Afleveringen
-
Co-Hosts: Ryan Muir, Tess Fitzpatrick, Houman Khosravani
Key Terms: Endovascular therapy (EVT), Mechanical Thrombectomy, Large Vessel Occlusion, CT-Perfusion, Perfusion Mismatch
Summary:
In this episode the hosts review the past 15 years of evidence for the role of endovascular therapy for acute ischemic stroke and trace its evolution to present day guidelines for the acute treatment of stroke.
What is endovascular therapy?
What were the early trials of EVT – what did we learn from them?
MULTI – MERCI
PENUMBRA PIVOTAL
IMS-III
MR. RESCUE
These early trials facilitated the development of later trials done between December 2010 and December 2014, that outlined a reduction in mortality and stroke disability (as measured by theModified Rankin Scale (MRS) at 90 days).
These trials were summarized in a meta-analysis performed by theHERMESin collaboration in 2016.
MR. CLEAN
ESCAPE
REVASCAT
SWIFT PRIME
EXTEND IA
In the HERMES pooled analysis thenumber needed to treat with EVT was 2.6 persons to reduce MRS by 1 point.
One trial was done later also favoured EVT, but was not included in the HERMES meta-analysis - theTHRACE trial
These trials led to the2015 AHA/ASA focused update and recommendation that endovascular treatment should be offered to patients with acute ischemic stroke when:
Pre-stroke mRS score 0 to 1
Even in those patients receiving IV r-tPA within 4.5 hours of onset
Causative occlusion of ICA or proximal MCA (M1)
NIHSS score of ≥6 and ASPECTS ≥6
Presenting within 6-hrs of symptom onset
While the above trials demonstrated benefit of endovascular therapy performed within 6 hours of symptom onset (although REVASCAT demonstrated a benefit within 8 hours) in the context of acute ischemic stroke, two trials were recently published that demonstrate benefit beyond6 hours and up to 24 hours in select patients.
oDAWN
oDEFUSE 3
As a result of DAWN and DEFUSE 3, the2019 AHA/ASA Guidelines now suggest:
Within 0 – 6 hours of symptom onset:Direct aspiration thrombectomy as a first pass or mechanical thrombectomy with a stent retriever should be done if the following criteria are met: (i) prestroke MRS of 0 – 1 (ii) causative occlusion of the internal carotid artery or MCA segment 1 (M1) (iii) age >18 years (4) NIHSS ≥ 6
Within 6 – 24 hours of symptom onset
In selected patients with acute ischemic stroke within 6 – 16 hours of last known normal who have a large vessel occlusion in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomyis recommended
In selected patients with acute ischemic stroke within 6 – 24 hours of last known normal who have a large vessel occlusion in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable
-
Co-Hosts: Neha Patel, Phavalan Rajendram, & Katherine SawickaSummary: Great Episode on Thrombolysis - we will have a future episode on TNK as well.-What is tPA?-Indications for tPA-Does time matter?-NINDS -ECAS III -TNK-TEMPO2 -Contraindications for tPA-tPA and EVT -SWIFT DIRECT -Door-to-needle time tips -Post tPA care
-
Zijn er afleveringen die ontbreken?
-
Co-Hosts: Ryan Muir, Tess Fitzpatrick, Houman Khosravani
Summary:
In this episode the hosts discuss the approach to the acute assessment of a patient presenting as a code stroke. This episode also reviews the indications, relative contraindications and absolute contraindications to thrombolysis.
Defining roles within the Code Stroke Team: splitting the team into MD1 and MD2.
Assess patient stability.Airway,Breathing, Circulation,Glucose. Ask yourself is this the type of patient who needs intubation or ICU? Is this the type of patient you may need help from the ER doctor managing vitals?
Examination and NIHSS performed by MD1 while MD2 is collecting collateral information (don’t delay the scan for the full NIHSS, this can be completed later).
Before travelling to the scanner, be prepared: thrombolysis kit and anti-hypertensives
Be on the lookout for “STROKE MIMICS.”Some common stroke mimics are depicted below in theTable 1Adapted from the 2017 American Academy of Neurology Continuum Article titled,“Clinical Evaluation of the Patient with Acute Stroke.”
ASPECTS score
MD2 to review indications and contraindications to thrombolysis and endovascular therapy
Risks of thrombolysis: hemorrhage, angioedema
Documenting the discussion of consent for thrombolysis and endovascular therapy
-
You've heard of thrombolysis? We are here to deliver anxiolysis when it comes to learning about stroke. This Stroke-focused podcast is developed by a keen group of doctors who are in the Neurology program in Toronto. It is geared towards residents and medical students with a keen interest in stroke and stroke-related topics. Ideas and opinions are our own and this podcast is not a substitute for expert medical advice. We are the official podcast of the Canadian Stroke Consortium. Follow us on X.com @strokefm
