all right so let's talk about acute ischemic stroke this is a moving Target it's so common we worry about it so much but see a lot of patients that come in where we have to be thinking about this right 700 000 cases per year a lot of people right and in the last three decades there's something a lot of literature that's been coming out some of it conflicting and keeping up with it is awesome it's so hard yeah yeah we're gonna try to summarize some of that for you but obviously what this article says exactly but you got to kind of see what your institutions doing and having them update things but we'll go through this so treatment as you know is Guided by time from onset of stroke symptoms to arrival to the Ed because that can be different depending on how time sensitive or how how soon someone presents right and then severity of their neural deficits is another sort of indicator of what might happen yeah what you may or may not do right exactly and then findings on your Imaging so when that radiologist calls you with what they see on the CT scan or Mr or whatever then you can have a conversation and guided from that as well right so onset is really important so always asking when was that last known well time do they go to bed with this symptom did you see them beforehand is it a wake up stroke or not I mean there's a lot of ramifications now based on the timing so it's really important to suss out asset paramedics call for collateral it's going to be really key in trying to figure out what treatment modalities so yeah time is brain right so severity so up front most people want to use on a Stroke Scale that's a good way to objectively talk about your neurodeficits and a lot of things were study based on that too exactly right and then eating that nihss is really important and how you communicate to your neurologist or your interventionalist or whoever it is right so gotta make sure you get a blood glucose right this is like one of those things where it's the mimic and you can do something about it right it's like magic that's like it's all better oh shocking your your glucose is 20. let me fix that for you all right so treat any hypoglycemia and then if there is a concern for stroke you've got to get that patient to the non-conceit yet as fast as possible don't delay it for the IV don't delay it for anything else except that made me the glucose and get them over if they're clinically stable finger stick in the scanner exactly right and then if it's negative in the appropriate situation you're still worried about the kinasechemic stroke right because it may not have been long enough for that to show up on the CT scan and for mrr so you know there's all this sort of discussion nowadays based on the newer literature of trying to figure out how much penumbra is left how much tissue is left to save that's ischemic but not dead right and so you can get that different ways you can get it with the CT perfusion scan you can also get it with a diffusion weighted Mr and you're really trying to calculate what the mismatch is and then figuring out how big is that penumbra because I don't have implications later right and we don't figure that out right these are the experts that are reading the stuff that just convey to us that there is a salvageable being right and then if you're looking for large vessel occlusions right getting the a part of the CTA or the MRA is going to be really important right so we've really changed a lot of it it's we've changed a lot of this and a lot of is getting a lot of Imaging yes pretty quickly yes right and then your place will have different protocols right like some people might be able to get the Mr quickly some of us can't and you just get the CTA or CT perfusion sometimes many of us yeah exactly you fancy you have an MR yeah you know so most of us aren't there yet um and so the treatment response a lot of this is using the modified Rankin scale so just for reference if you have zero you have no symptoms really anything less than two you're functionally independent and that's what we're really trying to aim for yeah and then you know six walking talking be able to take care of yourself right six is bad all right six is dead yeah it's kind of bad so um Ulta place right so right now anything less than 4.5 hours TPA is still considered first line so the dose just so as a refresher it's 0.9 milligrams per kilo over 60 minutes and then a Max of 90 milligrams and then 10 percent bolus over one minute and then you give infusion afterwards so logistically this is a little bit tricky but it does reduce the disability from ischemic stroke I mean there were studies that have shown this it is not recommended however in the minor strokes right it's a really really mild mild this is actually really important this that study was a game changer right and so nihss of less than six you probably shouldn't be giving TPA too no in fact you should not right frankly not recommended right and then excessive bleeding risk you know if you have somebody who has a bleeding wrist some sort of coagulopathy before you even get into having a stroke you don't want to give it to them and then if the CT shows are irreversible brain injury so this is something where it's a little bit more subtle but like if you have somebody that has that you want to have that conversation with a neurologist is it worth it yeah okay so um you can give it as soon as that non-car CT is negative right there's no bleed we're starting the TPA because that time tissue brain thing we want to get it on board as soon as possible and you don't want to wait for the results of the labs right so you don't want to know what the platelet count is or the INR and this is if people actually go wild these are these are changes from the original I mean the original you had all these like you wait for this and you do this here this is like they've really pushed this right up front right right they really want you to give it as soon as possible not having to wait for these other things blood pressure is something we do need to manage though before we give the tpas you want to get that less than 185 110 and you really want to keep it under a 18105 for the first 24 hours afterwards as well and that we're doing in