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Introduction History and Disclosures | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Introduction History and Disclosures | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Blood Vessels | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Blood Vessels | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Causes of Stroke - Changing Lifestyle  | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Causes of Stroke - Changing Lifestyle | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Antiplatelet Trials Summary and Ischemic Stroke Etiology - Difference Between Heart Attack and Stroke | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Antiplatelet Trials Summary and Ischemic Stroke Etiology - Difference Between Heart Attack and Stroke | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Hypercoagulability and Cerebral Venous Thrombosis | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Hypercoagulability and Cerebral Venous Thrombosis | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Genetic Stroke Syndromes - CADASIL Moyamoya Disease RCVS and Intra Arterial Spasmolysis | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Genetic Stroke Syndromes - CADASIL Moyamoya Disease RCVS and Intra Arterial Spasmolysis | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Public Education and Factors Influencing Outcome | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Public Education and Factors Influencing Outcome | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Cerebral Collateral Circulation | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Cerebral Collateral Circulation | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Leptomeningeal Collaterals and Device Evolution for Treatment | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Leptomeningeal Collaterals and Device Evolution for Treatment | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
anteriorarrestarterybloodcardiaccatheterscerebralcerebral arterycollateralsdevicedeviceshourshydrationloopsmeningealstentvessel
Time is Brain for Stroke Symptoms | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Time is Brain for Stroke Symptoms | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
IV t-PA Recanalization | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
IV t-PA Recanalization | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Global Aphasia and R hemiplegia | Thrombectomy | 64 | Male | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Global Aphasia and R hemiplegia | Thrombectomy | 64 | Male | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
angiogramarterybloodbraincerebralcerebral arteryclotcollateralscompletelydenseeyesfacialleftmiddlemiddle cerebralmidlineoccludedocclusionskull
Multifocal L Hemispheric Stroke and Crescendo TIA | Intracranial Angioplasty and Stentint | 62 | Female | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Multifocal L Hemispheric Stroke and Crescendo TIA | Intracranial Angioplasty and Stentint | 62 | Female | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
ACOM Aneurysm | Embolization | 68 | Male | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
ACOM Aneurysm | Embolization | 68 | Male | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Subarachnoid Hemorrhage | N - BCA Balloon Reflux Control and Embolization | 69 | Female | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Subarachnoid Hemorrhage | N - BCA Balloon Reflux Control and Embolization | 69 | Female | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Onset Headache Dysarthia and Dysequilibrium | Embolization | 55 | Male | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
Onset Headache Dysarthia and Dysequilibrium | Embolization | 55 | Male | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
The Future and Questions | Acute Ischemic Stroke- Presentation, Diagnosis, and Management
The Future and Questions | Acute Ischemic Stroke- Presentation, Diagnosis, and Management

okay guys we're gonna get ready to introduce the next class for dinner our next presenter is dr. Wolfgang leash I have the privilege of working this gentleman every day he's a good friend of mine very passionate about what today that the Wolfgang lease is a graduate of

the Hanover School of Medicine in Germany and computed as residency at New York University Medical School he's a nice lead exactly and critical care neurology fellowship at Massachusetts General Hospital and then when I was

completed a fellowship and endovascular surgery at st. Luke's Roosevelt Hospital Center with Columbia University in New York he is a board certified and neurology and vascular neurology does my eyes my privilege this morning to

introduce that the woof gang leash and he's the only one I know that's excited about obscure come then and friday night at six o'clock only because we can do something about it and helped us help the guy so thank you very much good

morning everyone thank you very much for turning I'll just uh on the last day of the needing it started with stroke and it's endless talk and the reason that is that the stroke I think arguably is one of the hottest topics in many topics and

medical today and I want to begin with maybe just reminisce really where he came from and and where we have rarely have come to if you think that stroke here in the 1980s and early 90s all it was is putting the patient in the corner

of the emergency room and giving them an aspirin and hope that they would get better that was the first step in stroke and stroke care and then people recognize that when the blood clot occlude the blood vessel in

the brain to come from the heart it comes from the collage rather come from we have bottled waters in the brain that you could treated without preneur in the keikyu sedative in acute from if you could like it most 1995 but TTA came on

the market the ni NE s dr national institute for neurological disorders and stroke was a great push forward in 20 years later and only in 2015 have realized at the point where we can actually safely and efficiently go up

into the brain open up the blood vessels and restore blood flow to the brain the stunning and efficient manner with pretty much reverse the symptoms of stroke so the f I think reached the pinnacle of treatment of stroke we can

really do something about it as miraculous I mean many of you have probably seen the recoveries that you can trees and the focus mouth ship that really ships in the pre-hospital care because the problem is not anymore

opening up the blood vessel the problem now is to get the patient the right patient to the right hospital in time yeah my disclosure the nervous system is

that the talk really starts off with some anatomical biological correlation

and want to focus more on the anatomy of stroke and then the diagnosis and few slides at the end of the treatment if we have time we can talk a little bit about hemorrhagic stroke too as I mentioned you know that Stoker's when the black

claw secluded address in the brain in the narrow sense or the title says acute ischemic stroke but stroke also includes haemorrhagic stroke of all commerce about 700 or 800 thousand strokes in the United States every year the number one

cause of disability I think at this point the number four or five cause of death has gone down every year because of our effort eighty percent of these strokes will be ischemic somebody comes in with a focal neurological deficit

twenty percent fifteen to twenty percent OB hemorrhagic what we're focusing on to today mainly the ischemic stroke why we fascinated with the nervous nervous system where the nervous system is the command center

of the body it is a central nervous system you have had has its tentacles all over the body every single organ relies on it and it has a lot of function that our autonomic as well as a subconscious we don't even know about it

and it is comprised of these self the neuron has many inputs here the dendrites and only one outside near the axon and then connects to other neurons and as a reminder on the surface of the brain lives the neurons and they send

their axons down the majority of the math of the brain is just fibers and

somehow these connections these trillions of connections then they give rise to what we call the consciousness which is what fascinates us the most and

we don't understand really how it happened 84 billion neurons in the brain is being said with 100 trillion synapses now before 2008 everybody thought there was a high number now are they say that's nothing compared to the National

