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go wrong in 33 more sessions. That hasn't gone wrong already. So right. Oh, it says play. I'm sure. What the Oh, it says play. We've already gone live. Terry. Did you do that? Yeah. Brilliant. Okay, welcome, everyone, to another mind bleep. Neurology event Tonight we are doing the rescheduled and already more successful version of the acute stroke Webinar. Uh, I'm Alex Gordon. I'm one of the neurology. Minor bleeds. Terry Tan is also here. Who's the other neurology? My weekly. And we're trying to be joined by, um, jihad. Uh, small seed from Derek Hospital in Climate is gonna be talking through acute stroke as always. All the contents available on YouTube and on mine, the bleeding on metal afterwards. Um, and you can see all the previous weapons. Webinars, buy those platforms if you want. It's difficult for your portfolio. Will, um, for the QR codes and a link feedback at the end. And if you fill that out, you can get get a nice certificate for your portfolio. Uh, jihad. I'm going to hand over two years. That's all right. Yeah, sure. Thank you, Alex. Thank you for having me. Um, and welcome, everyone who join us for today's session and sorry about last time. I'm sorry about the camera issue. I'm not sure why you cannot see me, but I'm hoping you can hear me. All right, So my name is Jihad and one of the neurology, uh, training in the different hospital. I'll be talking about acute stroke today. So, um, I thought I would start with the city head of stroke, because this is how we recognize it. And I think everyone can recognize the abnormal, um, hypodensity in the city, which shown by arrows. So if you see anything like this and the CT scan so this could be a stroke. And while we're talking about stroke today because it's one of the medical emergency and, uh, assuming we're talking about mining the sleep, so struck hold would be one of the reasons you're being called for why you hold it in the hip. So today, uh, the main talk will be how to deal with acute stroke in a in acute setting, Uh, like in an uncle night while you alone as a junior doctor, uh, but also will be covering general information about stroke. Hopefully after decision, you'll be, um, able to recognize stroke and you'll be aware about acute management of stroke and stroke types, and you will have the information to deal with acute stroke. So what is a stroke? Um, there are multiple definition for stroke, but in general they all, uh, let's say I mean the same thing, which is acute onset of focal neurological finding in a vascular territory as a result of underlying cerebrovascular disease. And we'll be explaining this small room talking about the bath physiology of it and why we're talking about stroke because stroke is 1/5 cause of death, and it's the first cause of disability worldwide. So it's a very important, um, topic to be aware of. Um, it's very important, um, cause of death and disability, as you can see from the data. So in general, we have two types of stroke, and I'm sure you're all aware about that. And the main, uh, type is a systemic stroke. Uh, about 85% of all stroke cases and 15% goes to a hemorrhagic stroke. And within the ischemic stroke, we have, um, four subtypes of ischemic stroke, which is a large resilience is and This is, uh, will be the main talk about today. As as this is the main, uh, type of stroke that we can act on acutely and, uh, eventually treat patients out of it. And the other type of small vessel disease which we call plaque on a stroke. And we have embolic stroke. And the last one is cryptogenic stroke, which is, um, stroke of unknown etiology. And the second, um, other, uh, version of a stroke is a hemorrhagic stroke. And this is again constitute of ischemic, uh, intracerebral hemorrhage and subarachnoid hemorrhage. So each type of a stroke has its own causes. Um, but in general, um, stroke has causes. As we all know, some of them are modifiable. Um, and that's the thing that we called primary prevention or secondary prevention stock. And if I would seem like genetic cause, uh, so as a physician, we should be able to help people not having struck by acting on the fiber reason such as hypertension, diabetes, hypercholesterolemia, smoking as we can. You know, uh, a F uh three lifestyle and the nonmodifiable. As we say, genetic cause of stock as the famous one will be a capsule and obviously we have the stroke in young clotting disorder vascularity other cause of stroke in young. And as we said earlier, we're talking slightly about the mechanism of stroke. Uh, forget about all these details, but as we know, stroke caused by cut off blood supply. Tortilla closure, regardless of the cause, is a large vessel disease. More vessel disease caused the same thing which the mechanism lead to death of Neurontin itself. And obviously, this happened in the cellular basis. So we'll talk a little bit about each type of stroke. Um, starting by lacune. So I guess we all hear about, like, you know, stroke. So what is, like, you know, stroke like, you know, stroke is, uh, defined at small subcortical, in fact, and it has to be subcortical. I will tell you why later. And by definition like one has to be less than 15 millimeters in diameter and being subcortical, that means it is in the territory of deep penetrating arteries. Because it is, it will be the end of small arteries. Um, this lesion can present as lacuna syndrome, And again I will be talking about which is a different type of Laguna syndrome and most of the time, like own, can happen silently, and we'll just find them by doing a scan on patients. The most common, um, location for like on a stroke. As we say, it's subcortical deep penetrating. So it will be in a deep structure, same as