Stroke FM

The Society of Vascular and Interventional Neurology (SVIN) held its first Hybrid Annual Meeting November 17-20, 2021, virtually and on-site in Phoenix, AZ. It provided an opportunity for top-of-the-line education, networking opportunities, and discussions. Please visit their website: https://svin2021.com for further details and access to the conference. Become a member of SVIN and the CSC. In this episode, our host @neuroccm joins SVIN's new President Dr. Ameer Hassan @AmeerEHassan to discuss meeting highlights, and some key take-home messages from some of the great science presented at the meeting. Please follow us on Twitter: @strokefm Subscribe to the Podcast and give us 5 stars! Apple PodCast Spotify PodCast

This is an official Canadian Stroke Consortium (CSC) - StrokeFM Podcast episode: Neuroprotection and stroke care What does the future hold? Where are we coming from and where are we going? These and other exciting topics of discussion in conversation with Dr. Michael Hill (Calgary Stroke Program) as we chat about ESCAPE NA1 and ESCAPE NEXT. ESCAPE-NEXT is a multi-centre, randomized, double-blinded, placebo-controlled, parallel Group, single-dose trial designed to determine the efficacy and safety of Nerinetide in participants with acute ischemic stroke undergoing endovascular thrombectomy excluding thrombolysis. This is an official CSC Podcast episode (Season 2, Episode 8). As usual, see our Disclaimer about this educational podcast. Please follow us on Twitter: @strokefm Subscribe to the Podcast and give us 5 stars! Apple PodCast Spotify PodCast

In this episode we get together with Dr. Tess Fitzpatrick @TessFitzNeuro (first author on a recent paper on this topic: Quality of anticoagulation using intravenous unfractionated heparin for cerebrovascular indications) and Dr. Katherine Sawicka @KatherineSawic1 (our resident guru in Clinical Epidemiology and lover of all things research methods) to discuss challenges with anticoagulation using unfractionated heparin infusions. This is not to be confused with the fact that this agent provides a very good modality to providing anticoagulation and has very specific uses, but in the real world setting, IV infusion of this agent causes issues with the quality of anticoagulation achieved. We discuss how there may be better alternatives specifically low molecular weight heparin (LMWH) when it comes to use cases in stroke. Anticoagulating a patient with acute stroke is always a challenging topic, and there are nuances to be considered, to reduce the risk of hemorrhage, and therefore we looked back at the use of unfractionated heparin infusion in stroke and talk about how some considerations are very important to keep in mind. As usual - please note our disclaimer.

On this inaugural joint CSC (Canadian Stroke Consortium) Stroke FM episode, two colleagues from Calgary's Stroke program Bijoy Menon @bijoymenon and Andrew Demchuk discuss nuances of the soon-to-be-published MR CLEAN-NO IV trial (direct to EVT vs. bridging therapy) after the trial's results were showcased at ISC 2021. We look forward to future episodes as the joint CSC-Stroke FM collaboration unfolds on this podcast. We aim to highligh new and exciting scientific breakthroughs, educational topics, and all things part of the chain of survival for stroke care. Please join the CSC! - you can join for FREE for several membership types: Nurses and Allied Healthcare Practitioners Trainees (medical students, residents, fellows) Associate Physicians JOIN the CSC - In order to receive ongoing special updates, unique educational opportunities, and being part of Canada's (indeed the worlds!) stroke community. Thanks for the support from the CSC and its partners. Our music is graciously provided by BrkmstrCylinder.

AHA International Stroke Conference 2021 In this episode @neuroccm highlights three studies from #ISC2021 AHA's International Stroke Conference. We have the distinct privilege of having music by BreakMasterCylinder who has graciously contributed their compositions to our podcast focused on Stroke Education and awareness. We are most thankful - Please Follow @BrkmstrCylinder and contribute at Patreon. Featured Studies: ANGIO-CAT Study "Nonetheless this represents an extremely exciting time, and the message should not be lost that patients with large vessel occlusions can be screened to some degree of reliance clinically and imaged using a flat panel CT with what appears to be a safe modality, and then be taken to thrombectomy and not be denied thrombolysis if needed. This study shows a major speed-up effect in workflow processes. It is quite possible that future studies with higher number of patients, in a multicenter setting, could tease out outcome differences as well. Therefore overall, this is an incredibly positive step forward - Our tools are only as good as the people able to deliver them, and this workflow improvement study certainly opens the door to further optimization of hyperacute stroke care." excerpt from a news piece by @neuroccm for Neurodiem. BEST-MSU Study "Taken together, 17% more patients were treated with TPA, the full 30% or more in the golden hour, with significantly improved patient-centered outcomes. There were 10% more patients with a modified Rankin score of 0 or 1 at 90 days. Overall, this is an important step forward in pushing the boundaries of bringing the treatment to the patient, and if this is ultimately found to be cost effective this represents yet another hyperacute innovation in acute stroke treatment. This may have specific relevance to both large, populated centers that are spread apart geographically, and certainly more austere environments as well." excerpt from a news piece by @neuroccm for Neurodiem. MR CLEAN-NO-IV Study Direct to EVT (early window) vs. Thrombolysis + EVT - designed as a superiority study. "They did not show superiorly nor non-inferiority of direct to EVT vs. combination treatment. There were no differences in symptomatic intracranial hemorrhage which is a particularly important finding, given that one could expect a higher rate with the TPA group. Dr. Yvo Roos, in a post-presentation interview with the AHA, suggest that hemorrhage rates may be more related to either delayed recanalization or simply that reperfusion itself is the main culprit for hemorrhage rather than onboard thrombolytic. This is provocative and needs further study and further details need to be reviewed. Certainly, there is biological plausibility and that patients are heterogeneous enough in their physiology and baseline neurovascular characteristics that reperfusion as a physiologic insult can result in such findings. The important takeaway message here is that for patients that are eligible to receive thrombolysis – that thrombolysis should not be withheld in the era of thrombectomy, and thrombolysis should be delivered in a timely manner. Taken together, there appears to be more science and understanding of criteria that are still necessary to be discovered with regards to which patient should go a stroke center capable of delivering thrombolysis versus directly to center that can provide comprehensive care with both modalities." excerpt from a news piece by @neuroccm for Neurodiem.

