All right, let's go ahead and get started. I want to welcome everybody to AAP Virtual Didactics today. My name is Sterling Herring. I'm a PGY3 at Vanderbilt University in Nashville, Tennessee. As always, I want to recognize and appreciate those who have been most affected by the COVID-19 pandemic and recognize that that burden has not been shared equitably. We appreciate those of you who are on the front lines or who have been personally or professionally impacted by this more than the rest of us. We appreciate you. If there's anything we, your co-residents, your co-trainees, or the AAP can do anything further to support you, please let us know. As always, I'm going to go through some of these goals. The purpose of this virtual didactic series is to augment didactic curricula that are ongoing at your home institutions, to offload overstretched faculty. We know that residents have been pulled off schedule, that faculty have been stretched in a lot of different ways as a result of this COVID-19 situation. We are wanting to help with both of those. We want to provide additional learning opportunities for residents that have been pulled off, trainees of all types that have been pulled off schedule, and then to develop further digital learning resources and support for psychiatrists in general during COVID-19. We're going to keep everybody's video and audio muted except for our presenter. If you have any questions, again, my name is Sterling Herring. If you click on your participant list, that should be up near the top, Sterling Herring, you can double-click my name and you can send me messages with questions for our presenter. At appropriate times, when she said maybe it's the end of the talk or whenever she has time for questions, I will ask those questions. That allows us to make sure that AAP is supporting things that are appropriate. We can't just have an open mic night as much as that might be easier, I think, for everybody to ask their own questions. If you have any questions about the series or questions for AAP regarding the series, please feel free to reach out to me or to Candace Street. Her email is there on the screen, or you can track her down on Twitter as well, AAP, or AAP Physiatrist. Without further ado, we're excited to have Dr. Nneka Efejika with us today from UT Southwestern. Welcome, Dr. Efejika, and thank you for joining us. Thanks so much for having me. So good to see people who are interested in stroke prevention. I think that it'll be an excellent talk, and it's going to hopefully give some insights to medical students, residents, and fellows regarding some of the abbreviations you'll run into in practice when you're doing a stroke consultation. Let's see how we start the slides. All right. There should be a green arrow button. You click, and it'll ask if you want to take the screen away from me, and then it'll let you choose what window you want to open. Beautiful. And just so you're aware, we can then only see that window. So if there's anything popping up or anything going on on the side, we are not able to see that. All right. There will be stops for questions throughout, so you won't have to worry about getting to the end of the talk to have a discussion point. Sounds great. All right. Here we go. Do you see that green arrow I was talking about? Yep, I'm clicking on it. Oh okay, perfect. Trying to figure out what's going on with the screen. Sure, we have had our share of technical difficulties as you might imagine. Yeah, okay. That's what I want to share. Perfect. Y'all see it? We see it. Okay. Let's get started. Can everyone see stroke abbreviations? Perfect, looks great. All right, let's go. All right, so these are my disclosures. I have research funding to study stroke awareness and stroke outcomes. So the objectives of this presentation, as practicing physiatrists, one of our responsibilities on the consultation service is to determine whether patients with acute medical illnesses are appropriate for post-acute rehab care, whether they're going to an inpatient rehab, a skilled nurse facility, long-term acute care facility, or home plus or minus outpatient and home health services. Stroke is one of the most common post-acute rehab diagnoses you will encounter. It accounts for about 20% of Medicare admissions to inpatient rehab facilities. Interpretation of acute care interventions, therefore, is of significant importance when identifying candidacy for post-acute care. So what we're going to do today is kind of dissect what this group of people are talking to each other to encode. This is the UT Southwestern Stroke and Vascular Team, as you can see. It is led by the four disciplines at the top, PM&R, neurosurgery, vascular neurology, and neurocritical care. PM&R and UT Southwestern runs the continuum of care committee and the stroke rehab service line. And everybody in that picture is speaking to each other in a code that we are going to decipher for you today. So it is a cross-disciplinary code that we are all talking in when it comes to stroke rehabilitation and stroke outcomes. It's extremely important that everyone on this call has an understanding of that coding because there are things that happen within the first three days of an acute stroke treatment period that will impact the patient for years to come. So the objective of this talk is to teach y'all what code we are using when we're speaking in the chart. So this is an example of stroke abbreviations in acute stroke care. And I'm just going to read it out exactly as the abbreviations stand. I am not going to interpret anything at this time. No worries. At the very end, we will interpret this exact case. So 88YO, right-handed male, wake up stroke, LSN slash LKWT, 13 hours prior, NIHSS of 23, CT brain with no ICH, aspects of eight, CTA of the head and neck significant for proximal left, M1 occlusion, CTP with rapid significant for the above. This is actually pulled from a chart. There is no significant change. We have pulled this case exactly from a chart. And this is what you would see as a consulting physician. He was taken to IAT, fast post ERT with two passes. Achieved TICI 2B recanalization and the HSS improved to eight, MRS of two at 90 days. That is exactly what