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Just check if people can hear us and then we'll wait for a little bit. Hello, everyone. Welcome to our second medical clerking webinar. Um Can you just indicate that you can hear me if anyone could just message on the chat that you can hear and you can see the screen as well, please. Anyone can just write that in the chart, please. So we can double check that we can hear and see. Wow. Ok. I hope you can hear and see us. Um We're gonna wait for a few minutes just for people to log in. Ok? You can hear. Perfect. Thank you. Um So we're just gonna wait for a few minutes and then we will start up. Yeah, I, so do you think we can make a start? I think we just lost Jemima for a moment. Yup, I'm here. Ok. We can make a stop for sure. Definitely. Yeah. Ok. Okie doke. Um So welcome everyone to our second talk in our medical Clerking series. Um This talk is gonna be focused on neurology, um specifically strokes and um we have Doctor Dawson again leading this talk um and just again, a few housekeeping rules as per usual. Um If you have any questions, please just, um, write them in the chat and we can get back to them at the end or if you do want to unmute at the end, you can ask Doctor Dawson directly the question you have. Um, but yeah, so please ask any questions you have in the chat. And at the end I'll send over a feedback form for you to fill in that you can get your certificates through. So over to doctor. Thank you. Of course. II hope everyone can hear him. Thanks very much for, for joining us. Um So my name is Mark Cos I'm one of the doctors here at in the east of England. Um Yeah, very much looking forward to introducing the topic of clerking neurology and specifically because of how common it is. I've chose to focus on, on stroke. So what we're gonna talk about today is uh a very brief introduction to how to set up your assessment and very briefly um talk about stroke and the pathology of stroke. And then we're gonna talk about some typical cases um that are looking at both ischemic and hemorrhagic stroke and then touch on some more atypical findings and when stroke isn't actually a stroke, uh what to have in a differential diagnosis. And of course, we'll start for a summary and some questions towards the end. So first line is very much who, who gets a stroke anyway. So who is your typical patient? So, we've got two patient clinical vignettes on the left hand side, we've got patient a who's a 67 year old retired office worker who's got the comorbidities of hypertension type two diabetes and a raised BM I, and his presenting, er, issue was speech difficulty when reading the menu at a restaurant. Um, and then a day later he attends A&E as he doesn't really like going to the doctors, what he's prescribed from the GP records you can see is Bisoprolol Ramipril and Metformin. Uh, he drinks alcohol socially and he's an exsmoker. And you've got patient B on the other hand, who's a 34 year old, er, Northern European background. She is a diabetic type one using a Libre device, um, which is a continuous uh, glucose monitoring device that you see some people wearing on the arm. Uh, she takes the oral contraceptive pill and of course insulin and she develops blurred vision more noticeably when looking to the left and then she has sporadic right arm weakness and left leg weakness, no drinking or smoking history. And just from these two people, if I told you that one had a stroke and one didn't you, I'm sure you already have ideas in your mind about who is who. But then I wanna try and highlight what are the red flags in the history that may make you think that someone's symptoms are more likely to be a stroke when you haven't got a confirmed diagnosis. And what I wanna talk about is risk factors. So it's all about triaging risk of uh, symptoms and matching it to who's likely to have a stroke and who's not. Um, so for instance, patient a, who's a diabetic and doesn't really like going to the doctors or who is prescribed, Metformin. Um, whether his compliance is, is accurate, whether he's taking it as prescribed is another question in addition, hypertension. So if these are poorly controlled uh got systolic blood pressures of 1 71 80 you're more and more likely to develop a stroke. Um Other key factors we're looking through histories of patients, age is one but but not the defining factor. Smoking is another atrial fibrillation, af significant risk factor for developing ischemic stroke. Uh cholesterol, high cholesterol is another, that's why GPS are very active on minimizing uh harmful cholesterol and then any blood clotting disorders thrombophilia. And by all means, that's not an an exhaustive list of all the things that can predispose to having an ischemic stroke. On the other