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Welcome to the neuro transmitters, a podcast about everything neurology from challenging clinical cases to practical clinical pearls with the goal of reducing your neur a phobia. I'm Doctor Michael Can Trees and I'm joined today by my good friend Dr Praveen Vent Potential. Um Hey Michael, how's it going? Good. How are you? Not bad. Thanks for having me. And uh yeah. No, I'm, I'm super happy to have you here, especially since this was your idea for today to talk about some of the stuff coming out of the recent international stroke conference. Yeah, I thought it was something that is interesting and uh you know, I've been texting you. Uh you've been sending me articles regularly as articles and opinions pop out and cause I don't have opinions of my own. And then I said like, okay, maybe we should, maybe we should apply this in our patient population and go from there. So, uh why wasn't a bad idea to just talk about it so I could stop texting you and bothering you on your weeks off? No, this is great. Uh So for those who don't know Praveen and I work together at a community teaching hospital uh where I work as a neuro hospitalist. And Praveen is one of our neurointerventionalist are only neurointerventionalist and our interventional neurologist. Yes. Yes. Thank you. Yes. Proud, proud community neurology. That's right. So, um so tell me, where should we, where should we start up? Yeah, I guess, you know, mobile stroke units. I do think that that's, that's an interesting thing. Uh We don't have one in our community, but we do have our one in our hospital system. So um there's some, there's a couple of papers that got published uh or presented. Um one of them is it, you know, the mobile stroke units being effective. And the second one is the mobile stroke units uh being cost affected. And um you know, there was um a study from last year uh that came out saying that the mobile stroke units actually improved outcomes and ischemic strokes and these are just not related to large vessel occlusions. These were just uh these are even small vessel drugs stroke. So, so even if um um you know, you're, you're saying that we can bring the patient straight to the a comprehensive stroke center or bypass the primary stroke center, you know, the, the benefit that was shown in these um the mobile stroke unit is that, you know, they were able to um attain um uh the 3.5 hour to 43 to 4, 4.5 hour window uh to um a majority of uh stroke patient's in the field. Um And, and, and it wasn't perfect study. So they, the best way that they could randomize it was um they uh just compared the weeks that the mobile Stroot unit was functioning versus the week that the mobile stroke, you know, it wasn't functioning and they kind of randomize that into two arms. So, so, you know, that's the best randomization that they could get instead of like a real randomization, like one is doing okay, you get called. So it's not feasible. So this is more real world randomization with the related to the cost of a mobile stroking in and, and all that stuff and it did show a significant benefit, but there are people that are still um um uh skeptical about it. Um it's called the best MSU trial. So they found out that the modified rankings are actually better in any days because you're delivering TP a quicker to these patient's. And you know, they are also able to triage it to the closest Comprehensive Stroke center or if it's bleed because they have a CT Scan er inside, they can, you know, take it to a Comprehensive stroke center even if it's farther away than a thrombectomy capable stroke center. So these were like some of the advantages with the caveat that this is being done in a in a big city in big cities with multiple centers is not comparable to places like we do practice where we are the only um stroke center. I would wonder if it be even more useful in like, like more remote referral areas. I do, I do, I do think that that is, is definitely something because, you know, we do get patient's from, you know, an hour and a half away. Yeah. So, uh now we do have ems uh protocols in place uh where they do um um a specialized score ing uh to see if the patient is, is uh is a large vessel occlusion probability. So they, what we use is a van scale uh van and um if they're uh positive for a banned scale or if they suspect a large stroke, the ems personal uh just got clearance from um from our ed director and myself to bring the patient directly here instead of to the closest hospital. Um So that would be something that um that would benefit these patients that are coming from a longer distance. Okay. Um With relation to the royal communities, you know, where there isn't uh necessarily the uh need for post TP a care or even endovascular therapies uh to be considered. Gotcha. Interesting. And there's also the kind of like, like you said that sister paper there about the cost efficacy as well. Yeah. So this was one of the things, you know, if the cost efficacy, I think it was, I'm not sure but uh I did listen to um uh you know, the Society of Vascular Intervention Neurology conference. And uh you know, there was this panel, one of uh doctors IDA who it is part of our system in, in and, you know, he has the mobile stroking in Toledo and uh the cost effectiveness and they were talking about the cost of it and it seemed to be pretty expensive. So I think it's in the millions just to run it like a half a million to a million just to run it. Yeah, the reimbursement is, uh, they have an NPR pee on board and the reimbursement is not, um, extremely great. They just reimburse you for the console and I do not think that they'll reimburse you for the mobile CT. Yeah. Um, because it has to be, there's some rules that has to be done in the hospital, like after they arrived the, er, for the CT for reimbursement. So the reimbursement is not great. So, even if the reimbursement is not great, you know, is this high expense to, um, I don't know how much it's costing too. I think it will be like a 1 to $2 million investment to get the mobile stroke unit, just the portable skinner inside the van and all that stuff and then half a million dollars just to function it, you know, and, uh, just have someone waiting at all times and with CPA ready on the, the thing. So, yeah, so that's the, the question, you know, if it's a cost effective or not, it seems like, you know, they are cost effective. You know, it's a prospect of data and um the um incremental cost effective ratio of the mobile shoot, you know, it was about $33,000 and $537. Her quality addition did life year. Um it's less than the US threshold. So the years threshold is about 500 to 200,000 or almost to 100 and $90,000 for quality, effective late years. So this is what they use for proving cost effectiveness of thrombectomy knees and you know, all like all the major stuff in the past with the even relation to tee pee and stuff like that. So I guess, you know, keeping