them to our first of the 2021 2021 stroke educational series um my name is deb moats and i'll be your moderator today and feel free to ask questions throughout the presentation by typing them in the chat box on the right hand of your screen or pressing the microphone at the bottom of your screen or if you're using the phone audio press star 6 to come off mute everybody will be placed on mute to begin with i have the distinct pleasure to be able to introduce dr robert l allende he is a professor in the department of neurosurgery and emergency medicine and medical director of the neuro icu at the university of new mexico and albuquerque dr allende is the director of the university of new mexico's neurosciences intensive care unit providing modern neurocritical care his enthusiasm and thorough patient care along with his combined training in emergency medicine and neurocritical care ensure that his patients receive the best possible care as quickly as possible his friendly professional bedside manner makes him a favorite to his patients and the families in order to provide continuity and shared resources dr allende has dual faculty status and shares his time in the department of neurosurgery and the department of emergency emergency medicine he also will be working with the department to provide emergency stroke care for patients in rural hospitals through their telemedicine technology dr allende is a volunteer supporting the american heart association american stroke association in many capacities and he currently serves on the southwest affiliate stroke committee this president's presentation today is titled acute ischemic stroke guidelines so uh welcome dr allende well thank you so much deb um appreciate that introduction uh and i just wanted to thank everybody for being a part of this uh this is uh super interesting stuff a lot of controversial stuff so much so that in 2019 they had to update the 2018 guidelines um soon enough i'm sure they'll come out with a newer set of guidelines but for now this is what we got and it's still pretty good information um so let's get right to it i have no financial disclosures and this is essentially the the document that we're going to be uh building that the talk on top of american heart association american stroke association guidelines there's a lot of huge names in here just a shout out to some of the great em docs that i've worked with in the past uh dr opoya dayaway um is an em neurocritical care doc uh out of cincinnati actually just became chair of the department of emergency medicine in washington which is where i trained i also went to med school in cincinnati so that's where i know him ed yalk was my med school advisor in med school in cincinnati and i think oh not on this document but there's another one that we'll talk about where pete pinegos who co-chaired the committee for uh mission lifeline stroke he was also one of my mentors so i've been lucky enough to work with some of the big minds on on acute stroke here in the united states so real quick i think it's super important that we understand what we're talking about whenever we talk about recommendations so there's two ways that we discuss it and one is the strength of the recommendation like how strongly the association in this case american heart association feels that you should do or should not do certain tasks and then there's also the amount of evidence that goes behind each of those recommendations so just to quickly clarify here the class one recommendation is a strong recommendation you've got to do this if you don't do this you are potentially putting yourself at risk for malpractice if you're not doing these kinds of things it's that strongly recommended um class 2 a is a moderate recommendation um it's reasonable to do so these in effect you should be definitely doing these things 2b also you probably should be doing these things too uh but definitely not as strong a recommendation as class one class three don't worry about it don't do these recommendations the aha does not suggest doing these that are ranked as a class three and class three harm uh this is definitely don't do these potential interventions uh we're we'll be talking about one class three no benefits um in this talk the level of evidence the quality of the evidence this is you know the trials that went into figuring out what we need to be doing and providing us that backbone for how strong of a recommendation we want to give so a level a is the highest level of evidence that has more than one randomized controlled trial meta-analyses everything points to the same direction in regards to the recommendation level 2b this usually comes from a good randomized control trial at least one of those embed analyses that are pointing in that same direction uh level two be non-randomized so that's no rcts no randomized control trials but still evidence is still pointing in the same direction sorry let me just turn this off okay level c is of course worse there's no randomized controlled trials there's some decent data on there and level c essentially comes down to this is what makes sense this is what the experts do but we don't have any good data to back that up all right so we'll go ahead and start then with a pretty controversial topic of pre-hospital bypass so this is um starting with uh ems recognition of a patient with a stroke and figuring out which hospital they need to go to so just to read word for word at the top here if eligible for alt iv ultiplice the benefit of bypassing the closest iv alteplase capable hospital to go to a thrombectomy capable