Ep 120 ED Stroke Management in the Age of Endovascular Therapy

This is EM Cases Episode 120 - ED Stroke Management in the Age of Endovascular Therapy According to the Global Burden of Disease Study published in NEJM in December 2018 the estimated lifetime risk for a 25 year old during their remaining lifespan is 25% [1]. Stroke is the 3rd leading cause of death and 1st leading cause of major disability in North America. As we transition from the relatively simple era of systemic thrombolytics under 3 hours vs "ASA and admit" for over 3 hours, decision making has become much more complicated and varied, depending on where you work. Which patients need what type of scanning? Where should that scanning be done - at the stroke center or at the peripheral center? Which patients should get systemic thrombolytics? Which patients should get endovascular therapy? In this EM Cases main episode podcast, a follow up to our episode on TIA released in November 2018 with Walter Himmel and David Dushenski, we try to simplify the confusing time-based and brain tissue-based options for stroke management... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman, January 2019 Cite this podcast as: Helman, A, Himmel, W, Dushenski, D. ED Stroke Management in the Age of Endovascular Therapy. Emergency Medicine Cases. January, 2019. https://emergencymedicinecases.com/stroke-update-endovascular-therapy/. Accessed [date] Go to part 1 of this 2-part podcast on TIA/stroke Time and image based stroke management algorithm Activating a "code stroke" on every patient that experiences any acute neurologic event within 24hrs of symptom onset based on the DIFFUSE 3 and DAWN trials [2,3] may outstrip resources, with only a tiny minority of these patients receiving potential benefit. There is currently an effort to identify those patients clinically who might be most likely to benefit from endovascular therapy so that not all stroke patients require transport to a stroke center with multiple imaging modalities and resource-heavy acute stroke team care. The workup and considerations for tPA and endovascular therapy (thrombectomy) depend on: * Symptom onset to needle time * Type of stroke, NIHSS or VAN tool (see below) * CT, CT angiogram and CT perfusion results * Contraindications to tPA/thrombectomy Time is the key factor in patients with a symptom onset-to-needle time ≤ 6 hours. Brain tissue salvageability determined by CT perfusion is the key factor in patients with a symptom onset-to-needle time of 6-24 hours. Acute Stroke Management Time & Tissue Based Algorithm Times are symptom onset to needle times at a stroke center. CTA = CT angiogram head and neck. NIHSS = National Institute of Health Stroke Scale. VAN = Vision, Aphasia, Neglect tool. NIHSS on MD Calc In the 0-4.5 hours category, plain CT will rule in hemorrhagic stroke and CTA may diagnose an underlying vascular abnormality causing the bleed. For patients in the 4.5-6 hours category, and with an NIHSS ≥6 or VAN positive, and plain CT and CTA consistent with cortical stroke, candidacy for thrombectomy is determined either by CT perfusion, or if CT perfusion is not readily available, by the