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You want to do? Um Welcome to this evening's presentation. My name is Billy. I am a Geriatrics and stroke registrar working in the east of England. And tonight I'm going to be presenting to you what I think is really important for junior trainees like yourself to know when it comes to stroke medicine. Now, a little bit of administration before we begin. Can everybody please join this uh slide link, please? I'm using it as a polling software to do things like word bubbles and what have you? Um No, the first thing I want you to do is give me your opinion about stroke medicine. What do you think about stroke medicine? Let's see if this works. Yeah. So those are some good responses. It is a challenging specialty because um it requires quite a lot of acute neurological assessments as well as understanding some of the localization of where the stroke is. Um I try not to kill somebody up there because I need to actually thrombo people and that can be quite difficult at times. Um And there is elements like rehabilitation and what have you um can people still hear me? Yes, we can hear you. Yes, good. So here are learning objectives and I'm gonna stop this. Um I'm first of all going to define what stroke is. I'm then going to do it in a very peculiar way. I'm going to, first of all, give you some co common stroke complications seen on the stroke unit. Really kind of sorry to interrupt you. We're just, we're just seeing the title page of your powerpoint, the title page of the powerpoint. Yes. So the first line, OK, let's see what's happened here. Let's try that again. So I'm gonna share my entire screen next. That might be more useful. Sorry about this. Um This year. Do this. Can people see this slide correctly? Yes, in the beginning, right? And people actually see the poll earlier on. Can people see this? Yeah. So before we were just seeing your powerpoint and then we would see the slide though at another, we have, we would have to change a tab to go to slide up. But if you keep it like that, we can see everything from your screen. OK, good. So can you see the learning objectives now? Yep. OK. Let's continue. So this looks like a better way. So let's talk about the beginning. Let's give an overview of what stroke medicine is because I quite like definitions. Let's just hide that. So the definition of stroke is this, it is a clinical syndrome of vascular origin by that we mean the brain the spinal cord, the retina, which leads to rapid onset of signs and symptoms related to the brain or other parts of the nervous system, which lasts longer than 24 hours or leads to death. So, acute focal neurology or acute loss of consciousness, we've also got a transient ischemic attack, which generally is the same thing but lasts for less than 24 hours and makes the assumption that all goes away within that period of time. Now, we are very interested in ensuring that our stroke patients come to the front door as fast as possible, which is why in the NHS, we've got the fast campaign face, arms speech and time, time is brain get here quickly. We've deliberately picked a um a system that is very, very sensitive but not particularly specific because this needs to work for public and bearing in mind. A lot of physicians are not stroke experts who get scared by acute neurology. I think it works quite well for you guys too. Now, I use something very similar to B fast B as in balance and ice and I'll just go through each letter of the acronym turn to give you an idea what you'd be looking for. We straightly, we're gonna start from the back of the brain going forwards. We first of all, start with cerebellar signs. So like your drunken gait and your an inability to stand properly or you can't really do pass pointing. You've got eye symptoms, like you're getting blackouts in one eye, like a curtain coming down that army roses, jacks picture or you get curtains coming from the side, from one side to the other, from the other position, that's fine. Um which implies something that's a bit more in the brain itself. As opposed to the eye itself. You got facial drip straightforward enough, you got your arms and your legs, you got your speech, speech can also mean language. It could be either loss of articulation. Um It could also mean loss of the ability to produce language like I suddenly lose the ability to speak. Um And if you're not sure about what exactly is going on and somebody is in front of you of acute neurology or your friends or get them to call the patient in and we'll see them the first caveat of this talk. Um I won't be able to teach you localizing every single neurological sign and symptom in a one hour slide. However, this is something that you can develop with experience, time goes on and there are plenty of resources and I can always link you to something now causes a stroke. You've got your ischemic strokes. So for example, you can see in the picture of the left, you've got some what we call gray white matter differentiation on the right, much more pronounced in the left uh on the right. Sorry, you've got hemorrhagic stroke. Big white thing that looks a lot like blood. Of course, the one that's here looks substantially worse than this one. You can even see blood pooling down in the corner and the ventricles here. And a theoretical classification that we don't often get too involved in, in daily practice is subretinal hemorrhages. And here are some examples of what a subarach hemorrhage looks like on scans. If you've not seen it before, you can see blood within the sulci