hand, um hemorrhagic stroke, there's fewer typical risk factors, but some I've mentioned are autosomal dominant polycystic kidney disease, having a previous family history, a known cerebral aneurysm. So, the most common mechanism or one of the most common mechanisms of having a brain bleed and a hemorrhagic stroke is a rupture of a berry aneurysm or for instance, patient b if our 34 year old librarian had Marfan's disease, a, a connective tissue disorder. You'd be willing to take her symptoms a little more seriously and ensure that you're ruling out a hemorrhagic stroke. As Marfans is a risk factor for developing aneurysms, which in turn is a risk factor for bleeding aneurysms and stroke. So I really wanna, when you're flaring patients and you're seeing background history and what else a patient has a diagnosis of what you're really doing is identifying risk factors. And in your mind trying to think of how likely are these symptoms to be one of the more serious pathologies in your differential, which in this case is a stroke. So although exa teaching examination definitely works better at the bedside. Um I just want to run through a few things that you should be examining as part of a focused medical examination in undoubtedly what's going to be a very busy hospital environment. So for any patient, a basic heart lungs, uh abdominal exam and having a, a feel of the legs. Is there any um fluid, are there any lesions or diabetic foot ulcers and various things? Cos you may be the only clinician picking these up and although patients come in with a stroke, there's nothing to say that they can't have two or three things there then wrong with them. So a focused cranial nerve exam, something that you see often in in the written notes is acronym P EA RL or pearl. And what it really means is pupils being equal and reactive to light. Um very useful quick assessment. And what I want you to use is one of these small pen torches as the light is a lot dimmer than what you'll find on your phone. And you get a much more accurate assessment of the puberty uh reflexes and then going systematically as a quick neurological exam, you can forget about the Creon of one that stick to 2 to 7 is where is where the money is gonna be out in terms of examining for pathology. Um And I say this isn't a absolute, you know, top to the bottom exam. This is a very quick neuro exam to get you the right answers and quickly and then moving on to peripheral nerve nervous system examination. So you're gonna have tone um you know, is it high tone, low tone? No need to do left and right and there's no need to do anything further uh power. So can the patients raise their arms if so, can they do it against resistance or against gravity only or is there no movement at all or just a flicker? Um and documenting this on, on a power scale 1 to 5 and the sensation again, not getting your uh you know, your fine instruments out just gross. Can you feel this? Can you feel this close your eyes? Which leg am I touching? Which leg am I touching? Something very gross like that will tell you a lot of information quickly and then s specifics for stroke. Um So palma drift is quite sensitive. So arms up to the ceiling and with the patient closing their eyes, do they drift one hand down and it inverts like this. Um Quite significant telling that they've got a weakness. Then on, on the one side, important is coordination. So particularly with posterior or cerebellar strokes, what you're gonna have is the finger to nose pointing. And if there's lower limb involvement, the patient running their heel, their right heel, for instance, down the left shin and repeating that motion. And if there's real instability there, you'll see the shin and the he, the heel rather moving uh left and right. The next one, this did do kind. So it's sort of clapping the hand into the other palm and then switching um that rapid movement really taxes the cerebellum. So if you have them unable to do it, they're clapping all over the place and not quite sure of themselves. That's indicating pathology and the next. So, reflexes, um I've never really got a tendon hammer out and looking at the knees and the, and the brachycephalic and various er, er reflexes. But Bin's is one that you can elicit quite easily. And again, it's quite telling um of an upper motor neuron pathology. So, very important to document and then moving into more of the pathology of stroke and of course, there's ischemic and hemorrhagic and that's the pathological classification. But when you look at the clinical classification and what we most often use here is whether there's a pa or a tax. And what you're really assessing is how many of the following deficits are there. So unilateral. So let's say left sided weakness or sensory deficit of the