basal ganglia, internal capsule, thalamus, corona, radiata. And so this is what the colon looks like. As we said, Why definition has to be less than 50 millimeters and lacunes. Uh, this isn't all definition, but we still use it until now. For classification, uh, can be present as pure motor or pure sensory taxi hemiparalysis, dysarthria clumsiness and mixed sensory motor. So that's like June and then the other type of ischemic stroke is a large vessel disease. Uh, as the name shows, it's a stroke caused by occlusion of one of the large vessels, and this large vessels, as you can see from the cartoon here, is either a c a, which anterior tibial artery, and you can see um, it's the area that supply the, uh which part of the brain supplied by this artery and the the problem or the sign you find in the patient will be the area that's affected by cutting the blood supply to this part of the brain. And this big part is the M C A, which again is the most common cause of large vessel disease stroke. And we have a PC A. And we have, uh, vertebral basilar, uh, as another cause of our vessel disease. So I'm going through this just very quickly just to know, um, what you would see in a patient that can help you telling which artery is included. And this is, uh, help us to localize the side of this joke. So in general, minister of a larger stroke, as we all know, cause contralateral him uterus is. But the important, uh, other feature that tell us this is involving the cortex, uh, is having higher function being, uh, lost. Seems like, uh, lost some part of the vision uh, bilateral humiral anoxia or able to speech, which is another higher mental function and neglect an invitation. A stroke that affects the anterior cerebral artery again cause weakness. Uh, but the other unusual presentation of it is usually incontinence a C a stroke can cause get a black CIA and, uh, judgment's impaired and mental status. So stroke, uh, side can tell us, uh, more about where is the lesion? And we have a PC, a stroke, another type of large vessel, uh, stroke. And as you see, this is unlike other stroke has a very specific presentation affecting mainly visual, um, as as cortical blindness or hemianopia or visual like a nausea and can also affect memory. The last, uh, one is vertebral basilar artery stroke, which affect of osteria part of the brain. And as we all know, this affect balance. Um, so the patient presents with vertical double vision is or Korea ataxia, And, uh, and the last, uh, part of the skin struggle we're talking about is embolic stroke. And as you can see in public, strope they look like lagoon. But I said I will talk about this earlier. Why lacune cannot be has to be subcortical because mostly in public stroke are the cortical one. Although they are small in diameter and dimension. But by definition, embolic stroke has to be bilateral multi territorial stroke. So in this scan, you can see them in uh, this is this is the same patient. And if you're scrolling down through his brain can see one stroke there and the other stroke in the be, um, slide and the other stroke in the seaside. So you have multiple strokes in multiple territory, which cannot be explained by occlusion of one blood visit. So just looking at the skyline, I can tell this patient has an embolic stroke. That's mean the the pathology of the stroke is coming from central source, which causing the embolus to go to the brain and cause inclusion of the blood supply. So again, acute stroke is a medical emergency. And why is that? Because time is brain and with each one minute of large vessel stroke to millions neuron size. So that means as soon as recognized stroke, we have to act on it immediately. So let's talk about the practical side of it. So imagine you are on call noise shift. You're all alone in the world, and you're holding the sleep and you receive a call from the nurse. So what kind of cold you receive usually can hint to this year stroke and make you act quickly instead of postponing it too Later time, because obviously you'll be busy all along in the hospital. You have other jobs to do. But sometimes we need to protest things over other things. So I receive a call from the nurse saying, Doctor, this patient is becoming confused, drowsy, So confusion can be caused by many reason. The hospital. But to have confusion acutely, which makes you think, could this be a stroke? But the call you have might be a doctor. I have this vision, um, had a fall. Can you come and assess? So we received this called multiple time while we're doing uncles, and most of the time, patients be just except on the floor or felt dizzy or for any other reason. But could it be weakness in his legs or unsteadiness led to the to the floor? Uh, then, as I tell you, Doctor, I have this patient slept in the chair. So this is also raise the possibility of pathology on one side of his body, patient becomes slurred and the patient most some part of his vision. This is obviously a sign of a stroke. What do you do when you can process the patient the usual? We all know about obesity, and you start the usual in each vision regardless of stroke or no. And doing that, you can tell if this patient have other things to help you. Also looking at stroke. So look at the airways. Fine breathing is fine. And then checking the circulation you find the vision's having fast A F. So as we know I f is one of the important cause of the stroke. So could it be a stroke? And then I'm checking disabilities. Obviously, you need to comment on the Glasgow Commerce Day as big stroke can affect patient conscious state and abnormal posture. Obviously, if there's a weakness in one side, that would be very obvious on examination. An ongoing planter and equal people all this sign we call it