Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Acute Ischemic Stroke
18 Plays3 years ago
In this episode of the podcast, we discuss the management of Acute Ischemic Stroke (AIS). Our guest is Dr. Fred Rincon, a neurologist and critical care specialist with expertise in the resuscitation and management of acute brain injured patients. He is a Professor of Neurology at Cooper Medical School of Rowan University and Director of the Neuro-ICU at Cooper University Health Care in Camden, New Jersey.
Additional Resources
Management of Acute Ischemic Stroke. F. Herpich and F. Rincon: https://pubmed.ncbi.nlm.nih.gov/32947473/
AHA Guidelines for the Management of Acute Ischemic Stroke (2019): https://pubmed.ncbi.nlm.nih.gov/31662037/
Link to NIHSS Certification Course: https://www.nihstrokescale.org/
The intensive care management of acute ischemic stroke. D. Sharma and M. Smith: https://pubmed.ncbi.nlm.nih.gov/35034076/
Association of Neurocritical Care Services with Mortality and Functional Outcomes for Adults With Brain Injury. Meta-analysis. JAMA Neurology 2022: https://pubmed.ncbi.nlm.nih.gov/36036899/
Book Recommendations:
The Servant: A Simple Story of About the True Essence of Leadership. By James C. Hunter: https://amzn.to/3U6u6SI
How to Be a Leader: An Ancient Guide to Wise Leadership. By Plutarch: https://amzn.to/3eMBxhU
Recommended
Transcript
Introduction to Podcast and Episode Theme
00:00:06
Speaker
Welcome to Critical Matters, a SOUND podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
SOUND provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:25
Speaker
In today's episode of the podcast, we will discuss the management of acute ischemic stroke.
00:00:30
Speaker
Acute ischemic stroke is a major global cause of mortality and severe disability.
00:00:36
Speaker
State-of-the-art acute ischemic stroke care requires a multidisciplinary approach that often includes intensivist and or neurointensivist.
Guest Introduction: Dr. Fred Rincon
00:00:44
Speaker
Our guest is Dr. Fred Rincon.
00:00:47
Speaker
Dr. Rincon is a neurologist and critical care specialist with expertise in the resuscitation and management of acute brain injured patients.
00:00:55
Speaker
He is professor of neurology at Cooper Medical School of Rowan University and director of the NeuroICU at Cooper University Healthcare in Camden, New Jersey.
00:01:03
Speaker
Dr. Rincon is trained both in medicine and neurology with dual fellowships in critical care, vascular neurology, and neurocritical care.
00:01:11
Speaker
Since this was not enough for Dr. Rincon, he also completed degrees in neuroepidemiology and bioethics.
00:01:17
Speaker
Dr. Rincon is a phenomenal clinician, educator, and investigator.
00:01:21
Speaker
It's an honor to have him back on critical matters.
00:01:23
Speaker
Fred, welcome back to the podcast.
00:01:26
Speaker
Thank you, Sadio.
00:01:26
Speaker
Thank you for having me.
00:01:28
Speaker
Always a pleasure to talk about acute brain injury
Importance of Understanding Ischemic Stroke
00:01:31
Speaker
with you.
00:01:31
Speaker
And today we have, I think, an update on a very important topic.
00:01:34
Speaker
But maybe we could start with just answering why should intensivists care about acute ischemic stroke?
00:01:42
Speaker
That's a great question, Serge, and I can give you a couple of reasons.
00:01:48
Speaker
The main one, right, is because in particular care medicine, you will see 20% of neurological injury in your intensive care unit, and most of that neurological injury is going to be vascular.
00:01:59
Speaker
So, you know, knowing a little bit of ischemic stroke, which is 60 to 70% of strokes, is extremely important for intensives.
00:02:05
Speaker
The second reason, in my opinion, is there's a shortage of neurologists.
00:02:09
Speaker
So, you know, these patients are coming in, right?
00:02:12
Speaker
You know, patients are getting older, they're getting a lot of risk factors, right?
00:02:15
Speaker
And, you know, that's not changing, at least in our jurisdiction, right?
00:02:21
Speaker
You know, prevention strategies, you know, are there, but, you know, patients are still having a lot of risk factors.
00:02:27
Speaker
So they're going to have a lot of ischemic stroke and there are not a lot of neurologists take care of them.
00:02:33
Speaker
much less a stroke urologist.
00:02:35
Speaker
So there's a combination of things going on in the medical field that makes me think that critical care physicians should know about this, how to handle it, and how to take care of these patients.
Stroke Assessment Tools
00:02:51
Speaker
Excellent.
00:02:51
Speaker
And I think that before we dive into more of the management of acute ischemic stroke, there's two important scales that I think would be worth refreshing our audience memories, and there'll be links in the show notes.
00:03:07
Speaker
In terms of managing acute ischemic stroke patients, one refers to diagnosis and assessment of severity, but has direct implications and
00:03:16
Speaker
treatment but also how we monitor them which is the NIH and stroke scale and the other one is more important understanding how these treatments that we implement in the literature have impacted outcomes and that's the modified ranking score could you just give us a little bit of maybe like a 101 on NIH stroke scale and on the modified ranking score
00:03:38
Speaker
Yes.
00:03:39
Speaker
So those are two different scales that tell you different things.
00:03:44
Speaker
So the first one, the NIHR scale is a scale designed to track neurological injury after ischemic stroke.
00:03:53
Speaker
And we have used it not just for ischemic stroke, we also use it for hemorrhagic stroke and
00:03:59
Speaker
you know sometimes people use it for sobriety hemorrhages but in reality it was sort of like coin and designed uh to identify the degree of or the severity of injury after an ischemic stroke and it has uh several realms uh you know 12 uh different realms that assess different uh components of the neurological exam and a trained person can uh deploy a neurological assessment with the anastroscalon under uh three minutes and there are um
00:04:30
Speaker
centers or, or websites that would help you getting trained and certified.
00:04:36
Speaker
You know, it's just going to be extremely easy to get.
00:04:38
Speaker
It's a certification that perhaps you should think about having.
00:04:42
Speaker
I don't think there is any, you know, price tag to it, but, uh,
00:04:45
Speaker
but you could get certified.
00:04:47
Speaker
And it's extremely important because it sort of like tells you how bad or good the patient is.
00:04:54
Speaker
So you can actually categorize people into mild, moderate, or severe strokes on the basis of NIH stroke scale, up to five considered to be mild, six to 12, perhaps moderate, and more than 13 is usually a bad stroke.
00:05:10
Speaker
And it also helps you tracking the patient's improvement or deterioration, right?
00:05:15
Speaker
So in terms of communication, it's an extremely important tool to, you know, predict disability.
00:05:21
Speaker
It also predicts mortality and helps you to, like, track the patient in the hospital, you know,
00:05:29
Speaker
for their admission.
00:05:30
Speaker
As I said, in terms of communication, extremely important, right?
00:05:34
Speaker
Because you are tracking the degree of improvement or deterioration after an intervention.
00:05:40
Speaker
And in general, we consider, you know, worsening of somebody's condition
00:05:46
Speaker
when the NIH stroke scale changes significantly, and we use usually a point, I'm sorry, a four point change in the NIH stroke scale to consider a significant change in the neurological
Role of CT and CT Angiograms in Stroke
00:05:58
Speaker
exam.
00:05:58
Speaker
It's part of the benchmarks that our stroke centers use to get accreditation and to track quality improvement programs.
00:06:07
Speaker
So in the first hours of ischemic stroke, you need to document
00:06:14
Speaker
an NIH stroke scale before the administration of thrombolytics or before endovascular thrombectomy and then 6 to 12 hours after
00:06:23
Speaker
the initiation of therapy.
00:06:25
Speaker
And then in the neuro ICU, you can develop even more sophisticated ways of tracking this.
00:06:30
Speaker
I mean, you could ask the nurses to do it, Q1 hour for the first couple of hours, post-DPA, and then eventually, you know, every, you know, six to eight hours for the first 72 hours.
00:06:41
Speaker
And it gives very objective information, you know, you know, to track the patient's condition.
00:06:48
Speaker
So that is severity, right?
00:06:50
Speaker
So it's a scale designed to measure severity of stroke, I'm sorry, and then it can use to predict outcomes as well.
00:07:01
Speaker
The modified ranking on the other side is a measurement of function and it's extremely valuable when you're dealing with stroke patients in general.
00:07:14
Speaker
It was also developed to deal with stroke patients and for this particular one then yes, ischemic stroke, hemorrhagic stroke scan,
00:07:21
Speaker
you know, apply.
00:07:23
Speaker
And it tells function.
00:07:24
Speaker
And when you communicate with, you know, with individuals, with family members, right, you can actually use this because there are,
00:07:33
Speaker
not just based on experience but based on clinical trials and statistics you can actually guide expectations of outcomes right and then you can use this to sort of like explain uh to individuals you know uh you know what the function is or is uh supposed to be you know uh after the intervention so um zero to six is very simple to remember zero no deficits six is death uh one is somebody that has had you know a stroke and has um
00:08:00
Speaker
no symptoms except when perhaps gets tired, you know, and anxious, right?
00:08:05
Speaker
You get symptoms from, from the prior stroke.
00:08:08
Speaker
So there's usually, you know, very mild disability too.
00:08:13
Speaker
It's mild disability is usually a patient that you see, you know, sort of like walking, uh,
00:08:18
Speaker
you know, on the street, perhaps with a limp, but with really no devices, right?
00:08:22
Speaker
Or perhaps with a cane here and there.
00:08:24
Speaker
Three is moderate disability.
00:08:25
Speaker
Somebody has had an ischemic stroke and has a lot of issues with the activities of daily living, perhaps needs some assistance in some of those activities of daily living, walks with a cane or with a device, right?
00:08:36
Speaker
But is able to beat himself or herself.
00:08:39
Speaker
and that sort of thing.
00:08:41
Speaker
A four is severe disability, and it usually represents that patient that is actually handicapped from a stroke and requires a lot of assistance.
00:08:50
Speaker
Sometimes, you know, patients end up with a trach and a peg, but are not vegetative, all right, or minimally conscious.
00:08:56
Speaker
So that's sort of like a
00:08:58
Speaker
an important definition of MRSO4.
00:09:01
Speaker
And then finally, five, somebody with an ischemic stroke that unfortunately is minimally conscious, perhaps evolving into a vegetative state, usually a severe brain injury, a severe stroke.
00:09:12
Speaker
And then six, as I said, death.
00:09:14
Speaker
So the clinical trials have been, in a stroke, have been designed to capture these outcomes in the long term, three, six months, and 12 months down the road.
00:09:22
Speaker
And there, you know,
00:09:25
Speaker
a variety of clinical trials, you know, for different interventions that have used this.
00:09:29
Speaker
And knowing those, you know, when you're having interactions about prognostication, right,
00:09:35
Speaker
this scale becomes very useful.