and even within the parts of the brain, um, between the brain. Sorry, that's where the vessels sit. It looks pretty nasty. The principles of stroke management come in sections. You've got your hyper acute management where we think about your thrombolysis, your mechanical thrombectomy, BP control neurosurgery, the really sexy stuff that you can do in a space of anywhere between moment of onset to up to about 12 to 24 hours after presentation. So you can see this is your carotid vessel going up. It's like driving up the M 11 and then you kind of turn eastward on the A 14. This is your left MC A. You can see a blockage there and then you could thrombolysis and suddenly bam that entire c blood vessel becomes cleared out and blood flows in beautiful outcome. You could do thrombectomy. We've stolen the wires from cardiology and repurposed them to our own devices. Um Basically go clot hunting, then you move patients onto the stroke units, which would be the place where a lot of junior doctors end up as part of their foundation jobs, quote unquote geriatrics neurology. And here the job of the doctors is to figure out why they had a stroke in the same in the first place. You could almost think of people having a stroke as having a syndrome of a representation of something that's an underlying process like atrial fibrillation or a tear in a blood vessel or something else. So that's all of these are for a, if there is a narrowing of a large blood vessel going into the brain, you go and clear out, look for any inflammatory vascular causes of strokes and to manage the complications of strokes, which we're gonna go into like this thing. Can anybody just shout out what this is? Remember, I won't be able, able to see your chat. Yes. Excellent, good. So I know that your microphone works excellent. Um And then you've got the rehabilitation site which you might see an element of stroke is one big MDT. We all work together to get our patients out in a way that allows them to return to a high quality of life if possible. So now you're on the ward now, go back to sli though. What common complications do you think you'll encounter on the stroke unit? Very nice. G CS. A lot of things. Quite a lot of different things. Good. Any more for any more? 10 more seconds, two dysphonia, very good. Get ent in further strokes and death. Very good DVT. Very good. Now you're thinking that is a good set of things that we're gonna cover to a large extent. Can you see the slide two? So we're gonna talk about some of the most common complications of stroke units. Um Some of which you've already mentioned and some of which you might not have actually like I didn't see cardiac complications or BP, which, which means that we're probably getting involved with seniors to help you, which is good. And then I'm gonna cover new neurology and VTES because people mention dysphagia, I'm gonna include dysphagia as part of infection. I'm gonna talk a little bit about it. So bear with me. First of all. Uh I'm not gonna teach you suck heads too much because they're quite useful. But stroke patients um as a result of either a large stroke or something a bit smaller, but in the back of the brain can lose their ability to swallow. And when they lose their ability to swallow, they effectively aspirate either noisily the gargle or silently, they don't develop anything until you get one of these an aspiration chest infection. And these are fairly straightforward to treat in a hospital setting. You do your curb 65 scoring. If you've never heard about it, it's a way to manage um severity of chest infections. Most of our patients exist on the more severe side. And in these instances, you get your speech and language therapist involved and they assess your swallow. They will do things like recommend whether a patient requires nasal gastric tube feeding and the kind of nutrition that they require and the quantity of um testing that you do in terms of swallow, like spoonfuls of yogurt and what have you leave that to them? You treat the chest infections but you also site ng tubes and check if they're safe. Can people shout out what GS are, is safe to use? C OK. Anyone for anyone else? All right. Why is a not safe to use the end because it's coed up in the esophagus. Sorry, sorry, I just wanted to say that the end was kind of well pointing outwards and in the esophagus. Yeah. So yeah, the tip is here. So, no, it's cod up. It's gone the other way. Um Why it be not safe to use because he went into the lung? Yeah, it's, it's gone down, right? My bronchus um c safe for use because you've got uh it's basically um in the stomach and I'll show you how to make sure that your G is in the stomach uh goes down centrally, bifurcates. The carina keeps going down the middle, um bifurcates in the middle of the diaphragm and should exist with a relatively good amount of depth in here. Quite straightforward, more difficult if the image is rotated. But generally that's how you do it. We've talked a bit about fast atrial fibrillation already. And this is when I start giving you some pointers about things you might encounter as F ones. I'm not quite sure how to deal with. So obviously, we do your ABCD assessments. I'm not going to teach you suck eggs and treat certain treat underlying causes. Um Generally, we recommend that patients who get into fast atrial fibrillation and require rate control. Your first line is going to be beta blockade, things like the Opr or metoprolol. Um However, and I've encountered this more often than well, quite frequently. If your BP is a bit tentative or the