focality an exam. So when we say there's no focality exam, this will make. The impression of stroke is slightly. But obviously, if he sees signing the patient only in half of his body and equal pupil planter up going in one side, patient cannot move one side of his body. This is a focal sign that means there's a problem on the other hemisphere. So the most important question you need to ask when you see a patient with acute stroke to be knowing the onset of the symptoms. And sometimes this might be difficult unless you have the nurse obviously witness it happening in front of her eyes. And if you don't have that information, the next question you ask would be. When was the last time this patient's in movement? Because that would be your time. That would be your time, where you start counting with sunglasses. Winter. Obviously, you also need to know about the duration because the symptoms resolved back to normal. That's by definition is t I A. And that's we don't need to treat as acute stroke. So you had that question. And obviously, after doing ABC, you need to do your observation. So again, checking the heart, checking the BP really high for this patient, which wasn't the case before. So this make you think that would be a stroke? Because as we all know, um, BP will be really high in acute stroke and again checking the balls. This patient is having false it, and he's not not known to be a chef. So this is new thing. Is this a sign of a stroke and then The most important thing you need to know and destructive will ask about is checking the blood sugar. And why is that? Because of hypoglycemia can mimic stroke, and it will be a reversible sign. So you'll find the patient having right side weakness. But the glucose is three. And by correcting that, all symptoms resolve back to normal. So it is a stroke mimic er, and you need to rule out hypoglycemia in every stroke patient and then going through what you need to do, you have to do an EKG on all patients. You have to do it on all sick patient, obviously, on stroke, patient is part of the work, and then you send for your routine plot and has to include a full blood count, um, e s and coagulation. And if the patient is, let's say has been happening, infusion running for any reason. Obviously, you need to stop that until I have the scan back and know what's going on with this patient brain. And then if you are in a tertiary hospital, you have a strong hold strong team or you're a part of the stroke team. Obviously, they need to be involved And the thing that structure will ask for or they arrange themselves is an urgent city head, including CT angio. So this is really important if you don't have a stroke team, Um, you cannot just request the plain city here. Do you need to request city and do which including, um, angiogram for head and neck. So to look for any conclusion, uh, that can clog can be taken out mechanically. So good job. You did all of that. The first thing this truck team will come to check will be an HSS score. And at this point, I'm not expecting you to be aware about it. And obviously, it's, uh, need a lot of practice. And even now, sometimes we need to stop booklet to look at it so we can remember it. Uh, so that's what's the importance of this score. The importance of it is guarding us. If this patient is a candidate for thrombolysis thrombectomy. So if the Vectra score is really low, especially not benefit from it, and again, if it is really high again, this special might not be a candidate for some people, is is all from back to me another importance of the energy score is we needed to follow up on patient later, after thrombolysis or thrombectomy. And why we need to do that to To check if the patient is really improving on the treatment you are providing. So this is what you usually get when you do a city head, an acute stroke patient. And as you see, you don't see much on that because, as we all know, struck a city had an acute stroke and being a woman because we're not expecting to see any changes in the 1st 24 hours or less in the first few hours. But the main reason we're doing the city had an acute stroke is to look forward and transferable plate. And the other thing, I'm not sure if you can appreciate that there is some here, some hybrid sense area, this kind. And for the train, I would be it would be very easy to spot. And this means that there is a clot in this vessel and and this is the right one c A stroke. So anything hyperdense in the scan is a blood obviously, and high burden is a dead tissue. So the radiologist will be able to tell you. Yeah, I can see. Uh, this scan doesn't show any evidence of a large territorial. In fact, there is no evidence of interest. Plead. There is high burdens, right? And see a which means there is a clot in m one, and he will tell you there's no contra indication for some places. So we assess our patient. We did the scan and then we need to decide if this patient is a candidate falls from the license. So as we all know, we have a very tight wind to by which we can give thrombolysis. And it has to be from the onset of symptom. Not more than four hours sometimes goes to three hours in elderly or diabetic patient. Um so that's why we need to be really sure about the onset of symptoms. Our the last time the patients see normal, but can we get some places to everybody? Obviously not, uh, because you need to look for any contra indication and some of these would be from the history, and some of them will be in the scan. As I said that the judges will tell you if there is a control medication and the rest. You will get it either from the patient from the patient relative from the patient notes, because your patient might not be able to talk. So that's the importance of having a