Stroke: Management in the Golden Hour

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Stroke: Management in the Golden Hour

11 May, 3:30 PM

[Music] good evening everyone and uh i welcome you all on behalf of team netflix uh we have with us uh this evening dr vinit vanga who is currently working as a senior consultant of neurology and neurovas vascular intervention at blk max hospital delhi he's finished his md in internal medicine with a gold medal and subsequently gone on to do his dm a neurology from delhi uh following which he's done a fellowship in stroke from royal men a melbourne hospital australia and the masters and stroke from austria uh he's also done two fellowships one is a fellowship in neuro intervention and stroke and a second fellowship in interventional neuroradiology and this makes him the only neurologist in north of india with a double neuro intervention fellowship under his belt uh so who better to get us started with the management of a stroke in the golden hour so um without any further ado we will begin with our first presentation uh thank you thanks for your kind introduction and i would first like to thank metrics for giving me this opportunity so we'll begin right away and the topic of today's discussions would be stroke management in the golden hour so golden by golden we mean that the patient presents early as early as possible but preferably within four and a half hours maybe a bit later but yes within the wind of thrombolysis i will say so the r still remains cold and if he is eligible for thrombolysis so we know that brain attack is is similar to heart attack where the oxygen supply to the brain is shut and time is very important and so we know that we have many neurons in the brain millions and billions of seeds so as soon as the blood supply is cut they start dying down it's it's akin to uh considering uh watering a plant if you don't water plant it starts getting dry especially in this hot weather if you water it in time then it comes back to its normal shape and greenery but otherwise it it gets dry and dies off so the definition of stroke is certain onset of focal neurological deficit there are two types of stroke mainly we are talking about ischemic stroke uh but there are a significant portion around 10 to 15 percent of the total strokes are hemorrhagic which is due to bleed in the brain today we are going to discuss mostly about ischemic stroke we will discuss hemorrhagic stroke and leave it to the degree to a later date so these questions that you have that you should ask whether the patient presenting to you is a really stroke and which territory what is the pathology and all those things for the management of stroke but for managing in the golden r we should ask certain other questions that whether there are any risk factors or not modifiable ones non-modifiable ones such as hypertension diabetes smoking drug abuse obesity sleep apnea so all these are the risk factors and the clots can form in the arteries they yourself in the carotids or in the brain or they can migrate up from the heart stroke is one of the major contributors of disability the major one the first the largest contributor of disability and one of the major contributors of death it's one of the common after the cardiovascular or the cardiac diseases accounts for around 5.7 million deaths overall so uh what is more common to understand it is contrary to our popular belief a stroke occurs more common in under developed or developing countries that's why it becomes even more important to uh address the issue of stroke and especially one of the non communicable diseases that's there so we know that around 4500 people now even larger so this is the old uh paper cutting that have used 4500 people in india get stroke every day which is a huge number for a country like us which is relatively young so the case fatality rate in this study was around 24.5 percent of urban and around 40 percent for rural so rural patients 40 of them actually die and disability rate is even even higher so they most of the patients suffer significant disability so that's why it's important that we uh recognize stroke early and treat it fast especially when the patient comes to us in golden period because we know time is trained so the current scenario is that the ambulance fetches the patient or the relatives come back themselves the uh the patient the earlier patient is initiated the treatment the better the outcomes uh diagnosis requires to stroke experts but yes there are certain things that even a general physician or a medical practitioner can do and recognize stroke so uh we contrary to the popular thinking and the old thinking that that mostly the stroke affects the old age which is not true it affects anybody at any age so it's just that the risk factors differ so these are the things of the past when we used to think like that and used to act slowly now we have to be very fast because we know that the time is brain and stroke is an emergency so we treat heart attack very fast we act very rapidly everyone moves fast and the patients also know their symptoms as soon as they have a chest pain or something fishy they come to the hospital and they come to the hospital and then they immediately the emergency team is fast and emergency team takes them to the cardiac cath lab and the stenting goes on but that's not how the stroke is treated stroke is treated a bit slowly and emergency services are not as active and sometimes we lose this precious time of golden r which leads to the problem so it's very important to know that stroke is an emergency as as emergent as a cardiac problem such as mi so we know that only one to three percent of all stroke victims received treatment with tissue plasmid and activator in the us and we're talking about us not india so and comparing to 25 of acute mi patients receiving treatment so that's quite a lot of difference but we also know that many of the acute mi patients die on the way of bringing hospitals so while stroke doesn't lead to death as commonly in the acute settings so it's it's very important so that means that we are missing or not recognizing the stroke or the stroke that is not leaching this or the stroke is not the patient is not reaching in time okay i'm not audible [Music] and the rest of the audience if y'all could just i try to use your phones also along with that uh we could probably have a better audio experience am i audible is it better uh yeah i can give you a thumbs up or if it's better now yeah okay so we know that we are talking about u.s and while comparing 25 percent of acute mi patients reaching to the hospital only three percent reached hospital for acute stroke which is a very very vast difference when we compare that acute mi patients around 80 percent of them don't even reach hospital they die either at home or while being while coming to the hospital so uh it's very important that we now we can understand that around 95 or more than 90 percent of the patients don't receive tissue plasma using an activator because of one of the other reasons either they don't reach in time or they are not recognized early or they are not treated early so it's very important that we diagnose and treat it early now what is what are the reasons for lack of treatment one is the patients don't