Desmond cortical representation is something that we learned mainly from stroke if you think about CT scans only been around since the 80s there is areas of the brain that has the sub special specialization as you know the motor

strip here in red and the sensory strip in blue they basically are needed to move around if you have a stroke in that area you will be paralyzed or in any of the fibers that go from there down into the body there are other areas of the

brain mainly in the frontal lobe februari highly connected has to do with emotion with personality sort of you have a stroke there you may not even find out maybe have a personality change but that would be a very subtle in

certain areas of the body are over-represented in this so called a monkey loose picture as you see how the hands obviously have way more cortical representation the lips the tone etc and

the motor strip this brain is looking to the left in red is the motor strip and blues the sensory strip and then you have on the the brain to areas that are language areas Broca's area in front of the court

of the motor strip in the inferior frontal lobe and in the temporal lobe you have Roenicke area which is part of the language areas where the understanding happen Broca's area would be where you speak in the back of the

head the visual area those are important pathways on the right the cartoon shows you the visual pathways that are crossing over just like the border Padres right many of these things or all of these things were found out with

stroke further patients there was no CT scan there was no functional MRI people had strokes in these areas then the problem they died for whatever reason the pathologist cut the brain they looked and saw where the store wasn't

and said oh look every every time someone has an expressive aphasia is on the left side of the brain everybody has a receptive shader it's on the left side of the brain in in the temporal lobe etc etc and this is how all these things

is really the blood vessels are the blood vessels the natural pathways of the body that are like streets in the neighborhood we tend to forget because we always look at the large blood

vessels and then we forget that there is the road that goes through every single cell so it's really a pathway that we can use we cannot get to the canted everywhere but if you inject medicine it's washing down to every single last

cell here's a representation of so cartoon of the of the blood vessels that go to the left side of the brain the left side of the brain female controls the right side of the body it also has a language both speaking and understanding

and when you have a blood clot traveling up the internal carotid artery oftentimes it gets stuck right at the bifurcation where the middle cerebral artery gives rise to branches that supplied the majority of one side of the

brain the vast majority two-thirds of one side of the brain is supplied by this branch for the middle cerebral artery and then you have in the middle of the enter through the lobby is kind of not very well seen in this car too

what I want to emphasize here is that a tiny little blood flow traveling up there getting stuck here gives you an enormous amount of damage right on the left side of the brain that controls the right side of the body you wouldn't be

able to move me paralyzed you will not be able to feel anything the eyes usually go to the side of the stroke because the opposite brain frontal eye fields push to the side that push push the eyes over so the patient looks to

what the side of the stroke and away from the side of the hemiparesis and you will see that later and if it's a left side of the brain it has the language so they come in they usually right awake and if you have seen that even my

emergency room physicians they sometimes if they have a patient comes in comatose they call it a stroke I'm not saying in comatose patient couldn't have a stroke but the vast majority of time the patient should be right away if they

have a left brain stroke they don't speak they don't understand they don't move the right side of the body they don't have sensation on the right of the back right there right away the eyes are open if they have a right side as we

install the opposite side to flip this brain around then if they have something in addition to the paralysis on the left they will be able to speak because language on the left side and they have a syndrome that's called an no joke Nora

from Greek unaware of the illness or neglect it could be so dense that you hold their hand in front of them and they don't even know it's their own hand they will deny it they can speak but they will deny that this is their own

hand in the posterior circulation as you know you have the two carotid going up and in the back you have to smaller vertebral arteries going together and from the balloting that rides on top of the brain stem here the pun Hans letting

for bridge because it's bridging the brain with spinal cord and that has all the tiny little perforators into the brains I mean you can imagine that if you have a clock back there that's a major problem because in addition to all

the motor fibers they bundle together and bring all the information from the brain to the body communicate you have in that region or the autonomous function the hard way the breathing the wakefulness these patients could also be

comatose a common stroke sitting room of the poster circulation that's being mistaken or missed because it doesn't involve weakness if the lateral medullary syndrome to know that Valen dark syndrome and it

has you have across centuries the sensory loss you could have epsilon rules this meat reacting an old singer testing and what's often part of mnemonic is the bobbing eye movement with stagnant but no weakness per se

that's often missed but these days everybody is getting CTAs in our institution we have comprehensive Stroke Center everybody it comes into the emergency room within eight hours get the CTA so it makes it much easier to

make these diagnoses causes well you

can't do much about that but you can change your life stuff from purely medical standpoint looking at the reason for stroke lifestyle modification has been shown to be even more effective

than the correct medical regimen right those are the big ones like all of vascular disease hypertension smoking diabetes Ethel epidemia those are all things that can be influenced by lifestyle always the simple medical

regimen many of these made many of these conditions they don't even hurt unless until you have a stroke or you have renal failure or you have clawed occasion or whatever it is right if you if you believe these numbers if you

control your hypertension you reduce your stroke risk we're thirty to forty percent smoking fifty percent within one year they sign up to five years diabetes forty-four percent reduction hyperlipidaemia as you take a statin

twenty to thirty percent atrial fibrillation with warfarin or utters Lewis with aspirin you should have a negative two hundred percent chance of having a stroke trials have been done if

sixth row comes from the heart we just

walk with still come from the next because antiplatelet i summarize for you just give aspirin aspirin has been around for 100 years it's a great drug it works wonderfully it's cheap you'll even need prescription right slovaks

works also aggrenox was works also the combination of aspirin and dipyridamole really started a spoon and studies have shown the daily aspirin a delirium should be just as effective as fear and 25 for the purpose of store

prevention again when we have the stroke it's different from a heart attack how not really that the blood vessel secluded if you have a coronary RV occluded you have a heart attack if you have the blood vessels in the brain

you're getting a stroke but the difference is in the path of mechanism in the heart usually what you have is a clock that ruptures and include to the coronary artery in the stroke typically most of the time majority of the time

you will have a clock that travels from another part of the body into the brain and then get started that's why we have a different approach to it from the interventional standpoint also because in the brain you can retrieve the blood

clot take it out in the heart it's difficult to retrieve and at the remotest luck maybe overlying pressure almost cetera but typically as you know what the cardiologist does they extend it down in the brain we go in we take

out the blood clot so the blood clot travels from another point the body if you remember a few slides under our causes of stroke but this these two are the big ones right from the heart or from the carotid artery that's why the

typical strokes cleaning work up for anybody comes into the hospital medical screening workup is an echocardiogram and the cross-duplex can now in an advanced center you do a CT angiogram oh they had in the neck then you see

obviously you can cover much more pathologies see much more not only the tiny little window at the carotid where's the storm is forming in the heart well you know that atrial fibrillation is a risk factor that

causes from information in the heart and that happens when the atrium of the heart is not contracting in concert with the main chamber the way blood is design is that if it doesn't flow for this warm sludge same thing when you cut yourself