big team, Um, as each one need to do a different job to make sure this patient get treatment on the right time so you don't need to memorize all of it. Obviously, it's written the stroke booklet, and no one can remember all of it. But you need to make sure that there's no contra indication before giving your symbolizes. So, as you see, there are too many, really. No one can memorize all friends. And, um, there are some relative contra indication, and this meaning these are flexible reason not to give thrombolysis. And by that you need to decide. Obviously, the expert and by the expert, I mean that stroke consultant. So if you have a patient who is in the the window for thrombolysis but has one of these relative contra indication, should you just don't give it? Course not? You need to discuss it with your senior and obviously the stroke consultant and then weighing benefits and you need to proceed with that so everything is fine. The patient is within the window. There is no contra indication for Thrombolysis, and the stroke consultant is happy to proceed. So what do you need to do? Some glasses should be given in high hopes way and we can afford It has to be given in races highly monitored bit and we'll try and stuff. And obviously by the stroke, nurses and the stroke registrar so highly of the higher ups paid patient should be a monitor monitor all the time closely monitored, and those will be 0.9 kg of multiple days or even on whatever use. But I think in the UK is everybody is using multiple is for now, except for the search for purposes. So you count your dose and, uh, and I think in all stroke book it. You'll have it already calculated for you. You give 10% of the bolus and then continue the rest as infusion to be run in an hour. During all this time, patient needs to be closely monitored in the high up space, and before giving that you need to make sure BP is less than 180 over 100. Obviously, as we said in a stroke, BP is always high. And that, as we all know, is a protective mechanism by which the brain increase the blood flow to compensate for the clot to the cut of the blood supply to the specific infected area. And usually we don't want to bring that down because, as we say, it is a protective mechanism. But in Thrombolysis, you don't want the BP to be high as this increase the risk of bleeding and hemorrhagic transformation. So if the BP remains to be high, you cannot bring it down less than 1 81 100. This is a control medication, and you don't you cannot proceed with sunglasses, so give whatever medication you want to give a little g t n whatever you want to give. Bring the BP down, and if you respond, then only then you can give you sample. Is is. And as we said, we need to repeat the energy score as we say it is a monitoring score. That's why it's very important to be done before and after. So Daniel Thrombolysis need to repeat the energy score two hours after and then 24 hours after. And obviously, if there's improvement and that's fine, you're heading in the right direction. But if there's worsening, you need to sit and think. Is it just evolution of the stroke? Is the stroke just progressing? Or could it be bleeding in the brain? So obviously, if there's a very, uh, NIH score is worsening and the patient GCS is drugging, you have to stop the infusion right away and your PT CT head. So, as I said earlier, you need to do an NGO brand together with CT Head is plain. CT is not enough in acute stroke. So you need to do a CT and you for the neck and head. And why is that? Because this is what you see in the city. And you, uh, you see the picture on your left side, Um, which says before treatment so you can see it up to the end of the distal corroded artery. So the contrast here is going fine, but there's nothing here. So that's mean the blood flow is not going any further. And this is actually a thrombectomy, um, scan, um, showing you the re perfusion after taking thrombus out. So here, as you see, there's no blood supply on this area, and then the interventionist successfully took the thrombus out. And then the dye is going all over the M C A. So that city had we did we first show it, show it. There is a clot in the AM one. Then as soon as you start your thrombolysis, you need to inform the interventionist that I have. This patient was having clot in his friend and is he a candidate? All of the interventions will be able to decide if this patient is a candidate, depending on manufacturers. So the interventions will come assess the patient and if he's a candidate, obviously they will take them to. And you, sweet, even before thrombectomy is trouble is is over. And if you don't have a thrombectomy service in your hospital, the patient need to be referred to a nearest center because turn back to me can be done up to 24 hours after stroke, depending on the side of the samples. So always give you a patient benefit of that. So this is very successful from back to me now we have this patient, as we said, um, I'm highly monitored. Bed had his thrombolysis done, and you're monitoring him very closely. And you'll find that in the book, it will say every 15 minutes and then every 30 minutes and then every hour and then every two hours, Um, so the nurses will know what to do, And then you checked your initial school, and it is worsening, and the patient is dropping his GCS. So what do you need to do? Obviously, the infusion is still running. You need to stop that because you might be bleeding and right away. You need to take the patient to the scan again to check if there's a blood in his brain. And meanwhile, it requests the fresh, um, fifties and take your blood. Uh, including fbc Kodak anthropology. Um, this is actually, uh, post thrombectomy care. So the patient had a