Stroke FM

Chat & Tap: screening for ELVO at the 6-24 Hrs, the ACT-FAST Protocol

Episode Title: The 6-24 Hour Window: Screening, "Chat & Tap," and WorkflowHosts: Dr. Houman Khosravani (Stroke Neurologist) & Dr. Christine Hawkes (Stroke Neurologist & Neuro-Interventionist)Location: Stroke FM Studios, Toronto The Original paper, ACT-FAST [https://www.ahajournals.org/doi/10.1161/STROKEAHA.117.019307] was a pre-hospital tool for detecting ELVO. This is now used in the ED as a first-pass clinical screen, that leads to acute CT/CTA Head and Neck. In this episode of Stroke FM, we unpack the specific screening protocols for identifying stroke patients in the extended 6 to 24-hour window who may be eligible for Endovascular Thrombectomy (EVT). Unlike the standard "FAST" screen, this protocol aims to identify Large Vessel Occlusions (LVOs)—severe strokes caused by major clots that require mechanical removal. We discuss the critical importance of accurate timestamps, how to clinically test for cortical signs (the "Chat and Tap"), and the essential workflow for emergency physicians to confirm candidacy before activating the regional stroke team. * The Rule: The 6-24 hour window is calculated from when the patient was last seen completely normal, not when symptoms were discovered. * Wake-Up Strokes: For patients waking up with symptoms, the clock starts when they went to sleep or were last seen well by family. * No "Resets": Hearing a patient move or hearing a fall is not sufficient to reset the clock; there must be a confirmed interaction where the patient was at their neurological baseline. However, if the patient self-reports - definitely consider that. Protocol for Emergency Physicians or Emergency Department Nurses - in a RN-led model: The initial screening (using ACT-FAST or similar LVO tools) should be performed locally by the Emergency Physician. If the clinical screen is positive, the following workflow applies: 1. Local Imaging First: Order a CT Head and CTA (Angiogram) of the Head & Neck immediately at your site. 2. Confirm the LVO: Review the imaging to confirm the presence of a Large Vessel Occlusion. Activate: Only once an LVO is confirmed on imaging should you call the Regional Stroke Centre or activate the "Code Stroke" transfer. Note: In our network, once the call is made MD-to-MD and accepted, the transfer coordination is streamlined through a nursing-led model to expedite care. Disclosures and Disclaimers * Medical Education Only: This podcast is for educational purposes only. It does not constitute medical advice, create a physician-patient relationship, or establish a duty of care. * Not a Substitute for Care: This content should not replace competent medical assessment, professional clinical judgment, or advice from a licensed physician. * Views & Opinions: The views expressed are solely those of the hosts and guests and do not reflect the positions of their affiliated universities or hospitals. * Patient Privacy: All cases discussed are fictionalized or significantly altered for educational purposes; no real-life patient data is used. * Verification: While references are provided, the audience should independently verify all information and consult the primary literature for full details.

Mastering your Fitness Metrics: Interview with intervals.icu David Tinker

Intervals.icu [https://intervals.icu/] is a Stellar platform to track your metrics, your fitness, whether you are a cyclist or love another sport. In this episode, Mr. David Tinker, founder and primary developer of this platform shares some key insights. Knowledge is power and metrics are important. It is also important to be able to integrate data across different devices such as wearables. David shares his journey from a software developer to the creator of Intervals.icu, a platform designed for sport analytics. He discusses the importance of user feedback, the integration of AI, and the challenges of maintaining data accuracy. The conversation also touches on the growth of the cycling community, the significance of coaching, and the future of open-source hardware in fitness technology. David emphasizes the platform's commitment to user data accessibility and the ongoing development of features to enhance user experience. Host: @neuroccm [https://x.com/neuroccm] (X) @neuroccm [https://bsky.app/profile/neuroccm.bsky.social] (BlueSky) Guest: @david_tinker [https://x.com/david_tinker] (X) davidtinker.bsky.social [https://bsky.app/profile/davidtinker.bsky.social] (BlueSky)

A Swell Simulation!