the patient less time in institutions where Medicare and Medicaid and insurance companies would pay for um time in rehab because they are, you know, they're modified, ranking skills are better um at the end of the day and then you get to go home. So I think that's, that's where the cost savings might be more downstream, more downstream. That makes sense and also probably repetition too. So you're, you're not blocking up, you know, you don't come to um uh an er, which has no stroke designation or hospital that has no jokes and then they have to transfer to uh hospital capable of post TP a care or cost of ambulance and helicopter transfer patient to your physicians too, you know. Um, two sets of scans, possibly even. Yeah. And, um, all that stuff. I think it kind of like, saves money in the end. I think it's interesting concept to consider. I'm not 100% convinced on it yet. But, uh, I do, I don't do think that people shouldn't throw this out the idea of a mobile stroke unit and, and also I wanted to say that I do think it will benefit communities like ours where the closest other hospital that could perform a thrown back to me or post DBK would be like either Cleveland Clinic or Pittsburgh or, or even Akron, which is like, even, you know, realistically speaking when I drive, um and I drive pretty fast and I drive, it's like an hour and a half uh to go to Cleveland and uh you know, about an hour and 20 minutes to go to Pittsburgh. And that's, that's without traffic on, on, on a Sunday or a Sunday night or a Saturday night to drop my dad off at the airport. Wow. Yeah. So I do think that this will benefit our community. I don't know what your thoughts are, but you've been more familiar with this region, but a little bit. So, I mean, it does seem like there is a certain uh population threshold you have to hit, um which is probably what's going to make it harder for rules, you know, rel areas I should say, but we have a pretty decent sized urban population here as well. Uh, and a couple decent sized suburbs. So they're, they're theoretically could be. And like you said, we've got a few satellite hospitals and so that would help probably with the triaging of the ambulance location as well. Um, but it certainly would be worthwhile to see what that, what that data looks like in different settings rather than large urban areas. See how it looks in more medium size or even small towns. Um, they're within a reasonable distance but the, the costs maybe a little prohibitive in some situations. Yeah, and especially, you know, the these um these mobile stroke units use already technology like this or rapid. Um, you know, how much additional, you know, when they stay the startup of it takes about a million to 2 million. I'm wondering how much of, um because we already use these. So, you know, it's, it's stuff that we already have, we already have neurology and we have, you know, the, all that stuff to tell the neurology stuff. So I'm wondering how much of it as actual, that stuff that we already have that can be saved upon is, is also one of my, you know, my thoughts, I mean, maybe it would benefit but you don't, you never know if, uh you know, if it's until more data is available and if it's generally a pliable nationwide and, and stuff like that. Yeah. Yeah. So speaking of TP A it looks like there's also some, some mention of connected place this go around. So now that we did the pre hospital triage, now we're going to like the acute care of stroke. Uh I like how your introduction to that. So, yeah, the TNK um there was this trial called the Chaplain trial. I think you said when I sent it to you. Yeah, I said Shibly Shibly. All right. So it's a Chinese study of course. But you know, it's always um the the effectiveness of the Chinese to conduct um um trials in stroke is remarkable. You know, that like I've, I've uh I think when we trained uh uh some of us, some of the physicians used to the uh the the chance trial. Uh people would not, there was some attendees that would not be favorite because it was a Chinese trial, but the trial was done very good. I mean, it's like until this day, I think there were like some publications that, that came after that, that were very, very thorough for subgroup analysis and, and etcetera, etcetera. So the trial was done very good. And that's what the same thing, the point trial also. And then that's why we used to go and the platelet in the acute phase. I don't think that, that the, the Chinese trials is something that we discredit is because it's a Chinese trial because their ability to do do some stroke of these, some, some of these stroke trials are remarkably well and, um, I think it's, I don't know if it's, uh, if there's a reason why but, uh, you know, they apparently do it well is, is my, uh, my guess but they, um, um, you know, they wanted to see if tonight to place, um, had a place, um, in the extended time window between, um, um, you know, 4.5 to 24 hours. So they wanted to see if there's any benefit of, uh, connect to place, which is, um, which is an interesting medication. Um, I know major centers across the United States have, um, have switched to connect to place, especially during the pandemic. Um, I think there was a shortage of tea pee, so high volume centers started to switch to connect the place to streamline it. Um, it's also, um, it's nice that it comes in a syringe and then you just like, give it to him one shot instead of like, you know, calculating, uh, what's the bolus and what's the trip and adjusting the pump to the bolus into the trip. I know the nurses always have a hard time with the pump. Hilarious machines. Yeah. And then they switch the pump and then the pump, you know, there's, they switch the IV. And there's always issues with that too that there's a blockage in the IV and there's no one to relieve the blockage and the, and the bump, you know, you could hear that hilarious pump beeping in the, er, for a long time. But this is a much more thing. It's, it's great for thing. I think a lot of centers have had good success with it. Um Initially they were doing it only for large vessel occlusions um based on the AHA guidelines that, you know, if you have a large vessel occlusion, a 0.25 make per kick dose uh tonight to place is considered uh a reasonable um dose to um alternated to uh TP A. Um it showed noninferiority, but in reality, I think before you took the patient to the lab, I think there was about a 22% re can rate in the connected place group and a 10% in the teepee a group. So you can actually see that, you know, there was like, you know, in 22% of the patients, I I didn't have, you know, no one had to go inside and, and, and, and do what they're on back to me exposing the patient to more risk. Of course, is it the same kind of thing that you would see where the, the length of clot tends to be associated with re perfusion? I think there's more data on, on the, on the, on the TP A side, but I haven't seen enough on the TNK side. So