00:09:38
Speaker
And again, there's also centers and websites that can train you and certify you so that when you give an NIH stroke scale and a modifying ranking scoring in the medical record, that is a certifiable scale, right?
00:09:51
Speaker
So it's also important,
Advancements in Thrombolysis
00:09:54
Speaker
right, because if you have somebody with a premorbid condition, right, of let's say five, somebody comes in vegetative and now you're suspecting the patient has a stroke, you know,
00:10:04
Speaker
Yes, you could treat that patient, right?
00:10:06
Speaker
But the jump on improvement is not going to be meaningful, right?
00:10:10
Speaker
Because there's nothing for that patient, right, to improve.
00:10:14
Speaker
The patient is not going to go back to a three or a two, right?
00:10:17
Speaker
So having those discussions with family is also important, right, at the point of care.
00:10:21
Speaker
Are you going to treat somebody with something that has a chance of or some risks, you know, bleeding and...
00:10:29
Speaker
you know, you name it.
00:10:30
Speaker
So that's when the scale becomes really important.
00:10:35
Speaker
And would it be fair to say that three and below is considered a good outcome and four, five, and six obviously are non-desirable outcomes in general?
00:10:45
Speaker
Correct.
00:10:46
Speaker
And that dichotomization, right, historically is what, you know, trials and stroke have sort of like used in the follow-up, right, of these patients, right?
00:10:56
Speaker
But I think ordinal scales are much better now than the dichotomized outcome that you mentioned, right?
00:11:01
Speaker
I think, you know, if you come in with a zero and having to jump to a two, well, perhaps, you know, and then you don't get back to zero, right?
00:11:09
Speaker
You know, even though it's within that sort of like, you know,
00:11:14
Speaker
you know, good outcomes or all that thing, right?
00:11:18
Speaker
You know, you have jumped, you know, excessively, right, within the function.
00:11:22
Speaker
So the ordinal scales in terms of measuring outcomes on the road, I think are more efficient, but you're right.
00:11:28
Speaker
Historically, what you said is what's considered a good outcome.
00:11:32
Speaker
Excellent.
00:11:33
Speaker
And I think that for today's discussion, Fred, before we started recording, we talked about some of the things that I wanted to focus on.
00:11:40
Speaker
We're probably not going to go, obviously, into every single little detail regarding acute ischemic stroke.
00:11:46
Speaker
There'll be references attached to the show notes.
00:11:50
Speaker
But...
00:11:51
Speaker
What I do want to talk about as a starting point for the management is neuroimaging.
00:11:56
Speaker
And obviously, that's the cornerstone of making therapeutic decisions.
00:12:01
Speaker
Historically, CT non-contrast of the brain was what we got, and we got that quickly.
00:12:07
Speaker
Can we start there and then maybe expand on what's next?
00:12:13
Speaker
Yeah.
00:12:14
Speaker
Yeah, so go standard right for it.
00:12:17
Speaker
Dealing with somebody with a stroke syndrome is imaging, right?
00:12:22
Speaker
And you could get a CAT scan within five minutes in the emergency department or in any other institution on the floor, in the circuit unit.
00:12:28
Speaker
I know they have portable versions of this stuff, right?
00:12:30
Speaker
And the resolution is pretty similar.
00:12:34
Speaker
So you have, you know, let's say, you know, a patient, you know, in the CT ICU that just had cardiac surgery and now is semi-parietic, right?
00:12:40
Speaker
And then you need a quick assessment.
00:12:42
Speaker
But let's say the patient has a couple of chest tubes and pacemaker wires, right?
00:12:46
Speaker
a portable scan makes a lot of sense.
00:12:47
Speaker
Now you cannot do perfusion or angiogram with those devices, but I think in the future, because now they're doing this angiograms, right, on these portable scanners and ambulances in Texas.
00:12:57
Speaker
So I don't know who you know about that, right?
00:12:58
Speaker
But this technology is going to continue to revolt and perhaps in the ICU,
Endovascular Therapy Developments
00:13:04
Speaker
we might be able to give
00:13:05
Speaker
contrast with a cat scan if you have a good protocol but in general right the non-contrast is the one um that is readily available and it helps you um discern between um or differentiate between hemorrhagic strokes and ischemic stress because that's a contraindication for uh
00:13:24
Speaker
thrombolytics right if you have somebody with an iph or an aneurysm that ruptured uh you know clearly a contraindication to give uh thrombolytics and that's how we start practicing you know and then over the last 10 uh to 15 years right the cp angiogram became an important component right uh of the assessment um because of
00:13:46
Speaker
the evaluation of the anatomy, right?
00:13:48
Speaker
So specifically for these patients been moderate to large or severe strokes, you want to know, right, if you're dealing with a vessel occlusion that requires a mechanical intervention.
00:14:00
Speaker
And the reason for that is very simple is that we learn from the clinical studies, right, in thrombolysis, right, that T occlusions or M1 occlusions, particularly T occlusions, right, meaning the distal, you know, internal carotid occlusion,
00:14:16
Speaker
they don't recanalize that well with just intravenous thrombolytics, right?
00:14:20
Speaker
And that is what opened up all these new era of revascularization, right?
00:14:25
Speaker
It's the T-occlusion proximal of the MCA rarely recanalized just with TPN.
00:14:33
Speaker
If you look at the literature, we're talking about rates
00:14:35
Speaker
around 20% of recanalization, which is the same as placebo in the original NINDS-TPA study.
00:14:42
Speaker
So we're basically talking that if you are recognizing a large-fresin occlusion, a carotid occlusion, or a T occlusion, an approximate MC occlusion, perhaps the chances of recanalizing that with thrombolytics are as good as placebo in the original 1996 NINDS-TPA study.
00:14:58
Speaker
So that's why CTA is so important.
00:15:01
Speaker
And it gives you a lot of information, right?
00:15:03
Speaker
You want data, you want information where you're dealing with these patients.
00:15:06
Speaker
Does the patient have an intracranial stenosis as well?
00:15:10
Speaker
Does the patient have a contralateral carotid stenosis or MCA stenosis that may require a little bit of more liberal blood pressure management down the road?
00:15:21
Speaker
Or does the patient have a dissectional, does the patient have a free thrombus also?
00:15:25
Speaker
Those sort of things, you know, you learn a lot from looking at the CTA.
00:15:31
Speaker
And on the basis of that, then you can sort of like predict, you know, your recanalization, you know, with thrombolytics and then the patient requires an intervention because of what I said, you know, recanalization is really low.
00:15:45
Speaker
Perfusion, right, is a more advanced technique, and not every center has.
00:15:49
Speaker
There's some centers in having corporate perfusion, right, in terms of decision-making.
00:15:54
Speaker
Most of the clinical trials in thrombectomy did not require a perfusion.
00:15:59
Speaker
It was basically an assessment of the degree of ischemia or infarct on a CAT scan, so on the non-contrast CAT scan.
00:16:09
Speaker
And you can interpret that just by looking at a CAT scan, and there is a specific scoring system
00:16:15
Speaker
for it called the aspect score that was designed also to, you know, sort of like, you know, predict, you know, the degree of court, right, versus penumbra, and then the rate of complications, right?
00:16:28
Speaker
So the lower the aspect score, a score of 10 is usually normal.
00:16:31
Speaker
The lower the aspect score, then the higher chance of complications after re-canalization by obvious reasons, because you're basically re-canalizing somebody with a lot of infarct burden, right?
00:16:41
Speaker
So that is from the non-contrast.
00:16:44
Speaker
The perfusion acts a little bit more on the basis of some interpretation of blood flow, right?
00:16:50
Speaker
So it tells you, you know, on the basis of how much contrast is circulating in the arterial and venous phases of the perfusion scan.
00:17:00
Speaker
And the software sort of like gives you a number, and there are more sophisticated, you know, packages right now out there.
00:17:09
Speaker
that can interpret that for you and can give you values of perfusion.
00:17:14
Speaker
And then on the basis of that, people can actually intervene.
00:17:17
Speaker
Some centers use perfusion to predict complications.
00:17:21
Speaker
So a bad perfusion scan will make somebody with a large vessel occlusion not be a candidate for intervention.
00:17:29
Speaker
Some other centers use more the clinical exam and the aspect score without perfusion, right?
00:17:35
Speaker
I think perfusion becomes really valuable
00:17:38
Speaker
when your clock is sort of like unknown, when you don't really know the last thing normal, and somebody wakes up with a stroke, for example, I think perfusion becomes really important to go back to that point that you mentioned at the beginning, the biological clock.
00:17:54
Speaker
And I think imaging is what is going to align you more to the biological clock, meaning the real time of the stroke rather than the clinical time.
00:18:03
Speaker
Because, I mean, sometimes...
00:18:05
Speaker
And you've probably seen this, right?
00:18:07
Speaker
Family members don't know when the lasting normal is, and it's just really devastating not knowing that because you cannot do anything.
00:18:14
Speaker
Or providers in the hospital, you know, a patient goes to the room six hours, nobody checks the patient, and then nobody really knows when the lasting normal is.
00:18:21
Speaker
But imaging can actually help you with aligning you with that biological flaw.
00:18:26
Speaker
Some of the people have used MRI technology and that's actually probably a next generation, right?
00:18:33
Speaker
But getting a stat MRI in the setting of an acute skinic stroke is something that is not pragmatic yet, at least in most centers in the United States, perhaps research.
00:18:42
Speaker
centers are more capable of using a MR technology with diffusion and flare, for example, to determine that biological clock in the patient is amino for thermolysis, for example.
00:18:55
Speaker
There was a study in 2017-18 that basically showed that MRI can assist in giving TPM patients that are waking up with strokes.
00:19:07
Speaker
Excellent.
00:19:08
Speaker
And I think, Fred, that it'd be fair to say, right, that time is of the essence.
00:19:13
Speaker
So getting a plain CT as soon as possible is the first point.
00:19:17
Speaker
And we shouldn't really delay doing that or the potential initiation of, as we'll see, thrombolysis.
00:19:25
Speaker
If we're trying to get like an MRI or CTA, CTP, we don't have that in place.
00:19:30
Speaker
But the initial plain CT will tell you if there's blood, which would be a contraindication for thrombolysis.
00:19:37
Speaker
But it also can give you information of the nature of the stroke as well, right?
Importance of Early Revascularization
00:19:41
Speaker
Like you could see a dense MCA, or you could see, I mean, significant findings that might give you an indication of how severe this is.
00:19:50
Speaker
Now, the CTA and the CT perfusion are obviously a step further that allow you to refine your best therapeutic approach in a much more calibrated way.
00:20:03
Speaker
Is that the way you would think about this?
00:20:06
Speaker
I do.
00:20:06
Speaker
I do.