patient's gurgling up with pulmonary edema and heart failure, you can use something like digoxin, save the amiodarone for our senior clinicians because we need to consider a lot of risks and benefits to it. Um If you reach a point where you need to DC cardiovert somebody, you really need to be seeing help and um leave the anticoagulation to us. I can tell you a bit about it in a question and answers right at the end. Um I know it's a bit early in the year, especially for F ones. But um do get your A L SS booked at some point. This is what you'll be dealing with in A LS tachycardia algorithms. If in doubt, call it support, you might need to DC cardio or somebody you'll get the slides. So you'll see this algorithm in more detail any questions so far? No. OK. Let's keep moving on to delirium. So, delirium and stroke is a bit difficult because you need to understand what is your old neurological status of the patient. So, are they normally dysphasic? Do they normally have some communication problems? And then you need to see what's new like, are they have they suddenly just become flat um as a result of something like an infection or even something like urinary retention, you can assess them for using tools like C AMI CU. Now, in other places and in other specialties, you might be using something like a four A T score, but they're not, they're not so accurate apparently in assessing patients with acute neurology. So use the C AM ICU that might be a bit better, but also rely on your multidisciplinary team to support you in this. Once you've identified delirium go and find the underlying causes and they're quite standard geriatric causes. So stroke patients can be in a lot of pain. They've got an aspiration pneumonia, they're dehydrated and they haven't really eaten anything because they can't, they can't swallow and they've not open the bowels. Those things are all quite part and parcel. Um Also stroke units are noisy, agitating places. Um people don't like being restricted, but when you've got an acute neurological deficit and the N and the cannula and the catheter, it's a very restrictive environment. So that might cause some agitation and just remember your patients who might have language problems can't communicate their knees. So they get aggressive and strokes. A lot of people get depressed. We have drugs. But please for the love of God use non pharmacological methods because if you train somebody with a stroke with loss of LORazepam, you don't know if their GCS is falling. So you can never detect if that agitation was as a result of some bleeding in the brain that you've not got. So try to calm them down using other methods before you start using these medications on the left, they do have a place. I sometimes use LORazepam to get somebody into a scanner if I really, really need them to be in a scanner. But otherwise I don't use it to control agitation overnight. For example, I try to get the nurses to special or do something a bit more. Um, um, tender loving care, good. So sad face, don't, don't try not to use drugs unless you absolutely have to. Speaking of drugs, this is when we start arriving into a bit more stroke specific management. Um, BP management and strokes can be quite difficult. It is a gray zone. A lot of different trusts have a lot of different guidelines, telling you a lot of different things. Find the one in your hospital and read it because often they will give you basically step by step guidance to manage it because they need imbeciles like myself as mere to come and actually do the work overnight and we're not really awake at night time. Uh, but general rules, um, a patient comes in with a massive bleed or a large enough bleed and needs treatment within six hours. You, you tend to try and get the BP down to quite an aggressive level of about 100 and 30 systolic. And your stroke patients would tend to be quite hypertensive. You're giving them a drug to basically crash their BP. So try, we, we have realized that our aggression has led to adverse drug effects. So try not to do it too aggressively, try not to drop it under 100 30 millimeters of mercury because then bad things happen like you just get more acute neurology because you've made somebody's brain ischemic. Please don't do that. Um After six hours after you get an NG tube in after they're a bit more stabilized. Try to use your routine. Nice guidance, approved antihypertensive medications go on to IC ps. Find those guidance and use that are quite useful after ischemic strokes. The reason why people are hypertensive in strokes in ischemic strokes, those caused by blood clots or parts of the brain is shutting down because of a narrowing is because the body is pushing blood into parts of that brain to try and get it reperfus. So if you drop their BP, then you just made the situation worse. So very high threshold unless you're thrombo them, I'll come to thrombolysis later. But if you thrombo somebody, you do need to bring their BP down a bit just to make sure that they don't then bleed all over the place. Fine balance. Which is why doing recess do in IC U in IC U don't do it on a random ward out. Lie a ward ple please just don't use IV the below in the middle of the night in a general medical ward because people won't know how to titrate it and you'll end up with more problems than you get. It's a bit like if you ask, like if you give somebody some Tyra or some other vasopressor on a random general medical ward and you just walk away. People don't know how to titrate to give you an idea of what those intravenous BP medications