is in the first two days of an acute stroke interval. So if you have this face and your response is similar to this GIF, no worries. The purpose of this talk is to take what we're looking at as far as acute stroke abbreviations. Some of them are listed here that we saw in the past couple of slides and translate them into things that we understand as physiatrists. So these are some of the post acute rehab mnemonics and abbreviations that we use. And there are members of other teams that have no idea what we are talking about. So again, our goal will be to translate some of the things that we encounter in post acute rehab and acute stroke and interpret them in a way that helps us portend better outcomes for the patients. So we're going to start with the first, where we should, LSN slash LKWT. That interprets as last seen normal, last known well time. Why is this important to physiatrists? It's important because hemorrhagic transformation is rare in the first 12 hours after stroke onset, the hyper acute phase, particularly within the first six hours. And when hemorrhagic transformation occurs, it's usually in the first one to two days and in almost all patients is present four to five days after stroke. Therefore, if a person was last seen normal within six to 12 hours, or they woke up with the stroke and they come in, it's less likely they're going to be acutely bleeding. However, if they present four to five days out in the kind of subacute phase, and they had an ischemic stroke, they're more likely to have hemorrhagic transformation, which means they're likely to have increased intracranial pressure and worse outcomes if not intervened on quickly. Therefore, it's important when you're looking at the acute care note to identify when that last seen normal times. It's of particular importance because the average acute ischemic stroke length of stay is about five days. So that means that by the time they're ready to come to inpatient rehab, they're right on that cusp, if they were going to bleed where they would bleed. So it's very important that we identify that in the chart before we bring a patient to inpatient rehab. NIHSS. So you will see this splash throughout almost all stroke charts, but this is the way that we interpret stroke severity. NIHSS stands for the National Institutes of Health Stroke Scale. So the purpose of this is a systematic tool that provides a quantitative measure of stroke-related neurologic deficits. There are 15 items on the NIHSS. Level of consciousness is divided into overall, questions and commands, gaze, visual fields, facial palsy, motor in the arm left and right, and motor in the leg left and right, limb ataxia, sensory, best language, dysarthria, extinction, and inattention. The range is zero to 42. In the literature, these are some of the cutoff ranges. Sorry for the typo for there. So less than equal to seven is mild, seven to 14 is moderate. There's an overlap with 15 to 20 of moderate severe and greater than 20 severe. In a comatose patient, the maximum score is 39. If a person is an NIHSS of 42, they unfortunately have expired. So this is some of the imaging you'll see in the best language and dysarthria assessment. When we have a patient in front of us who's acutely ill with a stroke, we ask them to describe the picture. If they're able to describe it without any slurred speech, we know they don't have dysarthria. If they don't have any paraphasic areas, anomia, difficulty describing what's happening on the left of the picture versus the right of the picture, then we know they don't have not just anomias, but also visual field deficits. We also ask them to read those five sentences, pretty standard, and listen again for best language, dysarthria, and see if they're actually missing parts of the sentence if they have a visual field defect. Next topic is stroke abbreviations with ASPEX. So what is an ASPEX score? ASPEX stands for Alberta Stroke Paragram Early CT Score, and it's a quantitative measure that basically evaluates the extent of early ischemic changes in the anterior circulation hyperacute ischemic stroke. So with the ASPEX, the MCA territory is divided into 10 regions. You can see here, points are subtracted for areas with early ischemic signs. Early ischemic signs are focal swelling, parenchymal hypoattenuation, and you get a point for each one. So you have your three superganglionic nuclei, M4 to M6, all the way on the right of your screen, the anterior, lateral, and posterior MCA. You have three subganglionic nuclei, M1 to M3, which is the frontal operculum, anterior temporal lobe, and the posterior temporal lobe. And then you have the four components of the basal ganglia, the caudate, lentiform nucleus, insula, and internal capsule. So when you're interpreting ASPEX, you're looking for early acute changes. The ASPEX score of 10 is normal. That basically means even if they're having a stroke, there are no early signs of hypoattenuation in any of those nuclei as discussed. A cutoff score of less than eight or greater than equal to eight is used as a rough estimate predicting independence and general outcome prediction in those eligible for reperfusion therapy. So basically, it is the substrate that is used along with other imaging modalities to determine whether a person's a candidate to be revascularized. So when you see an ASPEX score greater than equal to eight, they're more likely to have a better outcome versus less than eight. And that is achieved by looking at the CT scan of the brain sequences without CT perfusion. This is just a non-contrast head CT and looking for early changes. So it's important that as physiatrists, we look at a lot of imaging because we need to be able to interpret some of this data. If you look at some of the CT scan of the brain reports, not just the results, but the actual reports, and a lot of them in stroke protocols, they specifically will tell you an ASPEX score in the CT scan of the brain report. You now know that you can use that data as a physiatrist to look at whether the person was a candidate for further intervention to hopefully improve their outcomes. So ASPEX score. The reason why it's Alberta is because Andrew Demchuk, who was a stroke doctor in Houston, moved