Topic: Simulation Debrief – Airway Management in the CT Scanner Host: Dr. Houman Khosravani Guests: Dr. Nicole Kester-Greene, Lowyl Notario (APN), Miranda Lamb (Clinical Educator, now our *stellar* Patient Care Manager for our ED!) * Patient: 67-year-old presenting with full Left MCA syndrome (Right hemiplegia/aphasia). * History: Hypertension, Diabetes, on Ramipril (ACE Inhibitor). * Initial Action: CT Head (Aspects 7, no hemorrhage) $\rightarrow$ tPA administered in the CT scanner. * The Complication: Post-tPA, the patient developed hypoxia (sats low 90s) and significant tongue/lip swelling. * Note: Angioedema can be precipitated by the combination of tPA and ACE inhibitors. The team discussed the critical decision-making process when a "Code Stroke" turns into a "Code Airway." * Immediate Treatment: * Epinephrine: The team opted for 0.5 mg IM Epinephrine. * Debate: There was a discussion regarding IV vs. IM Epi. The consensus was to avoid IV bolus Epi in a stroke patient (due to hypertension risks) unless hypotensive, sticking to IM for the allergic reaction while monitoring BP. * Adjuncts: Methylprednisolone (125 mg) and Benadryl (50 mg). * Airway Strategy: * The Challenge: Assessing whether to intubate immediately or observe. Given the progression, the decision was to intubate. * The Method: Awake Intubation (using Ketamine/Lidocaine/Phenylephrine) was chosen over RSI (Rapid Sequence Intubation) to avoid cardiovascular collapse and maintain spontaneous respiration in a difficult airway. The debrief heavily focused on Human Factors and inter-departmental communication. * The "CT Trap": The patient was isolated in the scanner. Managing an airway in the CT control room/scanner is dangerous due to lack of space and equipment. * The Move: A critical decision was made to move back to the ED Resus room. * Communication Gap: There was confusion regarding where the patient was going, highlighting the need for closed-loop communication before moving a critical patient. * The Transition: The Stroke Team leader initially managed the code but recognized the need to hand over the airway to the EM physician. * Explicit Handover: The importance of clearly stating, "I am handing over the airway to you," to avoid the "two cooks in the kitchen" scenario. Dr. Kester-Greene introduced a specific communication framework to align the team during chaos: 1. Initial Summary: When the team arrives (Status, Diagnosis, Treatment so far). 2. Priority Summary: Mid-resuscitation (Re-evaluating what is most important right now). 3. Pre-Transfer Summary: Before moving the patient (Where are we going? Do we have the right equipment?). * "Speaking Up": The nurse noted early signs of anaphylaxis but felt unheard initially. * "Listening Up": Leaders must create space for team members to voice concerns (e.g., "Does anyone see anything I missed?"). The group established that for future cases involving angioedema in the scanner: * Secure the Airway: If imminent failure, manage on-site (or immediate vicinity). * Stable but Concerned: Transport immediately to the Resus room where equipment and space are optimized. * Clear Terminology: Use "Airway Emergency" to trigger the correct mindset shift from "Stroke Protocol." * Dr. Houman Khosravani – Stroke Physician * Dr. Nicole Kester-Greene – Director of Emergency Dept Simulation * Lowyl Notario – Advanced Practice Nurse / Patient Care Manager * Miranda Lamb – Interim Clinical Educator--> Now our Stellar Patient Care Manager

Code Stroke RNs

A unique role - Code Stroke RNs - Critical Care-trained RNs coming to Code Stroke as part of a Stroke Program 2023 - In this episode of our Systems of Stroke Care series, Dr. Houman Khosravani sits down with Beth Linkewich, Director of Regional Stroke and Neurovascular Programs, to discuss a game-changing role in hyperacute stroke management: The Code Stroke Nurse. As Endovascular Thrombectomy (EVT) volumes rise, hospitals face a critical bottleneck: the availability of anesthesia resources. Beth explains how her team bridged this gap by developing a specialized nursing role that allows patients to be safely transported to and monitored in the Angio Suite without an anesthesiologist present for every case. We dive into the "Huddle" decision-making process, the peri-procedural order sets, and the collaborative culture required to make this innovative model a success. Key Takeaways: * The Resource Gap: How the increasing demand for EVT created a need for alternative monitoring solutions when Anesthesia is not immediately available. * The Role Defined: What a Code Stroke Nurse does—from the Emergency Department to the Angio Suite—focusing on airway management, conscious sedation, and hemodynamics. * The "Huddle": The collaborative decision-making protocol between the Stroke Neurologist, the Code Stroke Nurse, and Anesthesia to determine if a patient needs an Anesthesiologist present immediately. * Safety & Governance: How peri-procedural order sets and Critical Care (Level 3) training ensure patient safety during the transition of care. * Collaboration: Why this model enhances, rather than replaces, the relationship with Anesthesia colleagues.

