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Episode 90: INSIGHTS - Acute Ischemic Stroke Pt1.

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Description

Listen to the third episode of NCS' INSIGHTS series - Acute Ischemic Stroke (part 1 of 2).

The INSIGHTS series is hosted by Casey Albin, MD and Salia Farrokh, PharmD, and covers different topics from Neurocritical Care ON CALL®, the only up-to-date, comprehensive resource to offer content exclusively dedicated to the practice of neurocritical care. Learn more about ON CALL®.

This episode is sponsored by Biogen.

Science that transforms patient lives. Science that seeks to solve societal problems. Science that acts with purpose. Science that is inspired by the diversity and passion of our people. Discover where science meets humanity at Biogen.

The NCS Podcast is the official podcast of the Neurocritical Care Society.

Contributors

  • Casey Albin, MD

    Casey Albin, MD is an Assistant Professor at Emory University School of Medicine where she is a member of the department of Neurocritical Care. She completed both her neurology residency and a fellowship in Medical Simulation at Harvard Medical School/BWH/MGH. She completed Neurocritical Care fellowship at Emory. Dr. Albin’s research interests focus on educational innovations in acute neurologic emergencies and neurocritical care. In addition to running simulation courses, she is the editor of a best-selling textbook The Acute Neurology Survival Guide and is passionate about open access neurologic education through Twitter, blogs, and podcasts. She serves on the Education Committee of the Neurocritical Care Foundation.

  • Salia Farrokh, Pharm.D., BCPS, BCCCP

    Salia Farrokh, PharmD, BCPS, BCCCP is a neuro ICU clinical pharmacist specialist at Johns Hopkins Hospital. Dr. Farrokh received her PharmD degree from Saint John Fisher College, Wegmans School of Pharmacy in Rochester, NY. Her postgraduate training includes residencies in Critical Care and Pharmacy Practice at Yale-New Haven Hospital. Dr. Farrokh’s research interests include effective antiplatelet therapy in neuro intervention patients, optimal pain management in neuro ICU patients, and use of neurostimulants in this setting. Dr. Farrokh is passionate about training and precepting students and residents and is a certified ENLS trainer.

  1. 00:00:10
    All right. Hi guys. Welcome back.
  2. 00:00:12
    This is Casey and Salia, and we are so
  3. 00:00:14
    thankful that you are tuning back into
  4. 00:00:16
    Insights, which is a podcast based on
  5. 00:00:19
    content from OnCall, which is a
  6. 00:00:21
    continually updated text book from the
  7. 00:00:23
    Neuro Critical Care Society, which is
  8. 00:00:25
    available online. We are so thankful
  9. 00:00:27
    for our sponsors, Sarah Bell and Biogen,
  10. 00:00:29
    and now a word from our sponsor.
  11. 00:00:31
    Founded in 1978, Biogen is a leading
  12. 00:00:35
    global biotechnology company that has
  13. 00:00:37
    pioneered multiple breakthrough
  14. 00:00:39
    innovations, including a broad
  15. 00:00:40
    portfolio of medicines to treat multiple
  16. 00:00:42
    sclerosis, the first approved treatment
  17. 00:00:44
    for spinal muscular atrophy, and two
  18. 00:00:47
    co-developed treatments to address a
  19. 00:00:49
    defining pathology of Alzheimer's
  20. 00:00:51
    disease. Biogen is advancing a pipeline
  21. 00:00:54
    of potential novel therapies across
  22. 00:00:56
    neurology, neuropsychiatry,
  23. 00:00:58
    specialized immunology, and rare
  24. 00:01:00
    diseases, and remains acutely focused
  25. 00:01:03
    on its purpose of serving humanity
  26. 00:01:05
    through science while advancing a
  27. 00:01:06
    healthier, more sustainable, and
  28. 00:01:10
    medication, but stroke is the result of
  29. 00:01:12
    reduced blood flow to brain tissues.
  30. 00:01:14
    And although mortality is not as high as
  31. 00:01:18
    intracranial hemorrhage in our country,
  32. 00:01:21
    the mortality can range from 10 to 20.
  33. 00:01:24
    Casey, could you please help us with
  34. 00:01:26
    the diagnosis and walk us through how
  35. 00:01:28
    you would diagnose someone who comes to
  36. 00:01:29
    the ED with possible signs and symptoms
  37. 00:01:32
    of skimmick stroke? Yeah, absolutely.
