All right. All right, American Association of Neurologic Surgeons. You guys get me for 30 more minutes. Thanks for hanging in Hopefully I'm not boring you So now we're gonna hit the other big topic to wrap it up What are what are the new things in stroke care? So International Stroke Conference just happened in February and the European Stroke Organization Conference just happened in May So we are coming at you with the most recent updates Objectives for here. We're going to talk about intracerebral hemorrhage. We're going to talk about the significant findings from the Zodiac trial So as we go through I'm going to emphasize some things that you really need to be taking back to your hospitals today or tomorrow And we're going to talk a little bit about the extended time windows for thrombolytics So this graphic here I'm showing you an intracerebral hemorrhage, right? Blood is white and bright on CAT scan And I feel like we call all of these stroke alerts and as soon as you see blood on the CAT scan your inpatient stroke team is now running away from the patient and the emergency team is kind of left standing there alone and Intracerebral hemorrhage is one of the most devastating neurologic emergencies that we have It's really important that we start looking at this like we approach a ischemic stroke And I love this idea and I'm actually mad that I didn't think about it first because now our Friends here in Switzerland are going to get the credit But basically what they're saying, so this is a study from Switzerland We know that the greatest amount of hematoma expansion for intracerebral hemorrhage happens in the first three hours but yet We have metrics for ischemic stroke where you need to do door-to-needle time of 30, 45 or 60 minutes but why do we not hold ourselves to any metrics really for hemorrhagic stroke in the emergency setting and I think that this is great Is that if we're thinking that we need to get door-to-needle times of 50 minutes for lytics We need to get door-to-treatment times for anti-coagulation reversal and blood pressure control within 60 minutes also What you can see here in this study is for stroke They were meeting a door-to-needle time of 50 minutes But it was taking 60 or 58 to do blood pressure control or anti-coagulation reversal This ICH bundle of care has been in place since 2019 It's three things together Anti-coagulation reversal blood pressure management and early contact with neurosurgery and once we put this bundle into into place back in 2019 We did see survival probability increased if you did this bundle Patients got faster targeting of their blood pressure management more patients were identified as neurosurgery candidates More patients were admitted to higher levels of care and a lot of patients Were less patients were made DNR, which is nice. We were giving it more time for treatment Anti-coagulation reversal we'll touch upon again Blood pressure management is tricky. The one thing that you want to do is you have to treat it quickly Okay, so you have to treat it within 60 minutes But again, we just touched on this in the traumatic brain injury talk, what is the target? So we think the targets about 130 to 140, but it's tricky You only want to lower systolic about 30 to 40 points to get to that target of 130 or 140 Once you start lowering systolic blood pressure greater than 70, it actually leads to worse outcomes You need to avoid very large drops in blood pressure, but you have to treat it actively at the same time So this is tricky you want to think 130 to 140 in your head But you want to think that I'm not going to get to that target too Quickly if I need to lower it by more than 30 to 40 points Examples of patients who need neurosurgery are listed here We're talking about possibly minimally invasive surgery versus maybe a decompressive hemicraniectomy You guys just saw this chart in the traumatic brain injury talk, it's the same chart for here again We're not going to go through everything, but we want to talk about indexing it alpha one more time Maybe you guys can put in the chat Actually, because I'm curious who actually has it in their institution and who doesn't But again what you want to keep in mind here is that There is no doubt that indexing it alpha did decrease hematoma volume expansion better than usual care Which again is your prothrombin concentrates like Kcentra But again, it was at the expense of causing an increased risk of thrombotic events and ischemic stroke. It's definitely a challenge Do we reverse or do we run the risk of unintended complications? Continuing on with intracerebral hemorrhage here the interact for trial just broke at European stroke conference in May Okay, so again coming straight to you six months new information And what they did was they looked at delivering blood pressure medication in the ambulance prior to getting to the emergency department The baseline characteristics here in The treatment group so this was in China If they were going to treat you they were targeting a systolic blood pressure of 150 Versus usual care not getting blood pressure treatment You can see in the treatment group that the blood pressure was definitely lower when they got to the emergency department All right, so the baseline was the same, but it was definitely lower as expected if you were treated Now there's two things to take away from this trial If you are having a hemorrhagic stroke you did have better outcomes See that's what you're looking at here You're seeing a better number of