once get so same thing happens here there's the atrial appendage as you see in this cartoon how in the atrial appendage this Rumble swarms and wait to fly into the brain in the carotid this

is one of our recent cases I took this

off because on into the into the talks because of this little duckling looking clot that's almost waiting to fly up into the brain dismiss the crowd bifurcation and you can have a plaque rupture there for some reason where the

crowd by Associated plug like and we see oftentimes the cervical garage this mysterious in a way there's never any luck here but it's always forming down here in the ball and then it can rupture and it can detect more

platelets and conform clot and it can spit or the entire team can fly up and cause a stroke that's why we do listen for breweries we do the duplex to do the CTA and geography is the gold standard dissection something you're very

familiar with the cause for stroke and younger people when the inner layer of the blood vessel comes off it formless left in this in the south lumen between the flap and the outer vessel wall clock will swarm it doesn't necessarily cause

an immediate stroke it could take a week to sometimes we will never get a stroke but it could at some point is larger than going to the brain and cause problems joint how the practicum initial ations cetera and you can have

intracranial disease obviously that also can cause stroke atherosclerosis within

hypercore ability work up the most common causes of stroke from a hyper credibility problem it's factor 5 Leiden

closed Foreman gene mutation there are others acquire type type of choir blue state in cancer pregnancy with pro long-term ability if you fly in from Australia we have seen all this and certain antibody syndromes like

antiphospholipid syndrome and typically the clot forms in the range where blood flow slower we think in that in that circumstance you think about psl patent foramen ovale where the clock would go from the vein in from the right harder

to the left heart then called a paradoxical embolism would go into the brain cause of stroke or we heard in another talk another day my furnace syndrome where you have clot forming in the pelvic veins because of the anatomy

overlying artery or vein slow flow sluggish flow we had one young patient come in like that we saw on the MRI sluggish flow in the brain had a big PS all the cloth flew from the pelvic pain into the heart from the right out into

the left heart to the brain that's the flippin in young women often you get you can get the visa bill by mr. Venus symbols luckily that a rare condition but is one of the conditions where you can get

blood squeeze or if the drainage is cloth blood will squeeze out of the ethereal side and you'll get bleep you see these tiny little spots of blood on the CT scan that's the one condition where you have to give blood thinners

and somebody has blood on the brain we can go in here you see a catheter we ascribe you've never been very successful be honest with you this is a devastating condition and anticoagulation is the way to go another

cause for stroke in a tiny little fraction people's genetic strokin was just one example here cadasil it's a not free gene mutation that can cause white matter strokes starts with headaches and the memory problems age 30 to 50

moyamoya disease is something that's very common in the Asian population it's an idiopathic meaning we don't know why really atrophy of the inter-cranial internal carotid artery and middle cerebral artery looking to the patient's

face either here the notice here the mouth is here there may be a hereditary component to it women often the sexes its more common in ages in here and it can present a stroke moyamoya means puff of smoke and on the angiogram you see

these tiny little collaterals because the shutdown of the middle to really happen so slow collaterals form in the local region and then they look on the anagram like a puff of smoke the rare condition that is difficult to treat

often has to go to bypass surgery it's also cause stroke in the young people's known as cerebral vasoconstriction Spoonamore reversible 30 basic infection syndrome or postpartum envy offices this lady was 23 she had she came in with

strokes and a tiny little speckle of subarachnoid blood and we found that her blood vessels had clamped down all over the place you can see we took her down many times with the endless wait and try to relax that vasospasm by injection of

verapamil and other radioactive substances but she still ended up with watersheds own interactions in the frontal lobe and in the parietal occipital areas

stroke is very important to have public

education like that a lot what I do I go out to talk to the firemen talk to local Edie's set up why because again when you compare to the cardiology you don't need any education it hurts like a lot in the people say that they feel to them as if

some in elephant is sitting on their chests in strokes it doesn't hurt so somebody else in addition to that you have brain damage the other can speak you can't talk or you are neglectful of your deficit so family member will have

to note it and I was just at the international stroke conference a few weeks ago and euston somebody said you should educate the children look that's a great idea because they will recognize over their grandparents and perhaps and

bring them in or educate their parents about about symptoms of stroke it is all starts in the community they need to know the symptoms of stroke numbness weakness double vision trouble speaking or swallowing those are the symptoms

without pain most of the time then call 911 right away you all have heard the phrase time is brain call 911 right away bring them to the right hospital where something can be done about it and this mnemonic refer before task if the face

is droopy the arm is droopy the speech is slurred think time think time so that we can give TPA in the 90s everything was thought to be based on time right time is important we'll see other factors are important the time is

certainly important this trial the famous n inds trial the TTA trials from 1995 showed that if you give TPA within three hours you have a thirty percent chance of improvement neurological deficits long-term outcome 90 days but

you'd buys it with a almost seven percent chance of risk of bleeding in the brain now I think we've gotten better we get a feeling for it who were the ones you look at the CT scan they have very brittle brain they already

have a lot of microvascular disease or they had prior micro hemorrhages then maybe we'll be more cautious you know it's all off the label but i think our numbers when we look at them they're lower than seven percent

the PPA treatment asymptomatic intracerebral hemorrhage but that's what this trial showed the randomized control trials a landmark trial to this very day this is the standard treatment TPA within three hours you know other

sectors that are influencing outcome age of its equal morbidity patient selection when you go to the intervention and a caesar intubation the operator skill and then i would like to introduce the concept of anatomy anatomy is the other

factor that i think is just as important maybe even more important than time what

is that that i'm referring to well this is the area where we practice the hampton roads area you see more for you see the paintings virginia peninsula and

there are certain tunnels right if you think about the tunnels and bridges these are tunnels these are bridges or bridge tunnels you can get from one side of the water to the other by taking the big road through the tunnel or you can

take a long road here this way that way or you go all the way around from the Eastern Shore and come down this way it will take you longer one way this way then that way collateral circulation means that you have an alternative

pathway to get to the same spot the blood vessels in the brain are like trees they come with a big trunk and then they fan out and become smaller smaller smaller smaller however it's not like trees in that the end arteries the

tiny little capillaries from one tree connect to the one from the one nexus two in addition you have connections at the base of the brain this gentleman is thomas willis he first described in 17th century the Circle of Willis you're

looking here is an Ender graphic picture with a lot of reflux and cross filling into the patient's face the eyes are here the nose here the mouth is here this is the head you see I'm injecting the left internal carotid artery here's