face arm or into the leg, harmonious hemianopia. So left sided visual deficit in both eyes or higher cortical dysfunction. And what I mean by that is, is there difficulty in speech, reading, comprehension of English um or a dysphasia or dysarthria. And whether you've got two or three of those following conditions is whether you've got a partial occlusion or a total occlusion, obviously carrying a worse prognosis. And the reason I've separated out the deficit of the arm face or the leg. Um So, what we're really looking at is the vascular territories and what of course is the homonal diagram? So at the very center of the diagram, this is the right section. So you see the foot here will be supplied by the anterior cerebral artery. And over on the right of the diagram here, this is the area supplied by the middle cerebral artery and there's not really gonna be much pathology that affects for instance, the face and the foot, but then spares the hand. Um So I just want you to try and think back to some very clinically orientated neuroanatomy, not learning about each detail as we go. But really what I want you to look at is um referring back to very basic neuroanatomy and keeping that in, in your mind. I'm just gonna refresh my slides here a moment. I'll just pause a moment just to make sure that you can all still see. Ok, if you bear with me a second, let me just update my slide to the med all platform. Apologies about the delay. Can someone kindly type in the chart if you're able to see my slides at the moment? I ca I can't see them right now. OK. Just bear with me a second, please. Great. So if you're able to just bear with us whilst we um we share the screen and the slides. Yeah. And if you take us to the uh the next diagram with the previous diagram, yeah. Um sorry, just back one more slide. Perfect. So what I'll move on to is um the other types of strokes that you commonly encounter. Um So lacunar strokes and posterior strokes. So your lacuna stroke, what you're gonna have is a unilateral. So either the left or the right and never bother, but it's gonna be pure sensory, pure motor deficit or it's gonna be a combination of the two. Alternatively, you can have a, a left sided weakness with an ataxic gait. And if it's this one will include the arm, face leg. And the reason why is because what you're affecting. Here is the internal capsule where all the fibers from the ascending tracks um run up and a very small space in the brain can be affected a significant deficit. And that's the only condition where you're gonna have arm, face and leg in. For all practical sake is a, a lacunar stroke. And that's really, really closely associated with hypertension, almost never would occur without. And then you've got the posterior stroke which can present in many different ways and give you lots of uh neurology to examine. Um So, amongst what we've talked about, but importantly, you get visual changes. So the harmonious hemianopia, uh cerebellar dysfunction. So that's where your ico kinesia test your clapping into the hand will really um show you that dysfunction, eye movement disorders. So you're getting nystagmus, bilateral motor sensory deficit is one and cranial nerve palsies, we've been peripheral neuropathy. So you your left arm weakness with facial nerve, uh weakness for instance. Um So there's a multitude of things to examine. Um Typically most patients have a, a pack or attacks, sometimes lacuna and posterior strokes can present in many funny ways. Um So be on the lookout for that. And if we move on to the next slide where we're gonna discuss a case, so our first case of the evening. So this is uh a real case lady I saw just a few months ago. Um So she's a 94 years old care home resident and she came in, admitted from admitted early in the morning with um a last seen well time at 4 a.m. So, although it's only happened at 6:45 a.m. the nursing staff last saw her well at 4 a.m. And it's that time that's really important to note in your documentation. Then importantly, she's also on Apixaban. So blood thinning medication last taken. So the care homes always document a really good drug chart last taken at eight o'clock yesterday. And even as you, you look at her, um you can see that she's avoiding the use of the right arm and that's been commented on in the ambulance notes, the medication. So yeah, the Apixaban is there. She's on Cocodamol. Um and she's using just small doses and that double T notation. So that's two tablets and with the Laxido, you've got one T. So that's, that's one tablet and that's a common notation. You'll, you'll see um inti thiamine which is just a ab vitamin. So not too much else in, in the medication history and on exam. So there is a limited examination we could do with this lady's not cooperative and