In this episode, two keen Resident MDs Drs. Ryan Muir (PGY4) and Jaime Cazes (PGY1) join us for an in-depth at how things are going! A recent look back from within the 2'nd wave of COVID (in Canada), which thankfully is subsiding. They provide insight into how COVID has impacted their residency training, what our program has done, and how new learning opportunities have manifested in the form of Virtual Care. #TakeCare Everyone and keep looking out for your #Wellness as we look forward to better days!

Did you ask about thrombolysis? We are here to deliver anxiolysis! In this second of a two-part episode of 2021, we discuss "crisis resource management" (CRM) in acute stroke - a cognitive, mindfulness, and non-technical framework for optimizing clinical performance and working in high-performing teams. CRM is a tool to master four operational domains: that of the self, teamwork, our working environment, and of course, (care for) our patient. Using CRM principles helps make us better clinicians, work more effectively in teams, and maintain a calm sense of vigilance. We re-introduce the concept of a "zero point survey" (Reid et al. 2018) as a starting point before coming on-call for a code stroke and as a tool for better self-awareness and performance. High-performing teams support good clinical outcomes at the resuscitation phase and apply to all subsequent patient care settings. Central to a high-performing team are principles of CRM and their timely application to stroke care. We review our paper in Neurocritical Care titled: "Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care" with three of the authors: Rajendram, Notario, Khosravani - In this episode we conclude this talk on "how to be a bad-a$$ stroke" resus doc! Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care by: Phavalan Rajendram, Lowyl Notario, Cliff Reid, Charles R. Wira, Jose I. Suarez, Scott D. Weingart & Houman Khosravani (Neurocritical Care, published in 2020) Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance Cliff's Great talk - Making Things Happen

Did you ask about thrombolysis? We are here to deliver anxiolysis! In this first of a two-part episode of 2021, we discuss "crisis resource management" (CRM) in acute stroke - a cognitive, mindfulness, and non-technical framework for optimizing clinical performance and working in high-performing teams. CRM is a tool to master four operational domains: that of the self, teamwork, our working environment, and of course, (care for) our patient. Using CRM principles helps make us better clinicians, work more effectively in teams, and maintain a calm sense of vigilance. We re-introduce the concept of a "zero point survey" (Reid et al. 2018) as a starting point before coming on-call for a code stroke and as a tool for better self-awareness and performance. High-performing teams support good clinical outcomes at the resuscitation phase and apply to all subsequent patient care settings. Central to a high-performing team are principles of CRM and their timely application to stroke care. We review our paper in Neurocritical Care titled: "Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care" with three of the authors: Rajendram, Notario, Khosravani Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care by: Phavalan Rajendram, Lowyl Notario, Cliff Reid, Charles R. Wira, Jose I. Suarez, Scott D. Weingart & Houman Khosravani (Neurocritical Care, published in 2020) Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance

Greetings Stroke FM listeners. We are back in 2021 with an exciting series of Podcasts, follow-up episodes, clinical and non-technical discussions and new future partnerships. Looking forward to releasing episodes as we record them this year and moving onwards! Take care + stay safe!

Song written and performed by Jaime Cazes

Key Terms: Thrombolysis, endovascular therapy, Hosts: Ryan Muir, Houman Khosravani Summary: In this episode the hosts discuss the future of stroke by exploring and proposing novel applied modern concepts of endovascular and thrombolytic therapies to innovative and creative ideas for the future. Endovascular therapy for distal vessels is discussed Improving geographic access to endovascular therapy (especially for wide spread countries like Canada) The role of the NIHSS score in the acute assessment of stroke in the future and the increasing reliance on imaging parameters to guide decision making The future of thrombolysis The future of neuroimaging: Evolving understanding of ASPECTS and MRI Brain (Solid state MRI in acute stroke assessments), and potential role for focused ultrasound Neuroprotection and extending time-windows