the middle cerebral artery is the anterior cerebral artery this is the poster of communicating artery connecting through the bachelor tip and this is the batline reflux into the Basel audio this is the tcom on the

other side and then you have a connection in the front between the two anterior cerebral arteries which called the a comb the entire thing is called the circle or will it at the base of the brain if you have an occlusion down here

it's no problem because from you can fill over here you can fill from the right to the left and from the back to the front the same thing if you have enough losing here you see that this one block that is that I'm injecting is

filling pretty much the entire brain that is a natural selection advantage is that evolutionary you would explain why it's how this came into being not everybody has a full circle of willis but it certainly helps that's why people

walk around is ninety-nine percent carotid stenosis and they can still be a thumb tomorrow you can call it occlusion we see it all the time right the other

collaterals that are very important of electro meningeal culero those are the

end our resident mean when you have two three standing next to each other the tiniest little blood vessel they will arch over and they will connect in the end territory so here is a gentleman with a with a internal carotid artery

injection and an acute stroke you see the white patch this is the area of the middle cerebral artery that is out however you see branches of the middle through the lobby coming down how is that it will udah dwell the anterior

cerebral artery fills here in the capillary phase and these capillaries in retrogradely flushed into these middle cerebral artery branches and they light up at very very late and that is ultimately the reason why we can treat

this patient six stops six hours eight hours ten hours after the text if I see this then I know already if I can open up the blood vessel I'm good the pager to think about a stroke is not like really like a cardiac arrest right to

cardiac arrest is the ultimate flow arrest days nothing slows everything standstill it only takes five minutes for the brain to be dead why does every have success well that is the reason there is still a trickle of blood flow

but it's not enough to sustain the cells for a long time it's like a boxer that's being knocked out in the ring you cannot go on you cannot get up cannot do anything else but he's still alive so if you give get back nutrition you give

back food you give back a hydration well then it will come back it's like a plant that it's about to die if you give water that will come back but if it's that is too late right so this is the this is the reason that we can do something up

to six hours or or even longer and we have seen the evolution of devices and what alluded to in another talk I don't want to get too much into it but in 2004 the first device came out the mercy device

like a corkscrew kind of device the idea was you can screw it in and then pull out the clock believe me it doesn't work very well but people made a lot of money with it now and then one year later serious later you came the kings of the

number system and the real breakthrough was in 2012 when somebody says hey in the periphery we always send the vessel downs and why don't we try this there and then they use the stent and they just notice that if they don't deploy

the spin but they just pulled entire thing out that sensitivity was designed as a stent a detachable stand the clock got stuck on it and that was really the pivotal moment where so when we first deployed to stand in across the closet

pulled it out it was incredible I mean it really worked so well you knew that this was a total shift change since then we have gotten you see the improvement and technology we went from the dial phone to the type phone to the car phone

to the smartphone and so we have newer devices they have now material science that allows us to show bring side french even six French catheters up into the brain to all the loops and loops and the engineering challenge was there that you

have enough flexibility to allow to do that without doing damage to the god better at the same time not have a collapse if you if you apply suction so with this the stent retriever it also works very well if you have a relatively

straight Anatomy can get to the end of the clot and then suck either you grab it with it or you suck it out with this this is our two main ways how we retrieved lot these days right and this

is how it looks on the suction catheter

in the idea is so simple right you have basically the clock sucks you can have it cork or sometimes it comes through the cancer right into the bucket and here's an example of the standard fever and how it's being stuck on the stand

now I mentioned already in 2015 actually it was in October 2014 at the world stroke conference a group from the Netherlands presented the first and still to this day the only completed we only completely finished randomized

control doubled Castillo control trial for huge stroke endovascular treatment pitched against medical treatment in the enter circulation and one illusions there are very careful because on the way leading up we had three negative

trials there were several negative trials and the reason was number one certain selection criteria etc but mainly also device divided the old devices just didn't work so well this was the first study that came out and

was presented the world stroke on tour for 2014 people got up there was such an excitement the community you wouldn't believe I've not been there but I heard they jumped up gave standing ovations in 2015 at the stroke conference it was in

national the American Heart also you think that reaches not research scientists are going to boring people but these people that was such an energy in the room those electric line was really incredible three thousand people

in fenton when they came up and they presented interim data the interim analysis of all these trials to quite honest us supposed to be number one this time was the Netherlands or they had to stop that trial because this was

positive so they had to all stop them early these are all times they're similar to that as tiny little differences longer time than those of different approaches different imaging selection etc but they all were positive

they all show that endovascular therapy and stroke actually works actually makes the difference right briefly want to go

over this paper here mr. Keane I had the privilege to meet at one of our conference this this guy Oliver Oliver

Burke I'm of the first author the very brilliant young 28 yield ND PhD students who got that first day besides man likely on the in- image on some professors all their life I trying to get a paper into that girona and now you

haven't said that would never accept I just went to my professor and asking for a project guide thistle and he said well you did all the words you might as well be the first author your is going to be cited in a hundred years so they

basically pitched within within six hours they pitched iv+ IV and I a you know Ivy versus ibni a and the outcome was that you had more recanalization you had a smaller in fact volume and you had a modified ranking

scale of 0.2 which is minimal disability no or minimal disability thirty-three percent versus nineteen percent which is a seventy percent relatively percentage increased chance of a good functional outcome you see here the shift analysis

with intervention and the control group how everything shifted to the right except for that some reason some other studies that also did but here that was there was a pivotal moment in installed medicine medicine altogether I don't

think we see very many such impactful trials during the Scientific careers so

when somebody has a stroke time is brain always think time is rain you learn now it's not only time it's also Anatomy as collateral not everybody is born the

same way but everybody has a full circle of willis but from the onset of symptoms the clock starts running if your patient developed any symptoms of stroke assume the worst the windows for acute treatment IV TPA three hours

intra-arterial TPA there were some studies called Pro X studies that were done in the past they were done with six hours Oh laboratory numbers why couldn't it be four and a half hours there was actually a trial TPA four and a half

hours we do that also sometimes in a subgroup of station what couldn't be five hours or two novels who knows that's what they chose and then they can accustom back to me based on the collaterals they may not the assignment

now I hear that there's trials coming out looking at wake up stroke right and wake up stroke is a story you don't know when X dot it could have starved before I wake up well when woke up or when you went to bed so then we do MRIs you do

additional imaging studies we're trying to find out select based on imaging criteria which patient is which patient is the one that that we were tweet so if you have any of these symptoms come to bring them to a comprehensive Stroke