for instance, her G CSE is only eight. Um So your eyes opening to voice a verbal, so non verbal and M four. So uh flexing into pain, not localizing, she's got a right sided facial droop. Um She is moving her left arm and the tone in the left arm is normal but on the right side, you know, it's a bit stiff. Uh what you're doing then examining is the plan is so down growing on the left, up growing on the right, which is more in keeping with what you're expecting and then your routine examination. So heart sounds, no murmurs, uh lungs were clear, no added sounds and no abdomen was soft and there's nothing of note on the cast or the lower legs. So if we move on to the next slide, we can see this lady's possibly had a hemorrhagic stroke based on her medical history. And if we can, um I just can't see the there we go. So this is her actual CT scan and the report that accompanies it. So the radiologist make a report very quickly with stroke. Um So you don't have to depend on your own interpretation. But in this case, regardless, it's obvious anyhow, um of course, the left and the right are switched over in this view. So they've concluded a large left parietal parenchymal bleed with local mass effect. And that mass effect is what's causing her, reduced, um reduced cognition and reduced G CS, um compression of the lateral ventricles as well. So you can see a a big hyperdensity. So the white area far more hypertense the bone and the surrounding uh outside. And that gives you a relative indication of how dense this fresh blood is. Fresh blood hyperdense, old blood hypodense. And if we move on from that image. So how do we manage this case? So I'm gonna draw your attention to the hemorrhagic stroke. So important to reverse any anticoagulants. Um This step will almost always be taken by the A&E doctors. Um as a medical doctor or clerking doctor, you're probably gonna come along a little bit later and then all the, the CT has happened and the reversal agents have been given. So there are some very expensive drugs to specifically reverse Thax and like Apixaban um in this hospital. So what we gave is a, an octaplex. So a high concentration of all the clotting factors to replenish those clotting factors that are blocked by her preexisting. Apixaban important to refer to neurosurgeons. Although, you know, in, in this 90 odd years old care home lady, they're not gonna exactly take her for neurosurgery. So, um it's more of a formality review rather than anything else in this case, um important to ask for new observations. So the nurses will do neuro obs as per protocol. And if there's any change, you can ask for a repeat ct head. And is there any rebleed um or is there any other changes and that could change your management more about palliative management if needed? And the next one so targeted BP control. So if you've got a bleed in the brain, any size, even in a, a smaller bleed, what you need to do is you don't want really big hypertension and making that worse. So you give uh IV infusions of medicines in this hospital, we give either a GTN infusion. So, nitroglycerin infusion, which is great for ischemic heart disease. It's great for angina. But as a continuous infusion, what it really does is dilate the venules and reduces BP, it's got a short heart life. So if you give too much, you can reduce and if you give too little, you can increase it rapidly. Um So target BP, control your hospital that you work in, they'll have a dedicated protocol for it. So the exact numbers, the doses you don't really need to know and certainly not off the top of your head. So in the other boxes, you see alongside is this, if this, if we didn't have the CT head findings and we felt that this was that we've ruled out an intracranial bleed with act head, then you're thinking that this might be an ischemic stroke and how to manage an ische ischemic stroke such as this case. Um What you do is give aspirin 300 mg any way you can. So if the patient can swallow, you wanna give it orally. Otherwise there's pr preparations or if they're gonna have a feeding tube, you can give it through an NG tube as long as you can get an NG tube in quick enough. Um Of course, never anticoagulate. Um You got a risk of hemorrhagic transformation of an ischemic stroke, although you don't have um a bleed. Now, giving anticoagulation, what you can do is transform that area into an area of bleed and that's gonna complicate the picture. So never anticoagulate, you do wanna get an E CG. So is the patient in AF um and a FSA big particularly if it's, you're not on a, a blood thinning, thinning agent can er distribute thrombi into the er cerebral arteries. So it again, it, it gives you something to address later on and I've mentioned it here. So these intima pneumatic er intermittent pneumatic