lumpectomy done successfully as we've seen this slide before, they should receive aspirin. According to the hour, Uh, 34th, um, protocol we give aspirin right away, depend on different centers. Other centers give it 24 hours after, and the patient needs to be transferred directly to has a bit or and I two depending on the situation and the type of anesthesia heresy. And then again monitor closely our ups and monitor for worsening neurology and Jesus. So we have a patient dropped his GCS but normalizes. And we said the first thing we need to do is a scan. So we had the CT head showing bloods and what do we need to do? We already stopped the transfusion, the job, and then we'll give 1 g stack of tranexamic acid and the ft. And then just, uh we need to discuss with the hematology Uh, Paul, um, should we give cryo for bringing precipitate, um, or was the next step and then, obviously, is if the bleeding is a large need to discuss with a new surgery if the vision is a candidate for evacuation, Um, and obviously, you need to consider mannitol and other, uh, other, uh, especially it's not for surgery, then other things that we can help with again. Keep your patient on our lips. So obviously you're giving us a place which is, um, a strong thrombolysis agent, and a hemorrhage of transformation or bleeding is a side effect. Although we don't see that very common. So I haven't seen one patient of myself had hemorrhagic transformation after giving the TB a happened, but very rarely. But I never had any patient who had a hemorrhagic transformation after. So the patient needs to be counseled about it, but it should not be put away of it because of this very tiny risk. And so we have that same patient with drop GCS and had city head, but the city had came back normal. So what other possibility? Why this patient is not waking up? Is he having seizures? As we know, seizure is a very, uh, common complication. Um, post stroke and any irritation breaking cause seizure. So that could be a possibility. His vision is having another stroke affecting conscious centers. Oh, does he have other medical emergency like P E? Is he having reaction to alter place? As we know, sometimes the place can cause a reaction. Um, it's a metabolic upset. Any other medical reason we need to think about? So, as we said earlier, anything that's hyperdense and city head is blood. Anything that dark is a schematic tissue or, um, brain tissue or a mass. So if you see here, there are there is a hypodensity hyperdensity. Sorry. Um, the right atmosphere with the dark area around it is an edema. And obviously you can see there is a making mine shift so the mid line is not going straight has been shifted. That means the spring is under pressure and mass effect because of the edema surrounding the blood. So this is a CT head of entrust plate, and obviously this is of a moderate size. So it's it's a It's not a small bleed causing mass effect as we can see and causing midline shift. So that type of bleed a hemorrhagic stroke, which needs attention of neurosurgeon guilty. Obviously, most of the time there will be no surgical intervention, but obviously you need to involve them if you see a CT head like that. So you had the same patient that the nurse called you earlier to see who was slumped in the chair or who had the fall on the floor and you did the city. It's unusual that scan so this patient is having a stroke again, but this time it is a hemorrhagic stroke. And as we said, if the patient is having anticoagulation for whatever reason, you need to stop that. And the opposite of skin dextrol and hemorrhagic stroke, you need to bring the BP down, Um, as quickly as you can. Um, study said, start between 3 to 6 hours by which the outcome will be better in controlling BP. So the target is 1 81 42 80 and you need to give whatever you you should. And obviously it has to be an infusion. So all the tablet, it's not. It's not indicated in this case. So here, depending on the hospital protocol, but we usually go start with Lamictal or and then we have a g t n. Then you can use whatever you have and for all interest repletes. You have to call neurosurgeon because this is their territory and you don't know when it's the time they will interfere with the patient. Most of the time, the intracerebrally to respond to, um, observation only, uh, conservative management. So tight control of the BP and reversing coagulopathy. So when you send the blood for your stroke patient, is there any deranged? Quite well, but you need to correct that and control the BP and close monitoring. So these are the main three treatment for interest appropriate. And if the surgeon said no surgical intervention, which you need to be in the higher ups pain ideally in a stroke unit Khyber Acute stroke unit monitor closely for 72 hours After that. Um, this is mostly the risky period. Which patient needs close monitoring jury and most people. If the bleeding is of moderate, small size will improve clinically. And you need to think about DVT prophylaxis for both type of stroke. You cannot give, like saying you cannot give the proximal whatever you use. So we usually use pneumatic compression or, um, whatever you call it in your hospital. So, um, we don't use steps talking, obviously, because it's useless opportunity to use other form to preventive itty because you have patient one been doing nothing for many, many days. Um, so you treated your operation. You treated your acute stroke patient. And then what do you need to do after Trump lies? Your patient? You took out the thrombus Good job, then what you need to do. You need to know why this patient had stroke in the first place and why you need to do that because you don't want him to have further stroke in the future. So mostly