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Stroke Updates

Rob Orman, MD and Ryan Radecki, MD
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN

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EM:RAP 2017 May Written Summary 839 KB - PDF

Thrombolytic therapy for acute stroke symptoms is based on the time the patient was last seen normal. This concept is based on the fundamental principle that time is brain. The longer you wait, the less chance of successful treatment. But is time really brain? In theory it is, but advanced imaging technology has shown that there may be viable brain tissue many hours after our usual thrombolytics time cutoffs. Inversely, patients presenting well within the ‘time window’ may have no viable tissue left.

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Ian L., Dr -

The cultural pressure will be less to give IV thrombolytics if it is validated that the finding of cerebral amyloid angiopathy on MRI for example increased dramatically cerebral haemorrhage after IV thromolytics .
In "Cerebral Amyloid Angiopathy in Stroke Medicine " Block F et al in DtshArztebl INt 2017 114(3)37-42 found that in those patients who had cerebral haemorrhage after systemic lytic therapy 70% of the patients who had bleeding had Cerebral Amyloid angiopathy compared to 22% in a control population .
They claimed cerebral amyloid angiopathy is present in 30% in the 7th Decade and 50% in decades eight and nine .

Ross B. -

Ryan's review of this topic is great. I'm particularly interested in the new practice of obtaining not only a non-contrast CT but also a CTA in nearly all pts who present with stroke-like symptoms. I have, in the past, felt that we could identify which pts would have a large vessel occlusion based on exam and NIH stroke scale. If the pt has a low NIH scale and minimal deficits, they probably don't have a large vessel occlusion and a CTA is not likely to change management. However, Dr. Redecke's contention that "small strokes" that then get much worse overnight might represent those strokes that have good collateral circulation (with only a small ischemic core) and then complete their stroke and should, possibly, have a CTA and CT perfusion study done to evaluate if they have a large vessel occlusion does not really agree with my previous thinking. We know that the risk of CT (at least in this population) is usually related to the risk of contrast and allergic reaction or contrast-induced nephropathy. Therefore, who should we be getting CTA's on? All pts with stroke like symptoms and no obvious contra-indications to contrast? Just those with probable large vessel strokes?

Richard H. -

Zero mention of ascending aortic dissection as a stroke mimic! I was very lucky because a patient that I had last year dissected all the way up to both carotids and was seen on the CTA neck (thankfully labs weren't done by the time my no contrast CT head was done or pt would have likely gotten TPA). My colleague was not so lucky and gave TPA to a dissection about a month later. It went as you'd expect... In neither of these cases was chest/back pain even remotely the chief complaint because the neurologic symptoms were so overriding. I haven't reviewed the literature on this particular topic, but these two anectdoes were enough to terrify me. PLEASE give more airtime to this unsung villain!

Pierre M., M.D. -

I was disappointed in Ryan's take on all of this. How about "the overwhelming evidence from RCTs is that there is little or no benefit of tPA in acute stroke and likely harm". Instead his point was "the train has left the station so get on board and here are a bunch of fancy new tests for you to help you use a treatment of unproven benefit more".

Why not say "in the absence of clear benefit we will not promote tPA or advanced diagnostic tests that help us use it more"?!?????

David P. -

Great review. I sit on the hospital stroke committee as the ED liaison and have been a party to the frantic pursuit of shorter door to needle times. There is a whole school of thought that if a difficult metric is reached we are giving good care. We jumped through all the hoops and got our national stroke honor badges and frankly I find it all a bit scary. There is even talk about TPA in the field. That post above with the ascending aortic dissection just makes me pucker up thinking about what could happen with these stroke mimics. "Time is brain" is a mantra repeated endlessly at our institution. I also worry about expectations in the community for recovery based on this-clearly some brains won't do well no matter how fast you give the stuff. Keep the spotlight focused on this one boys and girls because someone has to bang the drum of reason in this parade.

Craig M. -

To David P's point our Regioinal EMS is beginning a pilot where they have telemedicine via tablet on the rigs for neurologist's assessment prior to ED arrival in an effort to decrease door to needle time. I am a lone voice in the wilderness on this. The hospital's push is for the accredidations. EMS thinks they are actually doing something good for patients thanks to the AHA and stroke society. Yes the train has left the station and it's a bullet train. We are at the point where our neurology colleagues have gotten to the point where they are publishing literature about how stroke mimics that got tPA did "OK" in order to justify the expanded use of this drug! So now the cost of the drug includes the setup for all of this nonsense.

"Those who cannot remember the past are doomed to repeat it"--anyone remember solumedrol for spinal cord injury?

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Red, Hot, and Shot Full episode audio for MD edition 237:30 min - 331 MB - M4AEMRAP 2017 May Aussie Edition Australian 22:03 min - 30 MB - MP3EM:RAP 2017 May Canadian Edition Canadian 12:11 min - 17 MB - MP3EM:RAP 2017 May Spanish Edition Español 77:25 min - 106 MB - MP3EM:RAP 2017 May French Edition Français 23:24 min - 32 MB - MP3EM:RAP 2017 May German Edition Deutsche 73:18 min - 101 MB - MP3EM:RAP 2017 May Board Review Answers 211 KB - PDFEM:RAP 2017 May Board Review Questions 171 KB - PDFEM:RAP 2017 May MP3 Individual Segments 316 MB - ZIPEM:RAP 2017 May Written Summary 839 KB - PDF

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