center is uncertain it's a class 2b so again uh we're in favor of bypassing the closest iv all the place in order to go to the thrombectomy capable center but it is uh it's not definitely not the strongest recommendation this is backed by level b evidence so that's pretty good at least one rct and the meta analyses are pointing in the same direction um so the aha also publishes this mission lifeline stroke which is a super helpful document in this case this document helps provide a systems of care backbone for how ems can get the patient to the right place and it looks like this um it seems a little complicated but essentially on the bottom left there if they suspect the stroke you you start the things you figure out your last known well you um and then you try to figure out if you suspect a large vessel occlusion right here so this is where that controver the first part of the controversy and this controversy is how well can we detect the large vessel occlusion in the field because if you get it wrong every time then you're just wasting patients time uh your waste you're wasting that uh eligibility time your waste and brain cells and before getting all the place but if you get it right you get them to the more definitive answer of the thrombectomy faster so again the problem with the stroke severity scales not the initial stroke scales not like your normal cincinnati or your normal lan or your normal la pre-hospital stroke scale but these are the stroke severity scales these stroke severity scales all had area under the curves of 0.7 0.85 which is not too bad the probability of having an elbow with a positive elbow prediction test was thought to be only 50 to 60 percent whereas you know potentially greater than 10 percent with a negative test could also have an elbow thus more effective tools are needed to identify suspected stroke patients with strong probability of elbow so that's the counter to this recommendation is that our tests just aren't good enough yet and if they're not good enough we potentially over triage we potentially delay all the place and if it doesn't catch uh sorry yeah and if it if it doesn't catch what are we doing um my counter my counter to that or you know if i was a patient with a large vessel occlusion um i would want you to take me to the more definitive care for that sooner because the data is pretty strong in saying that thrombectomies get you to a better outcome more so than all the place so if you could catch 50 to 60 i think that's theoretically a win that's good enough for me but there's definitely definitely room for improvement now going back to the algorithm again if you suspect the elbow and you're going down that third column downwards and the last known well is within 24 hours this says to bypass the endo uh sorry to go to the endovascular capable center as long as you can one not miss out on getting all the place if bypassing is going to cause you to miss out on all the place don't bypass just get your tpa at one hospital and then go to the endovascular capable center and your comprehensive center is less than 30 minutes away that's what these recommendations are saying there's they also american heart also does state in uh a parallel document to this uh that when there is that there is insufficient evidence on specific thresholds of these time time limits uh and additional time travel for which to bypass uh other hospitals so it's can be very location specific can be can be kind of patient specific but these are just open guidelines to provide ems ems groups within a city you know here in albuquerque we have our um albuquerque fire and we have albuquerque ambulance systems that are those are two big ambulance systems in town and those guys work together to make a lot of joint protocols for pre-hospital providers so it's working through them with these guidelines that we come up with our recommendations so again thresholds of additional time travel insufficient evidence you're trying to weigh the laser all the place to delays in thrombectomy moving on now to well sort of moving on pre-hospital bypass to health care facilities able to perform thrombectomies if a patient is ineligible for a thrombolysis so this is now they don't even qualify for thrombolysis because they're out of the time window or they're on coumadin and they take it every day religiously so they're not going to be thrown back to the candidates well let's just go to the place that's going to provide the only um possibility for acute stroke treatments so go to the place that can do endovascular therapy or mechanical thrombectomy so class 2b evidence sorry recommendation level of evidence c um but like i said if they can't get all the place there's no reason for them to go to and also place only center when they have the potential to have a thrombectomy all right now this is getting to some cool interesting newer stuff some patients can get off the place after four and a half hours from the last known well so as many of you already know the ninds trial back in the 90s was positive was the first trial that showed benefit for using alteplase and treating acute ischemic stroke within the first three hours e cast three was the the third e cast and that demonstrated benefit of giving out the place in a within four and a half hours with a certain um newer set of exclusion criteria and now we're talking about extending this beyond four and a half hours so this is a class two a recommendation so definitely definitely has benefits and comes with level b evidence so the first trial that they mentioned here uh is this one and