrence

2693.4 -> happens in the first few weeks,

2695.29 -> so they selected patients who had minor deficits

2698.47 -> or no deficits based on their NIHSS stroke scale score,

2703.24 -> and then they randomized people to duals:

2705.61 -> aspirin or clopidogrel versus aspirin alone,

2708.73 -> and they only did it for a short period of time,

2711.73 -> and what they showed was that it worked.

2714.55 -> It decreased the risk of recurrent stroke

2717.13 -> with only minimally more hemorrhages,

2719.83 -> most of which were systemic,

2721.9 -> and so nowadays, as I'll come to in a minute,

2724.33 -> we do use this combination.

2726.67 -> There's a trial I'll go through very quickly

2728.47 -> that was published a couple years ago,

2729.94 -> the exact same study,

2731.56 -> only looking at ticagrelor as opposed to clopidogrel.

2734.89 -> Ticagrelor has the advantage,

2736.93 -> even though it's more expensive,

2738.16 -> that it doesn't have drug-drug interactions,

2740.41 -> CYP mutations do not get you in trouble

2742.9 -> with clopidogrel, quote-unquote, resistance,

2745.93 -> and so nowadays, in 2023,

2748.21 -> there are situations where we use dual antiplatelets.

2751.12 -> We do it in patients who have

2754.06 -> a minor stroke or a TIA,

2757.39 -> and we do it for only 21 days,

2760.09 -> so in the first 21 days,

2761.8 -> we will treat people

2762.73 -> with a combination, typically, of aspirin and clopidogrel,

2766 -> but aspirin and ticagrelor is an option,

2768.7 -> and then, after 21 days, revert to just one.

2772.12 -> If they were on nothing, we can revert to aspirin.

2774.295 -> If they were on aspirin at the time,

2775.51 -> we can treat them with monotherapy with clopidogrel.

2778.54 -> Other times, we use duals. There's not a lot.

2781.12 -> I guess if you have a fresh carotid stent, sure.

2784.42 -> Severe intracranial atherosclerosis,

2787.06 -> there's some data for giving those people duals

2789.73 -> for 90 days or so,

2790.65 -> but the key is

2792.19 -> if you're seeing a lot of patients in your clinic

2794.44 -> or taking the combination of aspirin and Plavix

2797.44 -> for secondary stroke prevention

2799.66 -> for months and months or years and years,

2802 -> that's fallen out of favor.

2803.77 -> Monotherapy is the way to go for secondary prevention

2807.76 -> with the exception of these short time periods

2810.64 -> for some carefully selected patients.

2813.22 -> Other things we do for acute stroke in the hospital,

2815.56 -> everybody gets a high-dose statin.

2817.27 -> We have great data that if your LDL's greater than 100,

2820.39 -> you should be treated with 80 of atorvastatin

2822.49 -> if you could tolerate it for at least five years.

2825.25 -> That helps reduce the risk of secondary stroke.

2828.965 -> In the acute period, we control glucose, fever.

2831.46 -> We give enoxaparin for DVT prophylaxis

2834.01 -> and then one that always trips everybody up

2836.26 -> is this idea of permissive hypertension,

2838.84 -> so we let people's blood pressure ride high

2842.56 -> because that is keeping perfusion

2844.93 -> to those areas of the brain that are underperfused,

2848.62 -> and so the national guidelines are

2850.12 -> if you don't get t-PA in the first few days,

2853.21 -> we should let people's blood pressure

2854.8 -> be as high as 220 systolic.

2857.29 -> Don't treat the person who's 210 to bring them back to 190.

2861.04 -> We don't wanna do that.

2862.36 -> We want to allow this permissive hypertension.

2865.51 -> t-PA has some rules after it

2867.46 -> that for 24 hours, you keep people less than 185

2870.76 -> but then revert to these guidelines.

2873.13 -> The way we do this is

2874.51 -> we not only don't treat people's blood pressure,

2876.82 -> but we usually stop their home blood pressure agents,

2879.256 -> maybe half-dose their beta blocker,

2881.44 -> maybe keep some of their clonidine going,

2883.24 -> but everything else, we will just stop.

2885.43 -> When we decide to back off on permissive hypertension

2889 -> and begin lowering the blood pressure

2890.74 -> 'cause, of course, that's required

2892.57 -> for secondary stroke prevention,

2894.58 -> it remains controversial.