00:20:09
Speaker
The perfusion can actually help you calibrating, as you're saying, and the CTA gives you enormous information about the anatomy.
00:20:16
Speaker
And if you look at the guidelines, right,
00:20:18
Speaker
IPCTA is becoming more like a standard here right now.
00:20:21
Speaker
So, you know, your stroke protocol, you should have at least, you know, a CTA.
00:20:28
Speaker
And of course, there are contraindications for it, right?
00:20:30
Speaker
But you just have to think about can the patient get contraindications or not.
00:20:36
Speaker
Excellent.
00:20:37
Speaker
So one of the key goals, obviously, in advanced stroke management is revascularization and limiting secondary brain injury.
00:20:48
Speaker
Historically, this really started with the initial studies that suggested that IV tPA made a difference.
00:20:58
Speaker
Those seem to take a long time to really catch on.
00:21:01
Speaker
And it feels, from my perspective as a non-neurologist, that for many years, we probably have underperformed as a medical community in providing TPA to patients who could benefit from it for many reasons.
00:21:15
Speaker
Maybe you can expand on those.
00:21:17
Speaker
But also now there's a new era with a whole set of endovascular therapies that are available.
00:21:24
Speaker
But also, like you said, with a much more biological approach at a time and to windows that seem to continue to expand.
00:21:35
Speaker
So why don't we start with IV thrombolysis?
00:21:37
Speaker
You want to take us through the history and kind of where it stands today?
00:21:40
Speaker
And then after that, we can talk a little bit more about endovascular therapy.
00:21:45
Speaker
Yeah, so the history of thrombolegic is actually a very, you know, sort of like complicated,
00:21:54
Speaker
um, history in, uh, in neurology, uh, cause it started with negative studies, right?
00:21:59
Speaker
It actually started with, uh, you know, uh, you know, people extrapolating, you know, doses for MI to ischemic strokes and sort of like learning very quickly that, uh, that that was not the, the, the, the right way.
00:22:12
Speaker
And then sort of like adjusting the dose, right.
00:22:14
Speaker
And, um, getting to a dose that was more amenable with, uh, uh, with ischemic stroke.
00:22:21
Speaker
But, um,
00:22:22
Speaker
Since 1995, 1996, with NINDS, there's been a lot of criticisms to the way of how we incorporated TPA into our momentarium to treat stroke patients.
00:22:36
Speaker
And when I was in medical school in 1990, right, there was nothing to do for these patients.
00:22:40
Speaker
I mean, you know, these patients would come in, and they would just like, there's nothing to do, and they would just go to the floor.
00:22:46
Speaker
They wouldn't even go to the intensive care unit.
00:22:48
Speaker
They'd go to the floor, and then they would just decompensate and die.
00:22:51
Speaker
I mean, you wouldn't even incubate this patient, right?
00:22:53
Speaker
It was just like massive stroke, nothing to be done.
00:22:55
Speaker
It was like a bad sentence.
00:22:57
Speaker
And then in 1995, you know, the results of the study came out, right, showing a benefit, right?
00:23:08
Speaker
And...
00:23:10
Speaker
A lot of people have criticized that study because the benefit was not really for the primary endpoint.
00:23:16
Speaker
It was for the secondary endpoint.
00:23:18
Speaker
On the basis of that, we started incorporating this stuff for managing our ischemic stroke patients.
00:23:25
Speaker
And then eventually, more clinical trials are looking at this.
00:23:29
Speaker
It started adjusting, dosing and timing, right?
00:23:36
Speaker
when you looked at the pool sort of like analysis of those types over 15 years right you see a clear um effect right and and and the skeptics are always saying well why aren't we considering the negative trials and it could just be a harmful uh intervention for
00:23:54
Speaker
for stroke reasons.
00:23:55
Speaker
And the answer to that is that I haven't seen a negative trial since we started using TPA in the last 50 to 20 years, right?
00:24:03
Speaker
And on the other hand, right, we have become more sort of like careful about selecting patients.
00:24:09
Speaker
And I think patient selection was an issue on the original studies, right?
00:24:12
Speaker
I think for dosing.
00:24:14
Speaker
But right now that we're selecting these patients so carefully, right, so like patient-based selection process,
00:24:20
Speaker
I think the rate of complications is actually lower.
00:24:24
Speaker
And the other issue was, right, the bystander recognition of this stuff, right?
00:24:28
Speaker
So now patients are coming quicker, you know, to the healthcare system, and then you're seeing a lower rate of complications, right, when these patients get thrombolysis or thrombectomy, right, earlier, right?
00:24:44
Speaker
Of course, you're giving this stuff, you know, at the end of 4.5 hours, right, you're probably going to have more complications.
00:24:50
Speaker
um that if you do it in the first 30 minutes of an ischemic stroke so um so that is the the issue right um over the last 15 to 20 years and so like the debate you know surrounding uh internal strombolysis but when you look at the meta announcement there are a couple that i can quote you know in gamma um by jeffrey saber for example uh the incidence of hemorrhagic complications the incidence of
00:25:13
Speaker
of mortality in the hospital, right?
00:25:15
Speaker
The incidence of being discharged to home and having a better functional outcome, right?
00:25:21
Speaker
All time dependent, you know, with intravenous thrombolytic.
00:25:24
Speaker
So when you add up all that information, you're like, well, I don't see any negative effect here, right?
00:25:29
Speaker
So I think it's time to sort of start thinking seriously about, you know, thrombolysis.
00:25:35
Speaker
The problem with thrombolysis, right, that you have a very narrow window, usually three hours with, you know,
00:25:44
Speaker
a lot of contraindications and issues.
00:25:47
Speaker
And then for a specific patient core, you can actually extend that to 4.5 hours with additional contraindications.
00:25:54
Speaker
So in reality, right, 3.5 hours, right, is very short, very narrow.
00:25:59
Speaker
So that's why a lot of patients are not getting it.
00:26:02
Speaker
And if you look at the...
00:26:05
Speaker
The administration rate in the United States, I think we are still like around, you know, 2 to 5%, you know, and when I started, it was like 2%.
00:26:13
Speaker
I guess it's coming up a little bit more because of all the campaigns and American Heart Association, American Heart Association education for bystanders to recognize it.
00:26:22
Speaker
So that's another problem, right?
00:26:23
Speaker
Is that people don't recognize this with enough time to get the patient into the healthcare system.
00:26:32
Speaker
um you know remember what i said about the ambulances circulating you know in texas that approach for example has increased the delivery of of of dpa in in um in in the in the field with really no uh you know major incidents of of complications right the question is can that be implemented everywhere and the answer is well that's typical because it's very expensive right and um
00:26:57
Speaker
And I don't think every jurisdiction has the budget to deal with this stuff.
00:27:02
Speaker
But if you leave more than 30 minutes away from a stroke center, right?
00:27:07
Speaker
Observational studies have shown that you are more likely to not get any intervention just because of that, right?
00:27:12
Speaker
So, you know, how are we going to cover that gap?
00:27:16
Speaker
It's a thing that we can need for the future in Europe, on the other hand, right?
00:27:20
Speaker
You know, you know,
00:27:23
Speaker
you can get access to a stroke center very quickly, right?
00:27:27
Speaker
So these ambulances, you know, they'll make a lot of sense, right?
00:27:30
Speaker
If you live in an urban area where you can get into the hospital within five, 15 minutes of being recognized, but it would make more sense for rural areas that don't have access to stroke centers.
00:27:45
Speaker
And a couple of questions here regarding thrombolysis, IV thrombolysis.
00:27:50
Speaker
So clearly, like you stated, Fred, the literature is solid in improving outcomes, both in terms of neurological outcomes, but also overall mortality long-term, right?
00:28:01
Speaker
And that includes accounting for potential complications like intracerebral hemorrhages, which, as you mentioned, is
00:28:09
Speaker
with the right patient population selection seems to be much lower than people believe it is.
00:28:15
Speaker
But the timeframe you said is three hours from onset of symptoms.
00:28:21
Speaker
So that's onset of symptoms to needle.
00:28:25
Speaker
And it can be expanded to 4.5 hours in some patient populations.
00:28:30
Speaker
But would it be fair to say that the goal is still to try to evaluate or put as many patients as possible at the door of receiving it, right?
00:28:41
Speaker
And then obviously you can go through the contraindications and if they don't qualify, that's okay.
00:28:45
Speaker
But also even for patients who might benefit down a little bit later from endovascular therapy, we should still strive to give IV tPA when possible.
00:28:55
Speaker
Is that correct?
00:28:57
Speaker
Yeah, that's correct.
00:28:58
Speaker
So,
00:28:59
Speaker
Thinking that somebody is a candidate for a thrombectomy and endovascular intervention does not preclude the patient from receiving intaminous thrombolysis as long as the patient is within the 0 to 4.5%
00:29:15
Speaker
window and meets all the inclusion and exclusion criteria.
00:29:18
Speaker
Yeah, that's right.
00:29:19
Speaker
They have tried to, you know, these clinical studies where, you know, you use half of the dose or different weird doses, right?
00:29:27
Speaker
And the answer is just like, no, you know, you use the full dose of TPA and then you get the patient to a thrombectomy.
00:29:33
Speaker
And the combination, right, it's actually, you know, associated with better recanalization scores, right?
00:29:40
Speaker
So, you know, and that's another thing that we should talk about, right, is the difference between tenecteplase and alteplase, right, is that, you know, when you compare both, they sort of like are the same in terms of re-canalization, but when you use thrombectomy or mechanical intervention, right, with tenecteplase, right, that combination seems to be
00:30:01
Speaker
better than without the place.
00:30:04
Speaker
So that's why some centers right now, like my center, converted to administering Thenecteplase for eligible patients when the suspicion for thrombectomy was high.
00:30:16
Speaker
So you're using Thenecteplase now more than before.
00:30:22
Speaker
So the use of tenaplase is increasing because of its improved outcomes when you combined IV thrombolysis with endovascular intervention.
00:30:32
Speaker
Is that correct?
00:30:33
Speaker
Correct, yes.
00:30:34
Speaker
So I don't know.
00:30:35
Speaker
I haven't looked at literature and see if there's more adoption in the U.S., right, for connected place, because, I mean, we fought to give TPA for 15, 20 years, right, so a lot of centers got very used to using out-of-place, right?
00:30:50
Speaker
And as I said, you know, when you compare head-to-head, they are the same in terms of, you know, outcomes and re-canalization.
00:30:59
Speaker
Right.
00:31:01
Speaker
But the problem with Alteplase is that it requires preparation.
00:31:05
Speaker
So it requires a pharmacist to make the solution based on patient weight.
00:31:12
Speaker
Connected piece on the other hand is ready to use.
00:31:14
Speaker
You don't need a pharmacist.
00:31:16
Speaker
So in my experience, some institutions have had a lot of issues with delivering Alteplase on time in the emergency department.