to Alberta. And that's why it's called the Alberta stroke score. Stroke is very much into territories and where you created different things. So that is the ASPEX. Notice that in the case, we said it was a L proximal M1 occlusion. I thought it pertinent to explain what M1 occlusions are versus M2, M3 and M4. So I endeavored to find a diagram, essentially a pictorial interpretation of the M1s and an actual carotid arteriogram. So as y'all can see, the M1 segment has multiple areas. It has a horizontal branch, which is pre-bifurcation. You can see on the right side of the screen, which is the M1 segment pre-bifurcation. Number two is the M1 segment post-bifurcation. As it rounds the bend with the MCA genu in number three, it goes into, you can see the lateral ventricular striates coming off of the post-bifurcation M1. Then it goes into the M2, which is number five. M3, which is number six. And you can also look at the display on the left that kind of just shows you where the Sylvian segment of it is versus the cortical segment, which is M2 and M3 respectively. And then you can see the M4 segment, which is the cortical branches at number seven. I assure you they are all there. It takes a lot of looking at arteriograms to determine this. Take a look at number nine, because that sometimes get confused with the MCA branch. That's actually the anterior coroidal artery coming off. It's very small if you can see it. So you'll see your ACA is obviously going toward the middle. That is not marked. The anterior coroidal artery is coming off specifically off of number nine, and that is not an MCA branch. It's actually a carotid branch. So be aware of that. But that's what we're talking about. We talk about M1, which gives off your ventricular striate arteries. M2, which is the Sylvian segment, which is an M2 superior inferior branch. M3, which is a cortical segment, and M4. When you're looking at patients who are candidates for recanalization therapy, you want them to have a large vessel occlusion. In this instance, it will be either a carotid occlusion, which is pre number one on the right, or a proximal or two distal M1 occlusion. You don't want to really get into the M2 branches, and I'll explain a little bit why later, because the studies that we looked at when it came to revascularization didn't have as much efficacy in smaller branches. So it works very well with proximal M1 occlusions and carotid occlusions. So it's important to kind of look at your neuroanatomy and look at your neuroimaging and correlate both when you're thinking about evaluating a person for stroke rehabilitation, because it's important to know if they had an M3 occlusion, then they're less likely to have really severe deficits versus someone who had a carotid occlusion or proximal M1. All right, questions so far? No questions yet, but I'm loving the office reference. You know, sometimes you just got to do it. No questions so far, everybody good? Okay. None yet, I'm sure some will come up. All right, we're going to press on. Let's talk about some of the acute treatment. So we've screened the patient, we've taken a look at their head CT, we see this patient had a proximal M1 occlusion, the person had an NIH stroke scale score of 23, pretty severe stroke. So what are we going to do about it? The head CT showed no intracerebral hemorrhage, last seen normal was several hours prior, but they woke up with the symptoms, right? So we may be able to treat this patient acutely. There are several options to do this. The first one is TPA, which stands for tissue plasminogen activator. So the original TPA study was done in 1995, and it demonstrated improvements in functional outcomes at three months if thrombolysis was administered within three hours of symptom onset, with the greatest benefits seen within 90 minutes. So again, time is brain. For every minute that goes by, you lose about 1.5 million brain cells. It is very important to intervene early. Another study came out in 2008 that extended that time window out to four and a half hours. And that was the European Cooperative Acute Stroke Study 3, another stroke abbreviation, ECAS3, that you will hear people say, the ECAS3 study extended the time window out for TPA to four and a half hours. So how does TPA work? So the mechanism of action is it binds on fibrin-bound plasminogen within the clot, within the thrombus. It also interferes with circulating plasminogen. The cons of it is it's inactivated by another thing called plasminogen activator inhibitor, and the half-life in plasma is five minutes. It's in and out very quickly. The dosage is 0.9 milligrams per kilogram, max dose of 90 milligrams. The bolus, which is 10% of the doses, give it over one minute, infusion over 60 minutes. Why is this important to physiatrists? The bolus and the infusion. If you're reading in the consult note that a person got the bolus, but they didn't get the infusion, you have to ask the question why. A lot of the time it could be because the person started bleeding. Could be because the person developed tongue swelling, or other types of edema had a reaction to the TPA. It's very important if the bolus was given, but the infusion stopped, you kind of have to figure out why. Because that's a complication that may not be present as a possible allergy, a possible indication to not get TPA in the future. You want to look for that in the consultation note as well. How are you eligible? We talked about the class one recommendation. I wanted to go over this specifically because you want to have some deficits. There's been this controversy about whether you should give TPA to patients with very mild deficits. If they have a clumsy hand, should they get TPA? There is the risk of bleeding with this. So you have to be cognizant of that. So you really wanna give it to patients who have some disabling deficits that you know would impact their quality of life. If they're in the three to four and a half hour window, you gotta be careful still. So you wanna make sure they don't have uncontrolled diabetes. If they had a prior stroke, be careful it was a hemorrhagic stroke. If they have really, if they have moderate to severe NIH Stroke Scale, if they're taking any oral anticoagulants, and