um that's there, but it's uh to what uh to our listeners soon, I tend to places just a genetically modified variant of all to place it has approval for M I um in our hospital, we have one dose that we have all time and then that one dose goes away then. So I have used it before with um no recon and of course, I was expecting the patient to have recapitalization but didn't, but you know, it was pretty safe um in the patient and um ended up having a thrown back to me too. So, um uh the advantages is over is and you don't have to worry about the uh drip and um as from an international standpoint, you know, um I always worry about it like, okay now I have opened up the clot and there's Tiki three recapitalization, but the TP is still dripping. What do I do? And that's an area like do I switch it off? Like do I do it? Like do I just let it run? You know that there's some questions that, you know, I already sucked out all the clock. I can actually see the whole clock come out, you know, it's like 89 millimeter clots. So it's a big clot. You know, there is some concern of destabilisation. So I just do let it run uh the rest of the five minutes or 10 minutes it is or do I just stop it because it's unnecessary and help me close the groin better so the groin or it doesn't risk, uh you know, doesn't bleed on it. So that was one of the things. So I think the tenecteplase has that advantage of it. So, um there was a trial um that all the place had, uh this T PA had a benefit between 4.5 to 9 based on CT perfusion that's called the extent trial. We have done that on a couple of patient's before, especially when the MRI machines are down or we can't get the patient to the MRI fast enough per the wake up protocol. So with I have to say within my limited experience with good experience um and low complications to it because you see the court already on the CT perfusion. Um So the shots are, they did the 4 to 4.5 to 24 hours. Um um They included 86 patient's who had an anti logical seclusion or Stevia stenosis. Um CT perfusion mismatch. They were randomized to two doses of connect place uh 0.25 mg or 0.32 mg per kilogram. Primary outcome was achievement of re profusion without symptomatic intercranial hemorrhage at 24 to 48 hours. And this occurred in 32% of the 0.25 mg per kilogram group versus 23.3% in the 0.3 in the 0.32 group. Yeah, Rican Lishan of 4 to 6 hours occurred in 44% of both groups. So I think the lower doses probably the way to go is, in my opinion, um uh safety results show that any intracranial hemorrhage was reported in 49% of the 0.25 group and 30% of the 0.32 group, which is, you know, obviously not like not surprising to me. I mean, it is surprising to me because they had more hemorrhoids in the 0.25 symptomatic heights. So this is what you really didn't need to know is symptomatic. So, and I stroke scale changer for by more occurred in 11% in the 0.25 group in the 9% in the 0.32 groups. So similar, uh, I would say within 2%. So I wouldn't read too much into that. Um, so the patient's were also allowed to, um, um, uh to go endovascular therapy at the discretion of the, the, the tree of the institution. Um I think that, um, uh, in, in the US, at least, I, I think that we do the extend trial and the wake up trial in patients who are not in no vascular candidates because, um, the diffuse trial and the Dawn trial kind of like established that, you know, it's reasonably safe to do it within the 4 to 24 hour window. Um And so we don't want to mess that up with an additional agent that can cause hemorrhage along with reperfusion injury and along with whatever you're, you're doing in these endovascular stuff. So, um, I would you reserve this for candidates that are not in the vascular candidates? Um, so, uh, I think this is a good way and there's a couple of trials that are going on in the United States. So it'll be surprised, surprised. I'll be surprised to show, see what they show. Yeah, but based on the recon rates of tenecteplase, I do think that it, you know, I'm a simple man, you know, if your, if your, if your pipes are included and you know, someone has to unblock that hairball in your, in your sink. Okay? Or else your sinks not gonna like do well, your house is gonna get flooded. So yeah, but you know, I, I think, yeah, I think like when do we stop as the question? Like how, when and that's the question that, you know, that's the golden ticket, you know, um initially where people were like, let's do it for three hours for the TP A and then they extended to 4.5 hours for TP A know endovascular therapy at all. And then in 2015, 5 landmark trials. Yes. Endovascular therapy to six hours. And there was this um Hermes analysis that, you know, said that was, that you can do it up to seven hours or seven hours and 18 minutes, I think. So 7.3 they, they included the people that were randomized within six hours. But, you know, there was a delay to take them to the operating suite and they still showed benefit. And then there's uh you know, after that, it went to 16 hours, which is the diffused three study and then 24 hours, which is the Dawn study, which is based on the CT profusion. So, um I do think that, you know, the, uh um you know, the, the playground of stroke is like ever evolving, ever changing. Do you think there's any upper limit or is it all going to be based off of like clinical perfusion? Mismatch is and things like that? Uh You know, that's what I would like to do is like individualized, terrorized medicine, you know, like, um and uh you know, like if I'm clicking an antiplatelet agent, I'd like to pick an antiplatelet agent now that we have options for this person with this because no to patient's are always the same. So I, I do think that there are people that um have um collaterals that are able to survive longer. And, you know, you know, if this patient came in the 25 hour, the 26 hour window and has a small core, a large number of like, can you just send this patient away and say I can't do anything, can't and do anything for you. You know, it's like plus or minus one hour and you know, who's to say that's the last one. Well, you know, who's to say that? Right. There's always, you know, as I'm sure anyone who's had to take an er call about stroke was like, well, we're not quite sure when they were last known to be without any neurologic deficits. Yeah, exactly. So, is it like, is it time brace or is it image based? And I think that we are going towards this image based um um image based um uh randomization or image based selection criteria um especially with this artificial intelligence uh such as deep learning like rapid and, and and is a I not to mention there's other companies to, but these are the two that I've used in the past and more familiar with. But uh they kind of like get smarter and smarter, more cases, more cases they see and they get smarter and smarter and smarter. So, you know, they, they're getting more accurate and accurate. And I actually um initially when