in 2018 mr guided thrombolysis for stroke with unknown time of onset this one came out in 2018 out of the new england journal called the wake up trial big trial this one had 503 patients they randomized patients to get all the place versus standard of care happened in eight european countries at 70 different hospitals and they included adults not too old last known well outside of the four and a half hour window uh stroke recognition of symptoms within four and a half hours of presentation but most of these were patients that were that woke up with their symptoms so they went to bed fine they woke up with symptoms and then they showed up to the ed they did early stroke they found the early strokes based on an mri so this dwi positive that's the fusion weighted imaging that's one of the sequences that we get with the mri that if that was positive which shows up very early when someone's having a stroke like within a few minutes and then flare negative flare become that's another sequence on the mri that shows a positive we think in somewhere between four and a half to six hours of this stroke um some might argue that it shows a positive when the you know when there's more edema associated with the stroke so the stroke is worse so this helps us to be able to determine how old the stroke is and whether or not we think that there's going to be salvageable brain they excluded patients that had ich for obvious reasons uh they excluded patients that had a plan thrombectomy and i think that's really kind of important here uh because when this trial was done not everybody was getting thrombectomy um so that that's kind of huge nah stroke scales that were really big greater than 25 and lesions on their ct scan that had greater than a third of the territory of the mca um as out they didn't include those patients and obviously if you couldn't get out of place you weren't after one day i think you went on mute i'm going to assume that that was just the second all right okay great okay so this is the demographics uh graph or chart from the study and i think it's really important to note here that the median inter the median interval between the last known well to the symptom recognition and oh sorry um last known to be well and symptom recognition and hours was 7.2 hours in the alt place group almost exactly the same as the group yes yes your um screen is not being shared anymore so if you can reshare your screen absolutely i think i'm sharing the wrong screen yeah it's not the right thing yes perfect i apologize guys i'm so sorry for that but again here all right we see that the times from last being well to symptom recognition was the same and this is the other thing that i already briefly mentioned i think it's important to know that you know 15 up to 15 of these patients had large vessel occlusions and potentially more so it throws a little bit of question into does this apply to all the patients that don't have large vessel occlusions we could see here that the alteplase group had a hundred and thirty one page fifty three point three percent at a favorable outcome versus the placebo group of 41.8 and on your shift analysis here uh you see that there is definitely a trend towards better outcomes a statistically significant trend towards better outcomes in the alteplase group versus the placebo group and then in 2019 this trial came out this is the extend trial this trial was done in australia new zealand thailand and finland um and they did a another double-blind placebo-controlled trial with alta place and they stopped this trial early because of wake up everyone's trying to save money so when a very similar trial comes up pretty positive they a lot of other trials will stop and do an interim analysis and see if they need to keep spending money so the inclusion here on this specific trial was outside of four and a half hours but within nine hours um they had to have a hypocrite hypoperfused but salvageable reasons of brain detected on uh imaging and the specifics of of that were a lesion core to mismatch of 1.2 so there had it had to be the perfusion deficit had to be bigger than the core uh absolute difference in the volume of dead brain versus ischemic brain had to be the difference there had to be at least 10 ml and the ischemic core volume had to be less than 7 ml 7 ml volume of of brain they used mr and mr perfusion or ct perfusion and for those of you guys that don't look at these all the times this right here is an example of a ct perfusion so on the left side of the screen you see that fuchsia color there what is being outlined in fuchsia is what the computer has determined to have a cbf or cerebral blood flow of less than 30 percent um 30 of what it should be and that is what we consider essentially the the core infarct and they're measuring this one to be 17 mls and on the right hand side of the screen you can see what they're calling um low flow time yeah the parts of the brain that are getting low flow and are at risk of becoming fuchsia if nothing happens so this is the t-max taking longer than six seconds the time to i think maximum contrast and that volume is 156 so there's a big difference on this on this particular patient with a mismatch ratio of 9.2 with a large amount of volume so this is an example of somebody that has a small infarct and will probably have depth deficits from that but has a lot of salvageable brain and their exam can be somewhere in in the middle but could be as bad as the entire green so if you can take out the stroke if you could take out the clot via ultraplace on this patient then awesome