2895.99 -> What we typically do is start a medicine

2898.93 -> at about 48 to 72 hours or at discharge

2903.4 -> and then work with our primary care colleagues

2905.83 -> to bring people's blood pressure down slowly

2909.04 -> over a matter of days or weeks,

2910.9 -> and there are some situations where we might, you know,

2913.33 -> do this a little longer,

2914.44 -> some where we might do it a little shorter,

2916.12 -> but this ends up being an important strategy.

2919.45 -> Let me just finish with a couple pieces on this final case.

2922.63 -> 73-year-old woman with high blood pressure comes to the ED

2925.36 -> after a five-minute episode of weakness that resolved.

2928.57 -> Her exam's normal except high blood pressure,

2930.64 -> and she's got a little stroke on her MRI.

2932.8 -> That's interesting 'cause this is a patient with a TIA,

2936.31 -> and it turns out that probably 1/3,

2938.53 -> maybe more of patients with TIA

2941.05 -> will have a little infarct on their MRI.

2943.69 -> As a result,

2944.59 -> we think of TIA and stroke as the same disorder:

2948.34 -> same workup, same treatment,

2951.1 -> and if you conceptualize that,

2952.51 -> this is sort of like our unstable angina,

2954.76 -> like, nothing much is dead yet.

2956.35 -> The patient's still normal.

2957.85 -> We have our opportunity to intervene,

2960.61 -> and we become very, very aggressive with patients with TDIA,

2964.42 -> sort of thinking

2965.253 -> of an unstable angina analogy.

2969.97 -> There's ways to estimate

2971.23 -> somebody's future stroke risk with TIA,

2973.39 -> and one of the things

2974.41 -> that we've demonstrated over the years,

2975.72 -> is that if someone with a TIA

2977.26 -> is either admitted to the hospital

2979.33 -> or goes to a specialized TIA clinic,

2982 -> and you do all those things, you start them on antiplatelets

2984.49 -> you do the echo, you get everything done

2987.31 -> in terms of the workup and secondary prevention,

2989.95 -> we can reduce the 90-day risk

2992.41 -> of having a stroke after TIA

2995.44 -> maybe 10%.

2997.327 -> No, 20%.

2998.26 -> No, probably as high as 75%,

3001.56 -> so it is very important to be very aggressive

3004.77 -> about somebody who may have had a TIA,

3006.9 -> and we've demonstrated that in multiple trials.

3010.89 -> Now, the final thing I'll talk about is that in this case

3013.41 -> this TIA was caused by a very tight stenosis

3016.32 -> in the carotid artery,

3017.85 -> and it's very important to look at the carotids

3020.64 -> because carotid artery stenosis leading to stroke

3023.67 -> is not only an important cause of stroke,

3025.53 -> but it's a very treatable cause of stroke

3027.21 -> when it comes to secondary prevention.

3029.31 -> You all remember the NASCET trial in the early '90s

3032.28 -> that showed that if somebody's carotid

3033.87 -> on the same side of the stroke or TIA

3036.18 -> was greater than 70% stenotic, you should fix it.

3040.56 -> Now, this was compared

3042 -> to best medical management at the time.

3043.98 -> We've gotten better, certainly,

3045.78 -> but remember that 70% number.

3048.27 -> If it's greater than 70%, fix it;

3050.25 -> if it's less, medical management is the best way to go,

3053.73 -> even in 2023,

3055.65 -> and in the world of stroke,

3057.09 -> don't miss carotid disease, don't miss AFib

3060.03 -> because we've got great ways to help those individuals,

3063.78 -> and when it comes to fixing the carotid,

3065.79 -> we can either fix it

3066.84 -> with a good old-fashioned carotid endarterectomy,

3070.02 -> or now there's a lot of data

3071.4 -> that placing a stent in the carotid is just as effective,

3075.42 -> and so it turns out that if you put a stent in,

3077.94 -> there's a little bit more stroke in the procedure.

3081.63 -> If you do an endarterectomy, there's a little bit more MI,

3084.69 -> but overall, things are equal.