compression stockings with the brand name flowtrons. Um so they prevent any build up of DVTs in the legs while the patient is naturally immobile or less mobile in hospital. And so there's good evidence such as that suggests that those patients who are admitted to a dedicated stroke unit do better in their rehab and their overall mortality and morbidity. So it's UK policy that to have patients with stroke admitted to a stroke unit. So that's your immediate management, what you wanna think about later and it won't change any anything just yet, but you're setting it up for the next consultant or the next doctor to come around to make some changes. So, adding on er HBA1C, a lipid profile um and various other bloods just to make sure. So if there's any lipids that can be addressed, you're starting the atorvastatin that they're diabetic, you want better diabetic control So start controlling those risk factors that we mentioned earlier in the talk. Um SSL ta speech and language therapy assessment. Um Does the patient, are they able to talk? Are they able to swallow? Do they have a safe swallow? Do they need an NG tube? Um and BP optimization. So it's not to chase aggressive targets but typically after a stroke, patients become hypertensive. And our first line drug here is um is a calcium channel blocker of, of various different types. And that's just all dosing or food and NG tube, it felt appropriate. And then let's say you're, you're suspected uh or clinically suspected or clinically diagnosed. Ischemic stroke didn't show anything at all on ac to your head. So you've ruled out a bleed but you didn't see an ischemic focus neither. So an MRI had followed up a few days later, will show you areas of mismatched perfusion. And that's then the gold standard of diagnosis when you're looking at vascular causes. So, carotid dopplers, is there any stenosis of the internal carotid arteries going up through the neck? Is there any stenosis there that can be reversed with vascular surgery? And that's just ruling out there is no critical stenosis of the internal carotid arteries. It's an easy ultrasound test to do and it can get deliver really good results as there's a reversible pathology. And then obviously much later, lifestyle modification is really important. Uh diabetic control, smoking cessation, not critically the the patient I mentioned a 90 odd year old care home resident. This isn't gonna be relevant for her. But other patients who have had a smaller stroke or generally uh healthier, this is the the critical point to intervene. So if we move on from this initial case, so we're talking about stroke mimics or differential diagnosis in stroke. And a Bell's palsy is a, is a key one so important in the bowels, pas a lower motor neuron issue of the facial nerve and what you're gonna have is upper and lower face affected. Whereas with a stroke, it's an upper motor neuron pathology and the upper face is innervated by both the left and the right hemisphere. So you can't really have a stroke in the left and the right hemisphere at the very same time. So that's why with upper motor neurone disease, you typically have facial sparing or upper facial sparing and you're gonna have lower facial droop. However, if you got both upper and lower face affected, you're thinking that's a peripheral motor neurone lesion and you're thinking Bell's palsy and this is by means no exhaustiveness. So ati a by definition is onset of symptoms that are stroke like and resolve within five minutes. And that definition has changed, it used to be uh 24 hours. Um But yeah, it's definitely changed to five minutes only anything longer, you'll be more worried. Um These patients typically come back to Ati a clinic and they get all the investigation and work up that I've just described, but it's gonna be as an outpatient basis or get act head if they're in hospital or refer them on to ati a clinic if you see them in a GP practice. Um But really you wanna start addressing those risk factors and start working on, on that process. Otherwise space occupying lesions. So masses and unfortunately, lots of time, cancerous masses can grow, grow, grow and then they become critical and then they present with symptoms such as whatever it may be left arm weakness, often associated with headaches if there's increased intracranial pressure. In addition, um nausea, vomiting, um and looking at the back of the eyes, any papilledema, um but your CT head will give you lots of information. So have a very low threshold um for investigating people appropriately. And I said the differential diagnosis of ti A S um and stroke very wide. Um like the first clinical vignette, we mentioned patient b the young 34 year old with that sporadic pattern of weakness. Um More in keeping with uh multiple