  38. 00:01:35
    So I think stroke could be tricky
  39. 00:01:37
    because so many presentations and almost
  40. 00:01:39
    any acute onset of neurologic deficit
  41. 00:01:41
    could be attributable to an ischemic
  42. 00:01:43
    event. However, time is really really,
  43. 00:01:46
    brain here and that many, many millions
  44. 00:01:48
    of neurons can die with each minute of
  45. 00:01:50
    the leg and there are two forms of
  46. 00:01:53
    treatment from the lysis and mechanical
  47. 00:01:56
    thrombectomy. And so I think it's
  48. 00:01:58
    really important to think about who
  49. 00:02:00
    qualifies for those and how you can
  50. 00:02:02
    identify those patients because
  51. 00:02:04
    unfortunately a lot of our patients
  52. 00:02:05
    present outside of the window for
  53. 00:02:07
    treatment or don't have a large vessel.
  54. 00:02:09
    and therefore don't qualify for
  55. 00:02:13
    thrombectomy. So let's talk about first,
  56. 00:02:14
    those patients that do present with a
  57. 00:02:16
    large vessel of fusion, because I think
  58. 00:02:18
    those are the isemic syndromes. So it's
  59. 00:02:20
    critical to recognize these. So large
  60. 00:02:23
    vessels include the ICA's, meaning the
  61. 00:02:25
    internal fraud at arteries, the MCA's,
  62. 00:02:27
    the middle cerebral arteries, and the
  63. 00:02:29
    vascular artery. The first two, the
  64. 00:02:32
    ICA and the MCA, are part of the
  65. 00:02:34
    anterior circulation. And that's where
  66. 00:02:36
    we actually really have the best data
  67. 00:02:38
    for thrombectomy The bass are still a
  68. 00:02:40
    large vessel, and we are pushing more
  69. 00:02:42
    and more for these patients to get
  70. 00:02:43
    thrombectomy. But the trial data is
  71. 00:02:45
    most robust for those anterior
  72. 00:02:47
    circulations occlusion. So fortunately,
  73. 00:02:51
    these ICA and MCA occlusions have a
  74. 00:02:53
    signature, right? So these are the
  75. 00:02:55
    patients who typically come in with a
  76. 00:02:57
    gaze deviation, which is going to be to
  77. 00:02:59
    the side of the ischemia, as well as
  78. 00:03:02
    contralateral weakness, and either
  79. 00:03:05
    aphasia, if it's a dominant MCA
  80. 00:03:08
    syndrome, if it's a non-dominant MCA
  81. 00:03:11
    syndrome. And so that's the syndrome
  82. 00:03:13
    that I think all providers should really
  83. 00:03:15
    have grilled into their head about like,
  84. 00:03:18
    that's the patient that's probably gonna
  85. 00:03:20
    qualify for thrombectomy and that's the
  86. 00:03:22
    patient we really need imaging as soon
  87. 00:03:24
    as possible. Now, balsar thrombosis is
  88. 00:03:27
    really challenging. I think there is a
  89. 00:03:29
    clinical delay in recognizing this
  90. 00:03:31
    patient and it really requires a very
  91. 00:03:34
    heightened level of suspicion. So I
  92. 00:03:36
    think of these with patients who have
  93. 00:03:38
    gaze perisis or any change in alteration
  94. 00:03:41
    of consciousness that happens pretty
  95. 00:03:43
    acutely. Yourself, could this be a
  96. 00:03:47
    balsar thrombosis? And to really
  97. 00:03:48
    examine that patient for either
  98. 00:03:50
    asymmetric weakness or maybe a gaze
  99. 00:03:53
    deviation or with any sort of changes in
  100. 00:03:56
    their pupillary findings, this can be
  101. 00:03:58
    subtle, but I think those are the
  102. 00:04:00
    patients that we really need to be most
  103. 00:04:02
    attuned to finding 'cause those are the
  104. 00:04:04
    patients that are gonna have the highest
  105. 00:04:05
    mortality and morbidity and those are
  106. 00:04:07
    the patients that can be helped,
  107. 00:04:09
    treatment.