00:31:23
Speaker
And that added to that clock that you start when a patient hits the emergency department.
00:31:28
Speaker
or when the stroke alert is activated, right?
00:31:31
Speaker
Is that, you know, if you're preparing this for five to 10 minutes, well, those five to 10 minutes are costing the patient, you know, 10, 20 million neurons, you know?
00:31:39
Speaker
So it's like 2 million neurons per minute, right?
00:31:41
Speaker
So, you know, that's why, but I haven't, you know, looked in the literature and seen, right, if the United States is adopting more than ectopies.
00:31:51
Speaker
What I can tell you, right, because of the price,
00:31:54
Speaker
is that my colleagues in Mexico, for example, or my colleagues in Colombia or Chile, they're using more tenecaplase because it's easier to use.
00:32:01
Speaker
So it makes total sense, right?
00:32:03
Speaker
I'm not, I don't have any concerns of interest about this trombolitis, but what I'm saying is that it's something that's easier to use and is associated with better outcomes, so why not using it, right?
00:32:14
Speaker
Makes sense.
00:32:14
Speaker
So let's talk a little bit, Fred, of endovascular revascularization or endovascular therapy.
00:32:21
Speaker
And that is a...
00:32:23
Speaker
a more recent history, but also similar, right?
00:32:26
Speaker
I mean, the first studies, perhaps because of how they were designed and the patient selection were not so encouraging.
00:32:32
Speaker
And some people kind of felt very cold about these therapies.
00:32:36
Speaker
But then I think a series of studies showed that they actually have a great impact on outcomes, but also have extended the window of things that are possible for the right selection of patients.
00:32:48
Speaker
So could you talk also a little bit about endovascular therapy?
00:32:52
Speaker
Yes, so I train in different phases of the development of endovascular therapy.
00:32:58
Speaker
So around when I was training at the end of 2000, 2005, 2008, right,
00:33:07
Speaker
This philosophy was getting implemented, and it made biological sense because of what I said, a clot in the terminus of the carotid is not going to dissolve very well with thrombolitis, so why not going after the clot?
00:33:24
Speaker
But that learning curve translated into experiencing some negative trials and some actually harmful trials.
00:33:31
Speaker
And then the other thing that was part of it, besides the learning curve of all of these providers, was the technology.
00:33:38
Speaker
So we were using a device.
00:33:41
Speaker
Well, I wasn't, but these interventionists were using these devices.
00:33:46
Speaker
that were for cardiac purposes or were for some other purposes, right?
00:33:50
Speaker
So there wasn't really like a device that was sort of like adapted.
00:33:53
Speaker
And that technology evolved, right, since 2005, 2015, right?
00:33:58
Speaker
So the first clinical studies, right, on thrombectomy were not promising, in my opinion, because of that learning curve, right?
00:34:05
Speaker
You know, you provided you to do a lot of these interventions to get really proficient with it.
00:34:09
Speaker
And then the technology was actually crappy, in my opinion.
00:34:13
Speaker
But then when these catheters started to evolve, and the companies started to manufacture catheters that were actually designed to treat brain vascular injuries, right?
00:34:25
Speaker
We have the stent retrievers right now.
00:34:28
Speaker
So, those are the ones that actually made everything possible.
00:34:33
Speaker
So that technology and the combination of people getting more proficient with this stuff is what led to the second iteration of clinical studies that actually transform the way that we think about thrombectomy.
00:34:47
Speaker
It's a very robust signal, right?
00:34:52
Speaker
And you see it at the bedside.
00:34:55
Speaker
So, you know, it is incredible seeing, you know, this 80-year-old that comes in, right, with a NIHR scale of 25, totally devastated, right, and then the next morning as an NIHR scale of 1 or 2, it's just like mind-blowing, you know.
00:35:10
Speaker
And no complications, right.
00:35:13
Speaker
It's good patient selection, good, you know, hands, provider hands.
00:35:18
Speaker
and very good technology, right?
00:35:21
Speaker
And I would just throw there very good critical care, right?
00:35:24
Speaker
Because those are the things that you need to sort of like have.
00:35:27
Speaker
When I talk about stroke care, I talk about a multidisciplinary approach.
00:35:30
Speaker
So it's just not the TPA or the provider with a thrombectomy or the ICU, Illinois.
00:35:36
Speaker
It's everything that happens, you know, from the paramedics that recognize the patient, right, to the rehabilitation centers.
00:35:41
Speaker
All of that,
00:35:42
Speaker
sort of like combination, right, of things that happen that makes the outcome even better.
00:35:48
Speaker
So I think those were the issues with thrombectomies that we were learning, A, B, the technology wasn't good, and then the second iteration of clinical studies actually showed a more robust signal, right, and because of the technology and people actually got more experience with it.
00:36:05
Speaker
And I think it's important to emphasize that for these endovascular therapies, we're looking at large vessel occlusions, right?
00:36:12
Speaker
So it's not for every stroke.
00:36:14
Speaker
It's also not for mild strokes.
00:36:15
Speaker
Like you said, I mean, NIH stroke scale, usually it's going to be 14, 15, 16 or above.
00:36:22
Speaker
But could you...
00:36:23
Speaker
Tell us, like, A, what would be the right patient selection and how we get to that.
00:36:28
Speaker
And give us a little bit of idea of the windows, right?
00:36:32
Speaker
Because this can be done, obviously, beyond the 3 or 4.5 hours.
00:36:37
Speaker
And give us a little more of an idea of that, Fred, please.
00:36:42
Speaker
Yes.
00:36:43
Speaker
So for the first question, what is sort of like a good rule of thumb of which patients qualify for surgery?
00:36:53
Speaker
for endovascular intervention.
00:36:54
Speaker
So obviously, if you're doing a CPA, you know immediately if they have large vessel occlusion.
00:37:00
Speaker
We define large vessel occlusion, carotid, double the carotid, MCA, M1 segment, M2 segment.
00:37:09
Speaker
And those are the ones that were included in the second iteration of clinical studies.
00:37:14
Speaker
But can M3 occlusions, right?
00:37:18
Speaker
And when I'm talking about M3, M2, and M1, it's the MCA, right?
00:37:22
Speaker
But can M3 occlusions or ACA occlusions or PCA occlusions or basilar occlusions derive a benefit from it?
00:37:29
Speaker
And the answer is...
00:37:31
Speaker
Possibly, right?
00:37:32
Speaker
But it hasn't been tested, right?
00:37:33
Speaker
There is a study right now trying to look at, you know, do M3 occlusions get better?
00:37:38
Speaker
We're re-canaling, and M3 occlusions recently had distal occlusion, right?
00:37:42
Speaker
So you would get a smaller stroke than if you're knocking out the whole MCA, right?
00:37:46
Speaker
So a good rule of thumb is that if you're using a CTA, right, anyone with a carotid occlusion after the M3 would be an eligible candidate, right?
00:37:56
Speaker
Most of the data, the most robust data for carotid occlusions
00:38:01
Speaker
um, these two occlusions and then the MCAs and the M2s, right?
00:38:05
Speaker
Um, but I, I would not, uh, not discuss, right, somebody with a PCA occlusion, right, with a, uh, interventionist.
00:38:13
Speaker
Why?
00:38:13
Speaker
Because a PCA occlusion could be devastating for somebody, you know, uh, that uses his eyes all the time.
00:38:18
Speaker
So you and I, for example, right?
00:38:19
Speaker
So, you know, are there risks and benefits, um, you know, in favor of proceeding with this?
00:38:26
Speaker
And the answer is, is, is possibly yes, right?
00:38:28
Speaker
Even though there is not a lot of, uh,
00:38:31
Speaker
clinical trial data on those particular territories.
00:38:34
Speaker
So that's in terms of the anatomy, in terms of the CTA.
00:38:39
Speaker
Clinically, right, if you are seeing a patient and you don't have yet information about the CTA, but you're looking at a CT scan and it looks pristine, normal, but the patient has a dense deficit, usually NIHRs scores of more than five would align with the patient probably having a large vessel occlusion.
00:38:57
Speaker
But that's not...
00:38:58
Speaker
That's not a rule in general, right?
00:39:00
Speaker
Because I've seen patients with mild strokes, NIH stroke scale, less than five, that have a large vessel occlusion.
00:39:06
Speaker
You could miss those, right, for intervention, and you're relying only on clinical exam.
00:39:10
Speaker
And there's a clinical study going on called low NIH stroke scale, large vessel occlusion, trying to determine, right, what is the best approach to, you know, treat those patients, right?
00:39:20
Speaker
So in my book, in my cookbook, right, when I'm dealing with somebody with stroke,
00:39:26
Speaker
CT, CTA, regardless of the initial scale, even TIAs, right?
00:39:31
Speaker
I tell the emergency department or whoever I'm working with, right, this patient is a CT and a CTA right now, and let's use a clear contraindication for it.
00:39:39
Speaker
So I hope that answers the first question.
00:39:44
Speaker
For the vascular artery, right, I think that
00:39:48
Speaker
You know, when you are dealing with a disease state that could be potentially devastating, right, I think that a trombectomy makes perfect sense, right?
00:39:56
Speaker
If you are locked in and you are within a reasonable window, you know, you should think about recanalization of the posterior circulation.
00:40:04
Speaker
I'm talking about the vascular artery.
00:40:07
Speaker
Perterial arteries, you know,
00:40:10
Speaker
because of where they are, you know, the collateralization that posterior circulation has from anterior circulation and from the contralateral artery.
00:40:18
Speaker
Perhaps not amenable for interventions unless you're seeing a dissection and a patient has a lot of symptoms, meaning flow failure, you can consider distenting, but those carry a lot of morbidity and mortality, right?
00:40:29
Speaker
So you have to have a discussion with the patient about that stuff.
00:40:33
Speaker
So that is in terms of the territory and the anatomy range.
00:40:37
Speaker
So timing, right?
00:40:37
Speaker
Timing is another variable that you can consider.
00:40:40
Speaker
So the original, you know, the secondary, the secondary, that is, looked at patients between 16 and 24 hours.
00:40:47
Speaker
So right now we are favoring, you know, in terms of timing for endovascular thrombectomy, after 24 hours in both the interior and posterior circulation, right, specifically, right, you can align that biological clock to imaging, right?
00:41:01
Speaker
So if you have a CT, aspects is good.
00:41:03
Speaker
You know, the patient has been down 16 hours, obviously does not qualify for TPA, but you don't see anything
00:41:09
Speaker
in the cat skin that worries you about a big core right of stroke so many originals are actually going after that if they document a large phase of the pollution right and for the posterior circulation uh the rule of thumb was up to 24 hours but you know i've seen cases where people have actually tried you know up to 36 you know but those are exceptional
00:41:29
Speaker
And in terms of the timeframe, Fred, I know that some people talk about six to 24 hours as windows, depending on the findings on a clinical exam, but also on the CTA and the CTP.
