2021 Stroke Educational Series- American Heart Association Acute Ischemic Stroke Guideline Updates
2021 Stroke Educational Series- American Heart Association Acute Ischemic Stroke Guideline Updates
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Content
0.08 -> them to our first of the 2021
5.279 -> 2021 stroke educational series
8.72 -> um my name is deb moats and i'll be your
11.2 -> moderator
12.08 -> today and feel free to ask questions
14 -> throughout the presentation
15.519 -> by typing them in the chat box on the
17.92 -> right hand of your screen
19.119 -> or pressing the microphone at the bottom
20.96 -> of your screen or if you're using the
22.72 -> phone audio press star 6 to come off
25.039 -> mute
25.84 -> everybody will be placed on mute to
27.76 -> begin with
29.359 -> i have the distinct pleasure to be able
32.239 -> to introduce dr robert
34 -> l allende he is a professor in the
37.04 -> department of neurosurgery
38.64 -> and emergency medicine and medical
40.8 -> director of the neuro icu
43.04 -> at the university of new mexico and
45.039 -> albuquerque
46.239 -> dr allende is the director of the
48.079 -> university of new mexico's neurosciences
50.399 -> intensive care unit
51.92 -> providing modern neurocritical care his
54.559 -> enthusiasm and thorough patient care
56.48 -> along with his combined training
58 -> in emergency medicine and neurocritical
60.079 -> care ensure that his patients receive
62.399 -> the best possible care
64 -> as quickly as possible his friendly
67.04 -> professional bedside manner makes him a
69.04 -> favorite to his patients and the
70.84 -> families in order to provide
72.96 -> continuity and shared resources dr
75.04 -> allende has dual faculty status and
77.2 -> shares his time in the department of
78.64 -> neurosurgery
79.84 -> and the department of emergency
81.28 -> emergency medicine
82.96 -> he also will be working with the
84.24 -> department to provide emergency
86.159 -> stroke care for patients in rural
87.84 -> hospitals through their telemedicine
89.439 -> technology
91.04 -> dr allende is a volunteer supporting the
93.6 -> american heart association american
95.36 -> stroke association
96.56 -> in many capacities and he currently
98.799 -> serves on the southwest affiliate stroke
100.799 -> committee
101.759 -> this president's presentation today is
104.159 -> titled acute ischemic stroke
106.88 -> guidelines so uh welcome dr allende
111.119 -> well thank you so much deb um appreciate
114.72 -> that introduction
116.159 -> uh and i just wanted to thank everybody
118.88 -> for
119.6 -> being a part of this uh this is uh
123.119 -> super interesting stuff a lot of
124.88 -> controversial stuff
126.32 -> so much so that in 2019 they had to
129.119 -> update the 2018 guidelines
131.92 -> um soon enough i'm sure they'll come out
134.4 -> with a
135.599 -> newer set of guidelines but for now this
137.599 -> is what we got and it's still
139.04 -> pretty good information um
142.319 -> so let's get right to it
145.599 -> i have no financial disclosures
148.8 -> and this is essentially the the document
151.84 -> that we're going to be
153.2 -> uh building that the talk on top of
156.56 -> american heart association american
158.48 -> stroke association guidelines
160.08 -> there's a lot of huge names in here
163.12 -> just a shout out to some of the great em
166.239 -> docs that i've worked with in the past
168.239 -> uh dr opoya dayaway um
171.68 -> is an em neurocritical care doc uh out
174.8 -> of cincinnati actually just
176.56 -> became chair of the department of
178 -> emergency medicine in washington which
179.519 -> is where i trained
180.56 -> i also went to med school in cincinnati
182.319 -> so that's where i know him ed yalk
185.519 -> was my med school advisor in med school
188.959 -> in cincinnati and
191.28 -> i think oh not on this document but
194.48 -> there's another one that we'll talk
195.68 -> about where
196.959 -> pete pinegos who co-chaired the
200.64 -> committee for uh mission lifeline stroke
205.519 -> he was also one of my mentors so i've
207.84 -> been
208.879 -> lucky enough to work with some of the
210.799 -> big minds
212.159 -> on on acute stroke here in the united
214.72 -> states
216.239 -> so real quick i think it's super
218.48 -> important that we understand what we're
220.319 -> talking about whenever we talk about
222.159 -> recommendations
223.519 -> so there's two ways that we
227.76 -> discuss it and one is the strength of
230.4 -> the recommendation like how strongly
233.12 -> the association in this case american
235.92 -> heart association
238.08 -> feels that you should do or should not
240.239 -> do certain tasks
242.08 -> and then there's also the amount of
243.84 -> evidence that goes behind
245.76 -> each of those recommendations so just to
248.4 -> quickly clarify here
250.239 -> the class one recommendation is a strong
253.599 -> recommendation you've got to do this if
255.84 -> you don't do this
257.519 -> you are potentially putting yourself at
259.759 -> risk
261.759 -> for malpractice if you're not doing
263.52 -> these kinds of things it's that strongly
265.759 -> recommended um class 2
268.88 -> a is a moderate recommendation um
271.919 -> it's reasonable to do so these
275.28 -> in effect you should be definitely doing
277.36 -> these things 2b
278.96 -> also you probably should be doing these
280.88 -> things too
282 -> uh but definitely not as strong a
283.68 -> recommendation as class one
286.08 -> class three don't worry about it don't
288.56 -> do these recommendations
290.88 -> the aha does not suggest doing these
294.08 -> that are ranked as a class three and
296.56 -> class three harm
298.24 -> uh this is definitely don't do these
301.84 -> potential interventions uh we're we'll
305.039 -> be talking about one
306.24 -> class three no benefits um in this talk
312.8 -> the level of evidence the quality of the
315.039 -> evidence this is
317.36 -> you know the trials that went into
319.44 -> figuring out
321.68 -> what we need to be doing and providing
323.6 -> us that backbone for how strong of a
325.759 -> recommendation we want to give
327.6 -> so a level a is the highest level of
330.72 -> evidence that has
332.08 -> more than one randomized controlled
333.919 -> trial meta-analyses everything
337.12 -> points to the same direction in regards
339.68 -> to
340.56 -> the recommendation level 2b
344 -> this usually comes from a good
347.039 -> randomized control trial at least one of
350.639 -> those
351.039 -> embed analyses that are pointing in that
352.88 -> same direction
354.32 -> uh level two be non-randomized so that's
358.639 -> no rcts no randomized control trials but
361.6 -> still
363.68 -> evidence is still pointing in the same
365.36 -> direction
367.84 -> sorry let me just turn this
371.36 -> off okay level c
374.479 -> is of course worse there's no randomized
377.919 -> controlled trials
379.759 -> there's some decent data on there and
381.6 -> level c essentially comes down to this
383.84 -> is what
384.319 -> makes sense this is what the experts do
387.44 -> but
388 -> we don't have any good data to back that
390.319 -> up
392 -> all right so we'll go ahead and start
395.039 -> then with a pretty controversial topic
398.56 -> of pre-hospital
399.84 -> bypass
404.24 -> so this is um starting with
408.08 -> uh ems recognition of a patient with a
410.639 -> stroke
411.759 -> and figuring out which hospital they
413.28 -> need to go to
415.36 -> so just to read word for word at the top
417.599 -> here if eligible for alt
419.52 -> iv ultiplice the benefit of bypassing
422.8 -> the closest
424.16 -> iv alteplase capable hospital to go to a