patients in the modified ranking score of 0 to 2 if you got treatment versus if you got control What was interesting though is if we lowered your blood pressure and you are having an ischemic stroke Those patients did worse Especially if you lower blood pressure to give lytics There's really two takeaways from this We need to own blood pressure control in the hospital Okay, we can't let EMS do it because we don't know which type of stroke you're having So this is something that we still need to own, okay? It actually also challenges the current practice of whether we should really be lowering blood pressure To have them be a candidate for lytic therapy, and I've actually been saying this for quite a while that If you give lytics to stroke patients if you do it enough you're going to have an outcome where patients bleed, right? It happens anywhere from two to six percent of the time But in my head patients that bleed are the ones where I have to lower blood pressure to then give a lytic So there's two takeaways from this Yes, we need to lower blood pressure for our hemorrhagic stroke patients But we need to own it in the hospital and not in the pre-hospital setting So the next time that you have an intracerebral hemorrhage I hope that we're all going to run towards it instead of running away from it We're going to reverse anticoagulation within 60 minutes. We're going to treat blood pressure within 60 minutes and We're going to take ownership of these patients meet time metrics like we do for our ischemic stroke patients as well This Zodiac trial, this is what I want you guys to take away from today, and I want you to start implementing it tomorrow this broke at international stroke conference in February it was in Phoenix this year What we've actually known since 1968 is that there's a marked clinical Deterioration with upright head position when you're having an ischemic stroke So actually Kaplan and Sergei just eight years later in 1976. They actually coined a term called positional cerebral ischemia When they noted that for patients with large vessel occlusions did markedly worse if their head was upright We have a bunch of studies that have shown that there's improved blood flow and stroke patients when the head position is down But we've never really looked at should it be zero degree head positioning? Versus 30 degree positioning now These are patients that have a large vessel occlusion and you're in the pre thrombectomy period Right, so I'm in the emergency department You guys are coming down from the floor the ICU to help me We're thinking that this is a large vessel occlusion Ischemic patient. What should we be doing for a head position? The trial did a baseline NIH that was obtained immediately after completion of neuroimaging Right, so you are laying in zero degree head position for your CAT scan Patients still received thrombolytics if eligible and then they were randomized to zero degrees or 30 degrees The intervention period concluded once they were moved to the intervention table for their procedure These statistics are really really overwhelming So early deterioration was greater than two points on the NIH stroke score prior to thrombectomy If you are in the zero degree head position You only deteriorated those greater than two points 2% of the time versus 55% of the time for 30 degree head position Greater than four points. It was still only two per 2.2 percent for laying flat But you worsened 42% of the time if you are in that 30 degree head position Number needed to harm of 1.88 or 2.48 So number needed to harm means if you were not to do this For just two patients if you were not to lay them flat instead of 30 degrees You could do harm by just not doing it for two cases It's a really really low number What's really really interesting is the NIH improvement at 24 hours We thought that thrombectomy would even the tables, right? It really shouldn't matter 24 hours later if you were in the zero degree or 30 degree head position But there was still a statistically significant difference And same thing at seven days or discharge. There was still a difference in the head positioning This is probably a little counterintuitive, right? So we just talked about Traumatic brain injury how 30 degrees lowers ICP but now We're talking about ischemic stroke and specifically large vessel occlusion And how zero degrees is so key to help these patients have better outcomes All right, so don't confuse the two The Zodiac trial it's safe It's free It's an important rescue procedure. What does that mean? It's not a treatment Okay, these patients still need to go for thrombectomy Okay, but these are things that we can be doing in the meantime to really make a difference What I especially take away from this are EMS friends if they have a really high race score greater than five They need to be laying these patients flat Okay, if you're at a facility that doesn't do intervention You guys are probably all at facilities that do interventions But let's say that you get transfers in right if you know that one of your spoke Hospitals has a large vessel occlusion. You need to say lay that patient flat Until they get to us Question comes up. What about aspiration? What about pneumonia? Okay, there was actually zero cases of any Pneumonia in this Zodiac trial. It was 90 patients and there were zero cases of any aspiration clinically significant pneumonia. So don't be afraid to lay them flat because of that. All right, next topic. Tension trial. For the tension trial, we need