you wanna make sure they don't have imaging evidence of ischemic injury involving more than one third of that MCA territory. Because if they do, the likelihood of bleeding post-TPA is higher. And that's what TPA looks like, and that activates vial. Again, that becomes a 100 milligram vials, bolus, infusion, bolus is 10% of the dose, given over a minute, infusion, the rest of the dose, given over an hour. Now when y'all look at that bottle, because you can see the manufacture of that, we're gonna come back to some of the concerns about TPA versus a newer drug manufactured by the same company. So these are the reasons why you give TPA. I wanna talk about what has to happen, how stable the patient needs to be. This is important to physiatrists because sometimes when you're looking at a patient, and you're looking at past medical history, that past medical history is pulled from a possible previous admission, but not what's going on acutely. So if a person is walking into the hospital with an acute ischemic stroke, and they came in years ago when they were medically well, things aren't gonna populate over into the note the way they should, because these are brand new vascular risk factors. So when you're looking at this type of consultation, and you're thinking about what's in the notes, if their blood pressure was high, so if they got TPA, that means they had to lower their blood pressure. You'll see patients on nicotinamide drips in a lot of centers, versus labetalol drips, it depends on how your center rolls, but they may have nuanced hypertension that's not documented when you pull a past medical history down. You wanna look at their blood glucose, it's gotta be above 50. You wanna look and make sure they don't have any changes on non-contrast head CT. If they do, guess what? They may have had an old stroke. If they're on antiplatelet drug monotherapy or combination therapy now, why? Did they have a cardiac event before that isn't diagnosed or isn't included in the past medical history? Again, the eligibility for acute ischemic stroke TPA treatment actually tells you a lot about the past medical history. Again, if they have end-stage renal disease, do they have a normal APTT? So you're actually able to abstract additional data in your consultation note by looking at these acute care eligibility for thrombolysis with TPA. So some of the contraindications, I mean, this should be obvious, active bleeding. Well, how do you define that? Well, yeah, if the cascade of the brain has an acute intracranial hemorrhage, if they had a history of intracranial hemorrhage, if they have signs and symptoms most consistent with a subarachnoid hemorrhage. As y'all can see, there's blood in the sylvian fissure and endohemispheric fissure there. If they had a GI beating event within 21 days, blue hour, psyllium fissures, red hour, endohemispheric fissure. If they're on medications that may make them bleed, low molecular weight heparin within the previous 24 hours, typically if it's weight-based. Direct thrombin inhibitors or factor Xa inhibitors, unless lab results are normal or they hadn't gotten a dose within the past two days. And I want to kind of go over direct Xa inhibitors because they're brand new anticoagulants. So I pulled this table so we can take a look at it. You can see the first drug is Dabigatran, which is Pradaxa. That is the first one and that's a direct thrombin inhibitor. Here are the levels that you could be looking for. And you can see it's variable, right? It's variable what you're going to see on PT, PTT, or thrombin time. So you have to be cognizant of that and really get a good history to have an idea. Rivaroxaban is Xarelto. You'll see that a fair amount and you'll see that the anti-10A concentration would be changed. It's also the same as with Apixaban, which is Eloquus and Edoxaban, which is Cyanza. In PNR, specifically in stroke patients, you won't see a lot of Edoxaban use. However, if you're doing cardiac consultations or looking at just venous thromboembolism treatment, you will see Edoxaban used more. So you also want to look at labs and imaging. If they got low platelets or a high INR, if they got a prolonged APTT or PT, or if the CT scan of the brain show extensive regions of clear hypotenuation, those people didn't get TPA or shouldn't have gotten TPA. And if they did get TPA and they're bleeding, you have an idea why. You also want to look at the past medical history. A prior ischemic stroke in the past three months, that brain tissue was friable, they're more likely to bleed. Severe head trauma within the past three months or acute head trauma. We have lots of patients who had strokes and fall and injured themselves. So they would have acute head trauma in this situation. Intracranial or spinal surgery within the prior three months or known or suspected to be associated with aortic arch dissection. And I kind of wanted to show that aortic arch dissection actually can be seen sometimes the CT angiograms of the head and neck at the very top of the aortic arch because they tend to go down to the chest as well. So that's an aortic arch dissection flap that you would see if you were reviewing imaging. You also want to look at malignancy because if a person has malignancy, they're more likely to bleed. So a structural GI malignancy, an intra-axial intracranial neoplasm or symptoms of infectious endocarditis such as fever, night sweats, chills, pleuritic chest pain or a new murmur. It'll be really important to take a look at that because sometimes those things are missed. And as a part of the stroke workup, you're coming in as a consult doctor, maybe in the first day at UT Southwestern we're consulted very early or the first two to three days. So as the consultant doctor, you may hear the new murmur during the part of the acute stroke workup and remember this talk hopefully and say, hey, have we thought about endocarditis in this person? And sharing that with the stroke team will actually help portend better patient care. So the world of stroke rehabilitation, acute stroke care are very much blurred now. We start stroke rehabilitation extremely early. So we are a very important part of the acute care team as physiatrists. Let's talk about tenecteplase because there's always something else coming. Remember I told you all about TPA being made by Genentech? Well, look what Genentech's doing now. They have their next drug ready to go. So what is TNK or tenecteplase? It's a genetically engineered version of TPA with multiple point mutations. So what did those point mutations do to TPA you might ask? Well, it made it better. There's higher fibrin selectivity, longer activity than TPA. So remember we talked about the plasma half-life of TPA being five minutes. Look at the plasma half-life of tenecteplase, 90 to 130 minutes, which means you can see in the dosage part, it's a single injection over 10 seconds. 