427.52 -> thrombectomy capable center
429.759 -> is uncertain it's a class
433.599 -> 2b so again
436.96 -> uh we're in favor of bypassing the
440.96 -> closest iv all the place in order to go
443.759 -> to the thrombectomy capable center
446.72 -> but it is uh
450.08 -> it's not definitely not the strongest
451.52 -> recommendation
453.12 -> this is backed by level b evidence so
455.44 -> that's pretty good
456.88 -> at least one rct and the meta analyses
459.36 -> are pointing in the same direction
462 -> um so
465.44 -> the aha also publishes this mission
467.84 -> lifeline stroke
469.68 -> which is a super helpful document in
472.639 -> this case this document helps
474.72 -> provide a systems of care
478 -> backbone for how ems can
481.039 -> get the patient to the right place and
483.28 -> it looks like this
484.96 -> um it seems a little complicated but
487.84 -> essentially
489.12 -> on the bottom left there if they suspect
490.879 -> the stroke
492.16 -> you you start the things you figure out
494.56 -> your last known well
496.8 -> you um and then you try to figure out if
500.879 -> you suspect a large vessel occlusion
504.639 -> right here so this is where that
506.56 -> controver the first part of the
508.319 -> controversy and this controversy is
510.72 -> how well can we detect the large vessel
513.519 -> occlusion in the field
516.399 -> because if you get it wrong every time
518.159 -> then you're just wasting patients time
520.32 -> uh your waste you're wasting that uh
522.719 -> eligibility
523.68 -> time your waste and brain cells and
525.44 -> before getting all the place
527.36 -> but if you get it right you get them
530.48 -> to the more definitive answer of the
532.839 -> thrombectomy faster
536.32 -> so again the problem with the stroke
538.399 -> severity scales
540.399 -> not the initial stroke scales not like
542.48 -> your normal cincinnati or your normal
544.959 -> lan or your normal la pre-hospital
548.48 -> stroke scale
550.88 -> but these are the stroke severity scales
554.56 -> these stroke severity scales all had
556.56 -> area under the curves
558.32 -> of 0.7 0.85 which is not too bad
561.519 -> the probability of having an elbow with
564.72 -> a positive elbow prediction test
567.36 -> was thought to be only 50 to 60 percent
570.56 -> whereas you know potentially greater
573.44 -> than 10 percent
574.399 -> with a negative test could also have an
577.36 -> elbow
579.92 -> thus more effective tools are needed to
582.88 -> identify suspected stroke patients
584.959 -> with strong probability of elbow so
587.6 -> that's the
588.32 -> counter to this recommendation is that
590.56 -> our tests just
591.36 -> aren't good enough yet
595.6 -> and if they're not good enough we
596.959 -> potentially over triage we potentially
599.44 -> delay all the place
601.44 -> and if it doesn't catch uh sorry
605.36 -> yeah and if it if it doesn't catch what
607.2 -> are we doing
608.56 -> um my counter my counter to that or
612.399 -> you know if i was a patient with a large
615.12 -> vessel occlusion
616.64 -> um i would want you to take me to the
619.279 -> more definitive
620.64 -> care for that sooner because the data is
624.32 -> pretty strong
625.839 -> in saying that thrombectomies
629.04 -> get you to a
633.279 -> better outcome more so than all the
635.44 -> place
636.88 -> so if you could catch 50 to 60 i think
639.36 -> that's
640.32 -> theoretically a win that's good enough
641.92 -> for me but
643.44 -> there's definitely definitely room for
645.279 -> improvement
649.6 -> now going back to the algorithm again
652.8 -> if you suspect the elbow and you're
654.8 -> going down that third column
656.56 -> downwards and the last known well is
659.839 -> within 24 hours
662.959 -> this says to bypass the endo uh
666.72 -> sorry to go to the endovascular capable
670.399 -> center as long as you can
672.839 -> one not miss out on getting all the
675.76 -> place
676.88 -> if bypassing is going to cause you to
678.48 -> miss out on all the place
680 -> don't bypass just get your tpa at one
682.959 -> hospital and then go
684.399 -> to the endovascular capable center and
688.64 -> your comprehensive center is less than
690.72 -> 30 minutes away
693.12 -> that's what these recommendations are
695.279 -> saying
696.32 -> there's they also american heart also
700 -> does state in uh a
703.36 -> parallel document to this uh that when
706.16 -> there
706.56 -> is that there is insufficient evidence
709.6 -> on specific thresholds of these time
712.16 -> time limits
713.2 -> uh and additional time travel for which
714.959 -> to bypass
716.8 -> uh other hospitals so
721.2 -> it's can be very location
724.32 -> specific can be can be kind of patient
726.639 -> specific
728.8 -> but these are just open guidelines to
731.04 -> provide
734.32 -> ems
737.68 -> ems groups within a city you know here
739.519 -> in albuquerque we have
741.36 -> our um
744.48 -> albuquerque fire and we have albuquerque
747.44 -> ambulance systems that are those are two
749.44 -> big ambulance systems in town
751.36 -> and those guys work together to make
754.639 -> a lot of joint protocols for
757.04 -> pre-hospital providers
759.519 -> so it's working through them with these
762.959 -> guidelines that we come up with our
764.88 -> recommendations
767.12 -> so again thresholds of additional time
768.88 -> travel insufficient evidence you're
770.48 -> trying to weigh
771.68 -> the laser all the place to delays in
773.839 -> thrombectomy
779.04 -> moving on now to
782.32 -> well sort of moving on pre-hospital
785.12 -> bypass
786.24 -> to health care facilities able to
788.16 -> perform thrombectomies
789.92 -> if a patient is ineligible for a
791.68 -> thrombolysis so this is now
794 -> they don't even qualify for thrombolysis
796 -> because they're out of the time window
798.16 -> or they're on coumadin and they take it
800.88 -> every day religiously
802.56 -> so they're not going to be thrown back
804.399 -> to the candidates
805.76 -> well let's just go to the place that's
808.399 -> going to provide the only
809.839 -> um possibility for
814.16 -> acute stroke treatments so go to the
817.519 -> place that can do endovascular therapy
819.279 -> or
819.68 -> mechanical thrombectomy so class 2b
822.88 -> evidence sorry recommendation level of
825.199 -> evidence c
826.839 -> um but like i said if they can't get all
829.839 -> the place
831.279 -> there's no reason for them to go to and
832.88 -> also place only center
834.72 -> when they have the potential to have a
840.839 -> thrombectomy
842.88 -> all right now this is getting to some
844.959 -> cool interesting
846.24 -> newer stuff some patients can get off
849.76 -> the place
850.32 -> after four and a half hours from the
852.399 -> last known well
854.48 -> so as many of you already know the ninds
857.36 -> trial back in the 90s
859.12 -> was positive was the first trial that
861.36 -> showed benefit
862.24 -> for using alteplase and treating acute
864.639 -> ischemic stroke within
865.839 -> the first three hours e cast
869.12 -> three was the
872.24 -> the third e cast and that demonstrated
874.959 -> benefit
876 -> of giving out the place in a
879.199 -> within four and a half hours with a
881.44 -> certain
882.32 -> um newer set of exclusion criteria
886.48 -> and now we're talking about extending
888.56 -> this beyond four and a half hours
891.68 -> so this is a class two a recommendation
894.639 -> so
895.68 -> definitely definitely has benefits and
897.839 -> comes with level b
899.6 -> evidence so the first trial that they
902 -> mentioned here
903.199 -> uh is this one and in 2018
906.24 -> mr guided thrombolysis for stroke with
908.8 -> unknown