  108. 00:04:19
    Great, interesting. Now given all
  109. 00:04:21
    these challenges and unknowns, can
  110. 00:04:24
    imaging help us here? Absolutely. So
  111. 00:04:27
    imaging is crucial in the work of
  112. 00:04:28
    perin-acute stroke. So again, I think
  113. 00:04:30
    the two things that every patient really
  114. 00:04:33
    with an acute stroke syndrome needs to
  115. 00:04:35
    have done are to figure out, one, when
  116. 00:04:37
    was the time that they were lasting
  117. 00:04:38
    wealth, right? That's going to
  118. 00:04:40
    determine, does this patient with no,
  119. 00:04:43
    with neurologic symptoms, they qualify
  120. 00:04:45
    for thrombectomy, and then they need to
  121. 00:04:48
    get to the scanner, right? To qualify
  122. 00:04:51
    for any treatment for a sphemic stroke,
  123. 00:04:53
    you have to, one, have no blood in
  124. 00:04:55
    your head, and two, if you're going to
  125. 00:04:57
    be a candidate for thrombectomy, you
  126. 00:04:59
    have to have one of those large vessel
  127. 00:05:01
    officials. There are two imaging
  128. 00:05:03
    sequences that patients that have acute
  129. 00:05:06
    sphemic changes really need. One is the
  130. 00:05:08
    noncon head CT, that's just to rule out
  131. 00:05:10
    blood in the head, and then patients
  132. 00:05:13
    need vessel imaging, Right, and that's
  133. 00:05:15
    gonna be with the CT angiogram.
  134. 00:05:18
    we want both the head and the neck,
  135. 00:05:21
    because the neck can give us a lot of
  136. 00:05:23
    information about A, if there's an
  137. 00:05:25
    internal parotid occlusion, or B, if
  138. 00:05:27
    there is some sort of like critical
  139. 00:05:29
    pathology, you know, like a dissection
  140. 00:05:31
    or very unstable atherosclerosis in the
  141. 00:05:35
    neck. Like that will help us identify
  142. 00:05:37
    like, what was the etiology of stroke?
  143. 00:05:41
    So to summarize, for any patient who's
  144. 00:05:43
    presenting to the emergency department
  145. 00:05:44
    with acute onset, a focal or
  146. 00:05:47
    lateralizing neurologic deficits, that
  147. 00:05:50
    patient deserves a CT and a CTA head and
  148. 00:05:54
    neck upfront. For the sake of time,
  149. 00:05:57
    we're gonna skip over kind of the CT
  150. 00:05:59
    perfusion and how that plays into the
  151. 00:06:01
    neurologic evaluation for a mechanical
  152. 00:06:03
    thrombectomy. What I will say for all
  153. 00:06:06
    trainees and for emergency providers is
  154. 00:06:10
    talk upfront with your stroke team when
  155. 00:06:11
    you're getting this imaging. Hey, do
  156. 00:06:13
    you guys want the CT perfusion if that's
  157. 00:06:14
    available at your center.
  158. 00:06:17
    It's really important to make that
  159. 00:06:18
    decision before you get the CTA
  160. 00:06:28
    for mechanical thrombectomy and who's
  161. 00:06:29
    going to qualify for thrombolysis. And
  162. 00:06:31
    so maybe walk us through, Salia, a
  163. 00:06:33
    little bit about the mechanism of action
  164. 00:06:35
    for thrombolytics and sort of the
  165. 00:06:36
    inclusion, exclusion, and some of
  166. 00:06:38
    those pertinent must know for that sort
  167. 00:06:40
    of treatment. Sure. So as you
  168. 00:06:44
    mentioned, you know, a lot of these
  169. 00:06:45
    patients are screened and monitored to
  170. 00:06:47
    see if they qualify to get a
  171. 00:06:49
    thrombolytic or not. I'm going to start
  172. 00:06:52
    off by saying what these agents are,
  173. 00:06:54
    what they do, and then we'll walk
  174. 00:06:55
    through, okay, like who can get it,
  175. 00:06:57
    who shouldn't get it and all that. So I
  176. 00:06:59
    think the agent that most of us are more
  177. 00:07:02
    familiar with is AltiPlays. I'm not
  178. 00:07:04
    going to use TPA anymore just because we
  179. 00:07:07
    have ConnectiPlays now, and it's going
  180. 00:07:08
    to be really confusing, and I encourage
  181. 00:07:10
    everyone to just say AltiPlays or
  182. 00:07:12
    ConnectiPlays to make it very clear for
  183. 00:07:14
    everyone who's working with you and your
  184. 00:07:16
    team. So both of these agents, what
  185. 00:07:18
    they do is that they are local
  186. 00:07:21
    thrombolytic agents, invertebrate
  187. 00:07:22
    plasmid, and plasmid really converse
  188. 00:07:25