the ER because we're holding people for so long yeah don't get me started [Laughter] um and then for ICU admissions these patients need really strict monitoring so they're going to go up to the ICU and ideally if you're at a place that has a stroke unit that specializes in this you want that patient to go there I wouldn't want to be there I wouldn't want to be there too I'd want my mom to be there et cetera like that's just where the best care is and the benefit is time dependent so again really moving that needle of giving it as soon as possible and this is actually where the people that are the naysayers the the window that it really works the best is up to three hours we added three to four and a half right for a little teeny bit of benefit and some people even doubt that but this is yeah so sooner the better yeah we could go into yeah but we're not going to be here we're going to spare you this is all you need to know for the exam that you're taking yes three hours best benefits three to four and a half yeah maybe still some benefit um of course we all know the adverse outcomes right you can get bleeds from this and the studies it was shown it would be 6.8 of leads versus 1.3 it's a lot more it's a lot more yeah right and I think we've all I've seen I've seen that yeah and there is increased morbidity mortality risk but there's also some maybe increased benefits so you kind of have to talk about those things with the patients see what they're okay with you do and that's that's a whole other controversial thing but I am still a big believer in talking to folks about whether they want this or not yes yes so in terms of that expanded window we've got to talk about the wake up study right and so this is um really a study that talks about well if I went to bed and I was fine and I woke up with my stroke how long has it been since I've been having stroke symptoms when the patient can't tell you right and so you are trying to get at a specific size lesion to be included in the study and it's really getting to that penumbra thing that we talked about right how much of brain is salvageable and is that benefit for TPA there versus am I just going to have more bleeding risk and it's trying to really suss that out they need nihss scores of 25 less than 25 and um to be included in the study you were not to have a thrombectomy plan right and the end point was again sort of this modifying Rankin scale of how much functional disability did you have and it was really trying to get them to zero one this really independent person at 90 days and the treatment benefit you can see here is 53 versus 42 if you didn't get all to place in that extended window and so for patients if there's no thrombectomy available the conclusion was well maybe you can still give all to plays up to a certain number of hours they said maybe nine hours here if you met the criteria in the clinical trial right yeah yeah so it gets kind of complicated this is one where your institutional you're going to follow what you do at your institution or this particular paper for taking this test they actually didn't get into a lot of detail of SARS if it meets the criteria they didn't really get into a lot of the details so um I think the key here is to real life know what you do in your own Institution for this exam I think they'll keep the questions pretty simple I don't think they'll get into all the little nuances I think it's also helpful just to know that this is existing exactly literature that's coming out that like if you're you know people aren't it's not crazy to say you could give it after 4.5 hours if you can identify of those patients might right exactly re-identifying the right people you know whether that's with MRI imaging Etc you're trying to find that penumbra okay next one so mechanical mechanical thrombectomy so in less than six hours right that shows the biggest benefit and the idea is that you're like getting the clot somehow you're catching it sucking it out no fetch it right and then you can save the brain this is best in large vessel occlusions right you can imagine like just how hard it would be to get something teeny tiny but really the large muscle occlusions is where you've seen the most benefit so you do need some sort of Imaging to figure out if it's a large muscle occlusion typically it's an A Part rate CTA or MRA um and then it's really the more severe Strokes than ihsses of six or higher and it's the most benefit within six hours there's some studies to say I can go on past that but that's really a conversation you got to have with your specialist at your shop and I'm sure if you have this at your place you already have all your rules down on what they're doing yes exactly so several studies showing that throwback to be can be done and most of these patients did get IV all to place while they were sort of getting prepared for their thrombectomy so just because you got TPA doesn't mean you're excluded from getting thrown back to me some did some didn't and the current recommendation is still to give it so if you have Alta place and it's a person who qualifies for it then you should still give it even while you're planning for the thrombectomy okay so there were two trials that looked at this one was a dawn one and this is when I was talking about like stroke symptoms six up to 24 hours here this is now further further out right and now we're talking about nihs's of 10 or higher so more severe Strokes um and there were specific Imaging criteria which I don't really get into but they did show a benefit of thrombectomy in this other extended window so up to 24 hours here yeah modified rank it up to two but they kind of cheated a little bit but yes they found a benefit yeah so they found a benefit here so take that for what you will the other study is called diffuse I love how they all I happen to make up some people sit around and make these names I'm sure they think about it for a long time they do but again it's another story talking about this expanded window of like six to 16 hours yeah not 24 like right 16 right and really trying to identify that mismatch of the core penumbra like salvageable brain and this one was nah scores of six or greater they found a benefit 45 versus 17 with