recognize stroke so everybody knows about chest pain as soon as you have chest pain or a bit of palpitation patient runs to the hospital emergency but that doesn't happen when you have slight deviation of face or slight tingling in your hand or slight weakness so all of that is not recognized as promptly as a patient who has acute mi so 40 percent of the patients if you stroke patients even they can't name a single sign or symptom of stroke and 75 percent actually misinterpreted their symptoms and 86 percent believe that their symptoms aren't serious enough so either they'll say okay it's like slight bit of numbness i probably have eaten bad or eaten wrong things or i was sitting in a wrong position that's why i having this and then they don't realize that's why they they either they don't come to the hospital or they go to the wrong hospital or to the wrong doctor or sometimes not even coming to the hospital and going back to the old practitioners where they are not treated uh with the right medicine so the physician's lack of experience is also one thing because everybody is reluctant to give thrombolytic therapy and acute stroke because of the risk of bleeding that it that that was there but that's that's that's the thing of the past but that's still prevalent and lack of the organization so all of this actually uh is the reason uh so i'll i'll cover one by one so what is more important is to first diagnose that's true then to recognize whether the patient is in window period of thrombolysis and then to thrombolyze so we'll discuss each thing one by one so coming on to the diagnosis of stroke symptoms we know that any of these sudden headache any blurring of vision any difficulty walking or difficulty maintaining balance any weakness of any of the limb of the body is the sign of symptom of stroke so fast fast is the pneumonic facial droop or facial deviation arm drift or leg drift weakness of one of the arms lasting more than 10 seconds or five seconds for lower limb and difficulty in speaking or understanding the speech we added to it b e so we now speak as b fast b for balance e for i so any problem with balance any problem with vision any problem with phase facial deviation any arm drift or any problem with speech is a symptom of stroke if it occurs suddenly or acutely so this is the mnemonic that everybody should remember so fast check your face check your limb check the speech so the problem with acute ischemic stroke is that there is a blockage of the blood supply so what happens like you can you can uh compare it with somebody tying a polythene on your face you false first start feeling a bit dizzy then you'll be probably unconscious and if if that polythene is right there on your face you will be died you'll die deprived of oxygen the same happens with brain as soon as the blood vessel is blocked the blood supply is cut off and the part of the brain starts to die and gradually this area the small area this gradually increases and every minute we know 1.9 million neurons or say 14 billion synapses die but what is the therapy to open the this blockage what do you do when there is a pipe blockage in your in your home you open it up either you put some detergent and or you push it mechanically the the blockage has to be pushed or plucked out mechanically and that's what's the therapy for acute stroke thrombolysis or thrombectomy so we know time is brain because as the time passes by every minute we are losing around 2 million neurons and this is this becomes even more important in elderly because they already have brain atrophy so the lesser the neuron pool the more the neuron dies eventually the deficit is even higher so this is how the growth of the infarctor happens with time and this small black areas then fog the surrounded gray area is the penumbra but as the time passes this black area completely involves the gray zone so eventually the patient has complete weakness so this is how it is so the gradually then fast core will increase the penumbra will also uh decrease so the thrombolysis has to be given early before the penumbra finishes and there is a large infarct core so this is how it is if you give thrombolylistic therapy then fast core remains small and whole of the penumbra can be saved while if you don't offer re-perfuse on all of this grays zone around the black part will become dead so we know that we are losing around 1.9 million per minute so which is which is very very important so the benefits of any from thrombolytic therapy so it's like you compare it like in povet times we were having less oxygen can you make all those people alive again by giving oxygen now no because they needed oxygen then ah manisha i could read your question could you explain a little about penumbra penumbra is a brain tissue which is vulnerable and will die if not restore the blood supply off so that's very important so it is the area of the brain which is deprived of oxygen but can still get back to normal if the blood supply of this area is restored within time so uh coming on to the thrombolytic therapy it's the one of the main stage of treating but it is time dependent for example i was discussing you cannot make all those dead patients alive who would who died because of lack of oxygen during covet times the same happens with brain if you give this thermolytic therapy late if you open this blocked pipe plate the brain is already gone you cannot revert it so what you can do is you can act fast and open this block pipe as soon as possible before before it is too late and the brain is already dead so we know the time saved is brain saved and this is how it happens the patient comes to the emergency department the assessment happens the stroke team gets notified through stroke code then the radiology that the the radiology colleagues also getting get a pager through stroke code and they are ready with their ct scan if there is no emergency scan going on in the ct scan the stroke patient is given priority we don't need most of the blood test this just the oxygen is just the sugar monitoring is fine and then you suddenly see like if there is no bleed in ct patient is early window you go ahead with the inconsent and then thrombolysis so this is how we go about it so we know uh that tissue plasma is an activator which is the thrombolytic therapy uh is it it has a number needed to trade of 4.5 to 14.1 depending upon time so if the patient comes very early within first hour we have to treat five patients around four and a half patients to make one patient better then if it the patient comes later between 30 minutes to around three hours then we have to treat nine patients who have a good outcome while the same outcome for four and a half are increases to 14. so this is how how fast it iterates that's why it's important to treat in time so for every 100 patients we treat with tissue plasma and activator 32 patients benefit if they are treated early while the same treatment if given late 16 patients benefit and three harm so the the risk benefit to harm ratio actually increases decreases with time so that's why we have to rush we have to fast because we know that uh the brain is dying so this is the effect of alteplase on the ordinal mrs so i'll not go into detail of all these i have included these trials to like if there are any neurologist