look like. Um, what you might see, we got our classic example, labetalol. You might find something like what you see on the right side. Um It is, it should be fairly idiot proof to the nurses and to yourselves. Find your guidance, read it with labetalol. Just be careful. If somebody's got really bad asthma, you might, you might make the asthma worse and try not to use this medication. Heart block infusion rates vary. You can also use GTN. A quirk of GTN is that it might eventually stop working because you're making a blood vessel to shed nitric oxide and eventually it will just run out. So your blood vessel stops responding to it, which is why we're quite careful with this medication. We try not to use it for too much. Speaking of drugs and coming back to something that's a little bit more um serious. And this is probably the last bit where we're gonna be talking directly at you is seizures, stroke, patients have seizures. You, you might see them more often than not. Um check for simple things. Are they actually having a seizure or it's a BP, one or their blood sugars, one or are they having like a massive BP drop? You know, do your basics, do your ABC DS, do your blood sugar measuring and then crack out the LORazepam. Um I don't know why people do this. They, they, they're like people think Keppra is like a magic drug and then you just give like pediatric doses 20 to 60 mg per kiv as a loading dose is massive, you can go up to like 4.5 g. I usually start with two. I don't because my patients are generally a bit older and you might just knock, come out and make them come go a bit loopy, but just be aware that the dosage is can be quite big. Um If you're reaching, if you're reaching the later points of seizure management and your patient hasn't stopped seizing. It's minute. It's 15 minutes, please. For the love of God, get it, get, get the med red down and we will think of other ways like sedating them, giving them anesthetics and trying to shut the brain down because they're not gonna stop seizing. Despite your best efforts, it takes about eight mg of IV LORazepam to saturate your brain to the extent that your LORazepam is no longer going to be effective. So there's no point giving four after four, after four, after four, it doesn't really work. You need to start using something else. Any questions so far? No, it doesn't look like it. How do you feel about assessing a stroke patient? I might have asked this question already. Come on. Let's see if you're all awake. Hm. So scared. Need more practice. See ns penis exam lonely. I want to refer immediately. Neuro exam is complicated. God, can you imagine doing like an entire cranial nerve, upper lower limb examination on a stroke patient? It takes you half an hour and then you get a consultant to go, they're fine and you're kind of wonder why are they doing that? This is a bit strange. OK. Let's have a, let's have a bit of a game. So uh you might, some people might have seen this video. Um can people see this video running and wanting to put garlic jugs and everything but not everything. Can people see the video running just so I know, OK, and s side of your face is drooping mom. It's probably nothing that are you ok? You're slurring. Why are you snoring? Raise your arms up in the air for me. That are you? Ok. Greasy. Call 911. I just look at me, Grace and tell them to hurry. Tim, look at me, look at me. Tim. Don't know. I think he's having a stroke. I think my dad is having a stroke. My husband, he, he cold. Are you cold? honey? Are you cold? Gracie? See, Gracie's gonna come sweetheart. We're just gonna go, we're just gonna go in the ambulance. Uh Americans can be quite melodramatic, never mind. Um So we're gonna come back to him. Um I get your worries about a stroke assessment. I mean, these, these guys show you can how terrify it is watching that makes my heart rate goes up a bit because when they come to you, it can be quite scary. Um Often we feel like this when we approach a first stroke patient. This, this was me when I, so I did a stroke fellowship about a couple of years ago and this was basically me for about the first six months like it, I was in the same boat as you guys and it's not easy. So it's about developing some sort of a system to allow you to be able to assess a stroke patient systematically and quickly and why, why and basically get things done as soon as possible. Um We're about a month and a half to two months in so as a general pro tip of life, um you should get MD Calc, MD Calc is like a Godsend. Um I get short of memory loss sometimes. It just helps me remember stuff I don't remember for the purposes of today. You've got a glass of comma scale. Generally, if somebody just drops a G CS in front of you, that's a bad thing. Um But in particular, I want you to down to look at the Nihss one. So if I just give you about 15 seconds to just get that into a QR Code, uh, reader and then just find it, that'd be quite helpful. Good. You'll come back. So, first case, er, this guy is, let's just call him Jim. Jim is a 56 year old guy. Um, we're now at 7 35. Um, he had a symptom onset at 6 p.m. whilst chatting to his wife and his child. Um, because we are in theoretical magic land, the paramedics somehow manage to get to him in half an hour and life is great and he manages to get to you by 7 p.m. So about an hour in, he's got a past medical history of atrial fibrillation and high BP and diabetes. And I'm just gonna leave to read the medications there and perhaps you might be wondering what's missing, he's got no allergies and as you can see