3087.45 -> Turns out in older individuals greater than 70,

3090.453 -> they benefit a little bit more from endarterectomy

3093.66 -> as opposed to stenting

3095.01 -> because you're probably going

3096.54 -> through these tortuous vessels on the stent,

3099 -> and therefore, you could flick off some clot,

3101.79 -> and it goes downstream,

3102.96 -> but don't forget about fixing people's carotid arteries

3106.17 -> as an important area of secondary prevention,

3109.08 -> so I hope in this last hour

3111.33 -> I've been able to go through important parts of stroke,

3115.35 -> think about what we're doing in 2023,

3118.14 -> give you a framework on what we're thinking about

3120.57 -> with acute ischemic stroke and all of these recent advances.

3124.23 -> I so appreciate the invitation

3126.42 -> to Department of Medicine Grand Rounds.

3129.18 -> We've so appreciated our partnership with your department

3132.06 -> and look forward to continuing that for many years to come,

3134.88 -> so thanks so much, Bob.

3135.93 -> Thanks for having me. Really appreciate it.

3137.73 -> - Thank you, Andy. That was fabulous, as always.

3140.94 -> Got a few questions, and lemme start with a couple.

3144.27 -> You said TIA, we treat it like stroke,

3146.16 -> but I assume, let's say they're improving,

3148.92 -> and you see them in the ED, do you ever lyse them?

3151.83 -> Or if they're improving,

3152.663 -> you're gonna wait to see if they get better

3153.747 -> and just start antiplatelets?

3155.374 -> - Well, it's a great question, Bob,

3156.78 -> so we have data

3159.18 -> that people who are, quote, improving

3162.15 -> often will go the other direction

3164.46 -> when they go to bed that night, right?

3166.2 -> They might be improving

3167.1 -> 'cause their blood pressure's going up.

3168.42 -> They're worried they're having a stroke,

3169.71 -> and then you're getting collaterals to form,

3171.81 -> and then, when they go to sleep that night,

3173.64 -> and thank goodness I didn't have a stroke,

3175.05 -> they wake up with a hemiparesis,

3176.94 -> so I think the rapidly improving piece

3180.57 -> is one where we're still pretty aggressive, in many cases.

3184.2 -> I think someone who comes in who's completely normal,

3188.07 -> a few hours ago,

3189.03 -> my right arm went weak when I was at dinner.

3191.16 -> 30 minutes later, it was better. Here I am, doc.

3193.92 -> We're not gonna give them lysis.

3195.45 -> That's not going to happen,

3197.22 -> but it's interesting

3198.54 -> to think about patients who are having rapid improvement

3200.79 -> and what we do with those individuals.

3202.26 -> I think it depends

3203.31 -> are they at a stage right now

3204.84 -> where they still have a deficit

3207.3 -> that would impair them going forward?

3209.82 -> So it kind of depends on the deficit.

3211.26 -> If rapidly improving is

3212.49 -> I've just got some tingling in the arm,

3213.99 -> okay, but we're gonna watch them really carefully

3216.51 -> here in the hospital.

3218.16 -> If rapidly improving, as I'm not as aphasic as I was,

3222.48 -> then, you know,

3223.53 -> we probably think about lysis in those patients.

3225.88 -> - 'Kay, a community center

3227.25 -> that can't do an embolectomy gives t-PA.

3231.9 -> Do all those patients get shipped?

3234.42 -> Or should they be doing a CT perfusion?

3236.91 -> Do they have the capacity,

3238.05 -> or I'm a little confused about those folks.

3240.48 -> What happens after their t-PA?

3241.98 -> - It's a heck of a question, Bob,

3243.24 -> and that's what part of that "New York Times" article

3245.85 -> was focusing on.

3246.72 -> I think the best route forward is,

3249.15 -> look, these CT scans, CT perfusion, CTA,

3252.99 -> are not tricky anymore.

3254.52 -> You need a multidetector scanner, which everyone's got.

3256.77 -> They can do a spiral CT for PE. I mean, no problem.

3260.22 -> What was usually the barrier

3261.87 -> is the ability to interpret these things,

3263.82 -> and now, with this automated software,

3266.25 -> many of our partner hospitals are investing in that

3270 -> so that when they call us,

3271.23 -> they can say, "There is a large vessel occlusion,"

3273.63 -> and look at it on my phone.

3276.36 -> I don't just have the UCSF ZSFG perfusion.