then you are potentially providing them with a lot of benefit here's an example of an mri with an mrp so again the fuchsia is considered the infarct core and the green is considered the low flow or the at-risk part of the brain or i should say the difference between the two is the penumbra so this for the mrp shows a volume of dead brain of 89 ml versus a volume of low flow brain at 124 leaving us with a mismatch ratio of 1.4 and a volume of 35 so definitely not as much brain to save and the amount of dead brain that the patient already has here is too high for us based on these trials to try to to save the extend trial exclusion criteria had modified rankings of greater than two already severe severe strokes and patients being planned to go to thrombectomy as you can see here there is improvements in the neurologic outcomes for the patients that got all the place and a proven concept here under tertiary outcomes you can see the increased uh amount of recanalization uh 67.3 percent in the ultra place versus 39.4 which was the essentially the spontaneous recanalization of the blood vessels heading towards the stroke area so we're more likely to open up clots and more likely to provide functional outcomes by giving patients all the place in this extended time frame based on imaging and again here's another shift analysis these are super common in uh stroke trials and you could see this statistical trend towards improved outcomes with a lower modified ranking score i love how this um uh this document the the new guidelines have all these controversial topics in them and this is definitely one of them so they're actually not recommending out to place for a certain group of patients so for mild non-disabling strokes nih stroke scales of zero to five all the places not recommended so this is that the sole um no benefit one that we were talking about discussing today so this was based on this rct this prisms rct came out in january 2018 and they had 75 hospitals they designed the trial for 948 patients in the united states of alteplase versus aspirin within the first three hours they only enrolled 313 patients at 53 centers so things were not going very well for them to be able to pick up more places and more patients and they ended up having to stop the sponsor this was an industry sponsored trial by genentech they said a quote financial decision based on the fact that the time that the trial could not be completed within the allotted funds in the specified time frame um so that's kind of sad that they didn't get to finish this trial and their eventual conclusion here was it's very early study termination precludes any definitive conclusions but uh thankfully they were honest and put out the data on the patients that they did have and we'll talk about that down in a little bit but before i do i think it's important to mention their inclusion of non-disabling strokes so what is a disabling stroke and they define that as the inability to perform the activities of daily living or being able to go to work so if you were able to do these things before and you couldn't do them now that's considered a disabling stroke and that determination was made by the local clinicians that were talking to the patients and in consultation with the patients and and their family members there's also an ability to to walk that was considered a disabling stroke so sometimes you see a patient with a small stroke that you know can't move their hand and it's not that big a deal but you know if you're if you're 80 years old you're right-handed and uh your left hand can't move as coordinated anymore it's not that big a deal it might not be disabled you could still eat you could still talk you could still interact it you wouldn't really necessarily call that disabling but if you were a concert pianist and now you can't return to work that's disabling um so it's a little bit different for every patient and it's definitely something that is difficult to put into practice globally it really needs to be down to the people that are involved in that physician patient relationship and trying to make that determination the exclusion criteria for the prisms trial was if they were already disabled if they couldn't take aspirin dysphagia or any contraindications to all the place and you could see here here's their shift analysis and although you could see a a uh placebo on these two so the all places on the top and the placebos on the bottom it looks like there's a trend towards better outcomes uh on the placebo and a trend towards worse out comes on the alter place group right there so this is the trial that made aha say we there's no benefit we don't have to give it to the patients that have these small and non-disabling strokes here's a new one connect the place connect the place may be a reasonable alternative to alteplase but specifically though in patients eligible for mechanical thrombectomy uh i think this is a really cool potential um move forward for us uh in general because you know all the place yes it has been the only medication only lytic used that had a statistical benefit in treating all comers with stroke within a certain time frame but it does come with um it's not just weight based these are all weight based but it comes with a small bolus followed by a one hour infusion and potential a lot more potential med errors that are associated with those connect the place however is a simpler medication in that it's just a single one-time bolus so this makes transport a lot easier you know depending on the ems agencies uh certain paramedics might be able to