00:41:41
Speaker
Could you talk a little bit about the timeframe?
00:41:44
Speaker
Yes.
00:41:45
Speaker
So, I mean, for endovascular intervention, for thrombolysis.
00:41:49
Speaker
Endovascular.
00:41:49
Speaker
Yeah.
00:41:51
Speaker
Yeah, so for endovascular, right, you know, 0 to 24, I mean, if you have somebody, as I said, you know, within a TPA window, right, and qualifies for thrombolytics, right, and you see a large vessel occlusion, you know, you should go, you know,
00:42:07
Speaker
after the occlusion, you know, you are within that window.
00:42:10
Speaker
So I would say 0 to 24 is sort of like what I would be thinking about, right?
00:42:15
Speaker
But again, if you don't have concise information about the timing, right, and the patient's at 36 hours, right, but you don't see anything in the CAT scan and you see a large vessel occlusion, perhaps that occlusion happened not really 36 hours ago.
Managing Post-Stroke Complications
00:42:28
Speaker
It happened probably like 10 or 12 hours before.
00:42:30
Speaker
And I'm sorry, you know, 0 to 6 hours before, and then you might be able to
00:42:36
Speaker
So in general, right, 0-24 hours is what I would consider some eligibility for TPA.
00:42:43
Speaker
And what I'm saying about the perfusion, right, is that some centers actually use it to predict complications, right?
00:42:55
Speaker
Some interventions don't use perfusion at all.
00:42:57
Speaker
Some interventions just go after the large phase of the perfusion on the basis of clinical exam aspects.
00:43:03
Speaker
Some other centers use perfusion because, right, it gives, there's some, you know, cohort studies that have shown that a mismatch, right, is associated
00:43:17
Speaker
with less complications than if you have a total match in terms of a number, I'm sorry, a total match in terms of core or ischemic infarct, right, in the patient.
00:43:32
Speaker
So somebody that has a completed stroke has more chances of complications.
00:43:36
Speaker
So some centers are using it just to predict complications and not going after the thrombectomy.
00:43:42
Speaker
And there are centers like,
00:43:45
Speaker
like for example, Jefferson have published a lot of this stuff.
00:43:48
Speaker
And I think, you know, from their perspective, it makes a lot of sense to use perfusion to treat patients.
00:43:57
Speaker
But as I said, some other centers, right, like Cooper, we are not using that much of perfusion unless, you know, there are a couple of, you know, indications, right?
00:44:06
Speaker
Patient wakes up with this stroke, nobody really knows when that happened, right?
00:44:09
Speaker
The perfusion can add a little bit more information for therapeutic interventions.
00:44:14
Speaker
And what you're looking for is a big mismatch, like you said, between the core of the infarct and the penumbra, right?
00:44:20
Speaker
So the larger the mismatch, the more likely that they would have lower complications, but also that you could help them with an endovascular intervention.
00:44:28
Speaker
Exactly.
00:44:28
Speaker
Perfect.
00:44:29
Speaker
And in terms of follow-up, immediate follow-up, obviously, we have like, I mean, thrombolysis, perfusion scores that they use in the lab.
00:44:41
Speaker
But ultimately, like you mentioned earlier, once they come back to the ICU and we're following them, it's following the NIH stroke scale that is going to give us, I mean, kind of the best tool to see how they're evolving, correct?
00:44:52
Speaker
Yep.
00:44:54
Speaker
Perfect.
00:44:54
Speaker
Let's talk a little bit of management now.
00:44:56
Speaker
I want to start with some specific complications related to stroke.
00:45:00
Speaker
And the first one, obviously, is cerebral edema and malignant MCA infarctions.
00:45:08
Speaker
But could you talk a little bit about that in terms of how we recognize it, who's at risk, and then what really should be the approach of treatment?
00:45:15
Speaker
Yes.
00:45:17
Speaker
Yes.
00:45:17
Speaker
So that's a great question, right?
00:45:18
Speaker
So really, edema,
00:45:22
Speaker
hemorrhagic complications, and I'll talk a little bit about seizures, you know, are sort of like the main ones that you are concerned about once a patient, you know, in type of the intensive care unit.
00:45:34
Speaker
So if somebody has had good re-canalization, right, with thrombolytics and TPA, right,
00:45:40
Speaker
there is a lower chance of the patient developing seruleidema because if you recanalize and you recanalize normal tissue, right, or penumbra tissue, then, you know, very unlikely the patient's going to have an infarct and it's going to swell, right?
00:45:55
Speaker
So, you know, recanalization scores, you know, I'm talking about TK2B2-3 are usually associated with lower incidence of hemichroniectomy, right, from seruleidema, right, that sort of thing.
00:46:09
Speaker
there's some expectation of some cerebrally dema right the patient has already some core some uh infarct right and um but but the burden right it's it's what predicts best
00:46:21
Speaker
the explosion of cerulean edema.
00:46:24
Speaker
And there are a couple of things, you know, that you could use, you know, from imaging.
00:46:29
Speaker
For example, if you have a two-thirds of a vascular territory effect that you should expect some cerulean edema with brain compression, right?
00:46:37
Speaker
Because most of the real state in the brain is from the, you know, for the MCA, right?
00:46:42
Speaker
So two-thirds of the MCA is associated with
00:46:45
Speaker
uh you know worse outcome more serious email more chance of complication involving the basal ganglia also you know because actually is the stem of the mca so that's usually a proximal occlusion that also predicts um
00:46:59
Speaker
you know, a lot of complications with serulidema.
00:47:04
Speaker
Hypertension and hypotension also, right?
00:47:06
Speaker
It's a U-wave or a U-perv response, right, to this stuff.
00:47:10
Speaker
So if you don't control the blood pressure adequately, right, post-regionalization, or if you let the patient drive too low because of the auto-regulation, then you're gonna cause more serulidema because of basically lactation, right?
00:47:23
Speaker
So you have to be careful also with the two extremes of blood pressure management.
00:47:27
Speaker
And in terms of management, right, medically, right, what we could do, right, I mean, the thrombectomy, as I said, you know, it's a game changer in terms of really considerate email.
00:47:35
Speaker
You get good scores and the patient drops from 24 in the NHL scale to 3 or 2, right, then you know, right, that patient is not going to have
00:47:43
Speaker
a large misprick infarction where you're going to deal with a lot of EDM and midline shift.
00:47:48
Speaker
But let's say that's not the case, then medically, what can you do?
00:47:51
Speaker
So the recommendations are, right, blood pressure controls, as I mentioned, hyperglycemia is the other thing that you need to be so, like, on top of, right, we usually recommend.
00:48:03
Speaker
patients, the nitro sugar levels, 150 to 180, what we call normal glycemia.
00:48:07
Speaker
We don't recommend more intense regimens of glucose management, you know, down to 100, 120.
00:48:16
Speaker
You know, there's a study already done in this research that showed that it didn't help and actually was associated with more hypoglycemia.
00:48:23
Speaker
So, sort of like similar to the Vanderburgh, you know, data, you know, in sepsis and
00:48:30
Speaker
in the medical ICU population.
00:48:31
Speaker
So, nice sugar seems to be okay.
00:48:35
Speaker
The other thing is, I usually preach about this, you know, when people ask me, you know, what to do in the ICU for these patients, right?
00:48:40
Speaker
So, if the patient didn't get good recanalization, by the way, sometimes patients get thrombosis again, right?
00:48:45
Speaker
So, you end up with those patients, they do two, three passes, and then,
00:48:49
Speaker
you know, it doesn't help, right?
00:48:51
Speaker
So there's nothing you can do about it, right?
00:48:52
Speaker
So before we consider surgery, right, can we do something medical?
00:48:56
Speaker
And the answer is yes.
00:48:57
Speaker
You know, there's stuff that you could do.
00:48:59
Speaker
I talk about hyperglycemia management already.
00:49:03
Speaker
There was a study called Games RP, you know, that used sulfonylureas, right, for the management of cerebral edema because these medications inhibit a special aquaporin, you know, channel that decreases the chances of
00:49:17
Speaker
of swelling because of inhibition of free water going into the neurons, right?
00:49:21
Speaker
So that was associated with lesbibylidema and lesbibylidema, right?
00:49:24
Speaker
It didn't really prevent the incidence of hematocytomy.
00:49:27
Speaker
And that's why there's a second study going on with intravenous glibanklumi,
00:49:31
Speaker
trying to look at the same sort of question, but at my institution, we have incorporated glyburide as part of the anti-edema, anti-serial edema protocol for these patients with really aggressive oversight of glucose at bedside, right?
00:49:48
Speaker
Because, I mean, this thing can cause hypoglycemia as well, right?
00:49:51
Speaker
So we do that.
00:49:52
Speaker
And then hypertonic saline solutions, right, and hypersmolotherapy, they can help.
00:49:57
Speaker
And I usually refer to...
00:50:00
Speaker
Due to studies, you know, of ischemic stroke in the United States that have used hyperosmolar therapy to keep sodiums around 150 to 155, I'm talking about headfirst, for example, that showed that the incidence of hemicronectomy was the same in the medical arm and in the surgical arm.
00:50:19
Speaker
that were treated with hypertonic saline.
00:50:21
Speaker
So that's another thing that you can consider, right?
00:50:22
Speaker
So as part of sort of like expert opinion in my institution, right, we have determined, right, that somebody with a the occlusion or an M1 occlusion that doesn't open up with recanalization is going to adapt with this sort of like prophylactic-prevented therapies, like we're right, hypertonic saline, or sodium so 150 to 155.
00:50:40
Speaker
And then you could add
00:50:41
Speaker
Even though there's not a lot of data right now even though there's a few logical data suggesting that You know fever was was bad and associated with exacerbation of single edema, right?
00:50:50
Speaker
But you know, it's gonna be very hard to talk about fever and prevention of Fever or treatment of fever in this era of temperature modulation I just know what to tell you right, but the study that was looking at that call intrepid recently closed because of
00:51:07
Speaker
So that means that they didn't achieve the primary endpoint or any significant difference in the outcomes of people that were treated for fever aggressively versus medical treatment alone.
00:51:19
Speaker
But, I mean, if you still believe in temperature modulation, you could say, well, perhaps I'm going to treat the patient that gets neurologically worse, meaning gets worse.
00:51:27
Speaker
Perhaps I'm going to do a little bit more normothermia, more aggressive intervention, trying to prevent it.
00:51:32
Speaker
So those are the things that you could think about, and then finally, right, if you cannot deal with it, right, if the patient's getting worse, the patient's going to end up with a hemichronectomy if it's a large hemispheric infarction, usually an MCA infarct of more than two-thirds, right?
00:51:45
Speaker
And then, you know, depending on the age, you know, sometimes it helps with functional outcomes in the long term.
00:51:53
Speaker
Usually older people, you're only saving lives, right?