10 seconds done going on your own, given as a bolus dose only. Another good thing about it is it's not inactivated by PA1. So it really hangs out longer. So you've got to ask yourself as podiatrists, well, why did Genentech make another version of TPA? Well, you have to wonder when the patent for TPA is gonna go off and are they gonna have this rearing to go? At this point, tenecteplase is used mostly in cardiac literature with cardiac patients. It's actually less expensive than TPA and it's readily available. And nurses love it because it's just one injection over 10 seconds. They don't have to stay there and monitor a patient for a whole hour. Which takes up a lot of time when a person's in the ED. So this is one of the first trials of TNK versus TPA. It was a RCT published two years ago in which about 100 people received TPA, 100 received TNK. And the primary outcome was reperfusion of 50% of the involved ischemic territory or an absence of retrievable thrombus at the time of the initial angiogram. 22% of TNK patients achieved the primary outcome versus 10% of TPA. The instant difference was 12 percentage points and the number needed to treat was 8.3. This means that patients with acute ischemic stroke for each patient received TNK, 8.3 patients would need to receive TPA to achieve that same outcome. 90 day outcome is also better in the TNK group which means the modified ranking score, the median one was in TNK was two versus three in the TPA group. Hemorrhage events were about 1% in both groups. So I've kind of made an error y'all and I'm apologizing. So Meryl from the Devil Wears Prada realized that I just explained a stroke abbreviation with an abbreviation. So I talked about this MRS and what that means and how the TNK group had an MRS of two versus the TPA group had an average MRS of three. So you're probably wondering, Dr. Refetchiko, what is the MRS? MRS is a modified ranking scale. It is an outcome measure that is used in acute stroke studies. So you can see here the TNK group received a modified ranking score on average of two which means a slight disability, unable to perform all previous activities but can look after own affairs with assistance. They can go to the bathroom, they can ambulate, they can do all their ADLs but they may not be able to go back to work. The TPA group achieved a modified ranking score of three, moderate disability, requiring some help but able to walk without assistance. So they can ambulate, so there's definitely a good effect but they definitely have more disability compared to the TNK group. And I wanna show y'all this graphically. These are the grata bars laid to the side that basically define out modified ranking scale. So in stroke studies, a modified ranking scale of zero which is normal, one is barely disabled and two, as I've been talking about is mildly disabled are what you want. So you wanna look at the MRS of zero, one and two. And y'all can see, look at the number of people who had no deficits in the tenecteplase group versus the alteplase group, 28% versus 18%. And you can look at the modified ranking scale of zero, one and two in the tenecteplase group, much better overall than the TPA group. So it's the next step. It's not FDA approved yet. They're waiting to do that. There is some debate in the stroke community about TPA versus TNK because this was a small study but it was a RCT that was very well powered to detect the difference. So we'll just have to see what we're able to come up with in the future. So that is TPA versus TNK. Let's move on to ERT. So ERT can be interpreted as endovascular recanalization therapy or endovascular revascularization therapy. Whichever way you want to do it, it's still ERT. You may see it in some of your notes as IAT, interarterial therapy. You may see it in some notes as MT, mechanical thrombectomy. They're all going around the similar thing of ERT. So these are the criteria for it. The initial studies that were done in ERT were done in conjunction with TPA treatment. So you first evaluate for TPA, which kind of screens out patients who have elevated INRs, who have poor renal function, who have low blood glucose or high blood glucose if their blood pressure is too high. They were already screened out with TPA. So this is a pretty optimized group of people. So within six hours, we want our premorbid modified Rankin scale of zero to one, which means they had no deficits to very minimal deficits. Causative occlusion of the ICA, again, that internal carotid artery, or the proximal MCA, as we discussed, that M1, age of greater than 18 years, and the ASTRO scale of greater than or equal to six. They got to have some deficits that were treated. Aspect score greater than or equal to six. Remember, we want at least an eight for the best outcomes, but we'll take a six, because that's just early CT changes that are subtle. You want to know why the ICA or the M1 is clotted. It's not for people who have calcification. They need to have a causative occlusion that is thrombus-related. Calcifications cannot be used with ERT to treat. The window can extend out to 24 hours in select patients with good collateral fall, and that's in the Dawn and Diffuse three studies that I will, of course, be talking about in a little bit. We are leaving no stroke abbreviation unturned, ladies and gentlemen. So we're in there. We're in the vessel. We want to pull the clot out, and then you see something in the consult note called an MTICI score. MTICI, what in the world is MTICI? MTICI is Modified Thrombolysis Cerebral Infarction score. It