909.839 -> time of onset this one came out in
913.6 -> 2018 out of the new england journal
915.68 -> called the wake up trial
916.959 -> big trial this one had 503 patients
922.399 -> they randomized patients to get all the
924.16 -> place versus standard of care
927.12 -> happened in eight european countries at
929.279 -> 70 different hospitals
931.36 -> and they included adults not too old
934.56 -> last known well outside of the four and
937.519 -> a half hour window
940.32 -> uh stroke recognition of symptoms within
942.88 -> four and a half hours of presentation
945.519 -> but most of these were patients that
947.279 -> were that woke up with their symptoms
949.92 -> so they went to bed fine they woke up
953.04 -> with symptoms
954.079 -> and then they showed up to the ed
958.48 -> they did early stroke they found the
960.48 -> early strokes based on an
962 -> mri so this dwi positive that's the
965.92 -> fusion weighted imaging that's one of
967.279 -> the sequences
968 -> that we get with the mri that if that
971.36 -> was
971.68 -> positive which shows up very early
974.88 -> when someone's having a stroke like
976.32 -> within a few minutes
978.32 -> and then flare negative flare become
981.6 -> that's another sequence on the mri
983.839 -> that shows a positive we think in
985.92 -> somewhere between four and a half to six
987.6 -> hours
988.56 -> of this stroke um some might argue that
992.56 -> it shows a positive when the
998.079 -> you know when there's more edema
999.6 -> associated with the stroke so the stroke
1001.519 -> is worse
1003.199 -> so this helps us to be able to determine
1006.48 -> how old the stroke is and whether or not
1008.959 -> we think that there's going to be
1010.32 -> salvageable brain
1014.72 -> they excluded patients that had ich for
1018.24 -> obvious reasons
1019.68 -> uh they excluded patients that had a
1021.6 -> plan thrombectomy and i think that's
1023.6 -> really kind of important here uh
1026.959 -> because when this trial was done not
1028.64 -> everybody was getting thrombectomy
1031.12 -> um so
1034.559 -> that that's kind of huge nah stroke
1036.799 -> scales that were really big greater than
1038.319 -> 25 and lesions
1040 -> on their ct scan that had greater than a
1041.76 -> third of the territory of the mca
1044.559 -> um as out they didn't include those
1048.079 -> patients and obviously if you couldn't
1049.52 -> get
1049.919 -> out of place you weren't
1059.84 -> after one day i think you went on mute
1076.559 -> i'm going to assume that that was just
1078.32 -> the second
1082.24 -> all right okay great okay
1085.76 -> so this is the demographics
1089.36 -> uh graph or chart from the study
1093.2 -> and i think it's really important to
1094.64 -> note here that the median inter
1097.36 -> the median interval between the last
1098.96 -> known well to the symptom recognition
1101.44 -> and oh sorry um last known
1105.28 -> to be well and symptom recognition and
1108 -> hours was
1109.039 -> 7.2 hours in the alt place group
1112.799 -> almost exactly the same as the group yes
1115.28 -> yes your
1116.32 -> um screen is not being shared anymore
1120 -> so if you can reshare your screen
1134.84 -> absolutely
1139.2 -> i think i'm sharing the wrong screen
1142.32 -> yeah it's not the right thing yes
1145.52 -> perfect i apologize guys i'm so sorry
1148.559 -> for that
1152 -> but again here
1158 -> all right we see that
1161.919 -> the times from last being well to
1164.559 -> symptom recognition was the same
1167.84 -> and this is the other thing that i
1170.24 -> already briefly mentioned
1172.08 -> i think it's important to know that you
1173.919 -> know 15 up to 15
1175.84 -> of these patients had large vessel
1178.72 -> occlusions
1181.039 -> and potentially more
1185.039 -> so it throws a little bit of question
1188.24 -> into does this apply to all the patients
1191.76 -> that don't have large vessel occlusions
1198.559 -> we could see here that the alteplase
1200.32 -> group had a hundred and thirty one page
1203.36 -> fifty three point three percent at a
1206.08 -> favorable outcome
1207.36 -> versus the placebo group of 41.8
1210.88 -> and on your shift analysis here uh you
1214.32 -> see that there is definitely a trend
1216 -> towards better outcomes a statistically
1219.44 -> significant
1220 -> trend towards better outcomes in the
1222.159 -> alteplase group versus
1223.52 -> the placebo group
1227.679 -> and then in 2019 this trial came out
1230.4 -> this is the extend trial
1233.039 -> this trial was done in australia new
1235.44 -> zealand thailand and
1236.559 -> finland um and
1239.76 -> they did a another double-blind
1242.799 -> placebo-controlled trial
1244.159 -> with alta place and they stopped this
1246.799 -> trial
1247.28 -> early because of wake up everyone's
1249.44 -> trying to save money so
1250.96 -> when a very similar trial
1254.24 -> comes up pretty positive they a lot of
1256.799 -> other trials will
1257.84 -> stop and do an interim analysis and see
1260.08 -> if they need to
1261.12 -> keep spending money so the inclusion
1264.4 -> here
1265.12 -> on this specific trial was outside of
1267.84 -> four and a half hours but within nine
1269.76 -> hours
1271.28 -> um they had to have a hypocrite
1275.48 -> hypoperfused but salvageable reasons
1278.4 -> of brain detected on uh imaging
1282.88 -> and the specifics of of that were
1286.32 -> a lesion core to mismatch
1289.679 -> of 1.2
1292.96 -> so there had it had to be the perfusion
1295.44 -> deficit had to be bigger than the core
1297.919 -> uh absolute difference in the volume of
1301.84 -> dead brain versus ischemic brain had to
1303.679 -> be the difference there had to be at
1304.96 -> least 10 ml
1306.48 -> and the ischemic core volume had to be
1308.799 -> less than 7 ml
1310.559 -> 7 ml volume of of brain
1313.84 -> they used mr and mr perfusion or ct
1317.36 -> perfusion
1318 -> and for those of you guys that don't
1320.08 -> look at these all the times this
1322.96 -> right here is an example of a ct
1326.24 -> perfusion so on the left side
1329.44 -> of the screen you see that fuchsia color
1331.679 -> there
1333.44 -> what is being outlined in fuchsia
1336.799 -> is what the computer has determined to
1338.88 -> have a cbf or cerebral blood flow of
1341.2 -> less than
1341.76 -> 30 percent um 30
1344.96 -> of what it should be and that is what we
1348.08 -> consider
1348.96 -> essentially the the core infarct
1352.159 -> and they're measuring this one to be 17
1353.679 -> mls and on the right hand side of the
1355.36 -> screen
1356.4 -> you can see what they're calling um
1360.159 -> low flow time yeah the parts of the
1362.24 -> brain that are getting low flow and are
1363.76 -> at risk
1364.64 -> of becoming fuchsia if nothing happens
1367.84 -> so this is the t-max taking
1371.52 -> longer than six seconds the time to i
1373.52 -> think maximum contrast
1375.679 -> and that volume is 156 so there's a big
1379.039 -> difference on this
1381.12 -> on this particular patient with a
1383.44 -> mismatch ratio of 9.2
1386.799 -> with a large amount of volume so this is
1389.6 -> an example of somebody that has a small
1391.679 -> infarct and will probably have depth
1394.799 -> deficits from that but has a lot of
1397.6 -> salvageable brain
1399.36 -> and their exam can be somewhere in in
1402 -> the middle
1402.88 -> but could be as bad as the entire green
1404.799 -> so if you can
1406.08 -> take out the stroke if you could take
1408.159 -> out the clot via ultraplace on this
1409.84 -> patient
1410.72 -> then awesome then you are potentially
1413.36 -> providing them with a lot of benefit
1418.4 -> here's an example of an mri with an mrp