transfer patients with ongoing drips and some might not so if that's the case then this really opens up the potential for how you know what rigs are able to transport patients from one center to another so that's the potential huge potential benefit there because it would decrease that time of searching for the right paramedics and searching for the right rig in order to transfer that patient the trial that said the demonstrator this was the extend ia tnk trial they had 202 patients in australia and new zealand open label blinded outcomes it was a randomized control trial and they used connect connected place versus iv alteplase in patients that were about to go thrombectomy super important in patients that were about to undergo thrombectomy the extend iatnk inclusion criteria um you had to be a potential candidate for both mechanical thromba thrombectomy and iv thrombolysis so that's there within four and a half hours the the large vessel occlusion locations were something that we can get uh ica mca or the basilar artery and there it's important to know that there was no upper limit of the nih stroke scale and there was no upper limit of age and here you can see the primary effect the primary outcome here substantial reperfusion at initial angiographic assessment and the number of patients with a reaper that had their vessels opened up by the time we looked at them under under fluoroscopy was actually higher in the connective place group than it was in the alteplase group so that's important to see and then here you can see on the secondary outcomes that also came with median score on their nah was statistically decreased also they're functional independent outcomes almost statistically different in patients with minor non-cardioembolic ischemic strokes so you know not the afib patients that throw up a clot from their heart on these patients that had a low nih stroke scale less than or equal to three and did not receive all the place just because they you know for whatever reason we found that um that we should be starting clopidogrel and aspirin within 24 hours of the symptom onset and continue for 21 days and this is going to reduce this recurrent ischemic strokes for up to 90 days um this is a change this is a big change as you can see here it's a class one strong lots of benefit you got to do this with level a recommendation and i think it's important to know that this is like i said a change because the older trials were saying that this wasn't a benefit and i think a lot of that came from putting this on too sick of patients and putting it on for too long because a lot of the patients in those older trials had bleeding problems either from leading into their stroke beds or having gi bleeds so what they were able to do in the more recent trials is find the less sick patients well the smaller strokes and only do the dual antiplatelets for when they're at the highest risk of getting their next stroke which is early on so the chance trial this was the big trial that helped determine this one 5 000 patients in china uh with a mild stroke or tia both groups got open labeled aspirin for 21 days and that dose was whatever they wanted and the treatment group received a 300 milligram load of plavix or a club peter grill and followed by 75 milligrams per day for 90 days and they started this treatment within 24 hours and you could see that there's a significant reduction in the patients having strokes and mis all cause mortality significant reduction in those on the dual antiplatelet group and the bleeding was not statistically significant between these two groups so by reducing the duration you're able to decrease the amount of bleeding but by having it on you're able to reduce the the amount of strokes that are coming up the point trial the other new one 2018 that pointed in the same direction another randomized control child this 4 800 patients uh north america europe australia and new zealand uh enrolled patients within 12 hours of their mild stroke or gia randomized controlled trial again 600 of plavix followed by 75 per day everybody received aspirin and they excluded patients getting antiquate that we're going to get anticoagulation and so this child was also positive their composite outcome of strokes and mis and death from ischemic vascular causes that was reduced the aspirin group had uh 6.5 versus 5 ischemic strokes were reduced 4.6 versus 6.3 these are smaller differences but in the grand scale of things you you're reducing disability on patients and it's you know meds that are that you take it home that you can give relatively easily so oh and we talked about this already why were these dual anti-platelet trials successful when the others weren't again it's this was in the particularly high risk of recurrent strokes so early on after their first stroke so they enrolled the patients within the first 24 hours and their low risk of hemorrhages so again less severe stroke and tas are less likely to bleed now moving on to mechanical thrombectomy so patients within the six to sixteen hour time frame of the last known well uh i should start out by saying the zero to six hour that's that's old news that's not a brand new recommendation of course we should be doing mechanical thrombectomy in patients with large vessel occlusions within the first six hours but this is the new stuff in in these guidelines new in 2018 uh but not in the update in 2019 so if you're within the first 16 hours of a last known well and you have a large vessel occlusion you can still get thrombectomy if you meet certain criteria and that criteria oh um