is basically the level of reperfusion you are able to achieve. Why do I have the MTICI up front, but then I have TICI label underneath it? Because as you can see, if you look at the table, it is very difficult to visually interpret a TICI 2C. Why? Because a TICI 2C is basically near complete reperfusion except some slow flow or a few distal cortical embolos. So in a picture such as this, as a static picture, you can't really interpret slow flow, but I'm hoping that y'all can see the difference between a TICI 0, look at that proximal M1 occlusion at the arrow, versus a TICI 1, where there is minimal reperfusion past the blockage. A TICI 2A, there's partial filling of less than 50% of the MCA territory. A TICI 2B, which is greater than 50% of the MCA territory. And then a TICI 3, which is complete reperfusion. So stem retrievers remain the recommended choices device for mechanical thrombectomy. However, direct aspiration is coming into focus. It's important for y'all to understand that when you're reading the note as well, there's a certain number of passes, which means that certain amount of times you go in there with a stent retriever to try to pull the clot out. If you look at figure B, that's an actual clot plot of somebody's MCA territory. It's about 1.4 centimeters with a stent retriever. Now, if you can imagine that retriever is going inside the blood vessel. So if you think about it, do you really want a lot of passes with that thing in your blood vessel? No, why? Because every time you do a retrieving pass, you've got to pull that retriever out and it's causing abrasions to the inside of the blood vessel. Those abrasions can cause distal embolization. So when you're looking at the consult note, you want to look for two passes or less, which means they got to get it right the first time. So you're looking for two passes or one pass and the clot was out and they recantalized with a TICI 2B score or better for the best outcome. That means you got blood flow into that area. If you see four or five passes, they really were attempting to recantalize. If they got four or five passes and they got to a TICI 2C, the person's probably going to be on anti-platelets or anti-coagulation. If they did four or five passes and their score is still a one, they're probably going to have a very large and devastating stroke. It was important to show y'all specifically what the stent retriever looks like to have a visual representation of why you want to have one or two passes only versus more. It's important to really characterize why we are doing ERT more now compared to years before. So this was the New England Journal of Medicine article for an article called Mr. Clean. How prosaic, they're using this trial where they're pulling out clots and they called it Mr. Clean. It was the first RCT, an interarterial treatment for acute ischemic stroke. And it was the first of five trials, there were five trials going on across the world, literally across the world, in which they were trying to figure out essentially the best candidates and the best way to remove clots from people's brains. And what they found in Mr. Clean is that in inter-arterial interventions with second generation stent retrievers, it dramatically improved neurological outcomes after ischemic stroke involving a documented large artery occlusion. We are not talking poster circulation either, by the way. Large artery goes for ICA, internal carotid artery, and that M1 I've been beating the drum about for the past 30 minutes. No significant increases in the rates of ICH, no significant increases in 90-day mortality. And when the Mr. Clean results came out in 2014 at the 9th World Stroke Conference, they basically stopped the other trials. So there were four other trials going on. In Canada, ESCAPE, Australia EXTEND-IA, Spanish RE-VAS, and SWIFT-PRIME. And at that end point, all five papers were published in the Journal of Medicine, that was in 2015. So a little bit later, we're gonna kind of go over those trials and y'all can see which ones extend to the six-hour window versus the 24-hour window in ERT. Let's talk about RAPID. In the case we said, the CTP with RAPID was significant for the above. So RAPID is a specific imaging platform that's used to optimize clot retrieval in stroke patients. It incorporates components of aspects, components of looking at the core infarct and the penumbra. And we're gonna talk about that a little bit more. So it helps select acute stroke patients with known occlusion of the internal carotid artery, approximal, M1, for ERT. So let's take a second look at that CT perfusion we saw earlier in that 88-year-old patient. So when we're thinking about patients who are candidates for ERT, we wanna look at their ischemic core. You want a tight core in the MCA distribution ideally that you can intervene on. As y'all can see, it's looking like a M1 occlusion. You want a penumbra that's large enough to salvage, which means it's having slow flow. And these are essentially the criteria. The mismatch ratio you can see is in the middle of the screen, second point of hypoperfused tissue to the ischemic core. So that's green to purple of greater than 1.8. We've got 5.6, right? Ischemic core volume, which means cerebral blood flow greater than six seconds of less than 70. We've got that too. Look at that core as we talked about in purple, it's pretty tight. And severely delayed volume, T max of greater than 10 seconds of less than 100. We're at 105. There aren't very many stroke doctors who still wouldn't go for that. And so that is the reason why this gentleman was taken to have ERT. In the note, we said he received a TICI 2B, which means greater than 50% of the vessels filled with only two passes. So these are some of the studies of interest in 2015 that involved RAPID. RAPID is a specific type of software that's FDA approved. However, you can do ERT just with a CT perfusion. As we discussed before, you've got to have working renal function to even get the TPA, and you do receive contrast to receive CTP. So again, they've already screened out the patients who are candidates for ERT and who can clear contrast. These are the 2015 studies of interest that basically show that ERT works up out to