to do a little bit review of what the Alberta Stroke Program, what an aspect score is. And aspect stands for Alberta Stroke Program early CT score. Your aspect score can go from 0 to 10. So hopefully all of us on this call have a normal brain and we're at 10. We break it up on a non-contrast head CT at the basal ganglia level and the corona radiata level. So you have your caudate, your lenticular nucleus, your insular ribbon, your internal capsule, M1, M2, and M3 of the MCA at the basal ganglia level, M4, M5, M6 at the corona radiata level. And what happens is for each area of infarct you would lose a point. So here's a normal CAT scan. Hopefully these are our brains at 10. But here's a completely infarcted brain here, right? You're losing points. Maybe the caudate is spared. This is probably an aspect score of 0 to 1 really because the whole MCA territory is infarcted. Now it used to be pretty hard and fast that if you had a low aspect score of 3 to 5 that we really didn't touch those patients. It was going to be an unfortunate outcome, probably institutionalized in a nursing home if you survived, maybe a trach peg, maybe a decompressive hemicraniectomy. But what the tension trial is now showing us is that even with this completely infarcted CAT scan or a completely infarcted cerebral perfusion scan that these patients actually did pretty well. The nice thing about the tension trial is you didn't even need to have perfusion, right? Most of your spoke hospitals probably don't have it. So you just need a non-contrast CT and CTA. Now they did look at 12 months out, but these patients had less disability, they were one point lower on the modified ranking score, and there was a 12 percent reduction in mortality. Now both groups of patients, when you have a CAT scan that looks like this, whether you get intervention or not, your mortality is about 45 percent. But in the past, these are not patients that we would do an intervention on. This tension trial is saying that if you give them time at that one year mark that we did see some benefit. So it's something to consider. There have since been some other trials looking at this as well. The tesla trial did not get as great as results, and I think there's a basics trial maybe that is coming out as well. But this is something to watch. Oh, can you guys hear? You guys probably can't hear the music. Poor Darth Vader music. All right, well imagine that there's Darth Vader music for this game changer ahead. All right, and what the game changer ahead is that European Stroke Conference presented this data looking at tenecteplase for stroke up to 24 hours, right? So you probably know that the extended trial was trying to look at giving lytics up to nine hours. Now we have this trial that's trying to give tenecteplase out to 24 hours. This was done in China where they do not have easy access to intervention. So these were patients that had a large vessel occlusion. They had salvageable tissue on CT perfusion, but they were given tenecteplase because there was no thrombectomy available. And basically the patients did get an improvement in their absence of disability and the rate of intracerebral hemorrhage was only about one percent. I think that what this is going to help translate to here in the United States is that only about 18 to 20 percent of strokes that we see are actually large vessel occlusions that can go to intervention, right? And the biggest reason why we can't treat patients with lytics here in the United States is because they have some type of contraindication. And the most common contraindication is that they don't get to us within four and a half hours. So for me what this study is telling us here in the United States is that for the 80 percent of patients that are small vessel ischemic strokes and not large vessel occlusions and not eligible for intervention, can it be safe to give them tenecteplase out to 24 hours? And I think it's a great question that we'll have to see, right? All of these studies again, they happen in Europe, they happen in China, much less strict research criteria. These trials will probably be repeated and we'll see what happens. So when you're looking at a perfusion scan, here you have increased time to peak, decreased blood flow, but this is a normal blood volume. So this would be a patient that could get tenecteplase past the four and a half hours. Here you've got increased time to peak, decreased blood flow, decreased blood volume. This would not be a patient that would do well. So to wrap up here, because I know we're at 1258, but we also started late. So this is actually my real case that we did. This is a 71 year old male who was last known well at 6 30 a.m. He lived in an apartment complex, so the neighbors found him in the laundry room with confusion, unsteady gait, and slurred speech. And he gets to the emergency apartment at 10 56, right? So he gets to the emergency department at four hours and 26 minutes. Now I have one of the fastest door-to-needle times in the hospital, but I cannot do it in only four minutes, especially if you're a walk-in through the front doors, right? Four minutes is just not reasonable. Past medical history, he's got risk factors, hypertension, high cholesterol, known stenosis of left M1, maybe some seizures. He says that he's not taking any medications, but what that really means is I haven't followed up with a physician in 10 plus years. Looking at his vital signs, his blood pressure looks good, right? Needs to be less than 185 over 