we'll talk about that criteria here in a second but i want to point out this is a class one recommendation so super strong recommendation with level a evidence so you cannot get a stronger recommendation or higher quality of evidence than what this recommendation has so there's two trials the first one we'll talk about is the dawn trial this one came out first thrombectomy within the six to 24 hour time frame with a mismatch between the patient's death deficit on their exam and the infarct size they plan for 500 they enrolled 206 in this multi-center prospective rct randomized control trial uh bayesian adaptive enrichment design uh and blinded assessment of endpoints that bayesian adaptive enrichment design uh is kind of tough to wrap your head around but essentially the the plan going into the trial was they were going to assess it at certain time points at certain numbers of patients and if they had either a super positive or super negative result at those earlier time points then they would stop early and and publish after that this was an industry sponsored trial which is different than the next one but it is important to note that the authors had unrestricted access to the data but the analysis was performed by data management staff from striker with oversight from independent statisticians inclusion criteria included pre-stroke uh modified rankings of lesson two so you have to be pretty independent and be able to work you have to have a large vessel occlusion present in the internal carotid artery or the first segment of the mca and the next parts the important part here it's this mismatch this clinical symptoms versus the imaging core infarct so if you look here they stratified it by age but essentially you had to have a decent sized stroke based on exam and the nih stroke scale of 10 and an infarct volume of less than 21 mls if you were on the younger side less than 80 you got to have an infarct size less than 31 mls and if you had a really big stroke with an nh stroke skill of greater than 20 your infarct size could be less than 51 mls so the imaging that you need in order to follow the don trial includes either an mri with the diffusion weighted sequences or a ct perfusion we looked at a couple examples of that before so getting now to the endpoints of this trial is that the functional independence at 90 days as you can see here the thrombectomy group was 49 had functional independence versus only 13 that's a huge huge uh number just you know the functional dependence is defined in this trial by a modified ranking of zero one or two so definitely able to still walk and get around and do your own adls but a big difference in their outcomes the intention to treat analysis here sorry um the shift analysis of this was as you can see definitely trended towards better outcomes than the thrombectomy group and pretty much in all the subs subgroups and then the next trial this is the diffuse 3 trial this was in the 6 to 16 hour time frame so that's why the class 1 evidence recommendation goes up to 16 hours because there's two rcts that go to this time frame this was done on 182 patients in 38 centers in the united states they did endovascular therapy plus medical therapy versus medical therapy alone this one was not industry sponsored this was sponsored by the nih and you could use any fda thrombectomy fda approved thrombectomy device but the non-contrast ct done with a this says aspect score greater than six um that's an objective way to determine how much good brain versus dead brain on that mca territory so this is you have to have a pretty good amount of um good brain left in order to be enrolled in this you have to have a large vessel occlusion present in the m1 i say or elbow again i'm pretty sure i meant to say ica you had to have a pre-stroke modified rankin of zero to two again that's you had to be able to do your own adls your infarct core had to be less than 70 mls and you had to have a ratio of ischemia to infarction of 1.8 you got to use mr and mr perfusion versus ct perfusion and here's i think i showed you this one earlier an example of an mr and mrp so this trial slightly different than the last one where they used a um they were able to determine the core by imaging but the penumbra essentially was based on the exam this trial looked at both the penumbra and the infected core by imaging so this is an example of somebody that has 89 mls of dead brain and 124 ml of brain that's getting low flow leaving us only 35 ml of penumbra the mismatch volume there in the center uh 89 mls of dead brain would exclude this patient from from getting endovascular therapy here's a ct perfusion so this is the core infarct you can see in fuchsia on the left is super small only four mls versus that on the green on the right sorry 81 mls leaving us 77 ml of at-risk brain and their and a ratio of 20.2 so huge huge chance for this patient to do really really well this one definitely would get a thrombectomy so the results here they only enrolled 800 and sorry 182 patients because they stopped early when the don trial came out and was so positive their shift analysis as you can see here definitely trended towards a better outcomes of the endovascular therapy you can see here that we had the the primary outcome and the secondary outcomes were positive functional independence was much greater in that endovascular therapy group all right and then for patients with l sorry within the 16 to 24 hours of last known well who have an elbow in the anterior circulation and meet the dawn eligibility mechanical thrombectomy is reasonable so this