    that. breaks down that clot or fibrin
  189. 00:07:28
    that is, you know, associated with the
  190. 00:07:32
    clot. Now we do talk about, you know,
  191. 00:07:36
    these patients need to have a blood
  192. 00:07:38
    pressure that can tolerate that
  193. 00:07:41
    thrombolytic agent because if the blood
  194. 00:07:43
    pressure is very high, they can convert
  195. 00:07:44
    that to a hemorrhagic stroke. So the
  196. 00:07:48
    threshold that we consider safe for
  197. 00:07:50
    these patients is systolic of less than
  198. 00:07:51
    185 and diastolic of 110 before giving
  199. 00:07:54
    it. The other thing that we obviously
  200. 00:07:57
    look at and think about is that what is
  201. 00:07:59
    their blood sugar, right? Because we
  202. 00:08:01
    know that low blood sugar and high blood
  203. 00:08:03
    sugar can look like stroke. So that's
  204. 00:08:06
    really one lab that the guidelines are
  205. 00:08:08
    recommending. We check before giving
  206. 00:08:11
    out a place or tenecta plays and we'll
  207. 00:08:12
    talk about tenecta plays a little bit
  208. 00:08:14
    later Other labs that we look at, I
  209. 00:08:18
    know that a lot of people really
  210. 00:08:20
    emphasize on platelet count and INR and
  211. 00:08:23
    things like that. I do want to
  212. 00:08:25
    highlight that. You really don't need
  213. 00:08:27
    to send for those labs unless you are
  214. 00:08:29
    concerned for coagulopathy. So in a
  215. 00:08:31
    normal, healthy individual waiting for
  216. 00:08:34
    PTT or INR or a planet count to come
  217. 00:08:37
    back is really a waste of time. As far
  218. 00:08:40
    as, you know, 10-inch the place,
  219. 00:08:43
    but we are now seeing a lot of interest
  220. 00:08:45
    for using 10-inch the place for acute
  221. 00:08:48
    scheme stroke to give you a little bit
  222. 00:08:50
    of background. There are some initial
  223. 00:08:52
    historic studies that looked at 10-inch
  224. 00:08:55
    the place in patients who had large
  225. 00:08:57
    visual occlusion and need a thermbectomy.
  226. 00:08:59
    And those studies, actually, all those
  227. 00:09:01
    smaller studies, they showed better
  228. 00:09:02
    functional outcomes than out of place,
  229. 00:09:05
    which was really interesting to see.
  230. 00:09:07
    More recently, the ACT trial, which is
  231. 00:09:09
    a multi-center, much larger study was
  232. 00:09:11
    published. And they actually found that
  233. 00:09:13
    even in the majority of those patients
  234. 00:09:15
    that didn't go for thermbectomy, the
  235. 00:09:17
    functional outcomes and the safety
  236. 00:09:18
    outcomes were pretty similar to out of
  237. 00:09:20
    place.
  238. 00:09:23
    connect the place has a shorter half
  239. 00:09:25
    life. So it's just an IV push as
  240. 00:09:27
    opposed to a push and a continuous
  241. 00:09:29
    infusion. So we love that for that.
  242. 00:09:30
    It's just the one shot you give it.
  243. 00:09:32
    It's an IV push. So it's easy, less
  244. 00:09:34
    resource, intensive. The other thing
  245. 00:09:38
    is that because it's more fiber and
  246. 00:09:39
    specific hypothetically, it has lower
  247. 00:09:41
    risk of bleeding. Although studies that
  248. 00:09:44
    are published, they're talking about
  249. 00:09:45
    similar risks of bleed as of now. The
  250. 00:09:48
    common dose that we see for schematic
  251. 00:09:51
    stroke is 025 mk, maxing it at 25
  252. 00:09:54
    milligrams. Remember that the vials are
  253. 00:09:56
    50 milligram vials, so you always have
  254. 00:09:59
    some waste
  255. 00:10:07
    I was switching to this because of the
  256. 00:10:09
    ease of
  257. 00:10:11
    dosing,
  258. 00:10:12
    the quicker administration kind of
  259. 00:10:14
    one-shot and done. The one thing that I
  260. 00:10:16
    saw one time, and I think it's just
  261. 00:10:17
    worth noting, is that because it's a
  262. 00:10:20
    one-and-done shot, you actually really
  263. 00:10:22
    need to have a good caliber IV. This is
  264. 00:10:25
    not something that you want to be
  265. 00:10:26
    pushing through like a 22 in the hand
  266. 00:10:28
    that sort of get infiltrated because
  267. 00:10:30
    this is your one shot So, yeah, I also
  268. 00:10:33
    wanted to ask you because I think this
  269. 00:10:34
    is coming up more and more clinically.