00:51:56
Speaker
So they're going to look the same way six months down the road, right?
00:52:00
Speaker
So they're only saving lives for people that are older than 60, 65 years of age.
00:52:04
Speaker
Yeah, and I think that's important with the hemocrinectomy.
00:52:08
Speaker
You mentioned that as a last, very invasive resort, but usually in your practice and what most people would recommend is to take a medical approach, try to control it, but if you're not successful, then in the right patient,
00:52:23
Speaker
discuss with the family the potential for hemicrinectomy but my understanding of the literature Fred and please elaborate on this is that actually in patients who are 60 or younger a hemicrinectomy done in a timely fashion will improve mortality and also will probably improve their modified ranking score is that correct
00:52:43
Speaker
Yeah, that is correct.
00:52:44
Speaker
It's actually neuroprotective when you look at the shift in the MRS from the historic clinical studies.
00:52:50
Speaker
And what you're saying is, you know, right on the spot, you know, younger patients at that 60, you should experience that effect.
00:52:56
Speaker
More than 60, perhaps not on the basis of...
00:53:00
Speaker
studies in Europe.
00:53:01
Speaker
But what I have to say about hemicronectomy, and again, I haven't looked at this systematically or scientifically, we looked at this in our own experience at Jefferson, where I used to work before.
00:53:15
Speaker
The incidence of hemicronectomy decreased with a re-canalization score.
00:53:19
Speaker
So we saw less hemicronectomies with patients getting actually re-canalized to
00:53:27
Speaker
very good levels, right?
00:53:28
Speaker
So I think that if you looked at this in some database, right, you will see that recanalization will be associated with decreasing on the use of hemichromatomy.
00:53:36
Speaker
And I hope that that is the trend, because, I mean, you are saving them from this very morbid surgical intervention.
00:53:42
Speaker
It has a lot of complications, right?
00:53:44
Speaker
So, as you mentioned.
00:53:46
Speaker
Well, and absolutely, if you think about cerebral edema as a result of secondary or extensive neurologic injury, and the whole point of revascularizing a patient is to prevent that.
00:53:56
Speaker
So it would make sense, right, that if we're successful, that we should see lower rates of malignant cerebral edema or malignant MCA infarctions, and hence less patients who would need a hemichrome anectomy, which is obviously, like you said, a good thing.
00:54:11
Speaker
The other complication that I wanted to ask you about, and you mentioned that it was hemorrhagic transformation, obviously, especially in patients who received IV tPA, but this can also happen without IV tPA.
00:54:24
Speaker
And just in terms of how to recognize it, how to approach it in terms of therapy.
00:54:30
Speaker
Yes.
00:54:30
Speaker
So hemorrhagic transformation, if you look at the original rates, 60 to 70%,
00:54:39
Speaker
you know, post-DPA and depending on the burden of infarct, right, the higher the core, right, and the lower the mismatch, meaning more infarct.
00:54:51
Speaker
And that's what CT perfusion would be very good at, you know, telling you, right?
00:54:57
Speaker
Those are the things that are associated with hemorrhagic transformation.
00:54:59
Speaker
Hemorrhagic transformation is also associated with hypertension, right, especially after recanalization.
00:55:05
Speaker
That's why the blood pressure guidelines for a post-thrombolytic patient is systolic blood pressure less than 180.
00:55:14
Speaker
And depending on the recanalization score, the patient has gotten thrombectomy.
00:55:18
Speaker
You can also guide blood pressure parameters, right?
00:55:21
Speaker
So if the patient gets a good recanalization, TK2B,
00:55:24
Speaker
three um then you know uh the the post hoc analysis or the the uh retrospective analysis right of of the studies that looked at this uh revascularization business have shown that just a little bit of pressure perhaps 120 to 140 are associated with better outcomes right and and and the answer is you know is that after re-canalization right you have to be very uh anal or very um
00:55:53
Speaker
strict about the top and then the low blood pressure parameter, right?
00:55:57
Speaker
So that's a second thing.
00:55:59
Speaker
So TIKI 2B or less, I'm sorry, not TIKI 2A or less, perhaps more liberal blood pressure, perhaps less than 160, right, would be good.
00:56:11
Speaker
And then if you don't get any recanalization,
00:56:14
Speaker
you know, TQ1, perhaps you should go back to less than 180 if the patient got TPA, or perhaps even considered a higher blood pressure level to allow collaterals to circulate.
00:56:26
Speaker
But, you know, that's a decision that you can make, you know, after knowing the anatomy of the patient, knowing the interventions that were provided and the complications that happened or didn't happen during the procedure.
00:56:37
Speaker
So,
00:56:39
Speaker
Hyperglycemia also associated with hemorrhoid transformation.
00:56:43
Speaker
So, as I said, you know, normal glycemia is like the goal in the ICU.
00:56:47
Speaker
Diabetic patients are at higher risk of developing complications.
00:56:53
Speaker
Of course, if you have somebody that was taking
00:56:56
Speaker
an inequivalent, right, direct oral inequivalent, right, and more like used right now for prevention stroke in AFI patients.
00:57:03
Speaker
So you don't usually reverse those for an ischemic stroke, right, so many people are going after those clots in the setting of DOAC, right, even though haven't seen that much of major, you know,
00:57:17
Speaker
greater complications and interventions are okay with that.
00:57:20
Speaker
That's another consideration.
00:57:22
Speaker
Any quiolopathy in general, right?
00:57:24
Speaker
The use of aspirin and antiplatelets are not associated with hemorrhagic complications except the combination of dual antiplatelets, right?
00:57:31
Speaker
So when you combine aspirin with something else, you are more likely to have more hemorrhagic complications.
00:57:37
Speaker
And there is an antiplatelet that, you know, we try to use in ischemic stroke and we stop using it because of the incidence of hemorrhagic transmission.
00:57:45
Speaker
It's called parazugrel.
00:57:46
Speaker
We don't use it
00:57:47
Speaker
that much that's probably the only one that I would say may be associated with hemorrhoid transformations um talk a little bit about seizures too uh you know the the the thought process for seizures after ischemic stroke is that you don't see that much of seizures you know in the uh in the uh aftermath of ischemic stroke with thrombolysis thrombectomy unless the patient gets a lot of like
00:58:09
Speaker
complications gets a subdural or gets a hemorrhagic hemorrhage from a dissection, right?
00:58:14
Speaker
And perhaps, right?
00:58:16
Speaker
But prophylactically, we don't use antiepileptics, post-ischemic stroke, right?
00:58:22
Speaker
Only when we suspect that the chances of having a seizure are high.
00:58:25
Speaker
You know, as I said, hemorrhagic complications may be one of them, right?
00:58:28
Speaker
Hemichronectomy or craniotomies, right?
00:58:30
Speaker
Maybe a second one.
00:58:32
Speaker
But prophylactically, we don't use antiepileptics.
00:58:36
Speaker
Excellent.
00:58:37
Speaker
And the other thing I wanted to ask you in this portion, which is not something that I have seen commonly, or I've not seen at all, actually, but is well described in the literature, is in patients who get out the pace, they can have an anaphylactic reaction.
00:58:57
Speaker
Any comments on recognizing and managing this?
00:59:01
Speaker
Yes, it's reported in the literature.
00:59:05
Speaker
I think the incidence is about less than 2% if I'm around 0.62%, if I'm not wrong.
00:59:11
Speaker
But yeah, I've seen probably two or three patients post-TPA that develop this allergic reaction that isโฆ
00:59:22
Speaker
similar to angioedema, right?
00:59:23
Speaker
And actually end up being intubated, right?
00:59:26
Speaker
It's rare.
00:59:26
Speaker
It's usually in the same side of the stroke.
00:59:28
Speaker
I don't ask me why.
00:59:30
Speaker
I've asked, you know, several colleagues about this, and I don't know if these...
00:59:37
Speaker
you know, it's related to a deafferentation somehow, ipsilateral to the stroke from adrenergics, you know, from the adrenergic system, right, and somehow these vessels, you know, in the mouth or in the throat are sort of like vasodilated, right, and then you give TPA, and then there may be also an effect of, you know,
01:00:01
Speaker
you know, endothelial stuff.
01:00:02
Speaker
I have not been able to explain it very well, but I've seen two or three cases with that stuff.
01:00:07
Speaker
And then the normal reaction, right, is that you need to deal with that airway, right?
01:00:14
Speaker
Protect the airway at least for 24 hours and then try to get the patient better treatment as angioedema.
01:00:20
Speaker
Perhaps some H2 blockers, you know, may help.
01:00:23
Speaker
I don't think steroids help that much, but
01:00:27
Speaker
So the treatment would be kind of, if you're infusing the alteplase, you would stop it.
Oxygenation and Ventilation in Stroke Care
01:00:31
Speaker
I mean, steroids, obviously, like you said, who knows if they help, but people usually get them and then treat them similar with H1 and H2 blockers.
01:00:38
Speaker
And if needed, maybe some epinephrine.
01:00:40
Speaker
So no different than you would treat any other adenemias.
01:00:42
Speaker
This is just recognizing it in the setting, right?
01:00:45
Speaker
Yes, and it's treansian.
01:00:46
Speaker
It's usually treansian.
01:00:48
Speaker
Maybe a genetic disposition to some bradykinen pathway.
01:00:53
Speaker
I don't know how to explain it.
01:00:55
Speaker
Perfect.
01:00:56
Speaker
So we talked about some very important aspects of general ICU management in the context of managing cerebral edema, preventing it, and just providing, I think, good care, especially post, hopefully, revascularization.
01:01:10
Speaker
But I wanted to touch on two more or expand a little bit on one thing.
01:01:15
Speaker
and talk a little bit about airway management.
01:01:18
Speaker
Any general considerations, Fred, that you could give us first on airway management in terms of oxygenation and ventilation for these patients?
01:01:27
Speaker
I think the same principles for any critically ill patient.
01:01:31
Speaker
You have a patient that requires airway protection in the setting of outer mental status or a neurological injury.
01:01:41
Speaker
you should get the airway protected, right, in terms of oxygenation.
01:01:45
Speaker
Avoiding both hypoxia and hyperoxia, I would say, are important in terms of hyperoxia.
01:01:51
Speaker
There's been a lot of observational studies on this stuff, right?
01:01:54
Speaker
But I think over the last 10, 20 years in the field of critical care medicine, we have to regress to the mean, right?
01:02:04
Speaker
So we used to do supermedicine for certain disease states.
01:02:11
Speaker
In subrana hemorrhage, we used to hypertense them and give them hyperbulimia and give them a lot of blood transfusion.
01:02:18
Speaker
We learned that that doesn't work.
01:02:19
Speaker
For sepsis, it's the same thing.
01:02:21
Speaker
We used to give them a lot of fluids, and then now it's like, perhaps we shouldn't.
