Mastering Stroke Codes

[@moxittos]

It's hard to express how privileged we are to have access to such information presented so beautifully. Increadible work! Thank you!

[@theneurophile]

Wow. Thank you! It’s my pleasure.

[@nowtelDarmendra]

Wonderful, I love to learn from all of your presentations .... Thanks a million

[@aconcretemoth9382]

god bless the light sense of humor that shows up in these

[@shyamakula149]

Thank you so much for continuing to put out such high quality content. I have immensely appreciated your channel as I train.

[@theneurophile]

My pleasure!

[@oliviamckay3335]

Please never stop making videos! These are the best thing I've ever seen

[@remm9188]

This is the best stroke speaker/presentation I have ever heard. Thank you doctor

[@theneurophile]

Wow! Thank you!

[@jjaboube]

Thank you for your incredibly high quality lectures. Really appreciated and hope you don't stop.

[@Magnus_E]

I'm so angry; it's been such a long time since I have witnessed such high-quality channel. Thank you so much!

[@BakarAli-z8y]

Got a lot of insights from your work as always, greeting from somalia, and thank you

[@adrianstlui]

As high-quality as usual. Thank you for clearing up my mind when there are so much new evidences coming up which is definitely confusing!

[@TropicalCayman]

The Rybinnik strikes again--just in time for my second overnight as a freshly minted PGY2. Many thanks for what you do!

[@theneurophile]

Nice! I hope it helps.

[@RashaAl-Khafaji-xi4qk]

Thank you so much. I appreciate that you said from the beginning that there may be differences in the approach between the countries. Thank you for the cases; they help in clinical practice and enforce reason of thinking.😇

[@hldmyhndPX]

welcome back!! Thanks for another fantastic video

[@aeneas4501]

Excellent, really excellent. Thank you so much!

[@farahtahir8175]

This was the lecture I didn't know I needed so THANK YOU VERY MUCH - if all my medical school lectures had been like this I could have been House by now XD.

[@theneurophile]

Thank you!

[@mb5101]

I’ve seem a lot of great teachers in my life, BUT you are the best 🎉

[@rodrigosanjinez]

Thank u so much, for such a didactic way to teach neurology. makes me love even more this specialty

[@RebeccaWeber-q2c]

Such great and high quality content! Thank you for making these videos.

[@theneurophile]

Anytime, Rebecca. I'm glad that this is useful.

[@asmanouadria3501]

Very interesting !! Thank you so much, we are waiting for more interesting videos

[@sanbetski]

awesome work!

[@georgebashour4333]

A neurohpil morning is an amazing morning 💙 Thanks for the awesome work!

[@theneurophile]

You made my day!

[@axelreeds1816]

gracias por lo que haces en pro de la educación ¡¡

[@zeljkacuk4498]

Thank you soooo much for this lecutre! Cant wait for another lecture!

[@MdRubel-qe6bl]

Its a Masterpiece presentation❤

[@dr.odayfathy4310]

Thank you so much from libya Keep posting such fantastic contents

[@desertdweller129]

Thank you for the video. Truly a beautiful presentation.

[@bryndis1762]

Really appreciate your channel, thank you for the tremendously good work! A great help in residency!!

[@theneurophile]

Our pleasure!

[@arcdexie913]

Much appreciated!🥰

[@igalenas21]

Is there somewhere we can access this chart

[@frankrobert1917]

great lectures.

[@ahmedrabie2574]

amazing as always

[@cheemDr]

Welcome back!

[@anasbit2]

I love your content ! Keep going

[@nhutnhut2x24]

Thanks for your share!

[@Kha1i107]

Great lectures. May i suggest dementia as a future topic

[@theneurophile]

Absolutely. We are working on it.

[@qqqq-mh5if]

Very good. Can i have a downloadable version of flow chart?

[@theneurophile]

Sure. Link is in the video description.

[@NeurologyPPUKM]

Thank you for the wonderful lecturer and quiz!! would like to ask, for case 3, shouldn't we start with thrombolysis at the first place as gait ataxia is consider disabling?

[@theneurophile]

Ataxia is absolutely disabling. In case 3, I mentioned that the patient’s ataxia has resolved upon arrival to the emergency department and he only had vague sensory symptoms, which were not disabling. That’s the reason we proceeded to DAPT instead of TNK.

[@Jaridmir]

Dr Rybinnik, is there a possibility of you sharing the chart as a separate image? Thank you regardless for the amazing video as always

[@theneurophile]

Sure. I put the link to the protocol in the video description

[@vanessa851991]

Love your videos. Is the contraindication for thrombolytics a DOAC within 24 hrs or is it within 48 hrs? I have seen both

[@theneurophile]

Thank you! After 24 hours (missing two doses of a DOAC), the level of anticoagulant is quite low. As long as, coags are normal, thrombolytic may be considered. If coags are not available, the safer time period is 48 hours.