sclerosis or the first episode of a multiple sclerosis. So again, lots of things can cause these cause these uh neurological symptoms. And if we move on then to stroke emergencies. So there's a couple of significant treatments that we haven't yet mentioned. Um So thrombolysis and thrombectomy. So, thrombectomy is the mechanical removal of a large um clot but it has to be an approximal vessel. Um naturally, that will give you very significant deficits. And it's only really used for patients who have a good physical baseline. And the new alternative emergency treatment is a, is a thrombolysis. So thrombolysis is about giving an infusion of alteplase, which is a one of our clot busting drugs. However, there's lots of contraindications and importantly, it does have to be done within 4.5 hours. So we've got two patients again. Um firstly, we got a 59 year old right handed person who then noticed his left arm weakness when he woke up at 7 a.m. and he was taking blood thinner medications. So you, you can always see some, some complications here. So he's already on a blood thinner. Can you really formalize someone who's already on a blood thinning medicine like Apixaban? Um It's a bit controversial but generally the answer is no and then the wake up time. So I said that it could only be done within 4.5 hours. Um But this chap woke up at 7 a.m. noticing the symptoms if he went to bed at 10 p.m. the last the previous night, who knows when it really happened? So his last seen normal time was 10 p.m. the previous night and that would make him eligible for thrombolysis treatment is one of the contraindications. So the suitable patient and the unsuitable patient. So timing is most destiny everything. It's really important to get an accurate timing history when you're taking any history from the patient or the relatives or the ambulance crew or whoever you might find. And then with these treatments there's lots of complications, they are rather risky. So they do need to be worth the risk. Um, so for instance, if your patient, like a 94 year old care home resident, there's no chance she's going for a thrombolysis or a thrombectomy as she doesn't have a good enough baseline to warrant the risk of both procedures. Um for instance, patient B here who's our kind gardener. So, you know, he's active, he develops a leg weakness whilst walking the grandchildren to school. So you can tell that he's a very active man. Um He's someone who has a good physical baseline. If he had a really proximal um middle cerebral artery ischemic focus, then he's someone you could consider for thrombectomy. If you're in the correct like a tertiary center, a larger hospital, alternatively, Thrombolysis, which is most often or almost always used in smaller hospitals. Um and more easily available. He, he could also be eligible for thrombolysis as long as he's in the appropriate time window. So I say timing is absolutely everything. And if we can head to the next slide just to draw some summaries about what we've spoken about this evening. So stroke very common admitting diagnosis, particularly in the UK where patients are living longer with greater comorbidities like hypertension and diabetes and that's causing a big burden of disease in the elderly. Urgent assessments requires CT Head to realize there's an ischemic or hemorrhagic stroke and is the patient eligible for thrombolysis or thrombectomy in case of ischemic stroke? So, CT head, um it is very stable uh investigation that's always arranged by the A&E team in the department and it may or may not show an ischemic focus. So if the CD is normal, that's not to say that it definitely isn't an ischemic stroke, it might be, but it definitely isn't hemorrhagic. So you can move forward safely with treatments like aspirin, er, in the future. Um, the medical management stroke is highly protocol as in your hospital will have lots of detailed guides about what to prescribe when to prescribe it. Um I've said further history taking and careful examination. Yeah, that can unpick stroke mimics and also make sure you're getting the time where the onset when they last seem normal and when they'd last taken any medications such as blood thinners. So if your patient is prescribed Apixaban, but they hadn't picked up that their prescription that week. Well, and they had a stroke. Well, they're not really on Apixaban anymore, so it's really getting that detail down can be life changing for the patient. And then, so taking your larking a little bit further than saying sort of left or right or left or right stroke, if you can use those clinical classifications, even say in a query of a PAX or query tax or this could be a lacunar infarct. Um That's sort of taking your, your, your, your larking to the next level rather than just a very