six hours. SWIFT, PRIME, and EXTEND-IA. And in 2018, the time window went out to 24 hours. I want y'all to look at DAWN, so I can try to explain how they come up with these mnemonics. So DAWN stands for diffusion or CTP assessment with clinical mismatch in the triage of wake up and late presenting strokes, undergoing neurointervention retrieval, which is a step retriever. The D, DWI, the A, assessment, the W, wake up, the N, neurointervention. So yeah, there's nothing intuitive to this, which is why we're giving this lecture to basically explain that it's important to have an idea of what the study stands for and not what the abbreviation means. Questions so far? Yes, we do have a couple of questions. One is, so TPA versus tenecteplase, I kind of made a note here. So outcomes, I imagine in the first New England study trial that you're talking about, probably also were a function of time. And I'm curious as the intergroup, any intergroup variation and symptom onset to medication administration. So it was only in patients who presented within a three hour window, and they were a very specific sub select population, you are correct. So it was within the three hour window only, it was TPA compared to usual care and not to another drug. So it basically was just checking the superiority of TPA over what was at that time in 1995, standard care. There were no interventions for stroke patients with ischemic stroke. You got your blood pressure controlled, your glucose controlled, you got put on an antiplatelet agent and they discharge you home. So this was groundbreaking because it came to actually looking at endpoints when it looked at actual outcomes of the treatment within a very select population. That was why it was important to do ECAS3 because people had already been treating patients with TPA off label for out to four and a half hours, because that was the only treatment that we had up until 2015 when the ERT trials came out. So there was a period of basically 20 years where all you had was TPA. So they were trying to do TPA in any kind of iteration. Now that things have changed significantly over the past five years, we're seeing outcomes expand out significantly. Furthermore, one more point about that, sorry y'all. I really love this. There are now studies that are showing that we may not need to give TPA, that we may actually just be able to go straight to ERT and remove the clot. So that would be the next stage of research that we're doing in this field. That's interesting. When I see trials with small numbers like that, and certainly trials landing in big journals, I mean, 101 and 101 is not a huge trial. I think if you're taking all comers I think at a major institution, I think at Vanderbilt, we would hit that pretty quickly. But my first thought is either this is a quickly put together study or it was very selective in its patient population. And when they land in big journals, they tend to be more selective. That's interesting. Second, kind of tagging onto that with retrieval, you mentioned wanting two passes or fewer when you're doing a symbolectomy. Is there, based on the picture you showed us and kind of my understanding of the procedure, that is then kind of pulled out and kind of dragged along to the exit. Is there any evidence or concern for further thrombus formation or damage to vessels between the embolic point and the exit point? An exit point? Great question. So they do sometimes do distal emboli detection to see if there is distal embolization within a day or so. And that can be done through TCDs or through other neuroimaging. After a person gets TPA, it's usually recommended that they have a CAT scan or an MRI within 24 hours. That's why on acute stroke order sets, they get the initial head CT, they get TPA and ERT, and then the MRI takes about a day. If you ever wondered why, that's why. Because they're looking at the MRI to see if they had distal embolization. Okay, thank you. A question was asked by Dr. Madhavi about bleeding risk. So what were the bleeding risks associated with tenecteplase in that study? And was that a Genentech-funded study or anything? Do you know? It was 1% in the TPA group and 1% in the TNK group, I believe. Great question. It was Genentech-funded. And then think about it. Weren't both drugs made by Genentech? Yeah, right? So I would expect that. 1%, so we're talking one to two people in either group. Correct. And then kind of going back to an earlier topic, broadly speaking, is M1 more proximal and M8 more distal, kind of in general, as a generality? M1 is definitely more proximal. Yes. That was my understanding, but I wanted to pass that question along. That is all the questions we have right now. Thank you very much. All right, let's keep going. Also, love the Chappelle reference. This is great. Listen, you gotta do it. I'm hoping everybody's still awake. Everybody's still awake. Stay with me, peeps. We're almost there. All right, so let's go back to the case. And now I will speak English and not stroke abbreviation. 88-year-old, right-handed male, woke up with a stroke. Last seen normal, last known well-timed 13 hours prior. However, because he woke up with a stroke, we basically count for when he woke up. NIH Stroke Scale of 23 indicated he has a severe stroke. CT scan of the brain had no intracerebral hemorrhage. Fantastic. His aspect score is eight. As y'all can see here, he definitely had some changes in the core and far, as you can see, in the subcortical areas. You can kind of guess from this CT ischemic core where the areas of the aspects they would check off. Eight's still good, isn't it? More likely to do well if we do intervene. CT scan of the head and neck significant for a left proximal M1 occlusion. So, so far, he is a candidate for ERT and TPA. CT perfusion was rapid, significant for the above. We've gone over small core, decent amount of size of perfusion, mismatch ratio greater than 1.8. Let's take this man to ERT. And we do. We take him to interarterial therapy. He had ERT with two passes only. He achieved ticky 2B recanalization, which means greater than 50% of the vessels filled. Unfortunately, it wasn't a 2C or a 3, but 2B will take. And the ASTRO scale improved from a 23 to an