and want to go through these trials they can go ahead with this nintz was the first which documented it then then atlantis came the ecos 3 episode all these trials used uh thrombolytic therapy and and have shown that there are significant uh positive outcomes uh in in these patients so uh these are the trials that have shown that it benefits what is important that you recognize the symptoms realize that the patient has stroke and one of the important tool is nihsa so nihs is a questionnaire through which we ask these questions score it uh on a scale of one two four one two three every time and give points to each of the deficit like deficit and um any visual field deficit gate deficit language deficit and they can then give points to these and through these nih score we know whether the stroke is mild moderate or severe so any stroke with stroke score which is zero to four is a mild any stroke score which is 5 to 15 is having moderate and any nih of more than 15 is it would be called as severe stroke but severity differs with patients for example somebody who's a painter has a mild deficit in his hand he can have a mild stroke definition wise but it can be disabling for him so that's why it's important that we know that it's not only the score which is important but the type of deficit which is very important so if the patient comes to us in window period in golden hours almost all of them should receive thrombolytic therapy within one hour that should be our goal door to needle time should be less than 16 minutes it should be as less as possible but should always be less than 16 minutes it's very very important so we have to do a ct ct is the only modality and probably one of the most fastest modality easily available widely available it's very important that we do ct as soon as possible and it will tell us whether there any hemorrhage or not any any early infarct science and if it is normal go ahead with thrombolysis don't wait mri is is not as frequently used because of availability cost and the patient if it is used having altered some thorium it becomes difficult to get an mri scan so these are the inclusion criterias for thrombolysis any person who is an adult more than 18 years presents to us within four and a half hours and is a eligible candidate for thrombolysis there were many relative exclusion criteria but almost all of them doesn't stand the test of time and currently i would say there are only very very less number of indications uh contraindications for acute thrombolysis so getting ahead with the stroke mimics so it's not that every patient who presents to you in emergency department has a stroke sometimes they have seizures hypoglycemia migraine but let me tell you one thing if you thrombolyze even if you thrombolyze these mimics for example a psychogenic patient who presents a stroke he will not have bleed so the incidence of any side effect is very very less so even if you thrombolyze some patient mistakenly thinking of that patient having stroke while is not having stroke and is a mimic then you don't stand to lose much in fact if you miss a stroke and thinking of it as a mimic then you stand to lose more so that's why i seem very important that we don't uh uh waste time in thinking too much about it so the dose for thrombolytic therapy is 0.9 mg per kg we are currently talking about l templates so i'll discuss about connectives as well so i'm currently talking about lte place at a place has a infusion dose of 0.9 mg per kg so 10 is given as a polar so for example you consider a patient presenting to you with around a 50 mg a 50 kilogram patient so 5 into 9 will be around 45 so you have to give 45 milligram total out of which 10 which is around 4.5 mg should be given as a bolus over one minute and the remaining which is around 40.5 milligram will be infused over next one r in ns so that's how it should be given it's very important that we perform blood pressure monitoring neurological assessments and look for any warning signs such as yes maximum is 90 milligrams you are absolutely right maximum is 90 milligram and so that's that means that the patient is very obese for example you have a 150 kilogram weighing patients probably will not use more than 90. so it comes in a vial of 50 and 20 milligram for example you need 70 milligram for somebody you use a 50 milligram wire and a 20 milligram and look for any of these warning symptoms such as headache hypertension nausea vomiting that means that the patient has blood so we have around uh out of hundred patients will have around six patients will bleed and around three to four patients will have this bleed as a fatal bleed so that's why it's important that we don't miss bleed and try to treat it as early as possible but minor bleeding such as gum bleeding mild nasal bleeding is not a sign of worry you should continue your infusion of thrombolytic therapy so we have to monitor the vitals and all those things the predictors of good favorable outcome are that we treat early have patient has a normal baseline ct is not diabetic and has a normal pretreatment blood glucose and blood pressure if the patient is of increased age had his prior head injury is diabetic having hypo hyperglycemia or high blood pressure then it's a problem ah okay so uh i i am reading many questions but i'll probably answer them one by one after after i am done with the slides uh so now coming on to rtp lt play so i'm moving slides a bit faster because in between there are slides that are not that important so i'm i've kept them on uh the media so that everybody could go through it but there are certain slides which are not as important so what we should remember is that lte place should not be mixed with any other medication we should not use iv tubing with infusion filters we should use cardiac monitor so all of this is very important the complications could be intracerebral hemorrhage minor bleeding anaphylaxis angioedema major hemorrhage so all of these can be the complications for thrombolysis and one should be ready to manage these what are the limitations of felt a place it has a very short half-life around three to five minutes it has a plasmogen activator inhibitor in the body which inhibits its function the arterial recognition is fewer than 50 in patients treated and especially less for those who have a large basal occlusion and it has a done percent 10 fold increase of symptomatic intracranial hemorrhage but that should not be the reason of stopping us from giving this wonderful wonderful drug so if uh we find that the thrombolysis is there there are many things to do but we will not go into detail about it uh can we can we load the next slide in between i'll try to answer so vishnu jaktap has asked me how to manage stroke in case uh where mri or so now coming on to the tnk that the clays so technically has a higher fibrin specificity it has a higher binding affinity there is a prolonged half-life that's why the tenecklas has been pushed into action and the current trials especially presented in iso european stroke organization the eso conference conducted in france around 10 days back has shown that the connect is non-inferior what are the advantages of connectives it is cheaper you can give it as a bolus dose ah low dose versus standard dose so low dose has been proven to be