from the video he's living a good life. Like he's got a very nice house. He also smokes. He also smokes bad, bad man. He smokes anyways. Um So by the time he gets to you, he has the following symptoms on the left. It's a bit bit bit droopy, bit drowsy. He's got this arm quite profound, right sided weakness. Like in a video, he wasn't really moving his right arm at all and he's not moving his right leg and he's got quite an bad CG I generated right facial droop. Um No ataxia, he's a bit dysphasic, very dysarthric. But when you ask him to do this, he says that you're doing both. Um So if you can't get the um MD CALC um then have a look at uh the bar on the left and then you should be able to uh work it out. So I'll give you about a minute to do that. And in the meantime, I'm gonna try something. Mhm OK. Good. So can everybody start writing their answers on the chat inside this metal program? And I'm just going to exit and have a look at the meal program and just see how it's going? Oh my God. So what do people think that Nihss would be if people want me to put the powerpoint slides back up? Um Just let me know now. Yes, please. OK, let's just share a window. I'll probably give you another minute or so. And then I'll have a look at the chat. Ok, let's have a look at the chart now and see what that says, uh, messages. Oh, no messages so far. Ok, fine. Let's head back into it. Um Would anybody like to shout out what they're getting? Hm, fine, I'll come back in. So, uh I screen show that. Ok. And then, yeah, so in that hyper acute case, um what we're seeing is somebody who was quite drowsy to a score of one, they were able to get correct questions and instructions. They had a right hemi op A. So the score is two, had a bad right face droop. So that's three no movement in the right arm and the right leg, which is for each and they can't feel anything that's too. So you kind of get this method of scoring which um enables you to, to quite quickly assess a patient's neurology and get yourself an answer in a way that's very, very relevant to a stroke case. You effectively compress a 30 minute neurological examination down to something that can be done in literally two minutes if you're quick enough, if not quicker. So let's keep going. Can people see the screen so I can keep going good. So what is the ct head finding here? You're seeing a rather bright um lesion here on the left hemisphere. This is actually a blood clot and this is what we call hyperdensity. Basically, there's a clot in the left MC, a territory um for those who are more attentive, you might see that the gentleman's right, left frontal lobe is beginning to um liquefy have that gray white matter differentiation. It's beginning to die. In fact, it's probably already dead. Um What we do next is we go for a hyper acute management. We provide thrombolysis, thrombolysis should be offered to patients who present within 4.5 hours of symptoms on set that might have been made apparent to you med school may have been made apparent to you on a stroke. Qu this will come into play very shortly for thrombectomy. It depends these, this is senior decision. Some people say up to six hours from symptoms onset, some people say longer depending on the tech you've got. So for our case, he gets thrombolysis 7:25 p.m. one hour, 25 minutes from onset, he gets a CT angiogram three minutes later. Uh which shows that there is um probably a bit of reestablishing flow, but you still get blockage downstream here. This entire left hemisphere is not there anymore. Um You get referral for thrombectomy transfer out 8 10 and then you get to your thrombectomy center ready for angio 9 p.m. three hours from symptoms onset. We are in a perfect situation. So I realized I've done something. Um Let me just stop presenting, share entire screen, share system audio, I realized sort of error. So you've done all of that stuff that how you feeling. I'm fine. Well, you've had a stroke but, because you got here quickly, you're looking at a full recovery. Hi. Yeah. You probably didn't hear the audio the first time, but Americans tend to be quite melodramatic. Right. Um, so well done post thrombolysis thrombectomy. Nihsss one, you get a bit of mild dysarthria, actually, that's not terrible in the grand scheme of things. Um, he makes a full recovery in about six weeks from onset. There will be inevitably some underlying cognitive issues. There will be some elements of the trauma that you get from having been in that acute stroke situation. Your memory might not be great. You, you might get a bit of problems in manipulating things, but generally that recovers quite nicely and he's now back to work and he stopped smoking. So that's really good. So what do you need, what do we need a stroke doctor to make a decision at the front door? You need to get your time of onset and lasting? Well, you need to establish contraindication, thrombolysis and this could be quite multiple. So things like anticoagulations, brain tumors, whether they've had a heart attack 14 days ago or that kind of thing. And you need to get an idea of their functional status and that's mainly for referral onwards to centers like thrombectomy. And what have you most of the time, sometimes you can argue that a patient is so disabled by something else that it's not not worth putting them for the risk of thrombolysis, like they're bedbound and severely affected by advanced dementia and already have a lot of previous stroke damage. You might not want to do anything, have a chat with about it. The common thread about amongst these three