CSC StrokeFM The ACT Trial TNK for Hyperacute Stroke Thrombolysis

In this official Canadian Stroke Consortium (CSC) episode, we dive deep into the landmark ACT Trial (Alteplase Compared to Tenecteplase). Dr. Bijoy Menon, the trial's Principal Investigator, joins the show alongside Co-Principal Investigator Dr. Rick Swartz to discuss the design, execution, and practice-changing results of this pragmatic Phase 3 trial. The ACT trial was a pragmatic, multicenter, open-label, registry-linked, randomized controlled non-inferiority trial. * Scope: Conducted across 22 stroke centers in Canada. * Timeline & Volume: Between December 2019 and January 2022, the trial enrolled 1,600 patients aged 18 or older with disabling acute ischemic stroke presenting within 4.5 hours of symptom onset. * Randomization: Patients were randomized 1:1 to receive either: * Tenecteplase: 0.25 mg/kg (maximum 25 mg) as a single bolus. * Alteplase: 0.9 mg/kg (maximum 90 mg) as a bolus followed by a 60-minute infusion. The study met its prespecified non-inferiority threshold, demonstrating that Tenecteplase is a reasonable alternative to Alteplase. * Primary Outcome (Functional Independence): An mRS score of 0-1 at 90-120 days occurred in 36.9% of Tenecteplase patients versus 34.8% of Alteplase patients. This represents an unadjusted risk difference of 2.1%. * Safety Profile: Safety outcomes were similar between the two groups: * Symptomatic Intracerebral Hemorrhage: 3.4% (TNK) vs 3.2% (tPA). * 90-day Mortality: 15.3% (TNK) vs 15.4% (tPA). A prespecified secondary analysis examined 520 patients (33% of the trial population) with LVOs (including ICA, M1/M2-MCA, and basilar artery). * Functional Outcomes: Among LVO patients, 32.7% in the Tenecteplase group achieved mRS 0-1 compared to 29.6% in the Alteplase group. * Reperfusion Rates: For the 405 LVO patients who underwent thrombectomy, successful reperfusion was comparable on initial angiography (9.2% TNK vs 10.5% tPA) and final angiography (84.5% vs 88.9%). * Conclusion: Treatment outcomes were not modified by the baseline occlusion site, and rates of functional independence, hemorrhage, and mortality remained similar between groups. A separate analysis highlighted that "time is brain" applies equally to both agents. * Onset-to-Needle: Each 30-minute reduction in onset-to-needle time was associated with a 1.8% increase in the probability of achieving a good outcome (mRS 0-1). * Door-to-Needle: Every 10-minute reduction in door-to-needle time was associated with a 0.2% increase in probability of a good outcome. * Effect: The effect of time to treatment on clinical outcomes was similar regardless of which thrombolytic agent was used. The investigators emphasized the practical advantages of Tenecteplase over Alteplase: * Ease of Administration: The single-bolus administration of Tenecteplase (5-10 seconds) eliminates the need for a 60-minute infusion pump. * Transport Efficiency: The single bolus facilitates rapid treatment and easier patient transfer for endovascular therapy when needed. * Robust Evidence: The ACT trial's large sample size and pragmatic design provide the necessary evidence to support Tenecteplase as a standard of care for all patients meeting standard thrombolysis criteria. * Dr. Bijoy Menon: Principal Investigator of the ACT Trial; Stroke Neurologist and Professor at the University of Calgary. * Dr. Rick Swartz: Co-Principal Investigator; Stroke Neurologist at Sunnybrook Health Sciences Centre, University of Toronto. Reference:Menon BK, et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke (ACT): a pragmatic, registry-linked, randomised, open-label, phase 3, non-inferiority trial. The Lancet. 2022.