1422.72 -> so again the fuchsia is considered the
1425.12 -> infarct core
1426.64 -> and the green is considered the low flow
1429.679 -> or the at-risk part of the brain
1433.44 -> or i should say the difference between
1435.12 -> the two is the penumbra
1437.2 -> so this for the mrp shows a
1440.24 -> volume of dead brain of 89 ml versus a
1443.6 -> volume
1444.24 -> of low flow brain at 124
1447.279 -> leaving us with a mismatch ratio of 1.4
1450.88 -> and a volume of 35
1453.44 -> so definitely not as much brain to save
1455.84 -> and
1456.64 -> the amount of dead brain that the
1458.08 -> patient already has here
1459.84 -> is too high for us based on these trials
1464.799 -> to try to to save
1469.279 -> the extend trial exclusion criteria had
1472.48 -> modified rankings
1473.84 -> of greater than two already severe
1476.799 -> severe strokes
1478.32 -> and patients being planned to go to
1481.52 -> thrombectomy as you can see here there
1485.84 -> is
1486.4 -> improvements in the neurologic outcomes
1489.36 -> for the patients that got all the place
1491.919 -> and a proven concept here
1495.679 -> under tertiary outcomes you can see the
1497.84 -> increased
1499.039 -> uh amount of recanalization
1502.159 -> uh 67.3 percent in the ultra place
1505.919 -> versus 39.4 which was the essentially
1509.44 -> the spontaneous recanalization
1511.84 -> of the blood vessels heading towards the
1514.24 -> stroke area
1516.32 -> so we're more likely to open up clots
1519.76 -> and more likely to provide functional
1522.799 -> outcomes
1523.919 -> by giving patients all the place in this
1527.12 -> extended time frame based on imaging
1530.72 -> and again here's another shift analysis
1533.36 -> these are
1533.84 -> super common in uh stroke trials and you
1536.559 -> could see this statistical trend
1538.32 -> towards improved outcomes with a lower
1540.559 -> modified ranking score
1547.52 -> i love how this um
1550.72 -> uh this document the the new guidelines
1553.279 -> have all these controversial topics in
1554.96 -> them
1557.279 -> and this is definitely one of them so
1559.76 -> they're actually
1560.96 -> not recommending out to place for a
1562.559 -> certain group of patients so
1564.4 -> for mild non-disabling strokes
1568.48 -> nih stroke scales of zero to five all
1571.279 -> the places not recommended
1573.12 -> so this is that the sole um
1576.4 -> no benefit one that we were talking
1577.84 -> about discussing today
1580.64 -> so this was based on
1584.64 -> this rct this prisms rct came out in
1588.08 -> january 2018
1591.039 -> and they had 75 hospitals
1594.88 -> they designed the trial for 948 patients
1598.32 -> in the united states
1600 -> of alteplase versus aspirin within the
1603.279 -> first three hours
1605.76 -> they only enrolled 313 patients at 53
1609.44 -> centers
1610.799 -> so things were not going very well for
1612.64 -> them to be able to pick up more places
1615.039 -> and more patients and they ended up
1617.44 -> having to stop
1618.64 -> the sponsor this was an industry
1620.96 -> sponsored trial
1623.039 -> by genentech they said a quote
1626.159 -> financial decision based on the fact
1629.12 -> that the time
1630 -> that the trial could not be completed
1632.4 -> within the allotted funds
1633.919 -> in the specified time frame um
1638 -> so that's kind of sad that they didn't
1639.36 -> get to finish this trial and their
1641.2 -> eventual conclusion here was
1643.2 -> it's very early study termination
1646.08 -> precludes
1646.799 -> any definitive conclusions
1651.6 -> but uh thankfully they were honest and
1654.559 -> put out the data on the patients that
1656.08 -> they did have
1657.76 -> and we'll talk about that down in a
1661.36 -> little bit but
1662.24 -> before i do i think it's important to
1664.88 -> mention
1665.84 -> their inclusion of
1669.76 -> non-disabling strokes so what is a
1672.08 -> disabling stroke and they define that
1674.799 -> as the inability to perform the
1677.279 -> activities of daily living
1679.36 -> or being able to go to work
1682.72 -> so if you were able to do these things
1685.919 -> before and you couldn't do them now
1688.08 -> that's considered a disabling stroke
1692.24 -> and that determination was made by the
1695.6 -> local clinicians that were talking to
1697.6 -> the patients
1698.88 -> and in consultation with the patients
1701.44 -> and
1701.919 -> and their family members there's also an
1705.039 -> ability to
1706.08 -> to walk that was considered a disabling
1708.32 -> stroke
1709.76 -> so sometimes
1713.44 -> you see a patient with a small stroke
1715.76 -> that
1717.2 -> you know can't move their hand
1720.799 -> and it's not that big a deal but
1724.08 -> you know if you're if you're 80 years
1725.679 -> old you're right-handed
1727.679 -> and uh your left hand can't move as
1731.679 -> coordinated anymore
1732.88 -> it's not that big a deal it might not be
1734.559 -> disabled you could still eat
1736.32 -> you could still talk you could still
1738.96 -> interact
1740 -> it you wouldn't really necessarily call
1742.399 -> that disabling but
1743.679 -> if you were a concert pianist and now
1745.84 -> you can't return to work
1747.039 -> that's disabling um
1751.279 -> so it's a little bit different for every
1753.2 -> patient
1754.64 -> and it's definitely something that is
1757.039 -> difficult
1757.919 -> to put into practice
1762.159 -> globally it really needs to be down to
1764.88 -> the people that are involved in that
1767.679 -> physician patient relationship and
1770.32 -> trying to make that determination
1774.32 -> the exclusion criteria for the prisms
1776.64 -> trial was
1777.76 -> if they were already disabled if they
1780.08 -> couldn't take aspirin dysphagia
1782 -> or any contraindications to all the
1783.76 -> place
1785.039 -> and you could see here here's their
1787.12 -> shift analysis
1789.84 -> and although you could see a
1792.96 -> a uh placebo
1797.44 -> on these two so the all places on the
1799.12 -> top and the placebos on the bottom
1801.279 -> it looks like there's a trend towards
1803.52 -> better outcomes
1805.039 -> uh on the placebo and a
1808.24 -> trend towards worse out comes on the
1811.679 -> alter place group
1815.44 -> right there so this is the trial that
1819.279 -> made aha say we there's no benefit we
1823.039 -> don't have to give it to the patients
1824.48 -> that have
1825.279 -> these small and non-disabling strokes
1834.399 -> here's a new one connect the place
1837.36 -> connect the place
1838.24 -> may be a reasonable alternative to
1840.159 -> alteplase
1842 -> but specifically though in patients
1844.32 -> eligible for mechanical thrombectomy
1848.08 -> uh i think this is
1851.279 -> a really cool potential um
1855.679 -> move forward for us uh
1858.96 -> in general because you know all the
1861.6 -> place
1863.039 -> yes it has been the only medication
1866.96 -> only lytic used that had a statistical
1870.559 -> benefit
1871.519 -> in treating all comers with stroke
1873.84 -> within a certain time frame
1877.279 -> but it does come with um
1880.799 -> it's not just weight based these are all
1882.399 -> weight based but it comes with a small
1884.32 -> bolus followed by
1886 -> a one hour infusion and potential
1889.76 -> a lot more potential med errors that are
1892.72 -> associated with those
1895.279 -> connect the place however is a
1898.32 -> simpler medication in that it's just a
1901.76 -> single one-time bolus
1903.76 -> so this makes transport a lot easier
1908.96 -> you know depending on the ems agencies
1912.159 -> uh certain paramedics might be able to
1915.2 -> transfer patients with ongoing drips
1917.76 -> and some might not so if that's the case