points is it's all about the information gathering. It's about the information gathering that you do quite quickly and therefore having a system is quite useful. So let's go back to the words and the complexity increases slightly. Um stroke patients, patients who've had strokes who come in in the first one or two days can develop all sorts of neurology was in hospital. And that's one a you have said before. This could be for a variety of reasons, you could have a hemorrhagic transformation. Blood just pours into what was infarct and you get this midline shift. Um Malignant MC syndrome is where such a large territory of brain is damaged by just ischemia that the swelling from that damage just pushes everything to one side and it kind of arrives to the in conclusion, you get a lot of brain pushed to one side. You get your brainstem pushed down into the frame of mag and you drop your G CS. Bad things happen. You can even have something like hydro hydrocephalus, bleed the right way and you block off your ventricles. And when you block off your ventricles, they start to swell again. You drop your G CS bad things happen, you can have more strokes mainly because we've not found the reason why they had the first one atrial fibrillation cancer. And that can cause problems because you just get random new neurology that came out of nowhere. Um But you can also have non vascular causes. We've mentioned seizures, low blood sugars, low BP infections, sodium calcium, those kind of things which makes life complicated. So how do you know if, what you see in front of you is actually new neurology as a result of a stroke or is it because of something else? I'll take you for a very classic case. So, on the stroke, you know, you got an 83 year old lady and the nurses are worried she's had a new stroke. She's had a right-sided MC stroke five days ago and she also gets UTIs on and off if all this happened. She's also had a type of diabetes and she's on insulin classic case. What do people notice about her vitals? Depression? What else? You too? Yeah. So febrile septic looking not very good. Um So you do ABC to ease. It's got left flank tenderness when patients get an infection or something that irritates the brain. Um, preexisting stroke damage tends to accentuate and you get a worsening of neurological symptoms, which is different to the other pathology I was seen earlier on. So somebody scored nihss as five because of drowsiness and motor symptoms. What would you really like to know right now, you need to know what they were like before. So let's run for the case. There's pre presumably an infection. So you have to read the notes and what you've noticed is that the NHS has always been about three or four. So the neurology has been staying pretty stable and you did a CT head because it's good to do imaging in these cases anyways. And you actually get signs of well, much older damage by day five, but nothing really new. So you treat their infection and they very much get better. They become more attentive. Their neurology settles down and actually they do well, they haven't had a new stroke. They've not had a massive bleed, they've not had anything, they've basically suffered what we call a stroke mimic good progress. No further imaging needed. What's interesting about our work as stroke doctors is that stroke mimics which are defined as anything that's similar that be similarity to strokes. But aren't they kind of are like 50% of our work? So we, we always face a bit of uncertainty. A lot of it are medical issues. Some of it can be function, neurology, software issues in the brain. Often younger people going through life stresses or psychological issues and what have you do? You manage these people quite gently. It's, it's not something that they have any control over. So therefore to assess these patients without going for the panic of is it a stroke? Is it not? What do I need to do? Where do I go next? Start forming your own system as new F ones, new F twos doing these assessments, you have to do your basics. Um When I started in my stroke as a registrar job, I kept wanting to think, do I thrombo this patient or not worrying about the other things at the end? When actually I wasn't doing my basics correctly, you have to do your basics correctly. Once you do that, then your decision to act is based on generally five things, their onset time. What the neurological deficit is background of medications and what's your functional baseline? This is all done with attentive history taking either from the patient or from their next of kin or somebody who knows him quite well or the nursing home or someone that just has information or the paramedics call us to help. The reason why we have crazy door to needle times of like 12 minutes is because we literally just pore people into the problem. Somebody does ABC de somebody does history taking, somebody organize a scan, get everything, get go and book a CT head just to begin with. Um, because by the time you get a CT head done stroke team will be there and we will be able to guide you through the rest. And what happens if we don't know if it's a stroke or not? Well, that's why your seniors are booking MRI S because they're, they're very sensitive and they're actually quite clear telling you telling you if somebody's got infarct or not, but they are no substitute for a good history and a good examination because otherwise you can, you might have just call everything a stroke. It's not good. Take a good history and finally, to address some of the dilemmas that you have in the stroke