non-inferior to the standard dose ivl take place uh but there is no superiority trial of some one over and other but for tonight is that there has been a controversy about those but the currently that the controversy is all settled that those currently that most of us use or most of the trials have recommended is 0.25 mg per kg 0.25 mg per kg body weight is the dose of the necklace so it can be given as a single bonus because it's more uh thriving specific it is more effective in platelet-rich thromboid and it is safer and it has a pro-coagulant it lacks the pro-coagulant effect which may turn decrease the early occlusion so this is what the scan looks of a patient of the almost similar patient without thrombolysis the patient gradually develops infarction of the right mcterry can you see the black side of the right right side of the brain is black so the whole of the right side of the brain has gone black because it has become dead so if we give thrombolysis all of this area of the brain could be saved that's why it's important to reduce the stroke risk recognize the stroke symptoms and respond fast now coming on to guidelines so any patient who presents to us within four and a half hours should receive thrombolysis and this is the guideline of aha so it is a class 1a recommendation to give thrombolytic therapy for any patient who presents early in the course if the patient presents late so wake up stroke one of the question was asked here wake up slow if the patient for example goes to bed around 9 00 pm and wakes up around 3 00 a.m in the morning and shows the signs of stroke then the onset of this patient will be considered at 9 00 pm 9 pm not 3 am so the patient last seen well is the onset time but now these patients are known as wake up stroke because the patient recognized the symptoms when he woke up from sleep that's why these patients are known as the cases of pickup stroke so what do we need to do in the current setting either you need to do an mri and show a diffusion flare mismatch or you should do a ct perfusion showing a significant area of penumbra with a small infarct core and you can go ahead with thrombolysis providing that the patient doesn't have a large vessel occlusion so how to treat patients with ckd with scope so you treat them them the same way as any normal patient there's no difference so coming on to mechanical thrombectomy now this is something that has completely revolutionized the stroke treatment in the modern era so what do we do if the pipe is blocked you try to open it by a detergent by a thermoelectric therapy but if the clot burden or the blockage is too hard and it is too big for this thermoelectric therapy to act then what would you do you will try to take it out suck it out or push it so this is what mechanical thymectomy done does you go in the brain with those big aspiration pumps and strength retrievers and pluck the clot out of the body so class one a recommendation for patients presenting within six hours and having a large vessel occlusion but it can be done till 24 hours so the currently the stroke window has been extended to 24 hours but today's topic is not about 24 hours we are discussing about the golden our golden r is zero to four point five or probably six hours that's what i call as golden hours and treat them early so these are the trials of mechanical thrombectomy that have been there so this is how the patient presents to us so what test we do before thrombolysis just measure the bp do uh the sugar testing and do a ct if there is no bleed in ct patient presenting early go ahead with from a word with thrombolysis nothing else is required just ask the patient about whether he is taking any anticoagulant drug has there been any history of malignancy so all those questions that you need to ask so recommendation in 80 years or older is the same so we have thermalized even patients who are hundred above above hundreds so not only octagenarians but even the patients who have crossed hundred we do for young stroke the recombination remains same machines up it remains the same for a young stroke patient as well you go ahead with thrombolysis though the ideology can be different it can be cardioembolic it can be sickle cell it can be dissection is mechanical thrombectomy superior to thrombolytic yes yes it is superior to thrombolytic because the number needed to treat for mechanical thrombectomy in trials has been around two to three which is better than the thrombolytic therapy but mechanical thrombectomy works only in large vessel occlusions it doesn't work if the patient doesn't have a large vessel occlusion because you cannot go into small vessels and open the artery the thrombotic therapy works even if the patient has a small vessel occlusion so the patient comes to try it shift it to ct and then go ahead with thrombolysis you find that there is a large vessel occlusion in ct angiography take the patient to the dsa room and do go for mechanical thrombectomy so the time is running we know that it is a class 1a recommendation for going ahead with thrombolysis it is akin to using of mask in covid so everybody uses masks in prove it so why not thrombolyze every patient who presents to you with symptoms and signs of stroke in the golden arm yes thrombolysis in cause hemorrhagic bleed so the incidence is much much less and then the benefits that there are so it you counsel the patient that out of 100 six to seven can have bleed but only three two to three can die as well but this is the risk that you take this is this is akin to the risk of driving your car and carrying and the tire getting flat so these are the trials i will not go into detail so the stepwise approach is this we we have to streamline the again and the make the process accountable we have to have multiple specialities involved and have to have a team approach what we need is iv thrombolytic and endovascular treatment and other research studies so i'll show this patient so focus on these two cases one is of mechanical thrombectomy and one is of iv thrombolysis so this 52 year old male presented to us with difficulty walking double vision facial palsy presented to us in golden hour for our window on the mri you can see the right side has slight diffusion restriction medulla as well as the cerebellum so the patient had right lateral medullary infarct the mrn geography on your right side on of the image has is normal so there was no major vessel occlusion no large vessel occlusion can we show the video can we have the video please yes [Music] the patient and the patient can we play the next video the second video of the same gentlemen foreign [Music] [Music] foreign [Music] or not so what i was telling is that i'm not very sure about the law whether the mci recommends it or not but i am very sure if you discuss if you do it in discussion with a physician or somebody who's in neurology for example i do many tele consultations for uh for stroke so if you thermalize these patients nobody's gonna jail you i'm very sure about it and and and i'm very open to having any tele discussions of uh anywhere in the country or abroad so obviously abroad i'm not licensed to do that but in india if you if somebody asked me that whether you acquired with thrombolysis with the ct scan even at 2 am in the morning i'll be very happy to give a