again a modified ranking score of zero to two yeah they kind of cheated a little yeah a little bit Yeah but it's out there so now you know yeah and in terms of blood pressure management specifically for patients getting thrown back to me it's not really clear guidelines for blood pressure management as opposed to TPA like we have a very clear goal but for thrombectomy patients is a little bit more up in the air so it's considered reasonable to maintain that blood pressure what do I do with that during procedure and for the first 24 hours so I think most places still logistically end up doing the blood pressure management even if you got the throne back to me only because oftentimes these patients you know like we talked about some are getting TPA and thrombectomy they're going to strict units where they're really watching the blood pressure and so you know this is out there it's a little unclear but you know says they know for sure they're not telling the truth yeah it's not clear no um the other new sort of player on the lytic options out there is connect to plays um we don't have it at our place and I'm really curious to see where this goes because it is much easier to give a secret ID bolus of tonight's place or tnk than it is to give TP and that like infusion bolus situation and so the idea is that if you can get the bolus in you're saving more tissue instead of having to have this do more more complicated bolus infusion thing with TPA which potential error as well exactly right and just more time to get it set up and the idea here is that it's another sort of uh tissue plasmogen activator and it's more fiber and specific and it's uh resistant to the plasma gen activator inhibitor and it has a longer half wave so all to say that there are studies that are now showing that it's it's pretty equivalent yeah yeah it's working its way into the market that already was studied under yeah so there's been a few studies five randomized control five randomized trials comparing it's a standard doses of ultiplates right that 0.9 that we talked about milligrams per kilo and then it shows that in these meta-analyzes that there really was no significant difference between getting tnk versus TPA and they looked at the modified ranking score of zero to one being functionally independent at the 90 day Mark so it's it's hard to say because I think that we're still this early period of trying to figure out it's worked its way into the guideline as an alternative so it's out there right and it's in this article as something to be aware of right it's it's definitely been it's now into the into the guideline right right and so um you know again what else can we do for these Strokes like you know back in the day this is all we did right exactly and so there you know this conversation here is talking about anti-thrombotic agents and the role for these right anti-platelet agents usually delayed for 24 hours after IV TPA because you don't you just don't want to have to like make them bleed more and then one thing at a time um and they're here specifically for aspirin you know 160 to 300 milligrams does lower the risk of her current stroke of debt or death in the hospital later compared to Placebo so um and then for those patients who have an NIH SS or three or less we're little we're getting down this is like a really minor tiny tiny tiny yeah really yeah there's really not an indication here for long-term anti-coagulation right basically there's also are people you're not going to be lysing right right cut off right exactly so dual anti-platelet therapy within 24 hours a stroke that may be better than aspirin alone you know they they say that there's decreased risk of substance stroke as well you can start regimen of like aspirin and Plavix or you can just do Plavix as well yeah I think this is a conversation you have with the neurologist the good news for us is that you don't have to start it until right like in fact you don't start it yeah this is the people do after you've figured out what's going on like this is beyond us okay so um therapeutic anticoagulation right within 48 hours is not better than aspirin alone or Placebo and you know here you if you're doing like Heparin drips or things like that it's really not necessary you're just increasing the risk of bleeding on top of risk of bleeding and you just don't want to get into that so but there's this thought about what about patients and aphids afib right that's the category we worry the most about food exactly right and they're the highest risk of like having more Strokes later on so what do we do with this patient population so here you know therapy accept you happy within 48 hours and continued for 14 days was no better than Heparin and there was increased risk of intracranial hemorrhage as well the risk of death and disability at six months was the same so not really worth it yeah I yeah interesting yeah yeah um and then just general supportive care we all know this right you admit that patient to a stroke unit which actually does make a difference yeah the whole Serpentine thing is important yes and then looking for for the sequelae of just having a stroke right you can get edema you can get herniation so if you have signs and symptoms of that Brewing then you need to get a neurosexual consult right away you want to monitor that patient from a cardiac standpoint as well which we all do and then we're into the heart have a really weird connection yeah really important stuff happens even though the heart can be fine yes yes and you want to make sure that they're in that sort of Goldilocks sweet spot of oxygenation and if you have fevers you gotta look into that and treat it okay so um other things too right so unless indicated by treatment you don't want to like mess with the blood pressure too much right this is the idea of this sort of permissive hypertension your brain is used to having that elevated pressure and if you all of a sudden decide to treat a number not the patient you get yourself into trouble your brain's smart it knows it knows what it auto regulates to a certain extent pretty well right and then if it's higher you can consider lowering it by 15 within the first 24 hours if you're worried about this sort