1921.919 -> then this really opens up the potential
1923.76 -> for how you know what rigs are able to
1926.32 -> transport patients from one center to
1928.08 -> another
1929.36 -> so that's the potential huge potential
1931.6 -> benefit there
1933.2 -> because it would decrease that time of
1936.08 -> searching for the right paramedics and
1937.519 -> searching for the right rig
1938.88 -> in order to transfer that patient
1943.6 -> the trial that said the demonstrator
1946.24 -> this was the extend
1947.44 -> ia tnk trial
1950.559 -> they had 202 patients in australia and
1953.44 -> new zealand
1954.08 -> open label blinded outcomes
1957.6 -> it was a randomized control trial and
1960.159 -> they used connect connected place versus
1962.32 -> iv alteplase in patients that were about
1966 -> to go thrombectomy
1967.76 -> super important in patients that were
1969.919 -> about to undergo
1971.039 -> thrombectomy the extend iatnk
1975.279 -> inclusion criteria um you had to be
1979.039 -> a potential candidate for both
1982.159 -> mechanical thromba thrombectomy and iv
1986.08 -> thrombolysis so that's there within four
1988.559 -> and a half hours
1990.08 -> the the large vessel occlusion locations
1993.44 -> were something that we can get
1995.44 -> uh ica mca or the basilar artery
1998.96 -> and there it's important to know that
2001.039 -> there was no upper limit of the nih
2002.72 -> stroke scale and there was no
2004 -> upper limit of age
2007.679 -> and here you can see the primary effect
2009.84 -> the primary
2010.88 -> outcome here substantial reperfusion at
2013.679 -> initial
2014.64 -> angiographic assessment and the number
2018.399 -> of
2019.36 -> patients with a
2022.799 -> reaper that had their vessels opened up
2025.44 -> by the time we looked at them
2027.279 -> under under fluoroscopy was actually
2029.679 -> higher in the connective place group
2031.2 -> than it was in the alteplase group
2036.72 -> so that's important to see and then
2040.399 -> here you can see on the secondary
2041.76 -> outcomes that also came
2043.919 -> with median score on their nah
2048.32 -> was statistically decreased also
2052.8 -> they're functional independent outcomes
2055.76 -> almost statistically
2058.839 -> different
2062.72 -> in patients with minor non-cardioembolic
2066.32 -> ischemic strokes so
2067.76 -> you know not the afib patients that
2071.28 -> throw up a clot
2073.52 -> from their heart on these patients that
2077.919 -> had a low nih stroke scale less than or
2080.8 -> equal to three
2082.079 -> and did not receive all the place
2085.52 -> just because they you know for whatever
2087.44 -> reason
2089.2 -> we found that um that we should be
2091.839 -> starting clopidogrel
2093.919 -> and aspirin within 24 hours of the
2096.8 -> symptom onset and continue for 21 days
2100.4 -> and this is going to reduce this
2102.32 -> recurrent ischemic strokes for up to 90
2104.48 -> days
2105.92 -> um this is a change this is a
2109.76 -> big change as you can see here it's a
2111.359 -> class one strong
2113.44 -> lots of benefit you got to do this with
2115.44 -> level a recommendation
2118.16 -> and i think it's important to know that
2119.599 -> this is like i said a change
2123.119 -> because the older trials were saying
2125.68 -> that this wasn't a benefit
2128.32 -> and i think a lot of that came from
2131.44 -> putting this on too sick of patients and
2134.72 -> putting it on for too
2135.92 -> long because a lot of the patients in
2137.76 -> those older trials had
2139.359 -> bleeding problems either from leading
2142.64 -> into their stroke beds or
2144.24 -> having gi bleeds
2148.16 -> so what they were able to do in the more
2150.64 -> recent trials is
2152.96 -> find the less sick patients well the
2155.2 -> smaller strokes
2157.04 -> and only do the dual antiplatelets for
2160.079 -> when they're at the highest risk of
2161.52 -> getting their next stroke which is early
2163.359 -> on
2165.68 -> so the chance trial this was the big
2168 -> trial that helped determine this one
2170.48 -> 5 000 patients in china
2173.52 -> uh with a mild stroke or tia
2177.68 -> both groups got open labeled aspirin for
2180.56 -> 21 days
2181.839 -> and that dose was whatever they wanted
2185.04 -> and the treatment group received
2188.16 -> a 300 milligram load of plavix or a club
2190.88 -> peter grill
2191.76 -> and followed by 75 milligrams per day
2194.8 -> for 90 days and they started this
2197.76 -> treatment
2198.48 -> within 24 hours and you could see that
2201.44 -> there's
2201.92 -> a significant reduction in the patients
2206.16 -> having strokes and mis all cause
2209.359 -> mortality
2211.52 -> significant reduction in those on the
2213.119 -> dual antiplatelet group
2216.4 -> and the bleeding was not statistically
2219.92 -> significant
2220.96 -> between these two groups so by reducing
2223.76 -> the
2224.079 -> duration you're able to decrease
2227.2 -> the amount of bleeding but by having it
2230.72 -> on
2231.2 -> you're able to reduce the
2234.24 -> the amount of strokes that are coming up
2237.359 -> the point trial the other new one 2018
2240.96 -> that pointed in the same direction
2243.359 -> another randomized control
2244.8 -> child this 4 800 patients uh north
2248.32 -> america europe australia and new zealand
2250.88 -> uh enrolled patients within 12 hours of
2253.68 -> their mild stroke or gia
2256.48 -> randomized controlled trial again 600 of
2260.24 -> plavix followed by 75 per day everybody
2263.76 -> received
2264.32 -> aspirin and they
2267.44 -> excluded patients getting antiquate that
2269.92 -> we're going to get anticoagulation
2273.68 -> and so this child was also positive
2276.8 -> their composite outcome of strokes and
2279.28 -> mis and
2280.88 -> death from ischemic vascular causes that
2283.92 -> was
2284.56 -> reduced the aspirin group had uh 6.5
2289.04 -> versus 5 ischemic strokes
2292.88 -> were reduced 4.6
2296 -> versus 6.3 these are smaller differences
2299.68 -> but
2300.48 -> in the grand scale of things you you're
2302.8 -> reducing disability on patients
2305.2 -> and it's you know meds that are that you
2308.24 -> take it home
2310.56 -> that you can give relatively easily
2314 -> so oh and we talked about this already
2317.68 -> why were these dual anti-platelet trials
2319.68 -> successful when the others weren't
2322.079 -> again it's this was in the particularly
2325.92 -> high risk of recurrent strokes so
2328.16 -> early on after their first stroke so
2331.119 -> they enrolled the patients within the
2332.4 -> first 24 hours
2334.16 -> and their low risk of hemorrhages so
2337.04 -> again
2337.599 -> less severe stroke and tas are less
2340.079 -> likely to bleed
2346.88 -> now moving on to mechanical thrombectomy
2349.52 -> so
2351.44 -> patients within the six to sixteen hour
2353.44 -> time frame of the last known well
2355.92 -> uh i should start out by saying
2359.28 -> the zero to six hour that's that's old
2361.2 -> news that's not a
2362.88 -> brand new recommendation of course we
2364.64 -> should be doing mechanical thrombectomy
2366.32 -> in patients with large vessel occlusions
2368.48 -> within the first six hours
2370.24 -> but this is the new stuff in in these
2372.4 -> guidelines
2373.599 -> new in 2018 uh but not in the update in
2376.64 -> 2019
2377.92 -> so if you're within the first 16 hours
2380.64 -> of a
2381.2 -> last known well and you have a large
2383.119 -> vessel occlusion you can still
2385.04 -> get thrombectomy if you meet certain
2388.4 -> criteria
2389.839 -> and that criteria oh um we'll talk about
2392.88 -> that criteria here in a second but i
2394.24 -> want to point out