tele consultation and you give my thrombolysis in pregnancy very very tricky topic so they have been case report series uh doctor mithal about thrombolysis in pregnancy but uh there have been no guidelines only recommendations so that the people depends upon the deficit if the patient is a candidate of large vessel occlusion you don't thrombolyze because the chances of placental bleed is high but if the patient is a candidate and you think that there is significant deficit you go ahead with thrombolysis this is what i have thrombolyzed a couple of pregnant patients in my experience and they have done well so coming on to this second case can you can so coming on to this second case this patient presented to us with sudden loss of consciousness within two hour window and what we could see is that there was cerebellar infarct some pontine infarcts and we could not see the basilar artery if you pinch and zoom in you don't see a basilar artery here [Music] where [Music] also do you want me to play the second video next [Music] huh so this patient had a a basilar artery occlusion if you see both the vertebrals are there but there is no basilar i took the catheter of diploid stent retriever and took the clot out and you see the first image on the left and the last image on the downright the artery is opened and the patient became absolutely okay if i would not have done anything this patient would have died so this is the difference that you make you are the difference between life and death thrombolysis and thrombectomy is the difference between life and death life and disability a functional life and a disabled life and you can make this difference if you recognize the stroke early treat it in time thrombolytic therapy or mechanical thrombectomy so thrombolysis is something that you that can be done at an any center which has a ct scan facility so how to differentiate between ischemic and hemorrhagic how can you differentiate is like the patients so there's no 100 differentiating point but if you want to differentiate hemorrhagic strokes usually have profound loss of consciousness from the beginning they have a lot of nausea and vomiting the bp is usually above 200 in these patients so any of these severe headache a bp of more than 200 nausea and vomiting at the onset and a very very acute presentation is a hemorrhagic stroke unless proven otherwise so that's how i differentiate in my clinical practice but you cannot thermalize a patient thinking it to be an ischemic stroke if you don't have a ct scan in your in which so when to do a ct and when to do an mri okay so we do a ct unless uh unless we find that there there we have a possibility of posterior circulation stroke but that are that those things are only there when the patient is passed this golden are if the patient presents to you with four and a half hours and stroke sign symptoms then you go ahead with the ct don't go for mri don't wait for mri go for thrombolysis on the basis of ctu what you all you need is just a normal ct that's it so that's how it is for recognizing the penumbra for doing mechanical thrombectomy you need a ct perfusion a ct angiography or an mrn mrn geography so all of this is required if you are if you want to go ahead with mechanical thermactomy and especially in late window for even mechanical thrombectomy in early window what you need is a ct and a ct angiography that's it role of a primary care physician so uh can can we can we go to these questions because uh so this is all about it thank you for your time we'll we'll discuss the questions there are many questions that that have been asked yes um we'll get to the questions right away um so we have uh dr nominees he was asked a role of primary care physician if one patient presents with stroke so i so i think that one should not differentiate these roles based on whether the somebody's primary care physician or a tertiary one what is the difference is is that whether you have the facility of thrombolysis or not whether you have ct scan whether you have medicine availability or not even if even if there is a primary care physician who has a ct scan around him and recognizes the stroke he can treat stroke by thrombolytic therapy you don't need to be a neurologist to streak stroke you don't you just need to be an mbbs doctor no guideline tells you that you have to be a neurologist to treat us true even an mbbs doctor can treat even an intern can treat stroke without any problem what is more important that you recognize the symptoms early and treat in guidelines you don't treat out of colin for example somebody treating a stroke without getting a ct scan is not right somebody treating a stroke if he is out of window without getting a proper imaging is not right but within four and a half hours a normal ct go ahead with thrombolysis you don't need to be a neurologist to do that when to begin aspirin after thrombolysis dr chalendra you can begin aspirin as early as 24 hours after thrombolysis so you don't need to wait beyond that doctor dr mitchell has asked me something why literal vertical i can't see these questions completely so you can just open the comments box on the right hand side and you will be able to see all the questions so bilateral vertebral artery dissection complicated by posterior circulation stroke so i'll technically tell you dr dr mitchell that this patient firstly this patient is very unlucky to have bilateral bilateral vertebral artery dissection so what do we need to do is so uh so dissection is not a contraindication for thrombolysis if you have this patient early in the course you formalize it if there is a dissection and it is occluding the artery then you might need to stand it uh early if it is complete blockage go for a mechanical problem we try to open it up if it doesn't open up you have to do an emergency stenting one of the arteries so if if it is not a flow limiting one then what you do is you should give anti-platelets or anticoagulation mostly antiplatelets after three to six months the patients do well the arteries open up well if the patient power improves within golden ar then we should thrombolyze no so the answer is no then you'll label it as a ti if the patient is improving if the patient has a rapidly improving weakness for example the patient had weakness while he was at home for by the time he reached your emergency is improved so that means the patient has a ti a dia means transient ischemic attack the patient doesn't have a cl doesn't have and in fact even if he has it in the mri the deficit is not there if there is no deficit the nihss and national institute of health stroke severity scale is low then you don't need to thrombolyze don't thrombolyze these patients you just need to evaluate whether this patient has an ideology and treat that ideology dhingra somebody who had an episode of carpoo pedal spasm suspected of tia what is uh what is the management so if you are suspecting it to be a tia evaluate for the tia do an mri brain mrn geography of neck and brain and do do all the tests that you do for a tif the patient doesn't have a tia and had a carbo fetal spasm treat hypocalcemia if that is the reason so as soon as the you recognize the doctor nirali as soon as you recognize that the patient has stroke before referring what do you need to do if you have