Center right away and and we will do what we have to do will decide whether it's a straw this is the John Smith John Smith came with a few settlers in 1607 to Jamestown right and then they explored the Chesapeake Bay it took him

three weeks in 1608 to get to tetas henoch and now boyfriend of Pocahontas by the way we hope it was consensual now we have telescope we have a video system where we basically see the patient evaluate

the patients our EKG we don't have a marker for stroke we evaluate the patient on the video if we think it's an acute stroke and if they meet the criteria we give TPA in the field and then we bring them by the helicopter

when John Smith went to step out to them three weeks and the locals hero two hours they were not friendly with him he was weird with a hail of arrows now it's at the handoff they're all friends it's like one of our hospitals there they

come with the with a helicopter within 15 minutes and will treat them we do advanced imaging and this is what we do is what we love to do we treat blood vessels in the brain these are the three founding fathers the PLO Junius the late

pls trineas from Paris the table again Toronto and Alex burns in a New York were claimed with and those are radiologists obviously but then as other specialties came into it they change the name of the society into no

interventional surgery society and called endovascular surgery whatever it is you know but you know catheter based treatment of the head and the neck in the brain is our suite and he used market catheters they there has been an

enormous improvement in material science you know you have probably seen that yourself these catheters they are so vital they can get too deep into the brainless really magic what's the problem when you put testers in the

brain where the old gods will tell you when I trained it was so meticulous it was you have to be so careful why because they still remember it doesn't take much to detect across a diary if you go into the brain once you're inside

the door are you pearson artery what you get is a subarachnoid hemorrhage it's a death sentence on aspirin Slovaks will happen but with these new catheters and wires we get very deep Ivy this is an

example of IV TPA yet IV TPA works we

know it works the work unfortunately only in ten to twenty percent of the cases but this gentleman came in with the left middle cerebral artery stroke you see the occlusion right they looking to his face this was a CT angiogram this

is the corresponding catheter angiogram eyes nose mouth right internal carotid on the left you don't see the internal karate the gentleman had two weeks earlier car accident and affected his left internal carotid

artery that is occluded volume the problem because of the circle of village the connection between the right and the left he enters intercommunicating army as you can see here with right infection give rise to all the branches of the

left middle cerebral artery it wasn't a problem until Klaus dislodged from this dissected carotid and got stuck in the middle treble re then the collazos were not sufficient the leptomeningeal Calleros were not sufficient the Circle

of Willis had taken care of it but the leptin injeel clouds were not sufficient enough now this guy came in with a stroke scale of 22 unable to speak unable to understand to completely paralyzed on the right side got TPA

within one hour of onset of symptoms witness onset of symptoms were last seen well and got immediately better now he was already on the angel see that said should i just stop not sure I'd let me let me do an angiogram but I didn't go

to the occluded carotid I went to the other side injected and you see that this segment which was included on the CT angiogram is now we can like based on the TPA alone at that point I didn't do anything else because once you start

digging in a clueless carotid you will mobilize debris you will cause more suitable problems right so the guy looks back to normal just based on me or just finish the angiogram and said arias I mean we was formed the next day and he

still comes back to mark immigrants and their lives completely cured the less broad was accurately left it included we never change anything here's another

gentleman with a skiing accident one week prior to a stroke which you can

also see on the CT on the Dryad you already see the dense middle cerebral artery sign let's see on the left this is the hyper dense middle cerebral artery basically the cloth that shows up on the dry head you don't even need to

do the PTA we do it routinely you can see the eyes the nose the mouth computer reconstructs the blood vessels come up here and the middle treble our is occluded down here the crowd oddly is not healthy again is dissected right at

the skull base where the blood vessel goes into the skull base that shakes around that's where when you have an impactful injury that's where that's where like to dissect again plot will form here it will not give you a problem

for a while and then when it is lodges and get into the middle cerebral artery then you will get the problem this gentleman is here with an acute stroke this is a video you see the eyes going to the left

to the side of the road I'm asking him his name is just babbling as the believe me he's not talking is not following commands will say open your eyes slowly I stick out your tongue he doesn't do anything can't see you can't understand

completely paralyzed on the right holding the arm up on the left holding the leg up on the left on the right side completely paralyzed this men would be destined for the nursing home I mean I mean there is that if you could even die

if you get a lot of swelling now three days later the brain starts telling us we punch yourself in the arm and first it doesn't look so bad and then three days later getting big and the brain there's limited space you could get

malignant feeble ademas well on the brain stem this is you want to play it again this is this is how these people these people present and we want to I just want to make one thing that's right awake remember what I told you about

wakefulness the entire left side of the brain is not working languages out eyes are going towards the left you see the facial facial weakness on the on the right despite that he's right awake completely paralyzed on the right ok

let's go on to the next that's 25 minutes later after we pull off the blood loss the eyes are in the midline amount to close your eyes open your eyes look at my finger look to the left look to the right look up look down show me

your teeth take out your tongue tell me your name and he says his name and completely back to normal and if you have ever seen that it's the most gratifying thing that you commander I challenge you in anywhere in medicine

show me where the cliq executive session treatment can achieve these kind of results it is absolutely miraculous everything because of the tiny little blood clot in the brain right this is the corresponding picture you see the

the occlusion York losing their middle tribal art is reputed eyes nose mouth here's the dissection of the internal carotid artery looking from the side early phase late phase you see how these coladas are coming down and I see this I

know a pull out the cloth he will get better most of the time you will get better because of these left immunity of clouds if you don't have that on the angiogram the chance that you will get an improvement is very slimming it's

done like a cardiac arrest you know if you don't have robust collaterals your time window will shrink down tremendously this is before after from the looking into the face before after looking from the side you see that I

section down down below we left that alone did call the problem and this is the clot that we pulled out there was with suction is one of the largest slots I put in the top is one of the largest slug they have a pool but these are the

kind of clothes that you can get you know and the CT the next day doesn't

show any stroke here's another one we can go deeper business the on ladle users off-label use we can go deeper sometimes you have a role anagram to

branch it goes to the motor strip look in according to you but when you have when you have a brain surgery and the being open up the skulls being open up then according to the neurosurgeon it doesn't cause any problems when you cut

out part of the brain we like to have been looking everywhere every part of the brain is important some parts of rambow important than others though and that's the motor strip by this goes right to the motor strip real ending