is class 2a benefits is very much there with level evidence b that single rct um [Music] for the dawn trial up to 24 hours so again 16 hours class 1 24 hours class 2a for the recommendations uh we are deaf we here at unm are definitely doing thrombectomy's up to 24 hours so summary of the recommendations here there's a lot of them uh i apologize but that's kind of the the nature of doing a lecture on these kind of recommendation recommendations so there's pre-hospital stroke severity scales are good use them they're not as good as we want hopefully there will be better ones coming out in the future pre-hospital bypass in the potent potential cases of large vessel occlusion can involve delays to alter place but you're weighing that against delays to thrombectomy so local decisions need to be made if the alta place is out of the question all the places out of the question just um go directly to where they can do thrombectomies and that bypass is going to save you a lot of time mri imaging can find patients eligible for alteplace in that greater than four and a half hour time frame avoid alter place in non-disabling mild strokes consider connect the place on your large vessel occlusion cases that are going to go for thrombectomy again super awesome if you're not at the comprehensive stroke center but at a primary stroke center and going to transfer them in that's going to save you time save your pharmacist time and make it easier for you to be able to get the patient transferred dual anti-platelets for the patients that are having small strokes start that early and continue it for only 21 days and advanced imaging can also be used to find potential thrombectomy candidates up to 24 hours after their last known well so treat those guys almost as if they were coming in at hour one you want to find them early all right and this is my reminder that uh the slides are done this is just a cool little picture from last summer um that's some elk down there in the bottom of this little valley in the jenna's mountains here in new mexico and with that i'm going to stop sharing my screen and open it up to questions great presentation dr alonday um i don't see any questions in the chat box right now does anybody have any questions you can star six to unmute or you can type them in the chat box so it looks like there's no questions so i just want to take the opportunity to thank you for oh wait a minute here's one uh are there any recommendations for a wake up stroke protocol for tia patients for tiaa patients so if their tia they woke up with us they went to bed fine woke up with their symptoms and the symptoms resolved awesome fantastic i would treat those like you treated um any of the other tias or the small strokes i.e dual anti-platelets uh for 21 days is going to be the best thing you can't give those you know once the symptoms resolved they're not eligible for um thrombectomy any longer or or all the place so i would not do all the place on those patients i guess before that um question was liability of not using dual anti-platelets um i can't say i'm the best person to answer that but now that it's in the recommendation i think it definitely puts you as a little bit more risk for not using the dual anti-platelets on these small strokes or at least if you're not going to use it make sure you document why you're not using it whether it be patient preference something specific about this patient you know they didn't tolerate plavix in the past making them higher risk just i would um you know with with any of these recommendations that are positive recommendations you want to do them or at least say why you don't view them uh and i think that i combined the wrong two questions yeah i think you did it right oh maybe you didn't yeah so yeah back to any recommendations for the wake up stroke protocol okay uh any recommendations for the wake up show protocol um so i want to say my recommendation would be to have all your stroke you know we here at unm if you have if ems calls us and tells us they have a potential stroke that had last that had a last known well within the last 24 hours we are going to stroke alert that patient and essentially we're going to take them seriously we're going to do a door to ct directly you know bypassing the ed bed first we're going to have our neurology residents come down and meet us down there for that initial assessment and we're going to try to figure out uh if the patient needs um a thrombectomy um in that delayed time fashion so that's gonna require more imaging but essentially we start out with you know they're walking through and we're talking to them while walking like how how are you doing start the nih stroke scale when were you last normal and calling the family if necessary and based on that information based on the rolling in imaging that we're getting the non-contrasted ct scan the cta you know if we see the entire mca dead then we're done but if we see that looking good then we move on to the next step and ask ourselves is there a large vessel occlusion if there's a large vessel occlusion with a lot of potentially good looking brain there then we um ask ourselves then we do either the ctp or the mri on an mr key depending on the availability of the mri machine which in our case luckily is about 20 feet away from our ct scanners so that's not that big a deal for us we're pretty lucky in that regard but for that's essentially our protocol we treat it as if their their last known well uh was within 24 hours we same thing we do for everybody else that even come in the afternoon too um criteria for three