The Clot Thickens - Integrating Thrombosis within Stroke Care

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, TorontoThe Original paper, ACT-FAST 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:Local Imaging First: Order a CT Head and CTA (Angiogram) of the Head & Neck immediately at your site.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 DisclaimersMedical 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.

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 (X) @neuroccm (BlueSky)Guest: @david_tinker (X) davidtinker.bsky.social (BlueSky)

Topic: Simulation Debrief – Airway Management in the CT ScannerHost: Dr. Houman KhosravaniGuests: 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:Initial Summary: When the team arrives (Status, Diagnosis, Treatment so far).Priority Summary: Mid-resuscitation (Re-evaluating what is most important right now).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 PhysicianDr. Nicole Kester-Greene – Director of Emergency Dept SimulationLowyl Notario – Advanced Practice Nurse / Patient Care ManagerMiranda Lamb – Interim Clinical Educator--> Now our Stellar Patient Care Manager

A unique role - Code Stroke RNs - Critical Care-trained RNs coming to Code Stroke as part of a Stroke Program2023 - 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.

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.

Episode: The Clot Thickens – Integrating Stroke into Thrombosis TrainingHost: Dr. Houman Khosravani (Stroke Specialist, Toronto)Guest: Dr. Stephanie Carlin (Assistant Professor, Medicine; Critical Care Pharmacist & Thrombosis Fellowship Graduate)In this special episode of StrokeFM, Dr. Khosravani and Dr. Carlin discuss a manuscript they co-authored regarding the educational gap between stroke neurology and thrombosis medicine. They explore the results of a pilot project that integrated a formal stroke rotation into a thrombosis fellowship, highlighting how cross-pollination between these two disciplines leads to better patient outcomes and more comprehensive specialist training.The Genesis of the Project:During her fellowship, Dr. Carlin noticed a high volume of consults involving stroke patients or patients with concurrent thromboembolic concerns.Surveys of other Canadian and US thrombosis programs revealed that none offered a formal stroke rotation, prompting the creation of this pilot rotation.The Clinical Synergies:There is a massive natural overlap between the two fields, specifically regarding:Anticoagulation management (e.g., for Atrial Fibrillation).Mechanical heart valves.Prothrombotic states (e.g., malignancy, Antiphospholipid Syndrome).Patent Foramen Ovale (PFO) management.Operationalizing the Integration:Duration: A rotation of 4 to 8 weeks is ideal to cover necessary topics.Alternative Models: For centers without dedicated rotations, integration can be achieved through joint case rounds, half-day presentations, or collaborative case conferences.Scope: This model is applicable not just to pharmacy or internal medicine, but also to vascular medicine, hematology, and neurology trainees.Dr. Carlin shares a compelling case study that illustrates the value of this integrated training:The Patient: A young woman in her early 20s on oral contraceptives presented with a large MCA stroke requiring TPA and thrombectomy.The Workup: Lab work revealed a prolonged PTT, raising suspicion for Antiphospholipid Syndrome (APS).The Learning Opportunity:The Stroke Team educated the thrombosis fellow on TPA, EVT, and the timing of antithrombotics relative to hemorrhagic transformation risks.The Thrombosis Fellow educated the stroke team on the nuances of APS testing (e.g., lupus anticoagulant interference) and appropriate contraceptive changes.Thrombosis Canada: A key resource for guidelines on anticoagulation and vascular health.Article: "The Clot Thickens: Integrating Stroke into Thrombosis Training" (The manuscript discussed in this episode).Episode SummaryKey Discussion PointsClinical Spotlight: The Value of CollaborationResources Mentioned