[@vanessa851991]

Ok thanks for the clarification! Also when you say coags when talking about DOACs do you mean PT/PTT/INR or do you mean anti-Xa?@@theneurophile

[@yodea4]

That was awesome!

[@samiheikkinen5375]

Thank you for yet again a great video! Such concise and useful information, now with recent studies to back it up! Question: case 2 had right field cut, but this is not common for right MCA stroke. Did she also have cardiogenic embolus in her left PCA?

[@theneurophile]

Thank you for that very important question. Let me clarify. Field cut with MCA strokes is very very common. MCA supplies temporal and parietal optic radiations. In fact, since MCA strokes are much more common than PCA strokes, if you see a field cut (especially with other symptoms) you are likely dealing with MCA and not PCA. Take a look at our video on vascular territories: kzbin.info/www/bejne/a5bRc2huoNOXoJY

[@samiheikkinen5375]

Thank you for quick reply. I am aware field cut is a MCA stroke symptom. My question was regarding the side of field cut. Why did case 2 have right side field cut with right MCA stroke, but case 4 had left side field cut with right MCA stroke?

[@theneurophile]

Oh. That might have been a typo. Thank you for catching that. I apologize. It should have been a field cut contralateral to the MCa lesion as expected.

[@freelowper7]

Good stuff. Just a minor correction. BP goal before administering TNK or TPA is

[@theneurophile]

Thank you. Unfortunately the package inserts for TNK and ALT differ. The BP goal here is from the TNK’s package insert.

[@m.sheikh5105]

I cant thank you enough

[@caiyu538]

Great to revisit

[@dr.nikhilagrawal3854]

Can you make a video for approach to neuropathy

[@giovasags]

A hugest amount of work offered to us for free. Thank you ❤ by an Italian emergency MD. Why is rivaroxaban not included in the initial workup 2:31 circa?

[@theneurophile]

Thank you! Sorry, I totally forgot about rivaroxaban (I mention it later). Yes, you should also ask about Rivaroxaban.

[@damiensegers3555]

The European Stroke Organisation recommends IV tPA in the 4.5-9 hour window for patients triaged by advanced imaging even if endovascular treatment is not planned or indicated given a core of less than 70 mL, a mismatch of at least 1.2 and at least 10 mL. What is your opinion on this? -Neuro PGY1 from Belgium

[@theneurophile]

Yes you are correct. We are routinely treating patients with IV TNK within 9 hours of symptom discovery (or midpoint of sleep) as long as patients present within 4.5 hour from symptom discovery and a core is =1.2x (at least 10cc). However, in patients without a large vessel occlusion, we tend to skip CTP in favor of MRI (FLAIR/DWI mismatch) to select patients for TNK because CTP does not have a great resolution for small cortical or subcortical strokes.

[@damiensegers3555]

@@theneurophile I understand, but my reading of Dutch guidelines and ESO seems to indicate that IVTL is also employed >4.5h of symptom discovery in known-onset, non-wakeup Strokes (e.g. AIS begins at 08:00 AM, IVTL at 16:00 PM). I suppose this is a European thing, and will be double-checking with my attendings. Thanks for the response!

[@theneurophile]

@damiensegers3555 Unfortunately TIMELESS trial was negative, and that was supposed to establish TNK in the 6-24 hour window. So while we can make the argument that in patients with unknown symptom onset and favorable imaging, TNK may be beneficial, when symptom onset/symptom discovery time is known, we have to stick to the 4.5 hour window from that time.

[@damiensegers3555]

@@theneurophile thank you very much for your time!

[@mb5101]

Thank you. Perfect. DOAC within 24 or 48 hours in your center?

[@mb5101]

@@theneurophile thank you. I meant doac in the last 24 hour is a contraindication or 48 h? In video you said 24 but in our center it is 48 h

[@theneurophile]

Oh you mean for TNK? 24 hours off drug with normal coags should be safe for TNK. ASA/AHA guidelines recommend 48 hours.@@mb5101

[@caiyu538]

great

[@phucthinhtran3038]

22:16 Deffuse 3 with core infract

[@theneurophile]

Yep. When I said “any core infarct,” I was referring to SELECT 2 and ANGEL ASPECT trials.

[@aygunasgarli2426]

Is BP should be

[@theneurophile]

The TNK package insert lists

[@maryambahadori-k9k]

do you check anti-Xa in your center if patient is on eliquis?

[@theneurophile]

Yes, we do. However, it takes a while to come back.

[@profaakashassad]

movies?

[@KatherinVlcek]

Excellent. Thank you so much! I'll be waiting for brain tumors.