  270. 00:10:37
    So many more patients are using DOX now.
  271. 00:10:40
    And so, what should I do if I have
  272. 00:10:42
    patients who's reportedly on DOX a now
  273. 00:10:45
    presents with signs of an acute ischemic
  274. 00:10:47
    stroke?
  275. 00:10:49
    Yeah, a very good question. As you
  276. 00:10:51
    said, a lot of people in the community
  277. 00:10:53
    are on
  278. 00:10:55
    Epixaban, River Oxaban Not so much on
  279. 00:10:57
    Dabikitran anymore, but just speaking
  280. 00:10:59
    of DOX as a class, I think the first
  281. 00:11:02
    question that you should ask yourself is.
  282. 00:11:06
    When was the last time that they took
  283. 00:11:07
    the medication? And the second question
  284. 00:11:09
    you can ask and hopefully you have more
  285. 00:11:11
    information on that, what is the renal
  286. 00:11:12
    function? Obviously, if the renal
  287. 00:11:14
    function is poor, then that 48-hour
  288. 00:11:16
    could possibly be extended to 72 hours
  289. 00:11:19
    and patients who are getting the bigger
  290. 00:11:20
    trend because of how extensively it's
  291. 00:11:22
    cleared renal-y. That could be also
  292. 00:11:26
    extended to sometimes four or five days,
  293. 00:11:29
    which obviously could be a problem.
  294. 00:11:31
    Gosh, so it's really like checking in
  295. 00:11:34
    with the family, trying to find one
  296. 00:11:35
    with their last doses and confirming,
  297. 00:11:37
    obviously, if they're reliably taking
  298. 00:11:38
    it, this is not a patient that
  299. 00:11:41
    qualifies for thrombolytics. Correct.
  300. 00:11:43
    So then what if someone is on aspirin or
  301. 00:11:45
    if they're on DVT prophylaxis? What
  302. 00:11:47
    about that? Sometimes we get questions
  303. 00:11:49
    about oatous patients on aspirin.
  304. 00:11:51
    Aspirin's okay. This patient's on
  305. 00:11:52
    subcue heparin per prophylaxis. That is
  306. 00:11:54
    okay. If someone's on prophylactic use
  307. 00:11:58
    of lobonox, again, on the floor,
  308. 00:12:00
    that's all okay. It does get, again,
  309. 00:12:02
    a problem someone's on therapeutic doses
  310. 00:12:05
    of how.
  311. 00:12:07
    or Lovonox, but prophylactic doses of
  312. 00:12:09
    these agents that we commonly see on the
  313. 00:12:11
    floor for, you know, DBT prophylaxis
  314. 00:12:13
    or aspirin. Those are very, those are
  315. 00:12:17
    okay to, you know, go ahead. If they
  316. 00:12:19
    meet other criteria for altepletes
  317. 00:12:21
    administration or technically is
  318. 00:12:22
    administration. That's okay. And you
  319. 00:12:24
    can go ahead and do that that. But to.
  320. 00:12:32
    Okay so you determined like based on you
  321. 00:12:34
    know the patient walks in you have no
  322. 00:12:36
    reason to think that they have a quite
  323. 00:12:38
    dilapathy so run in the middle patient
  324. 00:12:39
    you check a finger stick blood sugar and
  325. 00:12:41
    it's you know 135 and so you're going to
  326. 00:12:44
    go ahead and give them from the littics.
  327. 00:12:46
    Great! So what are some of the side
  328. 00:12:48
    effects that we need to watch for after
  329. 00:12:50
    we've given these? Sure, two things I
  330. 00:12:54
    think I'm going to start with the
  331. 00:12:55
    bleeding risk obviously it is very
  332. 00:12:59
    thoughtful and reasonable to think about
  333. 00:13:02
    bleeding. If your patient is
  334. 00:13:03
    complaining of a headache or you see
  335. 00:13:06
    worsening of the exam as you're giving
  336. 00:13:08
    your thrombolytic, whether it's
  337. 00:13:09
    alteplase or tinexoplase, as far as you
  338. 00:13:13
    know what you do if they bleed. Let's
  339. 00:13:14
    say they complain of a headache and you
  340. 00:13:16
    stop the alteplase in fusion or it's
  341. 00:13:19
    already, the tinex is already given.