I came over here, I think I was a fan of rapid and then we were using this A I and I didn't like how it selected it. So I kept on saving uh saving uh saving these cases that, that I thought that oh my God, you know, it's, it just lied to me that the court was so big, you know, this patient was a candidate. Definitely seen a handful of those myself. Yeah. And now I'm like, I got an I I did a case on uh Wednesday and uh the court that was noted exactly on is a I, so I success ended up re perfusing the gentleman. Uh He had intracranial stenosis which I had to angioplasty to take the thrombus out. Um, you know, but the court was exactly the, the court that you can see on MRI whatever it was on, on the, on the CT perfusion and it was like, perfect, perfect uh same shape, same location. So sometimes it is getting it exactly right. Yes, sometimes it is. I'm surprised that it gets like that level of accuracy. Interesting and, and some of these patient's were still really limited in the posterior circulation uh side of things that I do, I do. Um Yeah, just to deviate away from, from the IC I, you know, there are these um three big um uh the trials, I think one of them is, is the best study and they're not real trials, but they were like, they, they got, they had low recruitment rates. So um there's a basilar trial. These are the basilar trials. Um um Let me look them up while I talk to you about these uh trials. Uh So it's called the basics trial. Uh Basilar Artery International Corporation Study or the acute basilar occlusion and the vascular versus standard medical treatment. The best trial or the best study and the basilar artery occlusion, Chinese and vascular trial, Baocag Bausch trial. So, the basics in the best trial have shown um benefit have not shown benefit or failed to show benefit of thrown back to me over standard medical treatment. Uh and they had very slow recruitment rates and high crossover rates. Meaning when when a patient worsened in the medical arm, they took the patient to uh thrown back to me. So which is I think like uh some people would say in the field, I heard a lecture and since they said it's garbage in garbage out. So um their, their point of view is the patient that were worsening were the patient that we're going to do really poor. But then you randomized them into the endovascular treatment arm from the medical treatment arm. So that low outcome gets dinged on the on the endovascular arm. So um so it has to be a true randomized trial is what, you know, if I know that they're going to be a, you know, ethical issues. But you know, uh if the patient worsens in the medical management arm, you just don't do anything about it because that patient could, you know, have an MRI 23, Mrs A four could have an immersive five or you know, could pass away too. So we don't know is the answer, you know, like, yeah, but you know, in this day and age where everyone is doing a basil are thrown back to me and thrown back to me center since just myself to like uh, um, I did three last week. Remember we had the three on the 24 hour window. That was, yeah, Bachelor's in 24 hour window. All three of them did remarkably well. They got to pee and, and all that stuff. Um, and I did one, 11 on Wednesday, I think so. So, there's quite a number that I still do in our practice over here. I know. Do you stop offering it to them or do you not do it? You know, that's, that's the question, you know, that's the ethics. And I think that's where these academic centers would come into play and, and see if uh you know, they do it, the society, uh Vascular Interventional Neurology also sent out a survey of what I would do and they will have these very complex questions of like, you know, how are you changing your practice and stuff like that? Only thing that I, I said I would change is get a CT profusion along with it. And that way it gives me, you know, an idea of like, okay, this is really causing the patient trouble if it's a vertebral artery occlusion or especially the top of the basilar occlusion, this is causing some kind of profusion deficit. And um I do not think visits there and I don't think that they're trying um hard uh in the machine learning part rapid Orvis. But I, I, you know, I'm just speaking out of my own opinion. I haven't spoken with them or anything of that sort. But that would be a nice add on, especially with these three trials. And one of the trial did show the Bausch trial did show benefit to it, but that Chinese studies. So um people are gonna comment on that again, but as as expected, but the best in the basics trials did not show any major differences in the, in the thing. How are that being said? I would still, because we do see firsthand responses with the basilar, right? I mean, the risk of not doing anything is so high is so high and especially, you know, you, um if it's even younger and you know, you didn't do anything and now you have a blast or clot sitting in your head and you're 50 years old and, you know, you may get the flu and you get hypotensive right now, you know, you're gonna drop your BP and your whole brain stem is gonna infarct or, you know, so, you know, I mean, the these long term follow ups are not there as what I'm saying. You know, you, you are in a real world scenario. You cannot be, you know, even if your MRSA was one and I don't know how long can you prevent yourself from getting septic or sick or especially, you know, dropping your BP dehydrated or, you know, skipping a meal or? Yeah, I'd be wondering for the rest of your life? Was that episode of vertigo I just had, was that, uh, because there, that had a chronic clots sitting in my head and Bowser or did I just have a little inner ear thing happening? Yeah. Yeah. Who, who will be able to say if it's just there and gone? Yeah. But, you know, that's, that's, that's just my opinion, but that's where it is. And I do think to answer your question. Yes. I, I think there is value there and that's what I, surprisingly when, uh, they ask me these questions, that, that's what I thought I would do and that's what have been doing. I just add the CT perfusion to it even though it is not approved and I can see this additional, you know, profusion deficit. It does pick it up reasonably well. Uh, I have to tell you that but it does pick it up really well. We also use a software called Single. I'm sure that's, so that's the, um, Seaman's own CT profusion. That kind of picks it up better. Interesting. So, the single, but that does not, it's not automated. So it doesn't give you a court volume and stuff. That's more of how they used to do it in the whole school way. Not a candidate, you know, they said like court too big or, uh, or, you know, the number is too small or something like that. And now this gives you a mismatch ratio a number and all that to go by. So that's always there. So interesting. Yeah, so now that we we we've crossed over into, you know, at the end of vascular, um I wanted to tell you um about