branch we pull this out take most completely paralyzed tiny little slots got better afterwards this is an anterior sweet lottery goes up here you see the occlusion right there before after sucks it out with the tiny little

chance now show you how we can make lame people walk and i'm going to show you an example how we can make blind people see that's also off-label but it's something that we have done it's something that

can achieve good results in my opinion that's not scientifically proven but there's very little to you to lose if you have a stroke of the eye it's called central retinal artery occlusion it's painless sudden vision loss and one I

many opthamologist they don't even know that something could be done about they say I take an aspirin go home line hopefully it's going to get better right but you could send them to us and we have done hide those intra-arterial TPA

injections into the ophthalmic artery you see here the orbit and looping around all the way tiny micro cancer goes into the atomic Audrey and I'm injecting the Islamic artery and you see all the time those branches was very

beautiful Anatomy do you see the lacrimal branch of the tear gland the torpedo branch to the eyelid and you see branches that go through the different muscles that move the I the central retinal army you penned actually not see

but we know it's coming out here and going forward it's coming out here and going forward before and after and then when you look very carefully you see that there is a precious let's we call the colloidal blushes a little blush

semilunar freshen type of blush it's called the colloidal blush and that is part of the retina you see that is out and then afterwards it's their dissertations look I might be still sending a card every year in says thank

you got a vision back still the opthamologist didn't believe the devil's contributing to it I happen to believe it is something to consider is very little to lose if you don't have vision put TPA directly into the I a common

cause for Omarosa sue Jack's temporary vision loss in an eye or stroke of the I central retinal artery is the carotid disease and we get back to that how can you prevent in the long run well you all know we take the carotid the vascular

surgeon you could have something like that it's called the crowd and are directly look how barbaric you and how beautiful is this you could put a stent to very very elegantly and in a patient

like that who doesn't have a circle of willis doesn't have a bridge doesn't have an anterior communicating artery putting Clips here and here so that the surgeon can like dig around could be a problem because there's not enough

collateral right it's why they do in to offer this monitoring that happens they have to put a shunt or something yeah but we do you want such a scar we can do

stents in the brain as well there was a trial that looked at carotid

endarterectomy versus fraud and replaced him standing called the crest CR ESP showed that there is no statistical significant difference between the two methods insurances tend to favor the open surgical approach those chief all

you need is a scissors needle I'm two-million-dollar angio suite stands etc inter-cranial and replacing standing is another one that the that has gotten bad press and intracranial angioplasty and stenting can be done but there was a

trial called Sampras sa MMPR is that has shown that maximal medical therapy was aspirin started lifestyle changes that has more effective especially in the early phase they didn't do a very long follow-up then inter-cranial standing is

a very meticulous procedure and you can if you stretch a blood vessel disease in the brain you crack it open you know what happens it's the outcome is very bad but we can do it and especially in cases where their sales maximum medical

therapy so they're already asked on plavix commentary they still have strokes you do something this patient has progressive strokes multiple strokes right sales maximum medical therapy we went in did an angiogram from the front

you can see here the narrowing right there this is the 3d image of the of the middle cerebral artery any two branch here and here is the narrowing and we can lay the stand right in there stretch it very very gently before and after and

you see here before and after there this is a cone beam CT that we can do any Andrew 32 seed verify the stent placement see the surrounding structures

status is calling of a very small aneurysm in the enter communicating artery the different types of bleeds that we want to discuss on the brain twenty percent of all strokes leads and

could be a subarachnoid hemorrhage and the subarachnoid hemorrhage is the space between the brain and the skull where you have extravasation from a larger blood vessel that's typically aneurysmal the risk factor of the manual missus

tiny little bubbles if the but if there's a bubble on a bubble like this extension here that is a risk factor this particular patient did not bleed but we were concerned even though it's a small lane and we're concerned about

this in that anatomy and decided he should be treated or you the subject north hammers and then you have the interventional hemorrhage and these patients should be worked up just like in a scheme explore their orphaned

there's the next big frontier many of them are orphans for supper ignored hemorrhage we have good treatments for aneurysm so intraparenchymal hemorrhage we don't have that many treatments what could cause in rip frank moment most of

the time is said Oh Emma Lloyd in the office the old age correct little little blood vessel but it could be a vascular malformation unlike underlying it or it could be a tumor underlying it there's also get an MRI they should get an MRI

follow-up after three months this is a treatment that you're all familiar whiskey we be plan and then put the stents you see how extend is actually changing the anatomy of this this angle and we put some coils and

this is where this is the result prevent us from meeting it was after work you see how the stent preventing these calls from herniating to the parenthetical a

vm abnormal tangles of blood vessels that you were born with perfectly but

they change over a span of a lifetime could be an entire entire talk different treatment modalities there was a study is called Aruba aru da that has shown that if you have an asymptomatic a vm solely better not to touch it that's

what most people do these days but if an AVM has bled because these are blood vessels that are an enormous pressure our arteries and veins links directly together the shunt the veins are not designed to resolve this pressure over a

lifetime they tend to bleed and if they'd let me go ahead and treat them we can treat them surgically take them out altogether or you do a radiation therapy but if they bled acutely you said that I study the anatomy and find a weak spot

and fix that and that's what we do in the inner vascular treatment there's an example of an AVM frontal a vm that we treated with onyx the lava type substance that we can inject into the AVM and then and then obliterate it only

twenty percent of cases become completely obliterated they oftentimes go to radiation afterwards this is an

example of a subarachnoid hemorrhage where you have the blood in the base of the brain from an AVM this is a 69 year

old woman she had a hunter SWA meaning neurologically pretty much intact coming in and the subarachnoid hemorrhage you always think about aneurysm right but this patient had abnormal blood vessels in the region got an MRI and you see

that there is a cerebellopontine angle arteriovenous malformation normal blood vessels at the base of the brain right next to the brain stem that is that are partially floating in the subarachnoid space and when you look at this Andrew