of control yes right something that is very you know easy to titrate um and it's really sort of getting an idea of well is there hypertensive emergency contributing to the ischemic stroke here right you want to make sure that if they're going to be stuck in a bed that you give them some sort of DVT prophylaxis pneumatic compression stockings that's because the Sub-Q Heparin thing is a question exactly so exactly you don't want to increase bleeds on top of increased risk of bleeds and again screening participation right okay areas of uncertainty so you know there's been this burgeoning idea of mobile stroke units again all in the effort of like field right let's go out and see if it's better and figure out the diagnosis earlier yeah like it's cool in theory but I'm not entirely there are over a million dollars a unit like I have to think of a lot of ways to spend a million dollars yeah or you could just get them to us yeah we could take care of it and then also buy a regular supplies with that million dollars yeah yeah yeah or just a lot of nurses apparently um and then the efficacy of mechanical thrown back to me within the first six hours of stroke you know you got to be sort of really thoughtful of the inclusion patients that you're putting into that category and then this again sort of I don't know how to manage the blood pressure if it's just a thrombectomy without all to play it's like what do I do with that this is tough we're learning we're learning yes and then so other guidelines right so this really depends on your practice environment well I'll tell you in certain countries don't lice at all I mean it's just it is so different right and then some places are really aggressive about throwing back to me and some some sort of ethnic groups have different responses to therapy there's higher bleed rates in certain countries because that's it may be something that's related to your genetics and exactly fascinating yeah so there's a lot of variation out there and it really is incumbent on you to sort of learn what it is at your place um what does stand though is the IV all to place within 4.5 hours if you meet the appropriate criteria all right so there is an algorithm by the way in the article that puts all of this together if you're an algorithm person we just didn't want to put it back on a slide because it would be about this very busy you wouldn't be able to kind of get your way through it what's going through though it is worth going through so we'll summarize just the basics here so start with the NIH Stroke Scale get your last known well time everybody gets a non-contrast CT as soon as possible and you may be ordering more studies like CTA MRA diffusion weighted perfusions Etc depending on sort of your ins what your need is at that point in time if it's less than four and a half hours out to places first line but you're not going to use it in people with nah Stroke Scale less than six any better than excessive bleeding risk or brain injury that's irreversible and again that's with consultation with the appropriate peeps um you're going to give if you give the else Place immediately after negative CT you're not going to wait for any labs and you're going to watch that blood pressure bring it down as needed and we know that bleeds are higher this way but the outcomes at least six months out are the same if it's more than four and a half hours that's that wake up study and this is now anti-stroke scale less than 25 and the lesion has to be specifically sized and again that that is all stuff that's done at your institution right in the papers we're not going to like drag you through this Alta place has been shown to have a treatment benefit it's actually a little whiffy but it has been shown that so it's now accepted um and you may be able to treat even up to nine hours after the last no well time with specific criteria that was studied in the wake up study mechanical thrombectomy in the less than six hour window it has to be an nah Stroke Scale of six or greater very specific Imaging criteria Alta place first anyway and then these two trials the Dawn and diffuse trial showed some benefit but no good guide to BP management connected place is basically no clear difference with Alta places or a lot of these are sort of non-inferior already kind of studies the trials are pretty heterogeneous but it's now on the plate as something that you could use as an alternative and anti-thrombin anti-thrombotic agents gonna delay 24 hours which actually frankly takes it kind of out of what we usually would be doing anyway but aspirin overall reduces the risk of recurrence stroke and death in the hospital dual anti-platelet therapy again another 24-hour thing this is adding aspirin to like Clopidogrel is usually the thing it does decrease subsequent risk of stroke of this but it's not and and therapeutic anticoagulation isn't better than aspirin alone so this is that frankly this is out of this is one of those things where I I'm only going to take so much brain space with stroke stuff I'm going to put the platelet stuff out in the chat with the consultant category not in the remember to snatch it out of my brain category um admitting to the ICU neuro ICU preferred for sure those teams make a difference set so you're going to keep 95 94 ish or greater if they're febrile which is actually brought up a little bit in the paper but if they have a fever fever is not good your brain doesn't like to be hot so treat that fever and then of course go chase it find the source treat it if you need to but get that temperature down and then blood pressure basically it altaplace really will guide your therapy if you're giving out a place in this let's get that blood pressure down to the window and Target window and keep it there but if not if you're not giving out to place you're going to basically Let Them Sit as long as they're not getting worse you're going to let them sit you're not going to try treat them for the first 48 to 72 hours so this is a one summary article on stroke that's out there acute ischemic stroke remember your institution was going to guide your day-to-day therapy this is what you need to take this particular test and there's a range of things kind of in between yes