another thing that we have been talking about is the um intraarterial tea pee after stroke thrown back to me showed remarkable benefit. Did you? I don't think I included you in this text message because I, yeah, because I included um Doctor Cook. Um um in this message, see what his thoughts are if we can make this as a protocol. Oh yeah, you did see see me on that email. Yes. Yeah. So, and then we decided that we will include it in the protocol as a last resort, you know, if we don't do it. And uh so this is like more of like an infusion. Uh I think it's what, what uh it's called uh phase two B study. It was called the Troy study uh presented at the ISC. Um uh And what they did is, you know, um the history of IV TP A. Um um you know, it was, there was like phase one studies and phase two studies prior to the mercy retrieval device um in the uh in the two thousands, uh late two thousands I would say um and it didn't show a big risk, but I didn't, I don't think they showed a massive um massive uh benefit on to and I never went into phase through because it never really caught on. And a lot of people were skeptical about the hemorrhage rate. So this was a study where they infused, uh, TP A and in chart early. So, um, they just put the catheter right before the M one if I'm right. You know, I went through some of the date on it and, um, uh, they did it for people that, you know, they try to take the clot out. Uh, they were allowed six passes obviously into your circulation. Not, they excluded patients with the basilar, um, poor MRSA, excluded those patients' to as with every other, um, every other, uh, study. Um, they had a placebo, uh, which was not hip selling, which was some kind of neutral agent that they, and then they had the, um, so they had a placebo arm where they actually infused a placebo agent. Orange arterial. Did the physician. No, no, no. That's the, that's the, yeah, you know, it was pretty cool. Right. You know, that's why you kind of like blind, blind. The was nice that they kind of like blind, blind or at least I think that they did not know. So they were initially planned to do 200 patient's but they were only 1, 21 because they ran out of placebo, which is like one of the funniest thing that I've ever seen. You have to, like, stop a trial and like went out of placebo. Um There was zero patient's that had an intracranial hemorrhage in the treatment group. And then I think there was one or two patients in the placebo group that actually had bad. I know, I know. I'm always skeptical in the intercranial hemorrhage is like zero and when you expect it to be a little, yeah, at least one or two. But, you know, when it's zero, I was like, okay, that's not um that's not really great. So, and they also excluded patient's there was distal migration of embolize too. So if they're migrated emboli, you know that this same protocol not to say there are, there was other presentation that say that, you know, adding on a little bit of tea pee posted on back to me if there is digital migration of there are some retrospective analysis that are getting published right now that they say that they seem to achieve better functional outcome. But this protocol is, is um is what I um wanted to mention and I have it over here. So it's, it's the dose is 0.2 to five mg per kilogram, a maximum dose of 22.5 mg. So it's nowhere near like the 90 mg that you give IV and it's infused at over 15 to 30 minutes. Um I think I I would infuse it over 15 minutes as what I would do. It's administered approximate to the origin of the lenticulostriate or through the intracranial access catheter. So, you know, if you use aspiration and you can just park, just withdraw the cats are there and then just infuse it through that through the thing. We just, yeah, we just passed it through our pharmacy and our pharmacy approved it. So we'll, we'll have um we'll have a case and, and we're going to just reserve it for patient's just because it's a phase two B's trial, but it did show some kind of benefit we wanted to have as an option um as an if we're not able to re canalize the patient to um after multiple passes, I know that's something that you would see even with like, like sometimes with like the T three tg three be patient's, you'd still get those lenticular stripes knocked out with like an M one sometimes. Yeah. And, and then that's because the lenticular stripes don't have collateral flow, great, great collateral flow. So they get knocked out too. But you know, that, that, that's, I think that debate's been settled, you know, even if the political stripes are knocked out, you have this big um cortex that does other stuff like cognition, speech and speech and you know, and even in neglect and you know, yeah, being a, you know, you can see our rehab notes, which I have to appreciate our new have notes are really good in this hospital is that they kind of like put how much of a neglect is causing this patient, preventing this patient from returning to functional independence or occupational therapist. They kind of put that in the note, which I kind of like now I have more appreciation for hemi neglect and, you know, yeah, whenever I talk to a therapist, they always say it's one of the hardest things to rehab and, uh in the clinic too. So that's the, that's the, uh, you know, they, you know, even if that's uh 13 hour session when our 31 hour sessions per week that they do, they have to go home and still use their hands and stuff. And if they're neglecting that hand, you know, they're not doing that exercise for that hand to get stronger. So I do see that the recovery when I see these patient's in 90 days is also like harder when they have the neglect, which has also changed my practice. So now I do go after like distal tremblay if it let's go after it. So, um, you know, I don't leave clot um behind if I'm able to reach the clot safely. Um, and I have, you know, there's, your device is available on your aspiration catheters available and I had no complications with distal access to them. Three. Yeah, so far, but I do think that the benefit of doing a cleaner job is there and which has been, yeah, has been shown but, but this is more for patient's that I still have that M one claw and then you just want to re canalize it. You think you can ever hit those M fours? I don't know that I told, I, I remember sending you this, um, uh, stent retriever called the Tiger Trevor. You know, that you can adjust the size of the center tree ever. Yeah, I think that's, that's the, that's the way the future, that's the future. I think, you know, they have got authorization for a trial. I think it's called the Distal Study. Distals disdl maybe. Yeah, I don't know which centers are enrolling. Um, um, but I think that would be something that, um, would, uh, give us a little bit of, um, insight into the future of what to do. Gotcha. Yeah. But, you know, obviously what the study, you know, you know, people that received in charter all to place there