3280.53 -> I get the perfusion if something happens at our partners,

3282.96 -> at Marin General, for instance,

3284.487 -> and so we're able to see that in real time

3288.09 -> and bring the patient over.

3289.08 -> I think if you do it the other way,

3290.43 -> where you say, "We're just gonna ship the patient,"

3293.25 -> then we're taking up a lot of beds here.

3294.9 -> We're using a lot of resources to bring people here

3297.3 -> who don't need acute stroke therapy

3299.46 -> and wouldn't qualify based on the perfusion,

3301.32 -> or they don't have a large vessel occlusion,

3303.21 -> so I think that the best scenario is

3305.73 -> everybody has a partner hospital that they rely upon

3308.49 -> to accept their strokes if they need acute therapy,

3311.31 -> but they can do the screening there with imaging

3314.37 -> and use teleneurology

3315.66 -> or a conversation with their local neurologist

3317.64 -> or a conversation with the transfer center, us,

3320.22 -> to help determine whether this is a patient

3321.75 -> who should be shipped.

3322.583 -> We do this every single day at UCSF.

3326.16 -> - So community hospital does t-PA.

3329.01 -> Patient seems like they got a little bit better.

3331.32 -> They do the CT. It does not show large vessel occlusion.

3334.41 -> Standard of care.

3335.243 -> They stay at that hospital for the rest of their care.

3337.56 -> - That's the standard of care.

3338.46 -> Now, one of the things we've done, which, I think, you know,

3340.71 -> there are some community hospitals who feel uncomfortable.

3342.87 -> There's people who are medicine hospitals, for instance,

3345.06 -> Bob, who say, "Boy, I don't know about poststroke care.

3348.697 -> "I'm not as comfortable doing so.

3350.107 -> "We only see a couple a year."

3352.02 -> That's where we've been able

3353.19 -> to deploy our teleneurology resources,

3355.38 -> and so there's a variety of hospitals

3356.79 -> in Northern California, as you know, Bob,

3358.35 -> where we do all their teleneurology.

3360.27 -> Part of what we do is we help allow those kinds of patients

3363.6 -> to stay in that hospital close to their loved ones,

3367.14 -> not get shipped miles and miles away,

3368.97 -> and we see those patients every day

3370.8 -> and help manage them from afar.

3372.57 -> I think that's a really useful strategy

3374.46 -> to help people stay in their community.

3376.89 -> - Great. Anoop Muniyappa asked, "Does TP administration

3380.797 -> "delay when the embolectomy can be done

3382.357 -> "because of the risk of a complication

3384.637 -> "during the invasive procedure?"

3386.04 -> - It's a great question, and the answer is generally no.

3389.07 -> We don't wait, for instance,

3390.75 -> for that hour-long infusion to stop.

3393.33 -> The bolus goes in in just a minute or two,

3395.58 -> and then we're able to bring the patient to the IR suite,

3398.568 -> and we can do the embolectomy

3399.87 -> while it is still running through the patient.

3402.54 -> Important question, also an important observation,

3406.11 -> thinking about TNK as opposed to t-PA,

3408.69 -> again, getting on a rig

3410.1 -> to transfer from one hospital to the other.

3412.5 -> - But your experience in nationally

3414.69 -> the safety of doing this invasive procedure

3417.36 -> while the patient has just gotten t-PA is okay.

3419.49 -> - Generally okay.

3420.6 -> - Yeah.

3422.46 -> You made the point that you put this stent in

3426.75 -> and get the clot and then remove both.

3428.79 -> Do you ever put the stent in and leave the stent in

3430.8 -> when you find a stenosis

3431.79 -> at the time of the original procedure?

3433.53 -> - Yeah, well, that's a really important question,

3435.33 -> so multiple studies have looked at

3438.27 -> sort of acute stenting for a stenosis

3441.09 -> as opposed to a clot, a fixed stenosis,

3444.18 -> have not yet been able to demonstrate that efficacy,

3447.54 -> but I gotta tell you that's an area of active research.

3449.91 -> I'll give you a twist, Bob.

3451.38 -> It's a lot easier to think about doing that

3453.66 -> if the patient has not gotten t-PA.

