No abstract

Cardiogenic cerebral embolism represents 20% of all acute ischemic strokes (AISs) with one-third of these being caused by left ventricular thrombus (LVT). LVT is not a contraindication for treatment with intravenous recombinant tissue plasminogen activator (IV rtPA) for AIS. However, the subsequent treatment of a potentially unstable LVT is contraindicated for 24 h following the use of IV rtPA according to current guidelines. We present a 66-year-old man with AIS treated with IV rtPA. Echocardiogram shortly after treatment demonstrated both a large apical and septal thrombus in the left ventricle and at 12 h post IV rtPA infusion, therapeutic anticoagulation with heparin was started without complication. In practice, the action of IV rtPA outlasts its apparent half-life because of thrombin-binding and the prolonged effects and longer half-life of its product, plasmin; however, the pharmacokinetics do not warrant prolonged avoidance of therapeutic anticoagulation when clinically indicated. Our case demonstrates that anticoagulation for potentially unstable LVT can be safely initiated at 12 h following IV rtPA treatment for AIS.

Endovascular stroke therapy had been an 'unproven' therapy despite numerous trials of intra-arterial pharmacologic thrombolysis and mechanical thrombectomy. With the advent of stent-retriever devices, there has been a paradigm shift in the utilization of endovascular therapies for AIS. Our review discusses cerebrovascular hemodynamics, the basis of the recanalization models in AIS, aspects of intravenous thrombolysis, prior generations of endovascular therapy, and the recent successful AIS stent retriever trials. Expert commentary: Recently 'stent-retrievers', a new generation of mechanical thrombectomy devices, were shown to be associated with improved functional outcomes in AIS secondary to proximal intracranial anterior circulation LVO. Stent retrievers are a major advance in AIS care and will have significant impact on the evolution of stroke systems of care.

No abstract

No abstract

No abstract

INTRODUCTION: An ED-based “stroke code” demands timely decision making and prioritization of tasks by the stroke team neurologist while coordinating care with ED staff, radiology and pharmacists. Simulation-based medical education (SBME) focuses on obtaining clinical skills belonging to the psychomotor, cognitive and affective domains. SBME is superior to the traditional style of medical education and has shown improved outcomes of knowledge, skills and behaviors and moderate effects for patient-related outcomes in other emergency based scenarios including ACLS and procedure-based learning. HYPOTHESIS: To describe the rationale and design for a novel hospital based stroke simulation. SBME can improve stroke code efficiency particularly for inexperienced stroke team members. METHODS: Six incoming PG2 neurology residents participated in a pilot study using a high fidelity patient simulation of an acute ED-based stroke code at week 1 and 3 of orientation. The trainee independently managed every step from activation of the stroke pager including a focused patient assessment, ordering and interpreting labs and imaging, managing common obstacles, staffing with the on-call attending, working with ancillary staff and appropriate treatment as indicated. Residents completed an affective survey, pre- and post-test cognitive assessment and debriefing with feedback, as well as real time checklist and review of videotaped assessment of their performance. RESULTS: Subjects showed a 16.1% improvement in the cognitive assessment from week 1 to week 3 (p=0.02). The affective survey showed residents were moderate to highly confident in their ability to perform a history and physical prior to participation, yet they had low confidence utilizing the NIHSS and managing medications for acute stroke in the ED prior to participation. CONCLUSION: SBME can facilitate the acquisition of technical and non-technical skills such as leadership, team work, communication, situational awareness, decision-making, cognizance of personal limitations important for patient safety and a learning cycle of debriefing and feedback. Post-test and affective survey results demonstrate improvements in the cognitive domain and resident confidence respectively.

No abstract