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Approach to acute stoke- ivt, ct perfusion - CoPM Weekly Webinar 24 - Neurology

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💫 Short Summary

Dr. Prasad P, a neurologist, discusses acute stroke assessment, history of stroke treatment evolution, and advanced imaging techniques. The importance of timing for MRI/CT scans, thrombolysis-thrombectomy treatment, and effectiveness of bridging therapy is emphasized. Case studies demonstrate the benefits of advanced imaging in stroke management. Discussions on thrombolysis-thrombectomy protocols, cost-effectiveness, and future treatments like tenecteplase are covered. The potential use of dor Alpha and the necessity of early intervention in stroke cases are highlighted. The session concludes with insights on managing blood pressure post-thrombolysis and transportation of acute stroke patients for optimal outcomes.

✨ Highlights
📊 Transcript
Dr. Prasad P is a highly experienced neurologist specializing in stroke neurology at Hospital Queen Elizabeth.
00:30
He has conducted numerous stroke clinical trials and local studies, earning awards and publications in prestigious journals.
Dr. Prasad is recognized for his expertise in acute stroke assessment and management.
His knowledge and research make him a valuable asset in addressing and understanding acute stroke cases.
Updates in hyperacute stroke care discussed, focusing on progress and challenges in imaging and treatment.
04:08
Hyperacute stroke care is becoming more specialized within neurology, not commonly seen in general medicine in hospitals.
Thrombolysis and thrombectomy trials in Malaysia are outlined, emphasizing bridging trials with clinical practice.
Introduction of terms like MRSS score and GR bar, explaining their importance in stroke trials and treatment.
MRSS score ranges from 0 to 6, with trials typically examining scores of 0 to 2 or 0 to 3 at 90 days for different types of stroke cases.
Evolution of Ischemic Stroke Treatment before 1991.
10:04
Treatment focus was on preventing the next stroke, resulting in death or being bedbound for patients with large vessel occlusion.
Three main pillars of treatment were aspirin, more aspirin, and physiotherapy.
Introduction of the concept of non-inferiority margin to determine trial success based on confidence intervals.
Non-inferiority trials are crucial in understanding the historical perspective and evolution of stroke treatment.
Impact of stroke on neuronal loss and aging acceleration.
10:52
Stroke accelerates aging by 8.7 hours and results in a loss of 1.2 billion neurons per stroke.
Large vessel occlusions and trials that revolutionized acute stroke management are discussed, including the NDS trial with Alteplase.
Advanced imaging techniques like CT perfusion and MRI are explored for diagnosing and treating strokes outside the treatment window.
The Wake Up trial in 2018 showcased the importance of using advanced imaging in guiding diagnosis and treatment for strokes.
Importance of Timing for Stroke Patients Undergoing MRI or CT Perfusion Scan.
14:28
The DWI-FLAIR mismatch is essential in determining eligibility for thrombolysis in stroke patients.
A CT perfusion scan conducted 9 hours from the midpoint of the stroke evaluates cerebral blood flow using sequences like MTT and CBV.
Prolonged MTT/TTP/T-Max on the scan indicates tissue at risk of stroke, necessitating intervention.
Understanding these imaging criteria is crucial for timely and effective stroke management.
Importance of tissue perfusion in stroke treatment.
17:46
Identifying dead tissue and tissue at risk through imaging is crucial.
Thrombolysis within specific time frames is effective in treatment.
Bridging therapy combining thrombolysis and thrombectomy shows significant improvement in patient outcomes.
Possibility of performing thrombectomy beyond six hours from onset, as shown in the DAWN trial using MRI criteria.
Case study of a 37-year-old man with a severe stroke and the use of C perfusion imaging.
21:55
Patient presented with left-sided weakness and a large vessel occlusion, requiring endovascular thrombectomy.
Emphasis on the significance of timely imaging and intervention in stroke cases to preserve brain tissue.
Highlight on the use of C angiography for additional assessment of blood vessel abnormalities.
Demonstrates the advantages of advanced imaging techniques in treating acute stroke patients.
Identification of occlusions in the M1 artery and importance of checking for both intracranial and extracranial occlusions.
23:58
Demonstration of how to identify a tandem occlusion and the need for city perfusion to confirm the occlusion.
Emphasis on the significance of T-Max in determining tissue viability and the potential for tissue death without intervention.
Conclusion with a visualization of the software used for calculations in assessing the severity of the occlusion.
Demonstration of thrombolysis and thrombectomy procedures on a patient with tissue at risk and no core.
29:05
Differentiation between common carotid artery (CCA) and external carotid artery (ECA) shown on an angiogram during cannulation.
Tandem occlusion treatment prioritizes relieving distal occlusion first for faster brain flow reconstitution.
Clot removal using a St reever and stenting of the proximal occlusion demonstrated on the patient.
Successful treatment resulting in most of the brain being reperfused, commonly done in stroke centers in Malaysia.
The effectiveness of performing thrombolysis followed by thrombectomy for stroke patients with large vessel occlusion is discussed in the video segment.
32:29