unit. So this keeps happening to me on Friday afternoons when I was at West Suffolk and it really annoyed me. Um It looks something a bit like this. You get someone with a bleed and the day seven and award and basically haven't had photos or IP CS on and off and then they suddenly just go and they look like they're about to die and you're like, this is a bit rogue. Um Does anybody have any idea what this is going to turn into? No, we'll keep going. Um So you do the ECG S can I'm gonna wait, ask you this question directly. Does anybody know um what this is showing? Ok. So you're seeing kind of S one Q three deep waves and T three there, you probably see an element of right bundle branch block as well. And the only thing that's missing here is Sinus Tachycardia got clear x-ray chest. And do you see this a massive great big Pe Palm emboli that's probably about to cause some trouble. So this is a very difficult situation. A lot of people just panic at this point because this is an extremely difficult situation. The reason why it's because it's a balancing act, there are really no right answers to this problem because every case of this is different strokes and venous thrombo embolisms, you have to, you have to basically see which one's worse, um, navigate what kind of stroke they've got blood clot. What, how big is it? Where is it size of the pulmonary blood and no symptoms? If you are to go down a pathway, like giving somebody low molecular heparins or Apixaban, you must tell people I would not thromb as a pe because you're just gonna to kill them. Um do evolve hematology and do involve respiratory if a bit further down. Uh because it'll usually help guide you as to alternative options or if there's any interventions, especially if you're a tertiary center, you can do funky things like a guided um embolectomy where you basically go in and punch a hole through that. Um pe and that allows blood to go through and the patient starts basically perfusing a bit more easily. There are other dilemmas. Some of you have said that already. Why if people keep stroking patients who have no rehabilitation potential? And there's a bit of a and I about it, if patients don't recover or swallow, what do they do next? Um IC U sometimes bias against stroke patients because they look at the brain, go bad neurology. Don't take, we sometimes get young patients, patients in their thirties actually who have terrible brainstem strokes and don't wake up. And those are very difficult discussions about how to approach the atopic of palliation. And what have you similarly, patients who have had large strokes are unrecoverable. How do you deal with those and others? There's plenty about. So at this point, I want to open this to the floor because I am a stroke registrar, ask me anything. So I'm gonna come back to the chat. Um and then I'm gonna ask people to turn on the cameras and start asking me questions and I'll try to answer them in the best way that I can go ahead. You can even ask me questions about things like getting specialties. Um I do quite a lot of medical education. Um and so on. Could you touch my medical management and when to start Aspirin and Clopidogrel? Um That's an excellent question. So, antiplatelets, um you tend to start um as soon as a stroke patient arrives and they are not Thrombo Liz. So for example, if a patient is out of thrombolysis window or you can't do for, for whatever reason, and they've got an ischemic stroke, you can give them aspirin, an is guidance says 14 days of aspirin followed by clopidogrel. Now, this guidance is the most basic variant for questions you might see your bosses do other things. Um some people give geo antiplatelets for minor strokes or tias s some people give geo antiplatelets for carotid dissections. Um It varies depending on the pathology. But the most simplest variation is if it is an ischemic stroke, that nonn thrombolysis 24 hours after. And ideally following a form of imaging like a CT or MRI to rule that bleeding, I hope that helps. And so asks me very complex questions. OK. Um This is an excellent question and it is a research question. Um So management of atrial fibrillation is using anticoagulants and we are worried about whether anticoagulants causes bleeding or not. So if you imagine a table as the progression of the stroke occurs over time, your bleeding risk goes down as the stroke stabilizes but your um but your ischemic risk, your risk of recurrent stroke goes up. And at the moment, we're still researching at what point is it safe to give anticoagulant to somebody with a stroke? It's one of the reasons why we do MRI S in patients who don't have obvious ischemic strokes because we wanna see what the size of their infarct is. And based on that start anticoagulants, um massive strokes like entire hemisphere gone easily over 14 days, some a bit smaller between four and seven tias. As long as you rule out bleed start immediately. Hope that helps any other questions I can answer anything. Hello? Thank you, Bill for the session. I just wanna let everyone know that even if you think of questions later on, you can just text us or the Amazon Instagram or on whatsapp and we can send Billy the question and he can send us the answer back for you if you don't have any questions now. But oh, we have another question, so I'm sure. Oh OK. Um So on, I will actually write an appendix and send it to you guys as well. Um That's another good question. So 33 times when this happens, generally, um you can use g anti platelets. If somebody has a mini stroke or a what we call a minor