Here are the show notes for the StrokeFM episode covering the SVIN 2021 meeting.In this episode of StrokeFM, host Dr. Houman Khosravani sits down with Dr. Ameer Hassan, the President of the Society of Vascular and Interventional Neurology (SVIN), to discuss the major takeaways from the SVIN 2021 Annual Meeting in Phoenix, Arizona.Dr. Hassan shares critical updates on clinical trials, his personal philosophy on bridging therapy versus direct-to-angio, and the nuance of managing intracranial atherosclerotic disease (ICAD).Dr. Ameer Hassan, DO, FAHA, FSVINHead of the Neuroscience Department at Valley Baptist Medical CenterProfessor of Neurology and Radiology at the University of Texas Rio Grande ValleyPresident of SVINDr. Hassan provided a rundown of the pivotal trials presented or discussed at the meeting:Subdural Hematoma Embolization: The SQUID trial (sponsored by Balt) and the EMBOLISE trial (sponsored by Medtronic) are investigating the embolization of the middle meningeal artery for chronic and acute-on-chronic subdurals.Large Core Infarcts: The TESLA trial (PI Dr. Sam Zaidat) is moving forward, looking at thrombectomy in patients with large core infarcts, similar to the SELECT2 and IN EXTREMIS trials. The goal is to be more inclusive with mechanical thrombectomy.Bridging vs. Direct: The SWIFT DIRECT trial showed no statistical difference between direct-to-cath lab versus bridging lytics.AURORA Analysis: Confirmed that treating endovascular patients is safe, though the "number needed to treat" suggests patient selection (collaterals and salvageable tissue) remains vital.Dr. Hassan advocates for individualized medicine rather than a blanket policy.Scenario A: If the angio suite is empty and the team is ready, he takes the patient straight to the cath lab.Scenario B: If there is a delay (e.g., room occupied) or the patient requires transfer, he utilizes IV thrombolytics (TNK or Alteplase).Rationale: "Time is brain." If you can't cut immediately, lytics provide a bridge.Dr. Hassan discussed the risks of aggravating ulcerated plaque during acute interventions.Acute Stenting: Data suggests acute stenting is relatively safe, but Dr. Hassan prefers angioplasty first for ICAD.The "Wait and See" Approach: Based on the WEAVE registry data, waiting 5–7 days allows the "hot plaque" to cool down, significantly lowering stroke risk during stenting (from ~20% acute risk down to ~2-4% delayed risk).Hardware Selection:Dissection/ICAD: Prefers self-expanding stents (e.g., Wingspan) or Enterprise stents if dissection is suspected.Vertebral/Other Anatomy: May use balloon-mounted stents (e.g., Resolute Onyx) depending on distal vs. proximal diameters.AI Integration: Technologies like Viz.ai, Rapid, and Brainomix are essential for converting linear workflows (serial phone calls) into parallel processing (alerting the whole team simultaneously).Advanced Imaging: Moving toward advanced imaging (CTP) for the 6–24 hour window to identify salvageable tissue.New Journal: SVIN has launched a new journal titled Stroke: Vascular and Interventional Neurology.SVIN 2021 Highlights: Trials, Stenting Strategies, and the Future of Thrombectomy with Dr. Ameer Hassan🎙️ Guest Profile📋 Key Clinical Trial Updates🧠 Clinical Pearls: Dr. Hassan’s Practice1. Bridging Lytics vs. Direct to Angio2. Intracranial Stenting and "Hot Plaque"🚀 The Future of Stroke Systems

StrokeFM: The Future of Neuroprotection & The Story of Nerinetide with Dr. Michael HillEpisode S2_e07Is neuroprotection finally moving from "déjà vu" failure to clinical reality? In this episode, host Dr. Homan sits down with Dr. Michael Hill (University of Calgary) to dissect the fascinating journey of Nerinetide, the landmark ESCAPE-NA1 trial, and the biological detective work that uncovered why a potential breakthrough drug clashed with standard thrombolytics.The History of Failure: Why previous neuroprotection trials failed, primarily due to the lack of human-analogous ischemia-reperfusion models in pre-clinical testing.The Molecule: How Nerinetide works intracellularly by interfering with the PSD-95 protein to stop toxic nitric oxide production without blocking critical synaptic signaling.ESCAPE-NA1 Results: A deep dive into the trial that showed an overall neutral result (2% difference) but uncovered a massive, statistically significant benefit (approx. 9.5% absolute risk difference) in patients who did not receive Alteplase (tPA).The Plot Twist (The Interaction): The biochemical discovery that Alteplase cleaves and inactivates Nerinetide in human plasma—an interaction that was not present in rat models due to species differences in plasminogen activation.Biological Plausibility: How the creation of a "D-enantiomer" (a mirror image of the molecule) proved resistant to Alteplase cleavage, confirming the interaction theory.The Future: A look at ESCAPE-NEXT, the upcoming trial designed to replicate the successful "No-Alteplase" arm of the previous study, and the FRONTIER trial, which looks at pre-hospital administration."We essentially have a true human ischemia-reperfusion model... This is the number one difference between the possibilities that exist now compared to what we had done in the past." — Dr. Michael Hill"The trial was neutral... but when we looked at the two groups, we had a statistically relevant interaction... in the No-Alteplase group, the direction of effect was markedly positive." — Dr. Michael HillThe Trial: ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke)The Drug: Nerinetide (NA-1)Upcoming Trials: ESCAPE-NEXT and FRONTIERIn This Episode, We Discuss:Key Quotes:References & Further Reading:

In this episode Dr. Tess Fitzpatrick, and Dr. Katherine SawickaEpisode SummaryIn this episode, our guests discuss their recent publication regarding the real-world challenges of using Unfractionated Heparin (UFH) in acute stroke patients. The team explores the data behind the "hunch" that UFH often fails to achieve therapeutic levels quickly or consistently, and discusses the pragmatic shift toward Low Molecular Weight Heparin (LMWH).The Clinical ProblemTraditionally, IV Unfractionated Heparin (UFH) is the go-to for acute anticoagulation in stroke (e.g., for free-floating thrombi) because it has a short half-life and is reversible.However, achieving a therapeutic aPTT is difficult, often leading to patients being sub-therapeutic or supra-therapeutic for long periods.Study Design & IndicationsThe team conducted a retrospective study over three years, identifying stroke patients treated with UFH for specific cerebrovascular indications.Three main indications studied:Intraluminal thrombus (free-floating thrombus).Cerebral Venous Sinus Thrombosis (CVST).Cardiogenic indications (e.g., cardiac thrombus, low ejection fraction).The Results: Confirming the HunchDelayed Efficacy: For the first time the aPTT went over 70 seconds, 35% of the time it took between 12 and 24 hours to occur.Lack of Stability: 66% of patients never reached a "steady state" (defined as two consecutive therapeutic aPTT measurements).Overshoot: Patients spent 25% of the time in the supra-therapeutic range (too high), though major bleeding events were rare in this specific sample.Variability Causes: High variability is partly due to the non-specific binding of UFH to plasma proteins, monocytes, and endothelial cells, which are often elevated in acute phase reactants during stroke.The Shift to Low Molecular Weight Heparin (LMWH)The center is moving away from UFH and toward LMWH for these indications.Benefits of LMWH: It offers a predictable dose-response relationship, greater stability, and higher bioavailability compared to UFH.The "Safety Blanket" Myth: While clinicians like UFH because of the reversal agent Protamine, the team notes that Protamine is rarely actually used in stroke settings (unlike in cardiac surgery). It often provides a "false sense of security."Pragmatic ManagementStart Low: The team suggests starting LMWH at lower doses (e.g., roughly 2/3 dose) and titrating up, rather than immediately giving a full dose, to mimic the gradual onset of UFH without the instability.Exceptions: UFH may still be preferred for patients with severe renal failure or those requiring imminent surgery (within 4 hours).There is a desperate need for randomized control trials (RCTs) specifically in the stroke population comparing Low Molecular Weight Heparin vs. Unfractionated Heparin to solidify these best practices.🎙️ Meet the Guests🧠 Key Topics & Study Findings🏥 Clinical Implications & Practice Changes📚 Call to Action

CSC Dr. Bijoy Menon, University of CalgaryCSC Dr. Andrew Demchuk, University of CalgaryMR CLEAN-NO IV was a European multicenter RCT (Netherlands, Belgium, France) published in NEJM in November 2021.Question: Is direct EVT superior or non-inferior to IV alteplase + EVT in anterior circulation LVO stroke patients presenting directly to thrombectomy-capable centers?Design: PROBE design, 1:1 randomization, ~539 patientsKey Result: EVT alone was neither superior nor noninferior to intravenous alteplase followed by EVT with regard to disability outcome at 90 days after stroke. New England Journal of Medicine The incidence of symptomatic intracerebral hemorrhage was similar in the two groups. New England Journal of MedicineBottom line: Unlike the Asian trials (DIRECT-MT, DEVT) that showed non-inferiority for skipping tPA, MR CLEAN-NO IV couldn't confirm the same in European populations—so the bridging IVT + EVT paradigm remains standard for eligible patients at EVT-capable centers.