all stroke patient need to have a carotid Doppler if they didn't have city engine. If you did a CT MG, that's fine. We original. We already looked at the carotid. We already looked at the entrance to the blood vessel. That's fine. If not, then the patient need to have a carotid Doppler to look if there's any narrowing and why. This is very important because if any severe narrowing in the symptomatic side, which means the side of the stroke, the patient need to have intervention the 1st 15 days, so there's no point of doing it later on. The patient need to have an intervention while in the hospital in the case of acute stroke. And then if your EKG is showing a F, that's fine. We know that's an F. But if the ACG Sinus isn't isn't okay just to let go, Of course not because it's easy. It's just like a snapshot of the cardiac rhythm, and we need to look as to prolong monitoring, so usually we go for 72 sometimes up to five hours, cardiac tape and depending on the structure, uh, type. Obviously, if it's an embolic stroke, as we described earlier, which means coming from the heart, then we need to look even closer and make sure this patient is in a Sinus rhythm. And again, echo is not for everyone. Um, Echo indicated mainly in embolic stroke. And by that we need to look forward. Um, if there's any clot in the heart that's throwing thrombus everywhere or vegetation or whatever. So if it's a cardioembolic, patients have echo. Obviously, if the vision is young, he they need to be investigated extensively. An echo will show us if there is p o p, f. O, which is a patent foramen ovale, and this is also a common cause for stroke in young. Sometimes you don't see it in just any echo, so you might need to do a bubble echo. And, as we say, um, control of the risk factor. The risk factor we said earlier. Hypertension David is smoking, so you need to send for a little bit profile. You need to send for HBA one C for all stroke patients. And if the patient isn't young, we do more, obviously. So there is a list of a stroke in young, which checking for thrombophilia and vasculitis because these are the two other reasons to have stroke, especially in young and by young women. Old people, um, younger than 50. And again, MRI brain is not indicated for everyone, uh, depending on the clinical judgment. And if you thinking is, um more than what you see in the city head or for academic reasons, um so why the patient in the hospital is being managed and monitored in a stroke unit? Obviously, after you from buys them 24 hours time, he needs to be started anti platelet, given that he's in a Sinus rhythm so given again the hospital protocol, but mostly in the NHS. We go with 300 mg dose of aspirin in two weeks, and then, after that, uh, switched to close the door, please, 75 mg and then all stroke patients need to be on a statin even if the cholesterol is normal. Because statin has an anti inflammatory effect to acute stroke and two, uh, blood vessel and help recover better from stroke. As study showed So even if the cholesterol is normal, you should be starting, and any patient less than 80 should receive a higher dose of a statin, which is an 80 mg. And more than that, they can go for 40. Given if it's well tolerated and there's no side effect, obviously, and then you might need to think about patient feeding. So if he's swallowing fine, obviously stroke nurses will be able to assess the swallowing roughly. But all patients stroke unit with Big Stroke needs to be assessed by speech and language therapist for checking the swallowing and checking the speech and help the patient to find a way to communicate, especially if they have this physic and obviously, physio therapy and occupational therapy. And you need to tell the patient you need these three people are the, um, part of the stroke team to help them to be as independent as possible, but obviously not to promise them to be back to America. And depending on the, uh, pre morbid Um uh, patient situations, age. Many other factors. This event on the rehab, the stroke patient and where does it need to take place so rehab can take up for a few months after the treatment patient. We refer to rehab um, center, but luckily in most of the acute stroke that which it normalizes the victim must be. Most patients do even a faster recovery. And I had a couple of patients just after thrombolysis start walking. And so you take this current stroke. But obviously you don't need the patient to have another stroke. So what do you do this we call secondary prevention? Uh, that's why we keep the patient on long lifelong anti platelet and a statin as well to lower the incidents, often having another stroke. And again, we're talking about Sinus recommendation because the patient is found to be in a regular rhythm, need to be on anti coagulation. And obviously we need to control risk factors such as diabetes, tight control of the BP, smoking cessation patients to be counseled about this and give, given whatever help they need and council about excessive alcohol drinking and for all patients are discharged walking, they need to a counselor by the TV, the advice and, as we all know, as pretty as a guideline. All patients who had stroke and not allowed to drive for four weeks, and even then, if they still have disability, need to reassess, especially the patient with visual field. And we did all of that, then we need to decide on the discharge destination. Um, and if the patient is making good recovery can be discharged home with the help of OT obviously making the home situation, um, suitable for the stroke patient are all the the structural rehab hospital. If you need still ongoing inpatient rehab, Um, and everybody works in has who knows that she has another complication? Uh, which