basic f one level. You've really been sort of breaking into the sho level. So that's what I'd recommend is to be as accurate as, as you can using that clinical system that, that can be really helpful. And I think that's about all we really need to mention tonight from the slides. So thank you very much for your attention. Um If there are any comments in the chat, I'll be sure to address them as we go. Ok, we have one question. Um, uh Dr Addy says if a patient develops, uh I guess left ventricular aneurysm after acute coronary syndrome, how soon after could a cardioembolic stroke be likely? So I'll just pick up doctor Doctor A's question. That's really a question for, for your cardiologist and your, your senior team. Um, couldn't really accurately comment on uh the specific question and a great, great question that Doctor Ali asked. Um, ok. Does anyone have any questions for Doctor Dawson? You can just type them in the chat with anything? Um I had a question about, um, in terms of the thrombolysis therapy, um, like how many patients are usually eligible for thrombolysis like that you've seen. Yeah. So it's really been just a handful actually. Of those who have been eligible for thrombolysis. Um, often it's the time of onset is far outside the thrombolysis window. Um, if they do call a ambulance immediately, lots of times they wake up strokes. So they've noticed it just as they've got up. But really the incident could have happened overnight at any hours. Uh, before, even if some clinicians like to take the midpoint of where you fell asleep and where you woke up and you noticed the symptoms even then 4.5 hour window, by the time the ambulance is called patients into A&E and you've done the CT head, a 4.5 hour window is quite a stretch. So in reality is, I've only seen a, a very small handful um as a lot of those complications is, is timing and then lots of our patients now are on Dox. Um where giving thrombolysis on top of a DOAC, you won't often find many stroke clinicians who are willing to do such a thing unless there was something um a very significant deficit in a very young active fit patient. Um But it's a, a very case by case basis and the guidelines around the timings of things are due to be changing. Um So keeping an eye on the, the stroke guidelines for the UK, if you're working in the NHS in the near future, um It's definitely one to keep an eye on. Ok. Does anyone else have any other questions. We'll just wait for a while to see if anyone has this typing and then we'll wrap up. Um, I've sent over the feedback form, please. So if everyone can fill that in for us, it just helps us plan our events and you're also gonna be able to claim your attendance certificate as well. So we'll just wait for a bit just to see if anyone has any questions that they're typing or anything they wanna ask. Doctor Dawson about this top. Ok. Taz asks since Aspirin being a low dose thinner or since aspirin is a low dose thin uh thinner, how do you prevent? Um That's contraindications in the use of it if there's an issue with hemorrhagic contraindications and the use of it. Sorry. Say that again. Sorry. Yeah. So if you've proven a hemorrhagic stroke on admission, uh obviously you, you're not giving any further aspirin if patients already on aspirin, um they're usually on 75 mg and all you do is discontinue it. There's no reversal agent and there's nothing else you're gonna be given to stop that. Um The problem more often comes now with Dox and Apixaban or Rivaroxaban and their use. So they're definitely promoting or you were seeing more hemorrhagic stroke with more widespread use of blood thinners like um like the ones I mentioned and there in that case, what you're doing, you're giving active reversal agents. So Aspirin in itself has got a very low burden for, for excess bleeds. However, thorax and warfarin in, in days gone by a lot more. Um give a lot more propensity to cerebral bleeds. Not a problem. Thank you very much. Thank you. Um Does anyone else have any other questions? And one thing I will add to Taz question and answer. So, Aspirin's one but Aspirin has a, a shorter half life clopidogrel, which is another um low dose antiplatelet drug. It has a much longer half life. And again, there's nothing else you can do at that moment. Just stop, uh stop the offending medicine and move forward. Um You can give in other clotting factors uh as you see fit. Ok, I'm gonna assume that's all the questions we have. Um So yeah, thank you, Doctor Dawson for today and thank you everyone for joining us, as I said before, please do fill in the feedback form so you can get your attendance certificate. Thank you very much everyone and we'll see you next time. Bye bye. Thank you very much for your help. Thank you everyone. Bye bye bye, everyone.