eight. Modified Rankin score of two, which means he was walking and able to attend to some needs but required assistance at 90 days. Now it's important for me to go over one more time. MRS is measured at 90 days. We know as physiatrists, our career extends for the entirety of the patient's life. But that look at 90 days is very important when it comes to their functional mobility and their quality of life. So that is how you interpret a stroke abbreviation filled consult note. As y'all can see, a lot of it pertains to what we do as physiatrists, doesn't it? More than you would even realize. And all of this occurred within the first day of the acute stroke course. So again, lesson learned here. There's a lot of physiatric principles in here that pertain exactly to us. And some of the acute care interventions that are happening affect the patients for life. And we pretty much jump in at day, like I said, one or two at UT Southwestern. So we're seeing this and interpreting this acute care data on how it's gonna portend their rehab course and hopefully portend good outcomes. So if this gift resonates, no worries again. I'm available on email. I'm available on Twitter. Please stay in contact with me. You now have these slides on the AAP website that you can review one more time and reach out. I have tons of references for you. Everything here that we went over, some of the images. Again, those two trials that kind of started it all off. And thanks so much. Just in case you need it, just one more MCA review because I can't help myself. Hey, it's appreciated, always. No, this has been fantastic. It's always nice to know kind of where your recommendations are coming from. And I think it buys us a lot of street cred for those of us who are still making inroads either to new faculty or on new services. It always helps when you can say, well, whatever trial stated this, I think that helps a lot. So thank you very much for that. One question that came in, most recent New England study stated that endovascular thrombectomy alone was non-inferior to thrombectomy. Yes. However, non-inferiority doesn't equal effectiveness or efficacy. So do you think TPA is gonna remain then? Yes, I do. Unfortunately, there aren't enough thrombectomy capable facilities across the country to intervene on a large amount of people. Therefore, we need to have something that's intravenous and readily accessible for areas that don't have people who are able to provide that service of ERT. So it's very helpful that we have comprehensive stroke centers and we have thrombectomy capable centers. But if you take a look around the country, they're really concentrated in urban metropolitan areas. So what about people who live in rural areas who need access to thrombolysis in another way? So I think that TPA is here to stay. I think tenecteplase is creeping up and is gonna have its own significant role, but it's gonna be exceedingly important that we make sure there's accessibility in both areas. There was an interesting presentation at International Stroke Conference this year where they're actually using a robot, robot arms, this neurosurgeon, this brilliant neurosurgeon in Canada, to do ERT from a distance. The distance so far he's done it from is across the room, but someone else set up a groin puncture and he used the robot to actually remove an M1 clot from a patient without even touching the patient himself. So that could be a possibility in the future for ERT remotely. That's equal parts exciting and terrifying, I think. I think when you're innovating with surgical techniques, the question is always, what if? You know, what happens if you have a complication? Is the person that made the groin puncture, are they gonna be able to kind of manage that complication? That's interesting. I know here at Vanderbilt, we just in the past couple of years, we've rolled out a teleneurology program because our catchment area is large and rural. And so we might have somebody in the middle of Mississippi or Alabama or Arkansas or Kentucky or wherever. And they call in from an ER, rural ER with a stroke and our neurologist can kind of tele consult, tell them whether to push TPA and then ideally put them on a chopper and get them up here for thrombectomy. But sometimes that doesn't happen. Sometimes it's the local ambulance and they're gonna get here hours later. So I agree. I think there's gonna be a role for that moving forward just because not everyone does have access to surgical options. The stroke term for that is drip and ship. Drip and ship. I like it. Drip and ship. I'm gonna sound so cool. I'm gonna sound legit. They're gonna say, wait a minute, who's he been talking to? Who is this guy? Yeah. Hey, thank you so much. This has been fantastic. It really has been an excellent lecture. I appreciate that. I'm going to put your information back up on the screen here. Cause I'm sure some questions will come up, if not from our participants right now, at least from people who are gonna be watching this later. We're finding that as programs are ramping back up their educational programs and their, honestly clinics and that sort of thing, that we're getting more and more views in a delayed format, kind of the recordings online. So I'm sure questions will come up from that group. Here is, so of anybody that is participating or thinks that they have a colleague that may want to watch this, physiatry.org slash webinars. And we kind of made it a little bit easier. If you scroll down to the bottom of that page, there are direct links to all of these lectures now. So you don't have to, it's pretty straightforward. That also has the schedule for lectures that are upcoming through the end of the month. And if you have any questions, please feel free to reach out to me, to AAP, to Dr. Ofejika directly. There are our Twitter handles. Again, thank you so much, Dr. Ofejika for joining us today. Thanks so much everybody for attending and look forward to hearing from you. Thank you.

stroke abbreviations

acute stroke care

last seen normal

last known well time

National Institutes of Health Stroke Scale

Alberta Stroke Program Early CT Score

tissue plasminogen activator

endovascular recanalization therapy

modified Rankin score