Graham the vertebral artery injection from the front you see that there is indeed an aneurysm because of the high slow nature of these these the feeding blood vessels can develop in this case of quantum

perforator can develop in out poaching or dissection dissecting aneurysm on the way into the AVM the very dangerous and volatile situation and in that case you're looking from the side it's kind of hidden in between you do see though

and this on this image of this ADM is being said by these haunting perforating arteries and draining into the deep venous system straight sinus and transfer sigmoid sinus this is the culprit lesion this is what caused the

bleed and this is a 3d image now how do you treat that you could treat this coil but causes are probably not a durable result because this aneurysm has both an inflow and an outflow so if you have a high flow situation where you have

inflow and outflow the fusiform aneurysm then you will probably not achieve cure with coil so what we typically do in these get in these cases that we fill it up with liquid ambala cajon all the anxiety here is that it was very close

to the brainstem if you get leaflets of the liquid amala Gatien to the bagra army she will have a massive stroke may be locked in or quadriplegic perhaps even comatose or dead you use here at substances called NBC a really whether

this is crazy goo that you can get for five bucks at the home depot or you can buy from a medical company then costs two thousand dollars and the polymerizes very quickly when you injected other than this onyx substance which you can

inject very slowly over a long time this one as soon as it comes into contact with blood or and ionized the fluid will immediately polymerize to prevent the reflux we put a balloon into the bottle you see that this is the balloon is here

the microcatheter tip is he any aneurysm and I mean I took a deep breath is very nervous there and just injected slowly slowly slowly until it deflated into the AVM and then we stopped me deflated balloon pull

everything out very quickly so that we don't do what you in the blue balloon or the catheter and that was the result you see here is the native image with the blue daniel ism that is now secured and the runoff into the AVM and the bad

lottery and ballet tech everything is paid here's another this was the day later the follow-ups angiogram where you see the glue cast here and partially embolize ABM another example of an inter

cerebral hemorrhage that is rather small

that caused in this gentleman poster circulation symptoms disaster slurred speech disequilibrium balance problems headache sudden onset a bleed here never assume that such a bleed is a hypertensive sandwich always go

investigate in this particular case the CT angiogram was done was read out as negative I guess if you are very skilled you can look at tiny little blood vessels reconstruct know you could have found a tiny little a vm but many of

these you wouldn't believe how many of these people with low by hemorrhages left and right they go to angiography and you find something because the blood comes from some of the blood comes from a blood vessel obviously and there is a

I think and under diagnosed population of people who do have microwave iam the problem that could be fixed should be fixed this gentleman with this midline cerebellar hemorrhage blown out in both directions had this tiny little ad on

the microwave EMI croissant fed by the superior cerebellar artery and superficial cortical venous drainage looking from the side and again a feeding artery aneurysm you see here that is the culprit lesion or right here

we went in.we embolize put the market catheter the smallest my competitor we have called the manager equal magic the french catheter i had smuggled year Florida all the way to America because not on sale here thanks Mike

can go very very deep right in front of the angles inject the drop of you this is the next day sky did very well so

that much just as you know as a introduction into the stall treatments we do with ischemic and hemorrhagic what

is the future it was already lose two in one of the talks on monday you see this truck is not our trackers in texas is in houston but i do believe that this may be the future because it's gotten so relatively straight forward to all my

blood vessel if the patient shows up at your door that now the challenge becomes to basically get the patient to you that's done through education and to perhaps administer treatments that may open up the time window like pta

sometimes it works right away i happen to believe that it also perhaps prolong the time window it's not proven but when you have slow flow in these distal vessels there are collaterals perhaps to prevent slacks formation you can give it

earlier remember the notion of time is brain that will be better you could also make a distinction between ischemic stroke and I'm erratic stroke if you have the ability to do a CT scan right in the field and that is what that is

the mobile slope unit has a tiny little portable CT remember when I did my fellowship up dimensions we had that in the ICU for patients who were difficult too difficult to bring down to the actual CT scanner they push that around

and then somebody had there was startup company i think and in cambridge massachusetts and they invade and heavy idea put it in an ambulance bring the imaging to the patient and it started in houston a few years ago and now you have

one in Cleveland I think you have one in Toledo you have one in Memphis they just start one in New York I think and it's catching on and I do believe that this may be the future think about the possibility somebody comes in is

anything you don't really know in the beginning is an ischemic stroke is an erratic stroke so what you do with the blood pressure you have somebody with an included blood vessel you like the blood pressure high somebody has blood on the

brain we like the blood pressure low all these things the earlier you diagnose them the or you can tailor your therapy and you can guide them to the right place and make preparation but if you they do ctas

now in the fields with these kind of things they know we know already where's the occlusion you can set up the lab everything you cut down an hour you cut down even more than an hour and I happen to believe that this will be the future

mobile store grunick so thank you very much for your attention I'll be happy to take any questions thank you very much for your talk doctor I just want you to know that I'm Cheryl from North Dakota and although it's got its benefits to be

out there you know we start in like a vast area that doesn't have these type of services long time go in like two thousand we thought that we were going to get to number and do a whole stroke rope work up but we lost our neurologist

and it just makes me want to move somewhere where these services are available so I just want to thank you because people need this so another look you have a job opening yeah hey good morning thank you dr. leash I have

something of a personal interest in the subject in the last 18 months I've had two ischaemic stroke events and subsequently diagnosed with pfoa which they believe is the etiology I just wonder how widespread is the use of drum

vechta me in ischaemic stroke so in our area I think we have all the capabilities you know we're ready I mean that I don't know about the what the lady said about North Dakota obviously the distance would become different

there but in our area you we are available 24 7 the problem is sometimes politics we get into the way if you have if you have one hospital that it is like always exist legislators behind the science in a way you if you

if you will you've heard about the term Primary Stroke Center promise build centers are places that can give TPA now that's good but it's only good in ten to twenty percent of cases and if you have somebody using drop stuff in our

experience at a Primary Stroke Center and then secondarily refers to a comprehensive stroke and aware the plumber is available then you lose one to two hours in the process even if the hospital's only 20 minutes down the

street because of paperwork because of phone calls because of this that and the other and sometimes these two hours are the critical two hours where you could have helped this patient but the the hospitals are fighting for every patient

you know this is something that really has to be worked over the legislature to bring patients to the comprehensive Stroke Center where all the services are available to X as quickly as possible now in terms of the PS all you know that