a ct scan at least give aspirin if not anything at least give 300 milligrams in loading those if the ct is normal if you don't have a ct at hand don't give aspirin that's something that that can get you in a legal tangle so don't give aspirin if you don't have a ct scan facility around you because the patient when reaches to an higher hospital might find might may be found to have a bleed and then you'll be in a soup because you have given aspirin so don't give aspirin or any other drug if you don't have a ct any role of step two kinase in ischemic strep so the guidelines don't recommend that so we don't use the step two kinase do we need and you we don't need pt aptt inr values routinely dr pihu but if the patient is on anticoagulation for example he is taking warfarin or acetone then you need inr and inr should be less than 1.7 migraine patients have have been found to have stroke more commonly than the general population but the treatment remains the same for tie patients you should give dapt for at least three months as far as the chloropedrogel versus aspirin is concerned so the trials have shown aspirin to be beneficial better than the clopidogrel and in the american heart stroke association recommends aspirin and not clopidogrel as a single therapy role of pre-hospital care team dr i'm sorry we missed your question so a pre-hospital team has the most important role in acute stroke treatment so unless you recognize it in emergency unless you recognize it early do us get inform us and push it push everybody for a ct scan or investigation fast we won't be able to help the patient so you have the most important role in treatment of stroke because you are the first point of contact of stroke patient unless you recognize so it's very important for the pre hospital team to recognize the stroke recognize the symptoms the mnemonic is be fast balance eye face arm speech and t is for time so any of these symptoms the patient has a stroke inform your doctor get a ct scan fast and go for thrombolysis how i prime i'm sorry how i primarily approach you with major medical facility not available so if what so major fatty fat facilities not available mean either you don't have a ct so if you don't have a ct then you refer the patient as soon as possible because without doing a ct giving anything or doing anything can be a legal problem so i'll i'll not so rather than getting into a legal trouble it's very important that you refer the patient for a ct though what you can do is don't make the patient wait educate the patient that you have stroke if you reach the bigger hospital in time for example a ct scan facility in time if you receive the thrombolytic in time then you will improve that is very important because by the time the patient reaches us you have already told whatever we we would be telling him in emergency he also already has the knowledge about thrombolysis our job becomes easy anybody is gonna thermalize his job becomes easy so that's what you can do you can educate about it in two minutes and refer don't waste time an oxaparin is ischemic stroke if it is cardioembolic then an oxaparin has a role otherwise no so any patients treated with debigetron you give antidote in the emergency i have thrombolyzed the patient some days back giving the antidote and then thrombolyze the patient the patient was on predixa or debi gatrin so we thrombolyzed so you go at with antidote and thrombolyze the patient citycholine and piracetam have no role in the treatment of acute stroke avinash what was your question i am sorry we missed it sir uh dr abhinav's question is if the sudden onset chest pain or sop without ecg what medications can be given a sublingual nitrate too so the chest pain you're talking about chest pain so just when you treat the treat for mi the way you treat mi so like if you get an ecg find that the patient has mi you go you load the patients with aspirin and cropitude because then st elevated mi go for pci if it is nstm i go for an oxo current and go for an urgent angiography and treat it vinai pandey dr vino pandey platelets have to be given for three months multiple stroke episodes in applause same guideline and approach so apple mostly apla patients need they are eligible for thrombolysis but they need long-term anticoagulation sometimes for life to prevent stroke recurrence piracetam and ct colin have no role in an acute stroke no role at all acute mi and stroke are very interesting questions doctor surrender so patient has acute min stroke you thrombolyze the patient because the thermolitic dose is not uh for um if you start treating the mi so you first see which which thing is worse whether it is mi or whether it is stroke so if the patient reaches to you doesn't have a large vessel occlusion go ahead with thrombolysis and let the let the uh let the cardiac team treat the patients within pci doctor vineyard pandey asking a question uh yes i'm not able to find a doctor could you please re-type your question or in case of chronic you give high dose statin and double antiplatelets for three months and then single antiplatelet with statin tablet arena so arena has a diaphragm all with aspirin so it has a role in treatment of stroke so it is akin to double antiplatelet if you use aspirin clopidogrel the same role as of aspirin diapering all the trials have shown that it works but unfortunately later trials have shown that the clopidograil aspirin combination is harmful than aspirin alone so eventually adreno is not as freely as available as it was sometimes back but arena is almost equivalent to double antiplatelet aspirin and flooped overall combined intracerebral hemorrhage dr kajal we might be covering it later on today the topic was of management in golden art so i in the beginning i discussed that we'd be discussing only about ischemic stroke hemorrhagic stroke is a different disease a different beast altogether and we'll talk about it probably in a next talk that we'll have you can review the ppt shahid the ppt would be there you can go through it the the app is live you can anytimes go and see the slides the slides have no limitations these are not my personal slides so i this is to make public so i would request to the videos are not there so that's the patient identity that we don't want to disclose so that's why we have kept the videos different separately awesome cbs 2 silver stock dr vinay pandey how to differentiate severe stroke i am glad that you asked it national institute of health stroke severity scale is the scale that will tell you whether the patient has severe stroke large vessel occlusion or not if the patient has an nihss of more than six he has an 80 percent likelihood of having a large vessel occlusion if the patient has an anionthisis of more than nine he has a ninety percent likelihood of having a large vector occlusion so the more the deficit the larger the stroke so i'll tell you in in and brief if the patient has right hemi process with aphasia the patient has a severe stroke if the patient has a left hemiparesis with facial deviation then the patient has a large vessel occlusion why because right side of the brain controls the left side of the body and the left side of the brain controls the right side of the body and the speech is controlled by the left side so that's why right sided weakness