stroke, something with an NIHS has of under four. At that point, you use 21 days of du antiplatelets and then you move them on to a single antiplatelet. You can also use uh platelets in what we call carotid dissections. So where you get a tear in the neck, they tend to go on for about three months um before you switch them. And finally, if you've got Doris 87 year old frail lady with a bad carotid stenosis that people can't scoop or can't do interventions on, then you put them on your anti platelets. Um And whilst I'm at it, um you probably will, do you play those thing, patients with things like cardiac stents and what have you? Um But at that point, you'd be liaising with cardiology to um come up with a good solution to all of their problems. Oh, yeah. So, um, this hits a bit because we actually had something very similar, um, be for those who actually work in West Suffolk, somewhere between March, August and September, we had something very similar. Um, yeah. How, at what point do you, um, do you make that call? So, this is very difficult and, but the family, um, the patient and the family are the ones that should be helping you um guide that decision. So some patients could have made it very clear based on their life actions in life that they at no point would want to be disabled in a way that a large stroke like hemorrhagic stroke or cem strokes can lead them to have um family might be able to get an idea of that. Um advanced directives can living wills can, it's up to yourselves. Definitely you have senior help to get that information as clear as possible and then offer them the options. So in this situation, we go. So your relative or this patient has suffered a massive stroke, a malignant MC symptom or a massive bleed, they need to go for newer surgery. We cannot use neurosurgery to fix the stroke. That's already happened. This is very clear. It's not subdural, subdural, it's all about pressure, you remove the blood, the brain re expand, you get better, but it's about damage limitation. It's about making sure that you don't get brain stem compression. They're probably going to remain disabled. Is that something that you feel the patient will be happy with? And you have a good discussion. Um, and based on that you make adjustments. There is, that's actually a book. Um, there are ethical dilemmas or ethics in neurosurgery. I've got it in my house. I haven't read it. You should read it. I should read it. It will be quite important. How do you decide when mechanical thrombectomy is indicated? Um I hope that helps, by the way. Um Karen, that's hopefully very, it's a difficult topic, but I hope that's, that helps. Um So how do you decide when mechanical thrombectomy is indicated? Um So the easiest option is within six hours of presentation with what we call a large vessel occlusion. So when you get like a chunky blood clot in somebody's middle cerebral artery, um they are now something we call National Stroke Guidance. We basically made stroke very easy. We've published National Stroke Guidance accumulating like our entire um specialties. Um ge out of experience into all of what we do and they provide information on the more nic points. What happens after six hours. So if you got a large vessel occlusion after six hours, you generally require some more advanced imaging that's not touched on in this talk because it's quite advanced, such as things like CT perfusion, Mr perfusion. So contrast related scans or things like um MRI um Mismatch scans, they're all quite advanced imaging Um And with this technology, you can actually pull your thrombectomy window up to about 24 hours. This is why the specialty is cool. We're expanding our borders. 01 more thing. Um Patient with ac Cotton must have quite significant neurology. So, NIHS is above five. That's another that I need to mention. Good. Any other questions? So we've had ethical dilemmas. We've had advanced dilemmas. Um Any other questions out of interest? is anybody interested in stroke medicine? Uh We'll, we'll find some of you later. Um OK, if there's no more questions, oh Karen, see how you feel. It might be quite cool. Uh Depends on if your tertiary center or not. But um if people do find that through time, they become interested in stroke medicine and all it has to offer um stroke is a perfect combination of neurology, geriatric medicine, cardiology, radiology, and intervention with the ability to um delve into any of those things. Um And the ability to, to be riding on a knife edge. Um stroke physicians go to conferences every single year because news shit gets published every single year and that's what and therefore the the topic remains exciting at all times. So um do get Despina to um link me with you if you are interested. But on that note, thank you so much guys for coming and thank you for being with the it issues. Thank you, everyone and feedback form is sent to you in this group chat and is also sent on the whatsapp group. So I know there's been a delay with the certificates, but I literally went and found the person that we need the signature from. I handed them down and they're going to give it to us this week. So basically, you're just going to receive all the certificates you've attended together. Um Thank you so much, Billy. This was amazing. Thank you so much for doing this and I'm sure everyone found it very useful and uh any questions you guys have for Billy later, um I will make sure they get answered if you just text us on the group chat or on Instagram, whatever you prefer. Ok? Thank you, Lili. Have a good evening. Bye bye bye.