PSO is a not uncommon occurrence it's up to twenty-five percent of people walk around will hold an art there's Pedro Romero volleys the hole between the one hm the right card and the left heart that's a baby hands in utero because

obviously that's not breathing the baby there the embryo so the longer the lung doesn't have to be filled with blood the blood Sugar's jumps from the right onto the letter when the baby takes the first breast and usually that's all that trade

drama Nevada will close off however in up to twenty-five percent of people it doesn't and in most of these people you know think about look at this room I mean many people will have it it it's not that uncommon and most of these

people that doesn't call the parliament in itself when it can call the problem is if it's number one very large number two if you have a high-profile coagulative disorder you know there are certain blockage that can be done and

mention some of those performing gene mutation exercise like things like that I mean that can be tested because that causes the tents gives rise to blood clots in the legs DDT and then DVTs can go from the right heart to the letter

otherwise they give a pulmonary embolism they will get stuck in the lung stroke from a beam o'clock you can only get rid of pfoa so that's how these things go together alright thank you sir um after the topic

of what she brought from North Dakota I was at a conference in someone it was a vascular surgery based conference and someone had posed to an arrow interventionalist who is speaking about Calla radiology is in a neuro

intervention list covers the computer and talk about food we are just yeah is that something that rely idea so the idea is that the idea is that you can bring services to hospitals that cannot afford a for which is not feasible to

have a full time on staff and relative strength so what you can do is you cannot be patient remotely but you can I mean endovascular but not yet but the but you can you can certainly can certainly give instruction to the local

ED physician who may not be aware of the symptoms and signs of stroke I showed you a little movie about a patient with acute stroke and your maybe hopefully you'll all be able to immediately recognize you know the Hemi Theresa

sighs going to that way and in the other deficits anomalous diplopia etcetera but not everybody is the familiar visit so then they call in we have that in our own hospital system rule pasta like Japan over Eastern Shore where they call

in and say hey I feel somewhat suspicious of the stroke would you mind taking a look at the patient we don't have a component in the these phases heart attack is like to get a left leg and you know it's a heart attack or you

look at the EKGs already automatically read out we still need the neurological examinations a little bit like 19th century 19th century neurology runs because in the early stage you do a CT scan but the CT scan doesn't shoulder

school up to six hours after occurs if you have availability and I can do an MRI diffusion so that would show it immediately probably if there's permanent tissue damage but you have to have high degree of suspicion you need

to know you in your lawn the examination so for that we use it will tell the telemedicine somebody comes in with Prime in terms of stroke we give CTA they are you see him on the video give TPA there and then typically

we also do a CT angiogram there that you can send with mostly that goes to teleradiology where we can then remotely review these images see whether there is a large vessel occlusion is amenable to endovascular therapy and then you ship

them over I think this is all the the intent of the initial question was almost going that one step further and having a neuro intervention us essentially talk like a vascular surgeon through the endovascular treatment in

the area where it's prohibited to fly someone or I don't know that you can train somebody be annoying evangelist remotely but they were trying their vascular surgeon to happen maybe in the future we'll have like a automatic you

know an uber Cisco can you talk about your thoughts on sedation versus anesthesia yeah we're I think yeah as well as do you find that that after trial that just came out and brass will change the way that you you treat

strokes yeah and your thoughts on the des pieced irking trial that's currently underway yes so i can tell you i can i can tell you about what was the first part of aggression sedation the day sedation version i changed my practice I

train I used to train with a God would everybody's asleep the radiologist Alex Bernstein very meticulous or you know he didn't wheat straw was attending with it he only did a BM in davis was very very meticulous so everybody was put to sleep

I defaulters waiting for the cancer in the brain the patient should move yada yada yada and I'll tell you that mr. clean our talked to berkheimer about it in mr. Keane they did a post-hoc analysis off the study and he came down

very strongly the thing it was last year to stroll contents that he said look when we analyze our data and look who got general anesthesia and who got the and until that intubated the trial would not have been positive the mr. King

would not have been positive if you know they only would look at the internet intubated population so at that point I changed my practice I enjoy working on a on a on a patient who is under because it's just much nicer pictures much safer

to go up there the flip side of that is you know and that I change my practice and now the page moving around with a bit and you can get up most of the time but the flip side of that is even in the trial if you look into the challenge

you're really honest then you look at mr. Keane two people died two people died they were both in the awake group I don't know whether that is I don't know whether that is coincident or what but you know you can imagine if you have a

wire up there and patients moving around and your standard triva you boom push through the clots and all of a sudden you don't see anything anymore because you don't have a roadmap that you could get into a tiny little perforator and

just push it through you know and the end destruction verses from back to me is something that I've looked into as well in our practice we have switched from from the standard fever to suction the 8th system which worked well for us

in certain cases the Astra trial I think they took all comers right i mean they look they look suction worse and it seems to be from the preliminary data that they just presented seems that they it seems that they are pretty equivalent

in terms of but they took all comers i think if you look through subgroup analysis you look and you and give the compare the anatomy in these patients and i was feeling for it I think the suction work very well as an intuitive

thing that if you have dirt employee one user you know if you get more bigger claws you get to pass to put it up you don't have to dig through the clot you know so if there is a straight anatomy i get the CTA a look at the CTA if you

have a straight anatomy I go up pull out if it's very torturous if I need to do is Simmons catheter or something like that goes around loop around I'll use the stent retriever and I do think that if you tailor your circle that way and I

think future data will show that that the dent Center Cheevers is in and torturous anatomies probably superior to suction and I I tend to think that in a straight anatomy I means of some of the data suggest that in the straightener

instruction may be superior to stand because of the thickness you're very click 25 minutes 30 minutes times a week analyze ation but answer your question yes okay thank you yeah we do that to those we actually

just presented something at the strill contents that we looked into that that's typically people have different approaches some people use it from the get-go it's a little bit cost prohibitive because these catheters are

very expensive but most of the time is being done in a in a fashion that you would start with structure and then instruction doesn't work she kind of can't get there or again get them you use the statutory vasu that intermediate

catheter to grab the cloud and pull it out so that is the rest that is a rescue type of approach in our practice because it has been used as such we have the worst outcomes results because it takes the longest to open and in those are you

typically the resistant plots maybe with underlying pathology underlying atherosclerosis those are most difficult to grab so in our practice we don't have we don't have the we have the best out we have the worst outcome of these

combined folders but the reason is that it's the rescue approach and our practice if you have you know if you have the availability if you have the mind why not go up with everything you have suction right up there you have a

standard fever in there our area very anesthesiology yeah I mean I think we're cutting them on board pretty well so that goes back to the other question that we had general versus you really

save time if you don't intubate you don't do a line you don't do a lot of stuff you just obviously you go just in and go up and our red interior others means very well I still have the radio at the anesthesiologist in the room I

called them every single time sometimes we have started without them if they're late but most of the time they're there and we doing max you know I mean they're just there to basically do a little something residex or something and just

keep the patient a little sedated I do rarely but sometimes you know request that they convert if the patient is a fade it doesn't full of command is all over the place and we have them there and they can come go to general it's all

about the communication is am I think thank you very much [Applause]

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