were, you know, the clot dissolved. I know, obviously the clot, there was a high percentage of clots being dissolved but the MRS is like the charter are all to place. Um, which was 61 patient's in that in the teepee, a group. Um, there was about 21 individuals that we've got an Mrs of zero versus 12 in the placebo group. So 21 people, you know, went on their life without any kind of like deficit, they went back to them. But when you combine the Mrs of zero and one which is considered, you know, a good outcome in most. Uh, so that would be 21 plus 15. So that is like we're talking about 36 individuals versus, uh, 9, um, uh, 21. So clear, you know, increase by giving, um, TP A, um, to get these people, um, back home or, you know, um, to do what they're, what they're doing back to their family, you know, nothing, no deficits, which is, which is something that weights. Um, and they have this, uh, new scale called the weighted Mrs scale saying that, you know, the value of you having an Mrs of zero is much higher than the value of you having an MRI shift from a five to a four. Yeah, like if you're going, if you're going home and you're going to back to your, uh driving a truck, let's say, you know, that is remarkable if you're having a left MC, a stroke in M one occlusion and you're driving a truck in, in, in 30 days or 60 days because you have zero deficits from it. That's like a big, big value. Then someone, um, who is not able to drive a truck, let's say they're still home. But, you know, there have spasticity and they're not able to drive a truck. They know that that value is lower. I mean, it's still valuable, but it's not as valuable as, as, as, as you returning to your lifestyle and you don't have your, you don't have to worry about your bills. You don't have to worry about, you know, you know, paying the bills and all that stuff in your family and all that stuff and, you know, losing your house or paying your electric bill or some point that, you know, because you're, you, you still have your livelihood. People will say, you know, just get another job. It's not that easy to get another. No. No. Yeah. Especially ones that pay well and can accommodate any residual neurologic issues you might have. Yeah. Yeah. And then, and having no residual neurological issues is, it's pretty remarkable. Yeah, in the east end scenarios. But I think those were like the, I, I think like that most exciting more that I got excited about. I think one was the pre hospital trash and one was, we're talking about, you know, um, you know what to do in a patient that comes in the, er, and then you know, what, what to do in the end of vascular sweet. Of course, you know, that's, that's, that's sort of the most, um, where the magic happens. Magic happens is what I would say. Yeah, there are other stuff that I think, um, um, uh, you know, that, uh, one was one that I excited you and I'm like, oh my God. I don't know what to do about this one. It's the, uh, it's a Japanese study. Remember that one? Uh, refresh my memory, indovest, er, therapy and patient with the larger core you sent me that meme to, over on the Facebook group that you were on. Yeah, I believe, I read that some neurologist in a group. I, I remember, I said, like, now the Japanese study that gives tea pee to people who are already dead. It's not true. But that's a, yeah, it's, I think a funny group that Michael's in and, you know, someone was making that thing but that's the most like impressive study. It's a Japanese study. Um is uh there were actually seeing if people who um um and then they were tracking the same thing that we normally track in our studies as functional outcomes in 90 days. Um versus uh which, which the two arms were endovascular therapy plus maxim medical care versus maxim medical care. Uh And then they found out that the patients who received endovascular therapy were twice as likely to have good functional outcome. Uh meaning an MRS of 0 to 3 at 90 days. So two times and more, um the rate of uh intercranial hemorrhage um was also higher. Of course, you know, when you're taking a patient with infarcted dead tissue, you're taking out you're risking reperfusion injury and return, you could be symptomatic intercranial hemorrhage based on how much of it. However, the the benefit provided, the risk benefit ratio was, was more favorable towards um um um endovascular therapy. Um There are um uh there are some trials that are running in the United States, uh, particularly of interest is the Tesla study, the Tesla trial Thrombectomy for emergent salvage of larger slot and your circulation of conclusions, I think is what it's called. But that's, um, that's a study that's actually pretty cool that you can, you can probably, you know, if it comes out positive could go away with CT profusion, but they were looking at aspects between two and five. So now, normally one of the criteria is like the aspects, which is the Alberta Stroke program, the Canadian CT scale. Um And uh you need to have a five or above is, or 57 or above is good 5 to 7. I think it's good as what people say and less than five, they're usually not good outcomes is with the from the data, from the landmark trials have been. And um I think the uh the Tesla trial does the aspects less uh less than five after 24 hours and to see if there are any benefits related to this 11 problem I see with that now and correct me if I'm wrong. But there have been some retrospectives where there's a lot of inter reader variation in the Alberta scores. Yeah, to address you on that. Yes, there is some uh what uh what, what this trial does is that we have to all get trained in a certain way and be certified. So we're all like certified through an extension extensive program to make sure the quality of the randomization that makes sense and the aspects is good that being said um like the CT profusion trials, um I think they're rapid has uh a new feature out which is automated aspects scoring. So the the computer overlords um um yeah, and probably gonna ask, ask for a Bitcoin and Ethereum in the future as well if you want to see the scan, you know, uh pay us in Bitcoin. But yeah, I know. So the computer overlords are, are already on this and they kind of randomize it for you. I haven't experienced it um because, you know, uh we use solely visit over here, so I haven't experienced it personally, but I do not, I do think that it's a good, good, good add on to have in in future randomization of trials, automated aspects scoring. And I don't know if they can go back and um you know, feed the data from the Tesla trial and still running. So the trial is still running. So um I don't know if they can feedback the data into these um and rapid could feedback the data into automatic aspect score ing's or if rabbit could feedback the data from this Japan trial. Um The uh um you know, the rescue um uh Japan limit and um these guys included aspects of 3 to 5. It's pretty low. Yeah, so 3 to 5 aspects and obviously they