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Ridgeview and the Ridgeview Continuing Medical Education Program are proud to present the Ridgeview Podcast: CME Series. Quality, portable and on-demand continuing medical education, featuring a variety of our exceptional physicians, providers and other staff from Ridgeview and it's affiliates. Hosting the program are Fred Demeuse, PA-C and Jason Hicks, PA-C. Thanks for tuning-in, downloading and listening! 

 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview & Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Feb 6, 2020

In this podcast, Dr. Mark Young, a stroke Neurologist with Abbott Northwestern Hospital, discusses current guidelines for ischemic stroke management and care.

Enjoy the podcast!

Objectives:  
  Upon completion of this podcast, participants should be able to:

  • Summarize the latest guidelines and management for acute ischemic stroke.
  • Describe current interventional management for large vessel occlusion with thrombectomy.
  • Identify modified Rankin scores and the impacts on stroke patients.
  • Demonstrate an understanding of new timelines to guide therapy such as Diffuse-3 and DAWN trials.

CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.

To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.

 CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”

  

FACULTY DISCLOSURE ANNOUNCEMENT 

It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

SHOW NOTES:

CHAPTER 1:
One large impact on stroke care 2018 is the thrombectomy window expansion time for large vessel occlusion out to 24-hours.
https://www.ahajournals.org/doi/10.1161/STROKEAHA.118.023310

Current perfusion imaging available is able to identify core infarct- establish the quantity and mismatch ration of available brain that is salvageable.

Futile reperfusion is something that should not be undertaken due to high risk of reperfusion hemorrhage which can ultimately worsen outcomes.

Last known well time means exactly that. When was the patient last seen well. So if they go to bed and then come in with a wake up stroke then LKW is when they went to bed.

Some studies on wake up strokes showed that the majority developed symptoms 2-3 hours prior to waking up.

LKW and wake up stroke are different but can often help us guide therapy. For instances pt goes to bed is LKW time and then wakes up with stroke like symptoms. Perfusion imaging is instrumental in the decision process for these patients often guiding us with further management.

The NINDS trials came out in '95-'96. However the bottom line showed - in patients, with ischemic stroke within 3 hours, tPA administration significantly improved HIHSS scores but did not confer survival benefit.
https://www.nejm.org/doi/full/10.1056/NEJM199512143332401

Stroke neurologist typically want a call early in clinical course. Don't wait for CT prior to calling. Then when was the last known well time. Blood glucose, blood pressure, PMH and deficits (ie NIHSS), 'what are you observing'. Don't wait on labs - consideration is warfarin.

There are trials following the NINDS trial that show evidence that patient with low HIHSS with potentially disabling deficits and rapidly improving stroke improve with TPA treatment and that the hemorrhage rates are lower.

Definitely consider treating rapidly improving stroke sxs.

With stutter stroke sxs, the clock resets when the patient returns back to baseline.

CHAPTER 2:
Most stroke centers uses -0-4.5 hours time frame for IV thrombolytics.

Absolute and relative contraindications for thrombolytics include: greater than 2/3 MCA territory don't treat as there is little benefit. Patient on warfarin with INR greater than 1.7. Recent stroke or ICH. Endocarditis. Coagulopathy. People on DOACs. Significant thrombocytopenia. There are many more but these are the highlights.

American Stroke Association says patient must be off DOAC's for 48-hours before lytic treatment as relative contraindication.

Dr. Young's standard conversation with pt who are experiencing a stroke when discussing TPA. First, it is the standard of care, next the chance of hemorrhage is around 6-7%, but Abbott has a much lower rate of around 2.5%. We know that even with that risk patients do much better overall. At 90 days, the chance that the patient will be living independently are much better.

90-day Modified Rankin Scores are standards that we use to measure stroke outcomes. Modified Rankin Scale score of 0 is no deficit, no residual. MR of 1 can do everything you use to do although may still have mild symptoms that patient may notice. MR of 2 - you have some limitations but can live independently and do all ADLs MR of 3 - is dependent with ADLs although can walk with or without a device. MR or 4. Can't walk. MR of 5 - bed bound. MR of 6. DEAD.

Some criteria for TPA with lower HIHSS with compelling deficits are #1, what's disabling #2. Others include limb ataxia, aphasia, paresis, dominant hand problem, dysphagia, dysarthria. Controversy Hemianopsia.

Greater than or equal to NIHSS of 6 is generally recommended to get a CTA to evaluate for LVO stroke.

Imaging generally requires CT/CTA of the head and neck. Always include imaging of the neck.

Rapid perfusion imaging for LVO used in Diffuse 3 - (6-16 hours) for the window vs DAWN out to 24-hours.

CHAPTER 3:
So the order of imaging includes noncom CT head, CTA, CT perfusion.

When evaluating the imaging studies we want the core infarct to be less than 70ccs and the ratio of the core infarct to at risk brain penumbra to be greater than 1.8.

The use of rapid sequencing MRI has utility for post circulate symptoms, ie vertigo with/out nystagmus, abrupt onset. Generally diffusion weighted gradient echo/T2 flair images looking for blood. Other indications maybe for subacute findings/duration.

LVO's that can be intervened on include: anterior communicating, distal carotid or carotid terminus, MCA M1, M2, basilar, distal verts, maybe PCA/P1.

Important point if a patient has a LVO lesion and is within the 4.5 hour window at a small rural setting with lytic capabilities and the patient is going to a large tertiary stroke center does the patient still need to receive IV lytic therapy - knowing that the patient will require thrombectomy and answer is YES. No increased risk when using lytic with thrombectomy.

A little controversial but we maybe seeing the bypass of non-stroke hospitals specifically with LVO to tertiary stroke centers with a new scoring system that EMS can do called RACE (Rapid Arterial oCclusion Evaluation)  https://neuronewsinternational.com/racecat-trial-update/

CHAPTER 4:
After care by the PMD what can we expect from these patients follow a LVO?

90-day Rankin  50% with modified Rankin 2 less to live independently following LVO.

50% of LVO have a 90 mortality. 70-80% will not live independently.

Discharge meds for these patients will include DOACs or Warfarin, antiplatelet agents - such as Plavix. Occasionally patient will end up on dual antiplatelet therapy depending on disease state.

Stoke mimics that have been given thrombolytics have less than 1/2% chance of hemorrhage.