2395.28 -> this is a class one recommendation so
2398.24 -> super strong recommendation
2400.24 -> with level a evidence so you cannot get
2404 -> a stronger recommendation or higher
2405.839 -> quality of evidence
2408.16 -> than what this recommendation has
2412.8 -> so there's two trials the first one
2414.24 -> we'll talk about is the
2416 -> dawn trial this one came out first
2417.76 -> thrombectomy within
2419.599 -> the six to 24 hour time frame with a
2422.64 -> mismatch
2423.52 -> between the patient's death deficit
2426.64 -> on their exam and the infarct size
2432.16 -> they plan for 500 they enrolled 206
2436.56 -> in this multi-center prospective rct
2439.839 -> randomized control trial uh bayesian
2443.2 -> adaptive enrichment
2444.64 -> design uh and blinded assessment of
2448 -> endpoints that bayesian adaptive
2449.44 -> enrichment design
2450.88 -> uh is kind of tough to wrap your head
2453.68 -> around but essentially
2455.68 -> the the plan going into the trial was
2458.88 -> they were going to assess it at certain
2462.319 -> time points at certain numbers of
2464.24 -> patients and if they had
2467.119 -> either a super positive or super
2469.52 -> negative
2470.16 -> result at those earlier time points then
2473.359 -> they would stop
2474.4 -> early and and publish after that
2477.92 -> this was an industry sponsored trial
2480.88 -> which is different than the next one
2482.64 -> but it is important to note that the
2484.16 -> authors had unrestricted access to the
2486.16 -> data
2488.079 -> but the analysis was performed by data
2490.64 -> management staff from striker with
2492.48 -> oversight from
2493.359 -> independent statisticians
2500.4 -> inclusion criteria included pre-stroke
2503.28 -> uh modified rankings of lesson two so
2505.04 -> you have to be pretty independent
2506.4 -> and be able to work you have to have a
2508.8 -> large vessel occlusion
2510.56 -> present in the internal carotid artery
2512.8 -> or the first segment of the mca
2516 -> and the next parts the important part
2517.68 -> here it's this mismatch
2519.28 -> this clinical symptoms versus the
2522.079 -> imaging core
2523.04 -> infarct so
2526.72 -> if you look here they stratified it by
2528.88 -> age but essentially you had to have
2531.52 -> a decent sized stroke based on exam
2534.56 -> and the nih stroke scale of 10 and an
2537.44 -> infarct volume of less than 21 mls
2540.96 -> if you were on the younger side less
2542.96 -> than 80 you got to have an infarct size
2546 -> less than 31 mls
2551.04 -> and if you had a really big
2554.72 -> stroke with an nh stroke skill of
2557.2 -> greater than 20
2558.72 -> your infarct size could be less than 51
2562.839 -> mls
2565.839 -> so the imaging that you need in order to
2568.96 -> follow the don trial includes either an
2571.68 -> mri
2572.96 -> with the diffusion weighted sequences or
2574.96 -> a ct perfusion
2578 -> we looked at a couple examples of that
2579.52 -> before
2582.319 -> so getting now to the endpoints of this
2585.2 -> trial is that
2586.72 -> the functional independence at 90 days
2591.04 -> as you can see here the thrombectomy
2592.88 -> group was 49
2596.48 -> had functional independence versus only
2598.72 -> 13
2599.839 -> that's a huge huge uh number
2603.92 -> just you know the functional dependence
2605.359 -> is defined in this trial by a modified
2607.44 -> ranking of
2608.56 -> zero one or two so definitely able to
2611.839 -> still walk and get around and do your
2613.359 -> own adls
2616.48 -> but a big difference in their outcomes
2623.119 -> the intention to treat analysis here
2625.76 -> sorry
2626.24 -> um the shift analysis
2629.92 -> of this was as you can see definitely
2632.48 -> trended towards better
2633.839 -> outcomes than the thrombectomy group
2639.2 -> and pretty much in all the subs
2646.839 -> subgroups
2648.079 -> and then the next trial this is the
2650.56 -> diffuse 3 trial
2652.96 -> this was in the 6 to 16 hour time frame
2655.359 -> so that's why the class 1 evidence
2658.56 -> recommendation goes up to 16 hours
2660.48 -> because there's two rcts that go to this
2662.88 -> time frame this was done
2666.319 -> on 182 patients in 38 centers in the
2669.119 -> united states
2671.119 -> they did endovascular therapy plus
2673.44 -> medical therapy
2675.68 -> versus medical therapy alone this one
2677.76 -> was not industry sponsored this was
2679.68 -> sponsored by the nih
2681.76 -> and you could use any fda thrombectomy
2684.48 -> fda approved thrombectomy device
2688.48 -> but the non-contrast ct done with
2692.16 -> a this says aspect score greater than
2694.56 -> six
2695.28 -> um that's an objective way to determine
2698.88 -> how much good brain versus dead brain on
2702.4 -> that mca territory
2704.16 -> so this is you have to have a pretty
2705.52 -> good amount of um
2707.52 -> good brain left in order to be enrolled
2710.64 -> in this
2711.92 -> you have to have a large vessel
2713.2 -> occlusion present
2715.119 -> in the m1 i say or elbow again i'm
2717.599 -> pretty sure i meant to say
2718.64 -> ica you had to have a pre-stroke
2722.64 -> modified rankin of zero to two again
2725.28 -> that's
2725.68 -> you had to be able to do your own adls
2728 -> your infarct core
2730.72 -> had to be less than 70 mls and you had
2733.04 -> to have a ratio
2734.72 -> of ischemia to infarction of 1.8
2740.48 -> you got to use mr and mr perfusion
2744.079 -> versus ct perfusion and here's i think i
2747.52 -> showed you this one earlier
2749.599 -> an example of an mr and mrp so this
2752.64 -> trial
2753.04 -> slightly different than the last one
2754.64 -> where they used a
2756.64 -> um they were able to determine the core
2760.48 -> by imaging but the penumbra essentially
2764 -> was based on the exam this trial looked
2766.88 -> at both
2768.079 -> the penumbra and the infected core
2772.8 -> by imaging so this is an example of
2775.28 -> somebody that has
2776.96 -> 89 mls of dead brain and
2780.68 -> 124 ml of brain that's getting low flow
2784.4 -> leaving us only 35 ml
2786.16 -> of penumbra the mismatch volume there
2789.2 -> in the center uh 89 mls of dead brain
2792 -> would exclude this patient from
2795.68 -> from getting endovascular therapy
2799.68 -> here's a ct perfusion so this is the
2803.04 -> core infarct you can see in fuchsia on
2805.52 -> the left is super small only
2807.44 -> four mls versus
2811.119 -> that on the green on the right sorry
2814.64 -> 81 mls leaving us 77 ml
2817.839 -> of at-risk brain and their and a ratio
2821.359 -> of 20.2 so huge huge
2825.76 -> chance for this patient to do really
2827.52 -> really well
2829.76 -> this one definitely would get a
2830.88 -> thrombectomy
2834.24 -> so the results here they only enrolled
2836.48 -> 800 and sorry 182 patients
2839.52 -> because they stopped early when the don
2841.68 -> trial came out and was so positive
2844.88 -> their shift analysis as you can see here
2847.359 -> definitely trended
2848.8 -> towards a better outcomes of the
2851.76 -> endovascular therapy
2856.319 -> you can see here that we had the
2859.44 -> the primary outcome and the secondary
2861.839 -> outcomes were positive
2865.2 -> functional independence was much greater
2868.24 -> in that endovascular therapy group
2879.92 -> all right and then for patients with
2882.96 -> l sorry within the 16 to 24 hours of
2886.16 -> last known well
2888.319 -> who have an elbow in the anterior
2890.079 -> circulation and meet the
2891.68 -> dawn eligibility mechanical thrombectomy
2895.2 -> is reasonable so this is class
2896.96 -> 2a benefits
2900.16 -> is very much there with level evidence b
2903.839 -> that single rct um
2906.48 -> [Music]