includes pneumonia, mostly aspiration pneumonia or hospital acquired pneumonia being in the hospital for a long time or hospital acquired the infection and bit sore. But luckily this doesn't happen in a good house is because with the shame to have a sore in the hospital and most of the stroke patients end up to have depression. So you need to be, uh, careful and more than the patient mood patient might get contraction if they if they don't receive a good um, enough physiotherapy and ended up with some other kind of disability speech walking, um, bladder power. Uh, some people might develop neuropathic pain especially in the economic. In fact, um, so you need to control the pain, the pain relief and, as we said, stop seizure buses. Stop Seizure is a common complication, Um, and again, you don't need to treat that prophylactically, but you need to be aware it can happen and obviously a malignant, even see a So what is malignant? N. C. A. I guess we cannot talk about stroke without talking about malignant and see a because it's a life threatening condition. Um, so what is malignant? See? It's a term used to describe rabid neurological deterioration due to effect of space occupying super edema following middle cerebral artery territory. Stroke. So, as you can tell from definition malignant, See a, uh, often happen after a big middle silver ultra stroke. And by definition it has to affect more than one third of the M C A to cause a malignant stroke. So the edema surrounding stroke caused a tight, uh, pressure on the plane. And, as we know brain is, doesn't have much space really within the skull. So any edema can lead to pressure of this brain against skull and cause a severe, uh, complication, including death So how do you know this patient? Um, is having malignant MCP. So obviously you can tell with the stroke size and for patient with hae an actual score that's been higher disability. You can expect this patient to be liable to have malignant see, so you need to watch for that. And when you're watching, you'll be looking for headaches into a constipation. Obviously, stroke can cause headache, but that this patient has a very bad headache that is worsening. And then if you start to have vomiting because, as we know, increased intracranial pressure cause headache and hospital vomiting. Uh so these two things might make us just anxious about M. C M C A and obviously, um, worsening GCS and worsening neurology. And this is again supported by a geological evidence, of course, but this is what malignant NCAA looked like. Um, as we can see, stop involving mostly all of the M C, even some part of a C A, and causing pressure to the brain and causing midline shift, and this ventricle obviously cannot even see it. So this patient should be discussed with the surgeon and should be taken to the theater. Um, how to treat them. See A. As we said, malignant M. C is a life threatening condition as the pressure on the brain might cause the brain to her knee. It, which means the respiratory center will be pushed down through the the skull opening and cause the patient to stop breathing and dying. So if you see a malignancy, what do you do? You urgently called, you know, surgical. And if you try to what you were telling you, I'm busy. You say I have a life threatening condition. You need to listen to me. And how do you treat that? It's a life saving procedure called Decompressive splenectomy, Uh, and by this, obviously it's It's a large M C A. And the disability will be horrendous, and patient cannot come back to whatever he was before. But this is a life saving procedure, and you should offer it to all patients unless if they say no. Uh, so as we said, you know, this is usually poor, and this death usually care as a result, um, of trance territorial herniation as and as we said for instant compression, which compresses the respiratory center. So that's everything for me. Um I hope, uh, I was clear. And I hope that you found that really helpful. Any question for me? Thanks dot Uh, we had a couple. Uh, it's just a bit of a I think it's just some clarification about, uh, what is being looked for specifically in young stroke? Um, stuff in terms of what? There's something about trump failure. What else? Which, I think. Yeah. Yeah. So, um, starting you on, we we obviously look forward vascularity So you sent for vasculitis as using for vasculitis for all other, um, medical problem. Like sent for N a C Anca Bianca anti forcefully, bit. And, uh, you sent also for protein C and protein s, um, as a trauma failure. Work up. Um, you can send for hepatitis B. C. Uh, HIV, syphilis. It's a long list of, uh, stroke in young, including all causes. Uh, anything that possibly can lead to vasculitis. Anything that possibly can cause, um, um cryoglobulinemia or any any disease that can affect vessels in young, uh, lead to strokes happen. So generally speaking, it's seems like vasculitis screen in rheumatology, which include in a, uh, Yankee P anca anti phospholipids and protein CNS uh, HIV, syphilis, Um, and genetic, as we said. Also, if there's a family history of a stroke in young and, um, as we said, the famous one is called. This is someone written down here? Um, and you suspect that if you have stroke in young and when you ask, that is family history of many young people having stroke. And this could be an indication for MRI. As we said, the MRI, we don't do it usually unless it's indicated for that specific reason. So that has a very specific looking MRI. And the radiologist will be able to tell you this patient looks like capital police. And for genetic. Okay, brilliant. And then there's one. There's a question just from student paramedics, uh, paramedic about pre hospital at all. Is there any way to tell between