Trials such as Direct MT, SWIFT Direct, DVT, and SKIP are mentioned, with some showing non-inferiority and others failing to do so.
The current treatment protocol for patients with large vessel occlusion is to administer thrombolysis followed by thrombectomy, but the effectiveness of bridging therapy is questioned.
The speaker questions the effectiveness of this approach compared to direct thrombectomy.
A recent meta-analysis from the IRIS collaborators is highlighted in the segment.
Impact of thrombolysis timing on thrombectomy outcomes.
34:19
Thrombolysis within 140 minutes before thrombectomy led to significant improvement.
Positive trial results for posterior circulation interventions were highlighted.
Large ischemic core size influences treatment decisions for thrombectomy eligibility.
Early thrombolysis and timely interventions are crucial for improved outcomes in stroke patients.
Benefits of thrombectomy in patients with a core of 50 to 100 Ms or aspect of 3 to five.
37:39
Positive outcomes at 90 days of endovascular thrombectomy compared to medical management.
Aspect score calculation and the effectiveness of thrombectomy in cases of established tissue damage.
Cost implications of endovascular thrombectomy.
Marginal difference in outcomes between endovascular thrombectomy and medical care at one year.
Comparison of endovascular thrombectomy and tenecteplase in stroke treatment.
41:26
The segment compares outcomes and mortality rates between different treatment options, emphasizing safety.
Potential future developments in stroke treatment include the use of new drugs like retiplace.
Emphasis on the need for further research, particularly through phase three trials, to determine the efficacy and safety of emerging stroke treatments.
Potential use of dor Alpha for treating acute stroke.
44:55
Focus on breaking down fibrin in clots through WBC activity.
Ongoing trials for medium and distal vessel occlusions.
Possibility of changing acute stroke treatment in the future.
Importance of early recognition and understanding of stroke symptoms.
Importance of advanced imaging in Ministry of Health hospitals for neurological deterioration.
48:15
Emphasis on the need for CTA to assess intracranial stenosis and rule out other causes.
Significance of thrombectomy if a clot is detected.
EVT recommended for basilar artery occlusion within 24 hours for better outcomes.
Overall agreement on the necessity of endovascular thrombectomy for basilar artery occlusion to improve intervention outcomes.
Comparison of mechanical thrombectomy benefits in basilar artery thrombosis patients with Boui.
51:11
Patients with lower NIHSS did not benefit from endovascular treatment.
Severe stroke patients showed more benefits from mechanical thrombectomy.
Time window for treatment in posterior circulation varies based on artery location.
Access to mechanical thrombectomy is limited in Malaysia, impacting treatment options.
Considerations for treating patients with intracranial atherosclerotic disease (IAD).
54:15
Patients with significant IAD may benefit from double antiplatelet therapy, but risk of bleeding and individual factors must be assessed.
Large core stroke patients eligible for thrombectomy should not receive bridging therapy with anticoagulants due to high bleeding risk.
Antiplatelets or thrombolysis in large core stroke patients can lead to hemorrhagic transformation.
Pre-treatment before thrombectomy is not recommended to minimize risk of complications.
Managing blood pressure post successful thrombolysis for stroke patients.
57:39
Aim for normotensive blood pressure levels, especially after recanalization.
Debate on bringing down blood pressure within 24 or 48 hours, with a preference for earlier reduction.
Importance of BP control in cases of intracranial stenosis, with evidence supporting normotensive levels.
Discussion on hyperacute stroke scenarios post-cerebral angio procedures, including the use of flow diverters and the need for repeat imaging to assess occlusion or embolization.
Treatment options for blood clots, including flow diverters and thrombolysis, are discussed.
01:01:33
Monitoring for complications and the need for repeated scans is emphasized.
Different scenarios such as fluctuating symptoms are considered for decision-making on thrombolysis or thrombectomy.
The complexity of cases is highlighted, emphasizing the need for individualized assessment and decision-making in stroke management.
Immediate access to mechanical thrombectomy is preferred over thrombolysis in cases of stroke.
01:04:12
The decision to administer medication should take into account stroke severity, occlusion, and other factors.
Patients with NIHSS below five may still receive dual antiplatelet therapy within 72 hours.
Determining the underlying cause of stroke before deciding on treatment is crucial.
Patients presenting at a clinic should be directed to the nearest hospital offering stroke treatment for faster administration of medication and better outcomes.
Importance of direct transfer to the nearest hospital with stroke services for acute stroke patients.
01:06:22
Recent trial comparing outcomes of patients lying flat versus at 30 degrees, with better results for the former.
Consideration of aspiration risks and resource limitations leading to a personal preference of positioning patients at 15 degrees.
Reference to the Zodiac trial in stroke management.
Appreciation for the comprehensive presentation on stroke management.
Conclusion of the session with a great talk and announcement of next week's topic.
01:09:00
The speaker expressed thanks to the audience for their participation and signed off.
Anticipation for future sessions was highlighted as the session came to an end.