2908.16 -> for the dawn trial up to 24 hours so
2910.88 -> again
2911.52 -> 16 hours class 1
2915.44 -> 24 hours class 2a for the
2918 -> recommendations
2919.52 -> uh we are deaf we here at unm are
2922.48 -> definitely doing
2923.599 -> thrombectomy's up to 24 hours
2931.92 -> so summary of the recommendations here
2933.92 -> there's a lot of them
2935.119 -> uh i apologize but that's kind of the
2937.92 -> the nature of doing
2939.04 -> a lecture on
2942.079 -> these kind of recommendation
2943.92 -> recommendations so there's
2945.2 -> pre-hospital stroke severity scales are
2947.119 -> good
2948.559 -> use them they're not as good as we want
2950.48 -> hopefully there will be better ones
2951.839 -> coming
2952.16 -> out in the future pre-hospital bypass in
2955.599 -> the potent potential cases of large
2957.92 -> vessel occlusion
2960 -> can involve delays to alter place but
2963.119 -> you're weighing that against delays to
2965.28 -> thrombectomy
2966.24 -> so local decisions need to be made
2972.319 -> if the alta place is out of the question
2975.359 -> all the places out of the question just
2977.359 -> um go directly to
2979.44 -> where they can do thrombectomies and
2981.599 -> that bypass is going to save you a lot
2983.04 -> of time
2985.28 -> mri imaging can find patients eligible
2988.079 -> for alteplace in that greater than four
2989.839 -> and a half hour time frame
2992.96 -> avoid alter place in non-disabling mild
2996.839 -> strokes
2998.64 -> consider connect the place on your large
3000.4 -> vessel occlusion cases
3001.76 -> that are going to go for thrombectomy
3004.079 -> again
3005.04 -> super awesome if you're not at the
3008.4 -> comprehensive stroke center but at a
3010 -> primary stroke center and going to
3011.119 -> transfer them in
3012.88 -> that's going to save you time save your
3014.4 -> pharmacist time and
3016.24 -> make it easier for you to be able to get
3018.4 -> the patient transferred
3020.88 -> dual anti-platelets for the patients
3023.2 -> that are having
3024.559 -> small strokes start that early
3028.4 -> and continue it for only 21 days
3032.319 -> and advanced imaging can also be used to
3034.88 -> find
3035.839 -> potential thrombectomy candidates up to
3038.64 -> 24 hours
3039.76 -> after their last known well so treat
3042.96 -> those guys
3044.48 -> almost as if they were coming in at hour
3047.359 -> one
3049.359 -> you want to find them early
3053.599 -> all right and this is my reminder that
3055.68 -> uh the slides are done this is
3058 -> just a cool little picture from last
3059.839 -> summer um
3061.28 -> that's some elk down there in the bottom
3063.76 -> of this little valley in the jenna's
3065.04 -> mountains here in new mexico
3070.64 -> and with that i'm going to stop sharing
3073.2 -> my screen
3074.88 -> and open it up to questions
3083.359 -> great presentation dr alonday um i don't
3086.72 -> see any questions in the chat box right
3088.64 -> now does anybody have any questions
3090.72 -> you can star six to unmute or you can
3093.359 -> type them in the chat box
3106.4 -> so it looks like there's no questions so
3109.76 -> i just want to take the opportunity to
3111.52 -> thank you for oh wait a minute
3113.359 -> here's one uh are there any
3116.16 -> recommendations for
3117.599 -> a wake up stroke protocol for tia
3119.839 -> patients
3121.599 -> for tiaa patients so if their
3124.72 -> tia they woke up with us
3128 -> they went to bed fine woke up with their
3130.24 -> symptoms
3131.119 -> and the symptoms resolved awesome
3134.079 -> fantastic
3134.72 -> i would treat those like you treated um
3137.599 -> any of the other tias or the small
3139.52 -> strokes i.e
3141.28 -> dual anti-platelets uh for 21 days
3145.52 -> is going to be the best thing you can't
3147.2 -> give those you know once the symptoms
3149.04 -> resolved
3150.72 -> they're not eligible for um thrombectomy
3154 -> any longer
3154.72 -> or or all the place so i would not do
3156.48 -> all the place on those patients
3157.92 -> i guess before that um
3161.04 -> question was liability of not using dual
3163.28 -> anti-platelets
3164.559 -> um i can't say i'm the best person to
3168.72 -> answer that but now that it's in the
3170.96 -> recommendation
3171.76 -> i think it definitely puts you as a
3173.44 -> little bit more risk for not using
3175.119 -> the dual anti-platelets on these small
3177.28 -> strokes
3179.119 -> or at least if you're not going to use
3180.4 -> it make sure you document
3182.559 -> why you're not using it whether it be
3184.24 -> patient preference something specific
3186.24 -> about this patient you know they didn't
3187.839 -> tolerate
3188.559 -> plavix in the past making them higher
3190.4 -> risk just
3192.079 -> i would um you know with with any of
3194.079 -> these recommendations
3196.48 -> that are positive recommendations you
3198.16 -> want to do them or at least say why you
3200.24 -> don't view them
3202.48 -> uh and i think that i combined the wrong
3207.359 -> two questions
3208.8 -> yeah i think you did it right oh maybe
3211.04 -> you didn't yeah
3212.8 -> so yeah back to any recommendations for
3215.2 -> the wake up stroke protocol
3217.44 -> okay uh any recommendations for the wake
3220.64 -> up show protocol um
3224.559 -> so i want to say my recommendation would
3227.76 -> be to
3228.96 -> have all your stroke you know we here at
3231.68 -> unm
3232.559 -> if you have if ems calls us and tells us
3235.2 -> they have
3236 -> a potential stroke that had last that
3238.8 -> had a last known well within the
3242 -> last 24 hours we are going to
3246.079 -> stroke alert that patient and
3247.76 -> essentially we're going to take them
3249.359 -> seriously we're going to
3250.8 -> do a door to ct
3254 -> directly you know bypassing the ed bed
3256.4 -> first
3257.44 -> we're going to have our neurology
3258.8 -> residents come down and meet us down
3260.4 -> there for that initial assessment
3262.319 -> and we're going to try to figure out uh
3265.04 -> if the patient needs
3267.04 -> um a thrombectomy
3270.079 -> um in that delayed time fashion
3273.44 -> so that's gonna require more imaging but
3276.559 -> essentially we start out with
3278.4 -> you know they're walking through and
3279.68 -> we're talking to them while walking like
3282.16 -> how how are you doing start the nih
3284.48 -> stroke scale
3286.079 -> when were you last normal and calling
3288.24 -> the family if necessary
3290 -> and based on that information based on
3293.119 -> the rolling in
3294.16 -> imaging that we're getting the
3295.76 -> non-contrasted ct scan
3298.799 -> the cta you know if we see
3302.96 -> the entire mca dead then we're done but
3305.04 -> if we see that looking
3306 -> good then we move on to the next step
3307.68 -> and ask ourselves is there a large
3309.52 -> vessel occlusion
3310.88 -> if there's a large vessel occlusion with
3312.64 -> a lot of potentially good looking brain
3314.72 -> there
3315.52 -> then we um ask ourselves then we do
3319.839 -> either the ctp
3321.04 -> or the mri on an mr key depending on the
3323.839 -> availability of the mri
3327.04 -> machine which in our case luckily is
3329.119 -> about 20 feet away from our ct scanners
3332.48 -> so that's not that big a deal for us
3334.319 -> we're pretty lucky in that regard
3336.559 -> but for that's essentially our protocol
3338.72 -> we treat it as if
3339.92 -> their their last known well uh was
3343.04 -> within 24 hours we
3345.119 -> same thing we do for everybody else that
3346.559 -> even come in the afternoon too
3351.2 -> um criteria for three and a half to four
3355.76 -> hours are not clear
3357.119 -> any suggestions um yeah there's