  342. 00:13:21
    You go for a head CT. If they have a
  343. 00:13:25
    hemorrhagic conversion now obviously
  344. 00:13:27
    what What you want to do is try to
  345. 00:13:29
    provide them with the. vibranogen
  346. 00:13:32
    because, you know, these people are
  347. 00:13:33
    going to be deficient in vibranogen.
  348. 00:13:36
    Cryoprecipitate is the agent of choice
  349. 00:13:39
    to treat these patients with and to
  350. 00:13:40
    setting up this hemorrhagic conversion.
  351. 00:13:42
    Usually we talk about 10 units. People
  352. 00:13:45
    do talk about in the guidelines, also
  353. 00:13:47
    talk about you could send for vibranogen
  354. 00:13:49
    levels in these patients. If it's less
  355. 00:13:50
    than 150, you could give them
  356. 00:13:51
    additional doses for that. So that's
  357. 00:13:54
    really what we think about when people
  358. 00:13:56
    bleed on thermobilitic agents A lot of
  359. 00:13:59
    what I think of it as being like sort of
  360. 00:14:01
    in an Iotrogenic DIC picture for almost
  361. 00:14:04
    that first 24 hours. I mean even though
  362. 00:14:06
    the the half-life of these drugs is very
  363. 00:14:08
    short, the actual effect on the
  364. 00:14:11
    vibranogen levels can last a long time.
  365. 00:14:14
    Not practice is to tell people, you
  366. 00:14:16
    know, the second you see that that ICH
  367. 00:14:20
    get the 10 units of cryoprecipotent,
  368. 00:14:22
    but also send that vibranogen level so
  369. 00:14:24
    that it's cookie. Don't wait for it to
  370. 00:14:26
    come back go ahead and give them that
  371. 00:14:29
    kind of prior precipitate. and they can
  372. 00:14:31
    always give more base on the level.
  373. 00:14:33
    Correct, now that's a very good point.
  374. 00:14:35
    And you know, that's when we talk about
  375. 00:14:36
    pharmacokinetic versus pharmacodynamic
  376. 00:14:38
    half-life, that the drug itself will be
  377. 00:14:40
    out of the system, but the impact of
  378. 00:14:41
    the drug on the platelets and the
  379. 00:14:43
    coagulation cascade will still be there.
  380. 00:14:52
    Now, with the angiodema, I think,
  381. 00:14:56
    again, there are certain patients that
  382. 00:14:57
    are at higher risk, I think,
  383. 00:14:58
    African-Americans, you know, patients
  384. 00:15:00
    who have had angiodema with ACE
  385. 00:15:01
    inhibitors are typically the patients to
  386. 00:15:03
    think about when you're giving this drug
  387. 00:15:05
    and you see those signs of angiodema.
  388. 00:15:08
    In terms of what to give in this case,
  389. 00:15:10
    you know, thinking about hypersensitive
  390. 00:15:12
    reactions, right? So, in the American
  391. 00:15:15
    Heart Association, Gotland, as they
  392. 00:15:16
    talk about giving methyl pride 125 grams,
  393. 00:15:19
    they talk about giving Benadryl 50
  394. 00:15:21
    milligrams, all IV formulation, just
  395. 00:15:22
    because of the quick onset, um,
  396. 00:15:25
    renitidine or some sort of H to the
  397. 00:15:27
    blocker, just to, you know, block the
  398. 00:15:29
    histamine release. Now, if things get
  399. 00:15:31
    worse, obviously, and they are
  400. 00:15:33
    progressing, um, that's, I think,
  401. 00:15:35
    when we think about intubating, giving
  402. 00:15:37
    up and a friend, kind of like how we're
  403. 00:15:38
    treating anaphylactic, um, you know,
  404. 00:15:41
    um, episodes and, um, uh, reactions.
  405. 00:15:44
    So, those are some of the clinical pros
  406. 00:15:46
    to kind of think about when we're going
  407. 00:15:47
    through and judym of these patients.