with with aphasia means difficult to understand or speak means a large vessel occlusion a severe stroke left-sided hemiplegia with gaze deviation means a severe stroke can you can we uh we can to an extent precisely differentiate between embolus thrombus so so what is the thrombus thrombus can be of a thrombus which is formed in the artery locally in the brain or in the neck or it can be an ambulance so ambolus is a thrombus which has come from somewhere else so ambolas and thomas is the same when thrombus for example it is here and it dislodges from air and goes in the brain it is known as ambolus then in this case this would be known as artery to artery ambulance if the semi mumbolus goes from heart this will be known as cardioembolic stroke so that's the difference [Music] and dr pandey has asked me yes you should thermalize even a severe stroke you have to thrombolyze but that means the patient has a large vessel occlusion and will need a mechanical thermometer you thrombolyze as soon as possible and refer this patient for mechanical thrombectomy but thrombolysis has to be done so the chances of a doctor dr manoj kumar has asked so the chances of hemorrhagic conversion is there but the chances of improvement is also there so you don't differentiate on the basis of large vessel or small vessel so if the thrombectomy facility is not available you have thrombolysis in the patient is in window you go ahead with thrombolysis we bridge it you travel you thrombolyze and refer the patient for mechanical what is more important is if you counsel even if you don't do anything just tell the patient that you have spoke go to the hospital as soon as possible and discuss about thrombolysis the job of the next doctor becomes easy if you thrombolyze tell about mechanical thromectomy that job of the interventional neurologist or the interventionist becomes easy because the patient comes to me i don't have to counsel again because you have already done my job i only have to diagnose and treat this patient any other questions if i'm missing any target vpn ischemic stroke so you try to keep the pp below 180 uh there have been a trial which says that intensive bp hasn't been as good as uh strict control of pp hasn't been any uh having any fruitful outcomes when you compare it with the normal bp control so keep the bp below 180 180 by 110 that's your bp target because we have to maintain the cerebral perfusion pressure because there is an edema in the brain and the icp is high if you don't maintain the perfusion pressure that's a problem so don't bring the bp down by too much anti-epileptics so there is no role of prophylactic anti-epileptic in extreme extreme no role of propyl electric anti-epileptic in ischemic stroke role of many tall so manitol has been having a very doubtful role in manitoba this can be used to prevent mass effect in those patients who have a large infarct core uh but i would recommend decompression hemicranictomy instead of manitol for these patients but the patient doesn't want a mechanical thrombectomy and you have to give something give many tall or three percent saline post thrombolysis hemorrhagic management go give trenexamic acid uh if the hematoma is big try to evacuate decompress anti-epileptic of choice for patient of stroke anti-epileptics are not recommended for stroke if you have to give give levitrace a time young stroke and the common cause in our practice okay so young stroke can have a rheumatic heart disease and cardioembolic stroke dissection and vascular vasculitis these are the most common causes protocols for three percent saline difficult to discuss long question uh dr vini up uh it's it's it's a very so you have to monitor sodium every two hours or four hourly and then infuse three percent ns depending upon what are the uh so it's a difficult job so three percent and giving three percent ns is a very difficult job unless you have very good facilities in your so that's why many dollar decompression is my favorite when you discuss about decompression you can give diamox as well but it doesn't have that much rule yes in vasculitis you you try you don't thrombolyze these patients but how do you know whether the patient has a vasculitis before thrombolyzing unless the patient gives you history so if the patient gives you history of vasculitis in the past and has a stroke don't thrombolyze don't thrombolyze because these patients are more prone to bleeding [Music] thrombolysis versus primary coronary intervention go for both of them y to one so like go for thrombolysis and then pci or thrombolysis plus pci you can thrombolyze in cath lab as well thrombolyze the patient in emergency shift to cath lab continue the thrombolysis and continue with pci why to choose one when you can have both [Music] any other question that you are missing you answered almost all the questions either or in the q a or during other sessions i don't really see any uh questions here this is dr arnold she was asking you a people started in ti for how long would you take it for life for life life long and what would be the duration of dual antiplatelet some doctors p who says in my antibiotic to no role no role no role dr pihu no role of antibiotics no role of anti epileptics no role of city choline and pyrocidem no rule of neuro protectives are we done like i can't see any more questions if you can see can please tell me [Music] i think most of them uh so most of the questions have already been answered um i'll just give it like a couple of minutes if there are any more discharges fine you can give deep let it that's that's like double antiplatelet aspirin plus prohibitor but you have to add skating there's overstating [Music] so we we don't from so we thrombolyze the wake up speed but we have to see whether the patient has uh or not and that you can do by a ct perfusion or by an mri diffusion flare mismatch so dr shak muhammad asked me this of ct mri just counsel the patient and refer doctor after golden period so you treat the patient with rehabilitation give antiplatelets for a secondary stroke prevention uh treat diabetes clean treat bp because if you don't treat bp sugar all these things the patient has a bad outcomes try to prevent infection go for rehabilitation so bladder bowel back there maintain blood pressure maintain blood sugars avoid prevent infections and give active rehabilitation that is the management that you do after the golden r when you don't stomach role of migraine migraines patients are more prone to having infections they are eligible for thrombolysis yes so i think most of these questions are you want viruses not helpful in post office [Music] your name is very good hello fairy tale ravi raj hello ravi raj rather than hello palidol ravi raj dr surendra has asked me thrombolysis in pregnancy so if the patient has a large vessel occlusion go for mechanical thrombectomy and don't uh go for iv thrombolysis if the patient has a small vessel doesn't have a large vessel occlusion and comes in window and you are fairly sure that the patient has a significant deficit go ahead with thrombolysis but counsel the patient well i have done two thrombolysis of pregnant patients myself and have had literature review about that there are case series but there are no trials so the recommendations are a bit shady sheikh mohammed