3456.3 -> If they have t-PA on board, my enthusiasm,

3459.63 -> because if you're gonna leave a different kind of stent in,

3462.45 -> you're certainly gonna need to load them on Plavix

3464.247 -> and give them dual antiplatelets.

3466.44 -> We're doing that when somebody's had t-PA

3468.78 -> an hour or a few minutes before.

3471.09 -> That could potentially be high risk,

3473.04 -> so I think this is another reason why people are saying,

3476.317 -> "Could we skip the t-PA

3477.787 -> "in some of these thrombectomy cases?"

3480.45 -> - Mm-hmm. Great.

3482.07 -> Marshall Doyer asked a question

3483.57 -> that I don't understand, but I'm hoping you will.

3485.047 -> "Can you comment on," quote, "the ongoing disconnect

3487.747 -> "between neuro and emergency medicine communities

3490.237 -> "on the interpretation of the original NINDS study

3493.507 -> "underpinning thrombolysis?"

3495.69 -> - Yeah, I guess what I would say, Marshall,

3497.16 -> is that I don't want to,

3500.61 -> I don't wanna make it sound like that question is old news,

3503.37 -> but I think it is a little bit.

3505.41 -> You're reflecting something very important

3507.45 -> that from '95 to,

3510.63 -> name a year, 2008, and I'm just making something up,

3513.9 -> there was a lot of controversy in many EM societies

3517.14 -> about whether those t-PA trials,

3519 -> whether it really worked

3519.87 -> or whether it was too dangerous to be able to administer.

3523.02 -> I think that has largely gone away

3524.76 -> due to additional trials that have come out.

3526.95 -> I think the other thing that we've done

3528.9 -> is that I think the neuro world was probably not good enough

3532.56 -> in providing important backup to our EM physicians.

3535.74 -> Rather, early on, it was like, "We're not in the ED.

3538.087 -> "We're neurologists.

3538.92 -> "We're home, you know, with our reflex hammers,"

3541.2 -> and so, you know, you do this.

3543.51 -> This is something you should do.

3544.74 -> That was not a collaborative way of going forward.

3547.23 -> Now, most emergency departments do have a neurologist

3550.47 -> either onsite or by phone or by teleneurology

3553.35 -> and providing that partnership,

3555.09 -> I think many of our EM physicians,

3557.16 -> most of our EM physicians nationally,

3558.84 -> are much more comfortable with thrombolysis

3560.61 -> under those circumstances and increased new evidence.

3563.85 -> - Great. My last question.

3565.47 -> The justification for the TE in younger people.

3569.34 -> Is it just that they're younger?

3571.41 -> Or is the incidence of something that you'd be looking for

3573.48 -> higher in that age group?

3575.04 -> - The incidence is higher.

3576.24 -> I will give you the caveat

3577.71 -> that first, we've already done the CTA

3580.14 -> to make sure they don't have dissection,

3582.18 -> so if you've got a young person

3583.38 -> who doesn't have a dissection,

3584.61 -> you've looked at everything.

3585.69 -> It's probably coming from the heart.

3587.1 -> It's unlikely they're going to have atrial fibrillation

3589.71 -> unless they have congenital heart disease,

3591.57 -> and so the ability

3592.65 -> to really get at the best look at the heart we can

3595.77 -> is what drives that,

3597 -> and data suggests the younger you are with stroke,

3599.58 -> the more likely, assuming you don't have a dissection,

3602.13 -> that there's gonna be something found on the echocardiogram

3604.5 -> that gives you an answer as to why (no audio).

3606.3 -> - And the somethings basically are

3607.95 -> you find a clot or you find a PFO

3610.22 -> or those are the two-

3611.053 -> - Clot, PFO, endocarditis in those patients,

3613.95 -> you know, looms large,

3614.91 -> so a number of reasons why you're gonna get a better look,

3617.55 -> an abnormality of the aortic arch, et cetera.

3619.89 -> - Great. Andy, thank you.

3621.78 -> Incredibly instructive and interesting

3623.76 -> and wonderful the progress that we have made,

3626.43 -> including from you and your colleagues, so thanks so much.

3628.95 -> We'll see you back here next week.

3630.27 -> We'll be talking about advances

3631.8 -> and controversies in geriatrics.

Source: https://www.youtube.com/watch?v=nLM1_UQ_aQ0