110. Acu-check's good. His exam, he's got a right facial droop. He's weak on that right side. He has some dysarthria from the facial droop. He has some mild expressive aphasia. And his NIH stroke score is eight, right? Remember that an NIH stroke score greater than five, not only are you most likely having a stroke, but you're also most likely having a large vessel occlusion. Go to CAT scan. He actually has the GIF. It's on the non-contrast head CT. This is a hyper-dense left MCA sign. This is the only time that you can see blood on a CAT scan and still give lytics because you're actually seeing a clot in the vessel. Perfusion scan. Increased time to peak. Decreased blood flow, but normal blood volume. So this is all salvageable penumbra. And on his CTA, you can see the right MCA goes all the way out, but there's a cutoff right here of the left MCA. So what we did is we do get consent to treat in the extended window. The brother gave written consent. The patient was able to nod that he did want the treatment. And he was given alteplase at 1143, which is five hours and 13 minutes from last known well. And he gets admitted to the neuro ICO. His MRI, all it shows are these small, tiny areas of diffusion weighted restriction. Remember this whole hemisphere was infarcting. And the MRI just ends up with these little infarcts. So he rapidly improved with the alteplase. Treating up to nine hours aborted his need for intervention. His stroke score was only two the next day, and he actually got discharged to home with PT, OT, and speech. Yes, giving lytics comes with its risks of hemorrhage. Guess what? What the neurosurgeons do comes with a higher risk of hemorrhage. Right? They're floating catheters into small vessels of your brain. They can cause just as much damage as giving IV lytics. So I think in this case, not only does it show that you can treat safely past four and a half hours, but you might even be able to abort the need for a more invasive intervention. So in summary for you guys, take away the points for intracerebral hemorrhage. I want you to start thinking about it in time metrics. Let's make it parallel the urgent history of ischemic stroke. Starting tomorrow, I want you to educate your peers about the ZODIAC trial. If you have an ischemic stroke patient with a large vessel occlusion, keep them laying flat. If they're being transported, keep them flat. Educate your spoke hospitals. Educate EMS about what we're doing. That ZODIAC trial's results are very impressive. Yes, it was a small sample size, but I think that we can take a lot away from it. Endovascular therapy continues to provide clinical benefits, even in cases of large completed strokes. That is new thinking, depending on which neurosurgeons you work with. Okay, the neurosurgeons that I work with would never consider doing a thrombectomy with an aspect score of 0 to 1 to 3. Okay, but maybe some of these studies will start changing their mind. Extending the therapeutic window. So we've been talking about this for years now, that we really need to move away from time-based restrictions and move on to tissue-based imaging. Okay, just FYI, you know, why did alteplase get approved for only three hours when it came out in 1995? It's because they were using it in rats, okay? Like, that's where three hours comes from, right? And so the case I showed you, you know, if he had gotten to me within four and a half hours, I could treat him. But at five hours and 13 minutes, it makes a difference. Clearly, it's not really time. It should be tissue and advanced imaging-based. And that is what I'm going to leave you guys with today. I'm actually on time. We're just running a little over. So again, if there's time for questions, great. And if not, please feel free to reach out to me anytime. And I'll see you guys next year. Thank you so much, Dr. Greenberg. I found all of these presentations to be really clear and really helpful. There's only one question on this one. It says, do you have a particular guideline you follow for decompressive craniectomy criteria for ischemic stroke patients? We have lots of discussions about this every year, and no one ever seems to agree on eligibility for this and who is the best candidate. Yeah, I think that is very neurosurgical dependent. Just like we were talking about blood pressure parameters in one of the prior talks as well. I know for me, the neurosurgeons won't really do a decompressive hemicraniectomy on you if you're older than like 70 years old, actually. So there are plenty of trials that show that it's possible. Plenty of trials that show that if you do a decompressive hemicraniectomy, that the patients have benefit, but that benefit is a year later. And I think that we kind of rush patients and their family members through like worst case scenario in the ICU and kind of convince them to withdraw care or go the trach and PEG route. But I do think that it's worthwhile to give the patients a chance if they're willing to understand that the long-term outcome is at least a year in these cases rather than the usual three months that we quote. That's the best I've got for you. I bet if I asked five different neurosurgeons the same question right now, you would get five different answers. So sorry that I can't be more clear on that one. That was wonderful. Thank you so much. We really appreciate all the talks today. All right. Thanks for having me.

stroke care

intracerebral hemorrhage

thrombectomy

endovascular therapies

anticoagulation reversal

tissue-based intervention