and a half to four hours are not clear any suggestions um yeah there's the ecast trial did have a few more exclusion criteria than the ninds trial did that's that's definitely for sure however the more exclusion criteria you start putting on your protocols the harder it is to get through any of them and the longer it's going to take for you to give all the place to if you look at the fda uh contraindications for alteplase the list is really small american heart association also has a nice list of inclusion criteria which is short you know essentially having uh an acute ischemic stroke and they outline it for the three and a half hours too and they have a big long list of potential relative contraindications and those like i said are relative so you got to take those with a grain of salt on whether or not how bad you know did they have uh for instance do they have a intracranial aneurysm that is not protected you know did they never have a clip or a coil in there before that's if it's a large one a relative contraindication and it's only a relative contraindication not because we ever found that anybody was more likely to bleed but some studies excluded those patients because of fear of bleeding so that's why it's totally legit to give it to them but you are a little bit more worried major surgery within the past few weeks that's a that's another one what is the definition of a major surgery um you know that's i just pushed tpa a couple months ago on someone in-house an inpatient that had an orthopedic surgery on on their hip they had hardware removed and i just assumed though this sounds like a big surgery i'm not going to give them all the place and i was covering at a smaller hospital one of our sister hospitals covering the icu that night and um i was trying to get the patient ready for transfer and then the orthopedic surgeon called me and said i heard my patients having a stroke i said yes i'm transferring them down to unm to get a thrombectomy and they said is you know should we be giving them all the place because i hear that's something we should do i said well everything is a go for all the place except for the fact that they just had surgery yesterday and i don't want them to bleed out and he said oh the bleeding wasn't that bad uh and it's an orthopedic procedure if the bleeds i'll be able to go in there and stop the bleeding so here was my judgment was it was a large surgery the surgeon's judgment was it wasn't that big a deal to take care of the bleeding subsequent to that so i called the accepting docs that were going to be taking them down at unm and i said hey this is what he's saying are you guys all also okay with me giving tpa and they said if the surgeon says they could stop the bleeding the surgeon says they could stop the bleeding give the tpa so we pushed tpa on a post-op day one which was a new for me um so relative contraindications that's i guess my biggest the biggest problem there with that three three to four and a half and even after that um so i think my suggestion is to try to limit what goes on the papers for your residents and for those around you um to the big contraindications and clearly step up you know clearly say if you're gonna write all the contraindications that which ones are relative and which ones are absolute um that will help out and the oh 4.5 clear criterious first read okay aspirin 81 plus plavix for 21 days then aspirin or plavix uh those studies said aspirin after the 21 days um they didn't keep going on the plavix so that's what i would do and mark t tebow said thank you i have a meeting but appreciate this information thank you marty i see an anonymous attendee on the q a said for patients greater than four and a half hours from stroke then uh we should give all to place if in a center unable to do thrombectomy do we need to get mr first right uh prior to stroke so um if you're in a place that can't do thrombectomy i think the biggest thing you could do is actually transfer for thrombectomy um no one's done a head-to-head of ultraplace versus rhombectomy in the post four and a half hour time period um so i wouldn't i wouldn't do that i wouldn't not send the patient for thrombectomy and give them all the places instead i would try to get them on a helicopter or try to get them on um on an ambulance and and get them going for thrombectomy i think that's going to be the most legit thing you could do and less likely to get you chewed it is you know as we did see a good chunk of those patients in and those delayed multiples trials they did have thrown back they did have large vessel occlusions um so hopefully one day we'll have a better answer for you but i would definitely point uh in getting to definitive endovascular treatment first and do we oh to answer the second part of the question do we need to get mri first prior to stroke i think you mean do we need to get an mri first prior to giving all to place and the trials i'll just pull up the god fuse okay here we go screen for the wake up trial this one used just the mri and then this one the extend trial use the mr with mr perfusion and the ctp so you can get this done you can give all the place beyond four and a half hours if not going for thrombectomy based on a ct perfusion okay um so that is possible our time is up yep and and we're a little overtime so just like to thank you so much for your time dr allende it was an awesome presentation um thank you to everyone who joined us and if you have any questions please don't hesitate to reach out and i can get the chat so thanks for your time have a great rest of your day