showed uh you know uh better MRSA zero, better Mr So one better Mrs of to all across the board. And um uh you know, um was uh 31% good outcome 03 is what they, the authors define it as and 12 12.7% in the medical management group. So you are saving a group, group of people and, and that's why we wanna, I want to make uh make sure that's the number needed to treat is, is pretty high. It's like, it's, it's pretty low. It's, it's low as one and two for endovascular therapy. So, you know, it's like only something like that is like, it's like sepsis for antibiotics, you know, like, you know, it's like, so like, so obviously because it's so high and you were so low and depending on how you see number century, but, you know, we're excluding a good amount of population, right? So, and we don't know who are excluding, excluding. That's true. That's what, that's the difficulty that we have over here. I think so. So, yeah, I think you see that a lot of hospitals throughout the country, you know, especially ones that maybe aren't stroke certified, let alone like endovascular certified. Yeah. Um That was also speaking of that was also there was a study that showed that, you know, um um certifying your center to um a thrombectomy capable or comprehensive, actually improves your stroke outcomes either way, you know, even in the normal stroke patient's. And I think that was a great study. I don't know the exact details of the study. I don't have the data off of my hand, but that was, I think it was a poster. Um And that was very interesting to find out that and um that even it improves your like normal, like prime, like a thrombectomy people, stroke center, you know, has better outcomes in even a non LVO stroke or, you know, a small vessel disease stroke or, you know, a stroke that was caused by carotid hyperperfusion. And that makes reasonable sense. Um So, um I think the authors from that paper kind of concluded that they would recommend, you know, upgrading to, you know, throw back to me capable or comprehensive, which I do think that majority of, of centers across the United States at least try towards uh going to, but that leads you to the nationwide neurologist shortage. Yeah. What, what are your thoughts on that? Well, I think we need to train more neurologists. Um, unfortunately, that pipeline is uh pretty slow and I know that's been, you know, there's certainly some good authors about that. Just medical training in general being sort of lagging behind when you look at the explosion of medical schools versus residency programs. But I think that's probably a topic for another time. Yeah, I just because I, I don't think it's, I think it's all interconnected, I think. Yeah, definitely. I've always been a believer that the residency programs in Chris improve the outcome and, and, and we've, we've had multiple conversations between us and they were like, you know, if we had a resident in this situation, it would be completely different. Right? Yeah. Someone who is because, yeah, you and I, when we talked about it and this is a phrase I picked up from uh someone in the recent Continuum article, uh medical nihilism being a self fulfilling prophecy, right? So a lot of a lot of people don't necessarily have the faith in tea pee or stroke interventions or sometimes neurologic interventions of any stripe. And so you don't think it's going to work, you don't do it and guess what? It doesn't work. Um So yeah. Uh and I know that is something that, that has been seen when, when some places uh community hospitals institute a neurology training program where you have 24 hour coverage in house, you see that that change in culture shift a little more alacrity in interventions which improves times, improves patient selection. Uh more investigation to who's a candidate for what uh things, especially when things in like the stroke landscape in particular, shifting so rapidly. Yeah, and, and to be on, yeah, on the, you know, there was people that when, when, when I trained, you know, they were not big fans of doing cases of 90 year olds and yeah, all that stuff. So I had like 2 90 year olds come see me with an MRS of zero, this Friday and clinic. So I'm like, I do have multiple, you know, cases that they were doing great. You know, I do think that, you know, if from the data, from the Hermes analysis to, to go to the, they said, you know, the, the confidence, it's, it's so uh people over 80 you know, that the benefit is so overwhelmingly positive towards endovascular therapy that the line is like doesn't even is not even anywhere near your in the midline. Uh You're, you're either, you know, it's a binary outcome is sometimes what I say, even, even though it's not 100% true. But, you know, you, you be believe in the therapy and you offer it to him, not just saying that this patient is 95 years old, if this is 95 year old who's taking care of her great grandkids at home and while her, you know, she's babysitting her great care gets like that's pretty functional bimmer of society, you know, is letting absolutely letting them. So, so, you know, I do um believe in the um in the in stroke treatment and I think that people um likely to name a few, you know, they, they have been um at the forefront of this offering into a lot of people. Um And uh I think they have uh like not giving up on stroke therapies and stroke treatments and, and, and I think it has translated to, to the care that we, we, we have here because otherwise, you know, I don't think, uh, you know, these patient's would return to the quality of the life that they have been returning to write and, you know, to your point. Right. These, they don't have the same neuroplasticity as someone 2030 40 years younger. Exactly. Um, they're not going to probably rehab as well and you're going to want it more complications with things like aspiration, pneumonia and all those kinds of things that you see and patient's with significant post stroke deficits. Yeah. And to, to name a thing, I do think that, you know, even though people always, you know, use the published literature and all that stuff and there is highly, even though they're very good, you know, they're not as accurate because when you see the, there is this paper of access to thrown back to me and then they, um, it's published in the H A stroke journals and then, you know, Youngstown is like, uh, it's considered and the Youngstown in the area around this. So, the, the 50 miles around this area that we serve, you know, it's considered as a green area that meaning that we have a good, good stroke care here because we're close by to a stroke center within an hour which, you know, we're not a comprehensive stroke center. So, uh, we're, we're trying to build, to be a Comprehensive Stroke Center. But we're in the process of building it to, to that, um, to the state. But, um, the point that I wanted to make is that, you know, before we came over here, you know, they, um, they, these patients were not being transferred, these