stroke types to assist in treatment and prehospital environment while en route, which, uh, is all pretty future futuristic with that sort of stuff at the moment? Not well, I mean, it's you can with with With With exposure, I think you can obviously, if you suspect stroke, you have to bring the patient as fast as you can because it's better to to bring patient than to miss a stroke. So if we can bring the patient assistant will say No, it's not a stroke, Then that's better than to miss it. So, uh, the stroke that we're looking for, As we said, the large vessel disease that can benefit from from dialysis and thrombectomy and this is you need to look for, um, higher cortical sign. So besides the weakness, you will notice the patient is maybe neglecting one side of his body or have speech disturbance dysphasia so expressive or accepted. Dysphasia usually goes with them. See a stroke. Or, um, there is a higher cortical involvement if the patient is neglecting, or you can see clearly that he's not causing his eye or he's not seeing on the one side. So this is all point to a large vessel stroke and again to tell between what? It's not solid information, but obviously hemorrhagic stroke cause very high BP. So if you see BP reading of 200 something that mean this patient, uh, might have a hemorrhagic stroke, but sometimes it's difficult to tell the difference. Brilliant. Okay, we'll just see if we've got any more questions. Let me bring the country. I have four questions for me. Um, what is the optimum BP and both ischemic and hemorrhagic stroke? So I think we said that, but I can go through this quickly. So for for how much of stroke, the target is below equal or below 1. 40 80. So if the nurse will say, Oh, this patient is BP is fine. It's 1 15 or it's not fine. It has to be below 1. 40 80. This is for hemorrhagic stroke for ischemic stroke. As we said, high BP is a protective mechanism. We allow BP to be high, but obviously anything of 200 we need to bring that down. But very carefully. Unless the patient's for symbolizes, then we need to act on that and bring it quickly to be less than 1 80/1 80 over over 100 or 90 so we can give some glasses. Uh, let me see. What's the other question? Yeah, So, again, drug choices depend on the hospital policy. Um, you need to use obviously the IV. You cannot wait for the medication to work, so usually we go for laboratory. So if a hemorrhagic stroke will go for a little polyp, so you give 10 mg, then another 10, then another 10. If the patient is not responding, then you have to start an infusion. And obviously, because Lamictal we cannot give more than, let's say, 324 hours. So mostly the patient will consume that very quickly. And then you need to start with your second line immediately, which is G t an infusion. Uh, but you need to give whatever you have to lower the BP, especially in the 1st 72 hours, especially in the first six hours. Um, what is the prehospital management for stroke patients? Mm. I mean, uh, sometimes this is a tricky question because you don't know if it's a hemorrhagic or ischemic. We have many people who, um, you know, they just try to help their relatives, and they would just give us three and 300 but we don't know. It could be a hemorrhagic structure that's not wise to do so. If you suspect stroke, you need to call the ambulance right away, and you need to bring the patient the hospital as soon as possible. Yeah. Okay. I think the States they started looking at introducing, like, mobile straight units, which is basically a massive glories with the CT. Exactly. Yeah. And the mobile can Yeah, yeah, yeah. They can do the CT of the way and they can start the treatment on the way. Yeah, that would be nice to have that. Yeah, I think I think there was someone to look at this analysis. And it was just the the amount of money it was going to say, especially in the UK, where we don't Our hospitals aren't that far away from most places. Yeah. Cost effective. Um, yeah. Was was the time for some time for some glasses. So, as we said from onset from last time, it has to be four hours, 4.5. But some studies show that in elderly, uh, the safest time is three hours. So usually we try to not to exceed four hours. But if you have a patient of 80 arriving with three hours, usually just try to. I've been telling them about the risk and benefit, but you usually get some glasses for all patients who arrived before four hours with no Contra indication and forth from back to me. As I said, uh, I can extend to up to 24 hours, uh, depend on the interventionist, because now we have the perfusion scan. So most people, um who the thrombectomy candidate, uh, end up having perfusion scan by what you can tell the difference between actual infected tissue and the tissue that you'd be able to save. So if there's a difference big difference between the actual in fact and the number, then the patient be candidate was from victim, even if exceeding six hours. And if the number is in the basilar posterior circulation, then the limit is up to 24 hours. Because it's a life saving procedure, because basil, a fungus can kill the patient. All right, Why is you're welcome. I think we will call it that. We're session. Thank you so much for coming, everyone. Um, next session is on Monday next week. It started later, Kickoff time of 8. 30 with one of the neurosurgical trainees from the preferred on traumatic brain injury. And then we have the final sort of special for a little while again with jihad on neurological and phones next Friday, so hopefully you can join us there. Please call the feedback. Terry's put the link very tiny in the chat. You just scroll up. But yeah, I hope to see you all. See, um, thank you very much for coming. Thank you so much for having me.