3362.4 -> the ecast trial did have
3366.48 -> a few more exclusion criteria than
3369.76 -> the ninds trial did that's that's
3372.319 -> definitely for sure
3377.359 -> however the more exclusion criteria you
3381.44 -> start putting on your protocols
3383.2 -> the harder it is to get through any of
3384.96 -> them and the longer it's going to take
3386.88 -> for you to give all the place to
3389.44 -> if you look at the fda uh
3392.76 -> contraindications for alteplase
3396.48 -> the list is really small american heart
3399.52 -> association also has
3402.24 -> a nice list of inclusion criteria which
3406.48 -> is short
3407.119 -> you know essentially having uh an acute
3409.92 -> ischemic stroke
3410.96 -> and they outline it for the three and a
3413.359 -> half hours too
3414.799 -> and they have a big long list of
3417.52 -> potential
3419.04 -> relative contraindications
3424.48 -> and those like i said are relative so
3426.96 -> you got to take those
3427.839 -> with a grain of salt on whether or not
3431.119 -> how bad you know did they have uh for
3434 -> instance
3434.96 -> do they have a intracranial aneurysm
3437.359 -> that is not protected
3438.799 -> you know did they never have a clip or a
3440.72 -> coil in there before
3442.319 -> that's if it's a large one a relative
3445.52 -> contraindication
3450.24 -> and it's only a relative
3451.28 -> contraindication not because we ever
3452.96 -> found that anybody
3454.96 -> was more likely to bleed but some
3456.72 -> studies excluded those patients because
3458.96 -> of fear of bleeding
3461.44 -> so that's why it's totally legit to give
3464.88 -> it to them
3465.839 -> but you are a little bit more worried
3469.52 -> major surgery within the past
3473.359 -> few weeks that's a that's another one
3476.24 -> what is the definition of a major
3477.839 -> surgery
3479.04 -> um you know that's
3482.559 -> i just pushed tpa a couple months ago on
3484.88 -> someone
3485.68 -> in-house an inpatient that had an
3488.799 -> orthopedic surgery
3490.799 -> on on their hip they had hardware
3492.64 -> removed
3495.04 -> and i just assumed though this sounds
3497.2 -> like a big surgery i'm not going to give
3499.04 -> them all the place
3500.48 -> and i was covering at a smaller hospital
3503.359 -> one of our sister hospitals
3505.119 -> covering the icu that night and um i was
3508 -> trying to get the patient ready for
3509.119 -> transfer
3509.68 -> and then the orthopedic surgeon called
3511.52 -> me and said i
3512.799 -> heard my patients having a stroke i said
3515.04 -> yes i'm transferring them down to unm to
3517.839 -> get a thrombectomy and
3519.52 -> they said is you know should we be
3521.68 -> giving them
3522.64 -> all the place because i hear that's
3523.76 -> something we should do i said
3525.68 -> well everything is a go for all the
3528.16 -> place except for the fact that they just
3529.599 -> had surgery
3530.64 -> yesterday and i don't want them to bleed
3533.04 -> out
3533.76 -> and he said oh the bleeding wasn't that
3536.24 -> bad
3537.119 -> uh and it's an orthopedic procedure
3541.52 -> if the bleeds i'll be able to go in
3543.28 -> there and stop the bleeding
3545.76 -> so here was my judgment was it was a
3549.119 -> large surgery the surgeon's judgment was
3551.839 -> it wasn't that big a deal
3553.76 -> to take care of the bleeding subsequent
3555.28 -> to that
3556.88 -> so i called the accepting docs
3560 -> that were going to be taking them down
3561.76 -> at unm and i said hey this is what he's
3563.76 -> saying are you guys all
3564.88 -> also okay with me giving tpa and they
3566.88 -> said if the surgeon says they could stop
3568.799 -> the bleeding the surgeon says they could
3570.079 -> stop the bleeding give the tpa
3571.599 -> so we pushed tpa on a post-op day one
3575.68 -> which was a new for me um so
3579.2 -> relative contraindications that's i
3581.599 -> guess my biggest
3583.92 -> the biggest problem there with that
3585.52 -> three three to four and a half and even
3587.76 -> after that
3588.72 -> um so i think my suggestion is to try to
3594.96 -> limit what goes on the papers for your
3597.839 -> residents and
3598.799 -> for those around you um to the big
3601.559 -> contraindications
3602.96 -> and clearly step up you know
3606.559 -> clearly say if you're gonna write all
3608.319 -> the contraindications that
3609.68 -> which ones are relative and which ones
3611.359 -> are absolute
3612.88 -> um that will help out
3618 -> and the oh 4.5 clear
3621.28 -> criterious first read okay
3625.04 -> aspirin 81 plus plavix for 21 days then
3628.319 -> aspirin or plavix
3630.16 -> uh those studies said aspirin after the
3633.599 -> 21 days
3634.96 -> um they didn't
3638.24 -> keep going on the plavix so that's what
3640.559 -> i would do and mark t
3642.64 -> tebow said thank you i have a meeting
3644.88 -> but appreciate this information
3646.559 -> thank you marty i see an anonymous
3649.2 -> attendee on the q a
3650.72 -> said for patients greater than four and
3652.4 -> a half hours from stroke
3654.24 -> then uh we should give all to place
3658 -> if in a center unable to do thrombectomy
3661.28 -> do we need to get mr first right
3664.64 -> uh prior to stroke
3668.839 -> so um if you're in a place that can't
3672.079 -> do thrombectomy i think the biggest
3674.4 -> thing you could do is actually transfer
3676.799 -> for thrombectomy um no one's done a
3680.559 -> head-to-head
3682.4 -> of ultraplace versus
3686.319 -> rhombectomy in the post four and a half
3688.48 -> hour time period
3690.24 -> um so i wouldn't
3693.839 -> i wouldn't do that i wouldn't not
3696.96 -> send the patient for thrombectomy and
3699.359 -> give them all the places instead
3701.44 -> i would try to get them on a helicopter
3703.599 -> or try to get them on
3705.359 -> um on an ambulance and and get them
3708.319 -> going for thrombectomy i think that's
3709.92 -> going to be
3711.599 -> the most legit thing you could do and
3713.68 -> less likely to get you
3716.4 -> chewed it is you know as we did see
3721.359 -> a good chunk of those patients in
3725.52 -> and those delayed multiples trials they
3727.839 -> did have thrown back
3728.88 -> they did have large vessel occlusions um
3732.24 -> so hopefully one day we'll have a better
3734.799 -> answer for you
3735.92 -> but i would definitely point uh
3739.28 -> in getting to definitive endovascular
3742.319 -> treatment first
3744.72 -> and do we oh to answer the second part
3746.4 -> of the question do we need to get
3747.92 -> mri first prior to stroke i think you
3751.359 -> mean
3751.76 -> do we need to get an mri first prior to
3754.799 -> giving all to place and
3758.319 -> the trials i'll just pull up the
3767.359 -> god fuse
3775.119 -> okay here we go
3794.839 -> screen
3801.52 -> for the wake up trial this one used
3805.28 -> just the mri
3810.72 -> and then this one the extend trial
3814.96 -> use the mr with mr perfusion and the ctp
3819.2 -> so you can get this done
3822.72 -> you can give all the place beyond four
3825.359 -> and a half hours
3827.2 -> if not going for thrombectomy
3831.68 -> based on a ct perfusion
3836.839 -> okay um
3841.039 -> so that is possible our time is up
3844.319 -> yep and and we're a little overtime so
3847.359 -> just like to thank you so much
3850.48 -> for your time dr allende it was an
3852.24 -> awesome presentation
3853.92 -> um thank you to everyone who joined us
3855.839 -> and if you have any questions please
3857.359 -> don't
3858 -> hesitate to reach out and i can get the
3861.039 -> chat
3861.44 -> so thanks for your time have a great
3863.359 -> rest of your day
Source: https://www.youtube.com/watch?v=V_I_Gdeh4As