patients were like, they, they, I think there were either poor selection or they didn't want to take a transfer that was like on the bottom, er, because of more moderate ranking scale and stuff like that. So they were talking about 10 to 20 transfers or 10 to 25 cases being done with another 10 cancer, another 10 transfers. And then last year we did about 100 and 17 of these patient's now, I don't have the whole results but 100 and 17 patient's uh in small community hospital, teaching community hospital, it's pretty significant. That means that, you know, we're talking about, you know, 100 patient's did not get treated with endovascular therapy per year. Even though this is a great area per the aha studies that they were not the H A but the stroke studies that they published it has to be an advocate. Yeah. So imagine how bad it's going to be in an area where they, the study marked it as, as, as red or yellow, you know, uh, or like even like green or something like that. So, uh, you know, when I saw it I'm like, don't, you know, I don't think that's, that's right because you can see it over here. I just wanted to wait for our data to come back and now we have the numbers and I can actually say it, you know, it's not, you know, even though the paper suggests it's a great area to live if yet have a stroke while you don't get the thrown back to me. Guess what? So, I think that every hospital, um, every 50 miles should have um neurology coverage, hopefully 24 7. So do we do need more and we do need more stroke neurologist and we need more interventional neurologist is what I would say. You know, I think we have to have a look at the cardiologists. You know, there's more of these hospitals have five interventional cardiologist, but they have no neurologists, not even a neuro hospitalist. They have five interventional cardiologists and two EPS, but then they have to transfer it to some other hospital because they don't have a neurologist that's working on Friday, Saturday or Sunday. Yeah. Yeah, we do see that fairly often around here. So, I mean that that's all indicated that, that we do need need, do we need uh um increase in the number of residents and trainees? And I think um the job market is also great. So I don't see anyone going to be unemployed and yeah, any medical students listening, going to neurology. Yep, go into neurology. So that's our recommendation. Any, any final thoughts on the, the Isc Praveen. Yeah, it's a, it's overall good. Um, you know, I was a little bit just a surprise about how fast the stroke world is moving and, you know, it's just something to keep your remarkable and we do need more people. So, you know, if people, um, I would recommend even if you don't specialize, you know, to be well aware of stroke because, um, if I strongly believe if the neurologist, uh it's not up to date, then that up to date care is not passed over to the patient. So, you know, if, if you're in a smaller hospital or if you're somewhere else and you need to, I think the neurologist should take over, you know, stroke just like a cardiologist can take an M I, you know, because we have these issues, you know, people, there are some neurologists that don't like the stroke part, but I do believe that, you know, it's like, am I, you know, you call cardiology and they're going to say no, but not me, I'm a cardiologist who doesn't handle in mind. So I do think that the neural, the stroke should be a core curriculum in um all the neurologists and they should be updated. And when you know, there are going to be some more complex cases that you do need a vascular neurology for um for probably making the decision of TP a connected place or direct endovascular triage and that can be handled by them too. But I think that at least someone has to have the basic training um of stroke. So, um I do think it's a remarkable uh field and it has advanced neurology in terms of job opportunities and pay and all that stuff, stroke and neuro critical care and interventional neurology. All as a it is all I think all facets of neurology are moving almost breakneck speeds these days. Yeah. So I think, you know, going forward uh Praveen and I are probably gonna be trying to, but one of these out on a semi weekly basis talking about like different patient cases, um different articles that we've read, um things in the neurology feel that may be interesting. Hopefully. Um Anything in your mind, Praveen? I don't know. Are you going to include your email and get feedback from listeners? And I don't know, see how the direction of the podcast is gonna go. Yes, I will add that in at the end because I can't remember off the tough. Okay. But, yeah, I think that's, that's probably, that's something I would add if someone has a suggestion of how it would go out and, and we're just bored here and we just wanted to. Not, not really, we're at that part. Yeah. No, we're pretty busy but we wanted to have, uh you know, some discussions about how Real World neurology does. Um, just some real world experiences of just a couple of friends and who are interested in neurology and pro resident and pro resident education. Yes, that is one thing. Uh, I think it's kind of a, almost a tongue in cheek statement this point, but lifelong learning is important. Um, yeah. Do you remember the statement that I made? Like, I, I always had this theory that, you know, um, that he had this theory that the, uh, the expiry is 10 years for great neurologist is, I would say I, uh, yeah, 10 years. Yeah, I say that everything and I said the only way round is to keep in touch with residents or teach residents or be a part of the residents or else you're going to be like out today is, it would be very challenging. You'd have to really be diligent about, about your education. Yeah, I agree. I agree. Some people don't like teaching residents and this is what I said. And if you don't interact with the residents and you're 10 years out, I think you are not up to date because the way you keep yourself up today is to manage, like all this residents going to bring out this paper and then say like, hey, what do we do this? And what do you do that? And that's how you take up today is more interaction you have with residents. Of course, you're going to teach them and of course, going to take a couple more minutes to round on each case because you have to teach them this or they have to check through that. But, and today I do think it's like a beneficial. Um um it's a beneficial and I think these podcasts and these are new alternatives um that, that are ultimately beneficial. Anyway, we're getting around the one hour mark. So we should probably wrap it up for anyone who wants to reach us. Please email us at the neuro transmitters podcast at gmail dot com. Send us any suggestions for future conversation topics, journal articles, uh clinical presentations, anything in the neurology sphere that you think might generate some interesting conversation. Thanks Michel. Thanks for being.