has asked me i mean to ask what are the condition where we thrombolyze them even after this so that's that's what i said so if the patient has a wake up stroke for example he went to bed at 9 pm in the morning and woke up at 3 00 pm 3 a.m then the time is already gone but you don't know whether the stroke happened at 9 00 pm 10 pm 11 00 pm at 12 a.m 1 am or 2 am so don't know the window so the patient has presented to us after nine two three so you see you the patient has printed to you after six hours but you don't know when is the stroke happen we call these strokes as wake up stroke so these wake up strokes you can thrombolyze if you do an mri and find that there is diffusion hyper intensity but there is no flare change either you do a ct perfusion and find that there is a small impact code so hopsin has can you repeat your question i can see your question doctors have seen so the question is role of cerebral protein in uh in recovery uh not much so there's there be no trial as such it is not recommended isha cycles maximum dose of 10 actually is 20 milligram 20 milligram intubate strong stroke patients indication for intubating stroke patient is similar to intubation of non-stroke patients if the gcs is down the patient is prone for a aspiration intubate so dr isha's question is if does a child with a child of hemophilia that comes in with stroke i'll not thrombolyze don't thrombolyze these patients it's a contraindication for symbolisms sustain an injury you get a ct scan if there's no bleed in the brain go ahead with thrombolysis if the patient has sustained bleeding in the brain after falling because of ischemic stroke then you don't do thrombolysis intra-arterial thrombosis so intra-arterial thermolysis can be used springly so the guidelines are not very good proactive one and two were the trials in which zero kinase was used in swizzle and especially in burn people use it very frequently it can be used in those patients who have a very distal vessel occlusion where your stent retrievers can't reach or in those patients who have digital embolization after thermolysis or thrombectomy no if the ct shows in fact don't stop the aspirin don't stop aspirin aspirin is not to treat the infarct aspirin is to prevent the infarct so it is for prevention of infection so it stops from the infarction from recurring it doesn't stop then then fog which is already developed so tenect is uh dr abeer is 0.25 mg per kg polaris is enough yes it's enough don't go above it the problem in india is that currently dgci says that the role of teleclase is 0.2 mg per kg so that's a legal problem that you can get into with but the trials recommend 0.25 so if you use 0.25 you are kind of legally safe because the trials have used 0.25 and you can show this data some legal problem comes but not above 0.25 again stroke in pregnancy no that will that will that that will affect our mother so the if the mother is not well then obviously the fetus won't do but independently doesn't have any outcomes from thetas old hemorrhagic stroke we knew this thing depends upon the time if the hemorrhagic stroke was long back then you treat the patient with thrombolytic if the patient if the patient has a recent hemorrhagic stroke then you don't thrombolyze especially if it is a large hemorrhage management of hemophilia patient with stroke a tricky question so you manage conservatively give antiplatelets sometimes these patients tend to have these prothrombotic states you treat them broken vasculitis so don't thrombolyze if you if you get to know that the patient of a stroke who presented to you in emergency has tumble as vasculitis don't ever ever thrombolyze the chances of bleeding in vasculitis is very very high so i've seen in my personal experience and many other literature review there's no guideline for vespolitis patients having receiving thrombolysis but the chances of bleeding are high and my my suggestion would be to not thrombolyze these patients if you know that the patient has vasculitis [Music] so i don't recommend anything so lte plays antennas both can be used that's why i covered both in my talk so and and uh the trials have shown non-inferiority of teneclaes in from multiplayers but there is no trial yet to prove superiority of necklace overall templates other than extend iatnk which proved superiority of tenecklas overall take place is in patients with large vessel occlusion presenting early within three hours so any patient who presents to us early within three hours has a large vessel occlusion go for ten necklace other than that you are free to use whatever you want to use i i sometimes use lte place sometimes technically depending upon the patient cost and many other things but you can use any of these [Music] clinically you can differentiate if the patient has sudden loss of consciousness sudden nausea vomiting a bp in the range of 200 these are the signs that the patient has can can have bleeding indications to give thrombolysis stroke is the indication for giving thrombolysis patient if the patient keeps having infections despite uh conservative management then it's an indication for htmc bypass temporal artery mca middle cerebral artery bypass so that's the treatment if the patient has a ruptured aneurysm because of weakness you treat it by endovascular root by embolization so depending upon what is the presentation of whether it is hemorrhage or ischemia if it is ischemia you treat it by bypass so i hope the session was helpful and uh if there are no further questions ah no sorry thank you are you answering all the questions i have tried to answer most of it if if uh if somebody uh if if any question is left i'll be very happy to answer you can you can uh so you can have in the beginning i have given my email id i might be contacted on that email id i am i'm happy to be associated happy i will be very happy if someone wants an association with regards to tele consultations or tele consultations for stroke i do that free of cost i don't charge anything for it and i'm going on record i don't charge anything for it you send me a ct scan at 2am in the morning i'll tell you whether to summarize or not and you're free to use my name thank you so much it was a very helpful very informative session uh we will put in the email id in the comments uh and you all can have it uh you can take it from there and thank you so much uh for this amazing session and we hope to have you soon again on netflix for uh many more topics and uh thank you so much for coming in and we'll see you all soon for more sessions on netflix thank you sir thank you thank you thank you


The treatment of acute ischemic stroke has changed dramatically in the last two decades, with the introduction of intravenous thrombolysis (IVT) and, more recently, endovascular thrombectomy (EVT). Treatment within 60 minutes of symptom onset offers great outcomes, with much lower rates of morbidity and mortality in patients, according to recent studies. The Golden Hour refers to the extraordinary 60-minute window that exists between the start of symptoms and the onset of treatment. Let's hear it from Dr. Vinit Banga about the protocols that need to be followed to ensure rapid treatment in patients with stroke which will yield excellent results.

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