01:02:25
Speaker
It's still the same thing for...
01:02:30
Speaker
for oxygenation and they actually just keep a a pao2 you know 70 to 100 that's totally fine right um and then a saturation of more than 92 that's totally fine if you're following that in terms of co2 ventilation right normal carvia right you know 35 to 45 it's sort of like okay unless you're dealing with a patient with uh you know pulmonary comorbidities that you know requires a higher co2 you know to maintain a normal uh phs because the patient has
01:02:55
Speaker
uh coronary disease right um during the uh four three or four attacks of code i don't remember if it's three or four i just lost count but uh we saw a lot of kobe patients with uh uh you know lung you know acute lung injury right from kobe with ischemic strokes right and then we ended up you know managing both in the in the medical icu so um but the guidelines were the same you know try to keep uh
01:03:18
Speaker
a pO2 of 70 or above, right?
01:03:24
Speaker
You know, people have suggested to do neuromonitoring in those patients that are comatose, right?
01:03:28
Speaker
You know, perhaps, yes, you know, I cannot tell you, you have an ischemic stroke, you know, if you should go down that path here unless you have, you know,
01:03:39
Speaker
uh, established protocol, right, and, and know what to do with the, uh, with the information, right, but, um, uh, but that's in terms of oxygenation and ventilation, you know, um, for the weaning, right, and, and, and this is an important thing, right, is that, um, I mean, sometimes patients, you know, get better, and then they, they get weaned, and then they get liberalized from, from the ventilator, and, and, and that is great.
01:04:02
Speaker
Sometimes patients with ischemic stroke, especially the ones that don't respond to therapies, end up with a hemichroneectomy, right,
01:04:08
Speaker
may need a tracheostomy, right?
01:04:09
Speaker
So when to do, timing of tracheostomy is another consideration when managing the airway.
01:04:14
Speaker
And there was a study, you know, and we were so like enthusiastic about the set point study, you know, trying to see if early tracheostomy was associated with better outcomes in neurological patients.
01:04:27
Speaker
It just didn't include ischemic stroke rate.
01:04:29
Speaker
And I heard that, I heard not, actually I read, you know, I think it was published in JAMA a couple of months ago.
01:04:37
Speaker
There wasn't any major difference in long-term outcomes.
01:04:41
Speaker
But I just want to emphasize a couple of things about early tracheosis.
01:04:45
Speaker
I'm a fan of early trachis in patients with severe neurological injury that are not so hot in the intensive care unit.
01:04:53
Speaker
And I think that if you trach early, you're preventing a lot of things down the road.
01:04:58
Speaker
And sometimes families get...
01:04:59
Speaker
stuck on the issue of, oh, is this going to be permanent or not?
01:05:02
Speaker
And you have to elaborate a little bit on that, right?
01:05:04
Speaker
But I think early tracheostomy is associated with better chances of weaning from the ventilator in these neurological patients.
01:05:12
Speaker
I think ventilator free rates are higher in patients that get early trach, they can mobilize faster, they can go to rehab faster, they get less exposure to anesthetics and sedatives.
01:05:24
Speaker
that you need to use when you're ventilating them in terms of infections like ventilator events, ventilator-associated pneumonias.
01:05:31
Speaker
In my experience, I think that it helps you with decreasing the incidence of those complications in your unit.
01:05:39
Speaker
i'm a fan of early tracheostomy and the set point study use a scoring system to sort of like predict right and i think the scoring system works well at at predicting right who may need a tracheostomy in the long term and you use not just neurological variables you also use medical variables right that uh sometimes uh you don't think about you know when you have a patient with a stroke right you know you know
01:06:04
Speaker
Does a history of pulmonary disease or a history of pulmonary or lung injury, you know, in the acute setting predict an infratracheostomy?
01:06:12
Speaker
And the answer is yes, you know.
01:06:13
Speaker
So, you know, those sort of things, you know.
01:06:15
Speaker
Does the incidence of hemicraniectomy, right, predict, yes, it does, right, because it's a cumorbit stuff, right, so in the research intervention, right.
01:06:24
Speaker
So when you have all these points, right, and you end up with a high set point score, right, you can't argue that perhaps, you know, early trade, but as I said, it's not associated with better functional outcomes that if you do it late.
Blood Pressure Management Strategies
01:06:37
Speaker
But in my opinion, and this is just my opinion, Sergio, I think it helps you mobilizing patients faster, you know, trying to do stuff faster for these patients.
01:06:46
Speaker
And I think that obviously it's something hard to study, Fred, but also, and this is based on a very small end, but speaking with patients who have survived or recovered prolonged illness, more than one has had tracheostomies and I've talked with them and they kind of said that
01:07:03
Speaker
Why didn't you do it earlier, right?
01:07:04
Speaker
I mean, it kind of is much more comfortable.
01:07:06
Speaker
It's safer.
01:07:07
Speaker
The patients, I mean, can interact better, require less medications.
01:07:12
Speaker
So there's other advantages that maybe are hard to capture just in a mortality analysis, but that's definitely something to consider.
01:07:19
Speaker
The last thing I wanted to talk about, Fred, which you already did touch about, but I do think is an important aspect of what we do as intensivists in these patients is blood pressure management.
01:07:30
Speaker
And as you alluded to earlier, the relationship between blood pressure and outcomes is a J or a U curve, right?
01:07:37
Speaker
So very high blood pressures or very low blood pressures are going to be associated with problems.
01:07:42
Speaker
But what I do think is worth mentioning is the approach we should have based on where our patient falls in therapeutic interventions, right?
01:07:51
Speaker
So
01:07:52
Speaker
And I'll give you three categories.
01:07:54
Speaker
And I just want you to tell me how you would manage the blood pressure.
01:07:57
Speaker
So the first category is a patient who's not a candidate for TPA and is not a candidate for endovascular therapy.
01:08:07
Speaker
Yeah, so if you look at the guideline, they tell you that the SDP should be less than 220, and I sort of like agree with that, right?
01:08:13
Speaker
But you have to look at the patient as a whole, right?
01:08:15
Speaker
So, you know, would 220 be okay for his heart or for his lungs or for his skin, you know, that sort of thing?
01:08:21
Speaker
That's a decision you need to make, right?
01:08:23
Speaker
So let's say the patient has heart failure, has an EF of 20%, right?
01:08:27
Speaker
has had ischemic stroke, and then has a history of coronary artery disease.
01:08:31
Speaker
So the question is, would you allow that patient to have a blood pressure of 220?
01:08:34
Speaker
And the answer is probably, I would probably be a little bit more conservative.
01:08:38
Speaker
Perhaps I would say, perhaps 180, and then I will see the patient at the bedside, right?
01:08:43
Speaker
But again, it's on the basis of patient's variables, right?
01:08:49
Speaker
Because you have somebody with CAD or just had a stent, you know, it has an EF of 20%, has SVP of 220, may not...
01:08:57
Speaker
Her heart may not like that amount of blood pressure.
01:09:02
Speaker
Second group of patients is a patient who comes in with very high blood pressure, but is within the time frame for IV thrombolytics.
01:09:12
Speaker
Yes.
01:09:12
Speaker
So, you know, high is usually more than 220, right?
01:09:16
Speaker
So, by consensus, right, before we give TPA, we have to lower the blood pressure, you know, lower than 220 to make the patient...
01:09:28
Speaker
amenable for TPA.
01:09:30
Speaker
And then after he gets a TPA, the blood pressure has to be lower than 180, right?
01:09:35
Speaker
So when you think about the auto-regulation, right, that patient is actually on the right side of the auto-regulation.
01:09:40
Speaker
So yes, when you're lowering the pressure, you're just basically trying to prevent the capillaries to leak and then sort of like explode.
01:09:47
Speaker
and then prevent hemorrhagic complications.
01:09:49
Speaker
So I would say for this particular patient, perhaps 180.
01:09:52
Speaker
And when you look at the step down from 220 to 180, it's usually not more than 20%.
01:09:56
Speaker
So you are still within that sort of like rule of thumb that in hypertensive urgency or emergencies, right?
01:10:04
Speaker
Perhaps you should lower the MAP or the SPP by no more than 20, 25% of the baseline.
01:10:10
Speaker
Excellent.
01:10:10
Speaker
And the last category of patients are patients who are being wheeled off to the endovascular lab for endovascular revascularization.
01:10:20
Speaker
Yeah, so same thing as the ones above, right?
01:10:22
Speaker
If the patient didn't get TPA, then 220.
01:10:25
Speaker
If the patient got thrombolytics, perhaps less than 180.
01:10:30
Speaker
And then after recanalization, we can decide about where to clamp it, right?
01:10:36
Speaker
If we get successful recanalization, TIKI 2B to 3, perhaps a blood pressure less than 140 and more than 120 for the first 24 hours would be ideal.
01:10:44
Speaker
And if the patient didn't get very good recanalization, perhaps 160 or less would be also ideal.
01:10:52
Speaker
And in terms of drugs, Fred, what drugs do you like to use for these patients?
01:10:56
Speaker
I'm just curious.
01:10:58
Speaker
For blood pressure?
01:10:58
Speaker
Yep.
01:11:00
Speaker
Yeah, so I like the calcium channel blockers, and I also like the beta blockers, right?
01:11:05
Speaker
So we're using the neuro-ICU combination of either nicardipine or clavidipine or intravenous labetalol, right?
01:11:14
Speaker
I think there's a shortage for labetalol, so we've been using more nicardipine and clavidipine.
Conclusion and Multidisciplinary Approach
01:11:20
Speaker
Excellent.
01:11:21
Speaker
Well, I think that obviously we've touched a lot during our discussion.
01:11:26
Speaker
I think a lot of very important topics.
01:11:28
Speaker
The last thing I wanted to touch as we close the topic on acute ischemic stroke is just the road to recovery.
01:11:35
Speaker
And there's been a big push in the ICU in general for liberating patients from critical illness, for early mobilization, even in patients on the
01:11:43
Speaker
on the ventilator.
01:11:44
Speaker
Early mobility is a big part of what we do in the A to F bundles.
01:11:48
Speaker
Could you just talk a little bit about early mobilization and rehab?
01:11:53
Speaker
There seems to be kind of like a perfect dose, not too much, not too early and not waiting too long.
01:11:58
Speaker
But if you could just comment where the literature stands on that right now, Fred.
01:12:03
Speaker
Yes.
01:12:03
Speaker
So there's been a couple of clinical trials looking at early rehabilitation in patients with ischemic stroke, specifically post-
01:12:14
Speaker
thrombolysis, right?
01:12:14
Speaker
And then they found that if you mobilize patients within four hours post-DPA or thrombolytic, they had worse outcomes, right?
01:12:24
Speaker
But when you look at the details of those clinical studies, right, is that the amount of energy or METS, metabolic expenditure, that they were exposing the patients to were to high amount of pain, right?