  408. 00:15:50
    And the other thing is if they're in an
  409. 00:15:51
    ACE inhibitor, obviously you wanna make
  410. 00:15:52
    sure that you hold that and you're not
  411. 00:15:54
    introducing ACE inhibitor for these
  412. 00:15:56
    patients. Yeah, absolutely. It's not
  413. 00:15:59
    one of those things that you commonly
  414. 00:16:00
    encounter, but man, when it does
  415. 00:16:02
    happen, it can progress quickly.
  416. 00:16:05
    Fortunately, I've seen kind of over the
  417. 00:16:07
    next couple of days, it does sort of
  418. 00:16:09
    reside on its own.
  419. 00:16:12
    So, so many pearls and so much to think
  420. 00:16:14
    about, this is a really common
  421. 00:16:17
    and a diagnosis that I think that we can
  422. 00:16:20
    really do a lot of good by just acting
  423. 00:16:22
    expediently and as a team and trying to
  424. 00:16:25
    get patients in the center as quickly as
  425. 00:16:27
    possible, so the couple pearls to leave
  426. 00:16:29
    you with in the clinical side are really
  427. 00:16:31
    establishing that last thing well.
  428. 00:16:33
    'Cause that's gonna be really crucial in
  429. 00:16:35
    dictating what kind of therapy the
  430. 00:16:37
    patient eligible for. The other thing
  431. 00:16:40
    is look for an LBO syndrome, like look
  432. 00:16:42
    for that gaze deviation, contralateral
  433. 00:16:44
    weakness, neglect gonna are clue you in
  434. 00:16:44
    Those. aphasia or
  435. 00:16:47
    that this patient might qualify for
  436. 00:16:48
    mechanical from. to me and needs to be
  437. 00:16:50
    expedited through their imaging and to a
  438. 00:16:54
    thrombectomy capable center. Time is so
  439. 00:16:56
    critical, you know. Establishing if
  440. 00:16:57
    the patient is TBA eligible, don't
  441. 00:17:01
    think about it in terms of like, oh,
  442. 00:17:02
    well, they are within four and a half
  443. 00:17:04
    hours, we have time. No, you don't
  444. 00:17:05
    have time. So don't delay to get
  445. 00:17:08
    information that you don't ever really
  446. 00:17:10
    need and never ever delay a CTA for
  447. 00:17:12
    renal clearance. Salia from the
  448. 00:17:14
    pharmacokinetic and all the pharmacology
  449. 00:17:17
    furls Thanks to leave. Sure. I think I
  450. 00:17:21
    wanted to reemphasize that time is brain.
  451. 00:17:24
    So I think that's maybe the beauty of
  452. 00:17:27
    connect to plays that it's a one shot,
  453. 00:17:27
    it's faster. You don't have
  454. 00:17:30
    to get a pump. You don't have to go
  455. 00:17:32
    through, oh, like 10 bolus, 90
  456. 00:17:35
    infusion. And that is the key here, I
  457. 00:17:38
    think. Just making sure, checking
  458. 00:17:41
    blood glucose before giving out to plays
  459. 00:17:43
    or making that diagnosis and making sure
  460. 00:17:46
    that we're familiar with,
  461. 00:17:49
    what to do when they bleed, what to do
  462. 00:17:50
    if they have enduodema. And
  463. 00:17:54
    also, you know, making sure that as
  464. 00:17:56
    much as we care about, you know,
  465. 00:17:58
    giving this agent, we want to make sure
  466. 00:18:01
    that we provide the right care after
  467. 00:18:03
    they get that. So, blood pressure
  468. 00:18:04
    monitoring after you give out the place
  469. 00:18:06
    or connect the place is as important.
  470. 00:18:08
    We talk about for these patients, you
  471. 00:18:09
    know, keeping the blood pressure less
  472. 00:18:11
    than systolic of 180 over diastolic of
  473. 00:18:13
    105 for the first 24 hours Absolutely.
  474. 00:18:18
    All right, guys, well, that is all
  475. 00:18:19
    for today. And we look forward to
  476. 00:18:21
    seeing you on the next episode. Thank
  477. 00:18:23
    you again for tuning in and make sure
  478. 00:18:24
    you check out the on-call chapter,
  479. 00:18:26
    which you can visit by going to
  480. 00:18:28
    neurocriticalcareorg, checking out the
  481. 00:18:31
    education tab, and you can find it
  482. 00:18:33
    within the on-demand resources. All
  483. 00:18:34
    right, thank you again.