Key Terms: Transition to residency, Work-life balance, Mentorship, Surviving PGY1 Hosts: Sydney Lee, Jaime Cazes and Houman Khosravani Summary: First few days of residency Managing expectations Discovering the rewards of residency Going from off-service to on-service Balancing residency with lifestyle Mentorship Surviving call Three take home points A positive attitude will take you far Reach out to your fellow residents Enjoy yourself as much as possible

Key Terms: COVID-19, Stroke Orientation, NVU Hosts: Jane Liao, Houman Khosravani Summary: Purpose of modified procedures - Limit human-human interaction Handover in separate rooms Limit hand-off of items (pager, tools) and wipe down after doing so Virtual meeting apps (Zoom, Google Meet) for rounds/teaching when possible Have a moderator for meetings focused on keeping discussions concise Send residents home early if the day's tasks are complete and they are not needed Assign only one resident to go with the staff to stroke codes as opposed to the whole team https://www.codestroke.net/covid19

Key Terms: Protected Code Stroke, COVID-19, Personal Protective Equipment Hosts: Phavalan Rajendram, Jaime Cazes, Houman Khosravani Summary: The COVID-19 pandemic poses unique challenges in delivering hyperacute stroke care The “Protected Code Stroke” (PCS) protocol provides a framework for safely and efficiently delivering hyperacute stroke care Know when to activate a PCS Always use PPE with correct donning & doffing techniques Always appoint a safety leader Use crisis resource management principles

Key Terms: COVID-19, PPE, Pandemic, medical education Hosts: Jaime Cazes, Houman Khosravani Summary: This episode covers how COVID-19 has impacted healthcare and medical education from the viewpoints of a graduating 4th year medical student and a staff physician.

Key Terms: ICH, blood pressure control, spot sign Hosts: Phavalan Rajendram, Neha Patel, Houman Khosravani Summary: Hemorrhagic strokes (HS) account for ~15-20% of all strokes There is a significant morbidity and mortality associated with HS Early blood pressure control is key in the management of HS CTA can identify a spot sign (may indicate increased risk of hematoma expansion) Etiologies Find out if the patient is on anticoagulation so that it can be reversed Make sure the patient is stable before CT scan (may need anti-emetics, intubation, etc.) Early blood pressure control is key Blood pressure target < 140/90 See ATACH-2 and INTERACT trials on BP control in ICH Consult NSx early as surgical options may be available See STICH-2 trial on surgical management of superficial ICH without IVH Prognostication can be aided with “ICH Score”

Key terms: DAPT, Minor stroke, TIA Hosts: Tess Fitzpatrick, Katherine Sawicka, and Houman Khosravani Summary: Monotherapy with antiplatelet Dual antiplatelet evidence critical appraisal CHANCE POINT

Key terms: Feedback, communication, competence by design Hosts: Neha Patel, Phavalan Rajendram and Houman Khosravani Summary: Feedback can feel uncomfortable More feedback at more time points is effective for resident growth Competence by design Types of feedback Debriefing as a team after difficult and complex medical situations How to learn and grow from feedback as a resident Sandwich approach to feedback Be constructive, goal is to help person improve ultimately

Key terms: Stroke rotation survival guide, NIHSS tips, Burnout prevention Hosts: Katherine Sawicka, Tess Fitzpatrick, and Houman Khosravani Summary: Code stroke basics Establish roles within the team – history-taker, examiner Clarify history from EMS, family, bystanders (ie: last seen well) Know your NIHSS Anxiolysis Useful apps NIHSS score & stroke tools Neuro toolkit Do some reading ahead of time Canadian Best Practices guidelines are a great resource Learn ASPECTS Prevent burn-out

Key Terms: Endovascular therapy (EVT), Mechanical Thrombectomy, Large Vessel Occlusion, CT-Perfusion, Perfusion Mismatch Hosts: Ryan Muir, Tess Fitzpatrick, Houman Khosravani Summary: 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 Modified Rankin Scale (MRS) at 90 days). These trials were summarized in a meta-analysis performed by the HERMES in collaboration in 2016. MR. CLEAN ESCAPE REVASCAT SWIFT PRIME EXTEND IA In the HERMES pooled analysis the number 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 - the THRACE trial DAWN DEFUSE 3 As a result of DAWN and DEFUSE 3, the 2019 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 thrombectomy is 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

Key terms: thrombolysis, door-to-needle, contraindications Hosts: Neha Patel, Phavalan Rajendram, & Katherine Sawicka Summary: 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

Key Terms: Code stroke, protocol, intravenous tPA risks, intravenous tPA contraindications, ASPECTS and stroke mimics 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 the Table 1 Adapted 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

Introducing Stroke.FM! This Stroke focused podcast is developed by faculty and residents who are in The University of Toronto Neurology Program. It is geared towards residents and medical students with a keen interest in Stroke and Stroke related topics. This podcast is hosted by Toronto Stroke Neurologist Dr. Houman Khosravani and is regularly frequented by residents in the program including Phavalan Rajendram, Ryan Muir, Katherine Sawicka, Tess Fitzpatrick, Neha Patel, Sydney Lee, and Jaime Cazes. Check us out on stroke.fm