01:12:36
Speaker
So, you know, these were people that had just had a stroke and then they were asking them to, you know,
01:12:42
Speaker
you know, you know, walk the room and then play, you know, in a soccer field.
01:12:46
Speaker
And I'm like, no, I mean, I think early mobilization with sort of like, you know, individualized approach to the patient, right, with minimal, you know, metabolic exposure, right, may be ideal.
01:13:01
Speaker
So that's the criticism that I have to do this.
01:13:02
Speaker
So some institutions actually adopted a no mobilization,
01:13:06
Speaker
post-tPA on the basis of that particular study.
01:13:11
Speaker
My experience is that, right, if you're using isometrics, if you're using L-immobilization to the bed and assistance, right, perhaps, you know, the
01:13:24
Speaker
the effect is not there.
01:13:25
Speaker
So it really depends on what type of exercises they're using, right?
01:13:28
Speaker
But I am a fan of early mobilization, liberation from mechanical ventilation early, right?
01:13:33
Speaker
And early rehabilitation.
01:13:35
Speaker
I mean, that should be sort of like the goal, right?
01:13:38
Speaker
And the issue that we have both in the ICU and in the hospital setting, you know,
01:13:44
Speaker
it's your inability to discharge these patients to rehab.
01:13:47
Speaker
The rehab that they get in the hospital is not as good as the rehab that they're getting in the rehab center.
01:13:54
Speaker
So sometimes families, they're adamant about not being discharged, right?
01:13:59
Speaker
But in reality, a physical therapist can only do one or two hours of rehab two or three times per week in some patients in stroke centers, right?
01:14:11
Speaker
So that is a challenge to getting people to rehabilitation, right?
01:14:16
Speaker
So, you know, we usually start within 24 hours.
01:14:21
Speaker
As I said, you know, because of my criticism, I don't believe that early rehab is associated with abnormal outcomes in post-EPA patients.
01:14:30
Speaker
And, you know, we're just trying to wean fast, you know, and liberate for mechanical ventilation fast.
01:14:37
Speaker
Excellent.
01:14:38
Speaker
So, Fred, thanks again for giving us, I mean, this comprehensive overview and update, obviously, on acute management of acute ischemic stroke.
01:14:48
Speaker
As you said, it's something that requires a multidisciplinary team and a critical care specialist where they're a medical intensivist, surgical intensivist, or neuro intensivist or anesthesia intensivist are part of that, right?
01:15:03
Speaker
You've been to the podcast before.
01:15:04
Speaker
You've been a guest before, so you know the drill.
01:15:07
Speaker
Would it be okay if we close with some questions unrelated to stroke?
01:15:11
Speaker
Yes, yes.
01:15:12
Speaker
So in the last couple of years, two to three years in the COVID era, have there been any books that have really influenced you or that you gifted to others?
01:15:22
Speaker
Yeah.
01:15:23
Speaker
So I, uh, I always talk about the, uh, uh, the stoic books and I read a couple of other, uh, you know, stoic books, uh, you know, besides some Marcus Aurelius, I think that was the last one that I recommended, but, uh, um, I, I, I recently, uh, went to training administration and, uh, I read a book that really like made a difference in the way that I approach, um, you know, um, colleagues in general and, and, uh,
01:15:51
Speaker
and family members in general, right?
01:15:54
Speaker
And the book is an administration book, right, for leadership.
01:15:59
Speaker
But, you know, I think it talks more about than administration.
01:16:03
Speaker
It talks a lot about, you know, how to conduct yourself in general in life.
01:16:07
Speaker
And it's called The Servant.
01:16:11
Speaker
It's a book about leadership and the type of leadership that I use now.
01:16:17
Speaker
It's called Servant Leadership, right?
01:16:20
Speaker
And it inspired me to change the approach to just not administer stuff, but also how I conduct myself in general with family and friends, et cetera.
01:16:34
Speaker
So very inspiring.
01:16:36
Speaker
We'll definitely put that in the show notes.
01:16:37
Speaker
And I think it speaks to a couple of things, Fred.
01:16:39
Speaker
First is that when you think about the purpose of leadership, right, it's not to serve your own purpose or your own game, but it really is to make a difference in the life of others.
01:16:51
Speaker
And I think that whole approach of servant leadership is very important.
01:16:56
Speaker
It's interesting, and I know that we share an interest in old philosophy, like you mentioned with Marcos Aurelius, but I also had a chance to recently read a book by Plutarch, which is over 2,000 years old, and it's about leadership and kind of the same idea, like why would people go into leadership?
01:17:15
Speaker
It's about making a difference and serving the community or others.
01:17:20
Speaker
And definitely, I have not read The Servant, but I love the idea.
01:17:24
Speaker
I will put it in the show notes, and I,
01:17:25
Speaker
I will definitely check it out.
01:17:27
Speaker
The second question is a variation of a question I've asked you in the past, but what do you believe to be true in neurology or neurocritical care that most other intensivists don't believe?
01:17:44
Speaker
That's a loaded question, Sergio.
01:17:47
Speaker
I think that...
01:17:49
Speaker
You know, as you mentioned before, right, I'm training both, and you train me, by the way.
01:17:55
Speaker
So, you know, I've seen a lot of differences in approach, okay?
01:18:01
Speaker
And over the last 20 years, I think the field of neurocritical care has been trying to, you know, demonstrate, right, that there is a role for neurocritical care specialists in
01:18:17
Speaker
in the United States.
01:18:18
Speaker
So I just have to tell you, right, that there is a difference of how we see things as compared to people that have not trained or get exposed on treating patients with neurological injury, right?
01:18:38
Speaker
And we just talked about some of them, right?
01:18:40
Speaker
Sort of like this very sophisticated, you know, you sort of like calibrated way that you mentioned, right, to approach this stuff.
01:18:48
Speaker
And I'm not saying, right, that, you know, we do better in the neuro ICU than in the medical ICU.
01:18:56
Speaker
I think that the difference in reality is the team, okay?
01:19:00
Speaker
It's not the provider because you could train, you know, in the neuro ICU, but if your nurses don't get it, right,
01:19:07
Speaker
If your residents don't get it right, if your respiratory therapy don't get it right, then you are going to have issues with managing this patient.
01:19:16
Speaker
So I think the difference in neurocurricular care is the team that you're calling neurocurricular care.
01:19:23
Speaker
It's really not the provider.
01:19:25
Speaker
However, when you look at the literature, I would actually...
01:19:31
Speaker
I suggest the listeners of the podcast to look at the latest JAMA article on neurocritical care that basically shows the differences in the outcomes on neurocritical care patients being treated by a team of neurocritical care providers.
01:19:50
Speaker
We'll definitely put that in the show notes as well.
01:19:53
Speaker
And what's super interesting, Fred, is that the concept of the team, right, translates to other areas that has been studied.
01:20:01
Speaker
There's a study that I have often quoted and showed when I talk about team building, the science behind team building, that looks at CT surgeons that operate at more than one hospital.
01:20:12
Speaker
And traditionally, the belief is that the number of cases a CT surgeon has done correlates with their outcomes.
01:20:20
Speaker
But what's very interesting is that that number of cases does not translate from hospital to hospital, which means that at the end of the day, what really matters is not the independent surgeon, but the team that works with him at a given place.
01:20:34
Speaker
And I think it extrapolates exactly to what you were saying, which is great.
01:20:39
Speaker
And I have not seen this JAMA article.
01:20:41
Speaker
I have not read it at least.
01:20:42
Speaker
So I'm going to be very interested in picking that up as well.
01:20:45
Speaker
So I will put it in the show notes.
01:20:48
Speaker
And again, the final question, just to close, Fred, what would you want every intensivist to know?
01:20:56
Speaker
Could be a quote or fact or just a thought.
01:21:00
Speaker
I think that, you know,
01:21:05
Speaker
As a critical care physician, I think the concept of plasticity when you're dealing with neurological injury is something that you need to think about when you're treating these patients.
01:21:25
Speaker
Historically, we've been very nihilistic about
01:21:29
Speaker
uh, you know, treating these patients for, you know, whatever biases we have had, you know, uh, it could be personal biases or, or professional biases, right.
01:21:37
Speaker
But the concept of neuroplasticity and secondary neurological injury, you know, which is what we are, we have discussed here in the podcast, right.
01:21:44
Speaker
How to prevent that stuff, right.
01:21:46
Speaker
You know, it's, you know, an important concept because it will transform the way that you look at, uh, a neurological injury, right.
01:21:54
Speaker
If you treat these patients appropriately, if you deliver interventions that are associated with neuroprotection, and we talked about some of them for ischemic stroke, you will see down the road, if you have the chance,
01:22:12
Speaker
how those patients, you know, recover, right?
01:22:16
Speaker
So as critical care doctors, we don't have that much of experiencing patients in the clinic or stuff like that, right?
01:22:23
Speaker
But if you believe me, these patients will surprise you, right, if you treat them appropriately.
01:22:29
Speaker
So, you know, what I would like everyone to know, right, is that, you know, being nihilistic, perhaps up front, it's not a good idea, right?
01:22:36
Speaker
You still have a couple of days or hours, right, to determine, right, where the patient is going
01:22:42
Speaker
in terms of recovery or not, right?
01:22:45
Speaker
And being pessimistic at front, perhaps, in my opinion, not a good idea, right?
01:22:52
Speaker
Yeah, sometimes you see it clearly, black and white, right?
01:22:55
Speaker
You know, yeah, the patient's not going to do great, right?
01:22:57
Speaker
But sometimes, you know, you just have to give the patient time, right?
01:23:00
Speaker
And they will recover.
01:23:02
Speaker
And that's a great place to stop because I do think that especially with neuro patients, people who are not trained in neurology, like myself, who don't see patients long term might have an overly nihilistic approach to what they see initially.
01:23:19
Speaker
And you're right.
01:23:20
Speaker
I mean, even the initial TPA studies, part of the problem in adoption was that the real effects are 90 days post, right?
01:23:27
Speaker
Not necessarily in the hospitalization.
01:23:29
Speaker
So we failed to appreciate that it might be a big difference for that patient.
01:23:35
Speaker
Fred, always a pleasure to have you on.
01:23:37
Speaker
We'll definitely have you back on soon.
01:23:40
Speaker
And now that knock on wood, COVID seems to be...
01:23:45
Speaker
Less of an issue.
01:23:46
Speaker
I'm sure that we will cross paths in person soon.
01:23:50
Speaker
So look forward to talking with you in person as well.
01:23:52
Speaker
Thank you very much for sharing your expertise and your time with us today.
01:23:55
Speaker
Thank you for having me.
01:23:59
Speaker
Thank you for listening to Critical Matters, a sound podcast.
01:24:03
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
01:24:09
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
01:24:14
Speaker
To learn more, visit www.soundphysicians.com.