To Master Stroke Thrombectomy, It Takes Way More Than 50 Cases

 You better be prepared to interview your doctor and see if they pass the interview and are OK to be hired. YOUR RESPONSIBILITY!. You can't trust your stroke hospital to vet their doctors. They have allowed complete and total failure in all aspects of stroke.

To Master Stroke Thrombectomy, It Takes Way More Than 50 Cases

 

Competency a "touchy subject" for training programs, trainees, and new graduates

by Nicole Lou, Staff Writer, MedPage Today July 9, 2021

The learning curve in endovascular therapy (EVT) remained steep even after operators passed training and reached autonomy, one group found.

At seven French centers, established interventional neuroradiologists showed continued improvement in certain performance metrics as they accrued mechanical thrombectomy experience:

• Procedural time: increasing individual experience was independently associated with shorter procedure durations

• Recanalization status: increasing experience was independently associated with better Thrombolysis in Cerebral Infarction scores

• First-pass recanalization: there was no effect of operator experience on first-pass complete reperfusion

• Complications: operator experience made no difference in the rates of perforation or arterial dissection

Operators appeared to continue honing their skills up to around their 80th to 100th procedure outside training, reported Grégoire Boulouis, MD, PhD, of Université de Tours, and collaborators. Their paper was published online in Stroke.

For comparison, the investigators said, most training guidelines recommend that trainees undergo approximately 50 EVT procedures as a first operator before operating autonomously.

"This raises questions for designing training programs. It is a touchy subject that is often avoided," noted the authors of an accompanying editorial.

"The problem with experience is that it takes time to get it. Newly independent interventionalists can only get more experience by doing cases. Eighty cases are a large number that will take years to accumulate," wrote Shelagh Coutts, MD, of the University of Calgary Cumming School of Medicine in Alberta, and Diogo Haussen, MD, of Emory University School of Medicine and Grady Memorial Hospital in Atlanta. They cited an unpublished estimate that U.S. operators performed fewer than 12 stroke thrombectomies on average in 2016.

Even so, it is "reassuring" that the thrombectomy learning curve appeared to be volume-based and not time-based, "suggesting trainees and recent graduates can achieve a steeper learning curve by being exposed to larger procedure volumes," said Amrou Sarraj, MD, of UTHealth McGovern Medical School in Houston, who was not involved with the study.

He suggested that procedure volumes can be expected to increase as evidence grows and indications expand. "If this gain is directed towards increased exposure to trainees, this would have a significant beneficial effect on their skill levels," he told MedPage Today.

Furthermore, if there is a true minimum number of cases that needed to be completed before a operator can gain autonomy in EVT, it may not necessarily be 50, 80, or 100.

"Endovascular therapy for acute stroke, as any other procedure, has and will continue to mature and evolve over time, and the volume-outcome relationship may change with new technologies and approaches," Coutts and Haussen said.

Boulouis and colleagues performed a retrospective analysis of individual thrombectomy procedural data for 36 operators. The cohort had performed 4,516 procedures altogether from January 2015 to January 2020; after exclusions, 4,012 procedures with sufficient operator data were included in the analysis (median 97.5 per operator).

Operator experience was defined as the total number of stroke thrombectomies performed since 2015 -- the year EVT officially proved to be a game changer in acute ischemic stroke, thanks to the MR CLEAN, SWIFT PRIME, and REVASCAT trials.

The study's retrospective design was a major limitation that left room for confounding. Also, many of the participating centers had performed thrombectomies well before 2015 that were not counted by Boulouis' group.

"This is a powerful study that, despite some design limitations, demonstrates the importance of expertise in driving stroke thrombectomy outcomes. Expertise has been validated across a wide variety of surgical procedures, and it is not surprising that it is likewise important in stroke surgery," commented J Mocco, MD, MS, of Mount Sinai Health System in New York City, who was also not involved with the study.

"Stroke thrombectomy is an extremely technical procedure and the quality of outcome makes a tremendous impact for the patient. While there is still work to be done, this paper provides additional clear evidence that expertise matters and should be taken into account when designing stroke systems of care," he told MedPage Today.

• 

  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

Boulouis had no disclosures; a co-author reported grants from Microvention, Stryker Neurovascular, and Penumbra.

Coutts had no disclosures; Haussen disclosed relationships with Stryker, Cerenovus, Vesalio, and Viz.AI.

Saraj and Mocco noted no disclosures in relation to their comments.

Primary Source

Stroke

Source Reference: Zhu F, et al "Effect of operator's experience on proficiency in mechanical thrombectomy: a multicenter study" Stroke 2021; DOI: 10.1161/STROKEAHA.120.031940.

Secondary Source

Stroke

Source Reference: Coutts SB, Haussen DC "When more is better..." Stroke 2021; DOI: 10.1161/STROKEAHA.121.035303.

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Implementation of a sexuality interview guide in stroke rehabilitation: a feasibility study

 But you tell us nothing about the success or failure of sex in the patients. Useless since you didn't monitor the results of your intervention. Stroke survivors need as much sex as possible, what are you doing to ensure it occurs?

Go ask your doctor for EXACTLY HOW MUCH SEX YOU SHOULD BE HAVING TO RECOVER.  I'M DEADLY SERIOUS. Why the fuck doesn't your doctor know that answer?

My recreational therapist just said sex was ok to do. Nothing on how to accomplish. Missionary style sex just doesn't work anymore, or the Queens's throne, or the Mare, or the Swing(Look up Kama Sutra). Problems:

1.  Fingers and thumb will not stay flat.
2. Wrist collapses.
3. Elbow collapses.
4. Bicep spasticity pulls everything out of line

All this is why you need to be doing lots of sex, why the hell can't your doctor get you fucking again?

Sexual Frequency Predicts Greater Well-Being, But More is Not Always Better

 

Sex after stroke

 

Sex linked to better brain power in older age

Sex: The Ultimate Full Body Workout

 

Better Memory From This Extremely Pleasurable Activity - Sex

 

WHY SEX IS BETTER FOR YOUR BRAIN THAN SUDOKU 

 

Sex linked to better brain power in older age

 

Good News About Sex- It Doesn't Cause a Stroke

 

Sex Does Not Increase Heart Attack Risk - What about stroke?

 

Frequent orgasms may protect against heart attacks

 

An orgasm a day keeps the doctor away!

In case you don't have a partner she could prescribe this.

Electrosex

And the benefits of marijuana for sex here:

Sex, Marijuana and Baby Booms

The latest here:

Implementation of a sexuality interview guide in stroke rehabilitation: a feasibility study

Louis-Pierre Auger , Evelina Pituch , Johanne Filiatrault , Frédérique Courtois & Annie Rochette

Received 20 Jul 2020, Accepted 22 Jan 2021, Published online: 09 Feb 2021

• Download citation

 

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Abstract

Background

Although people who sustain a stroke can experience sexual difficulties, few address them during rehabilitation.

Objectives

Explore the feasibility of implementing a Sexuality Interview Guide (SIG) in stroke rehabilitation and describe the factors perceived as influencing its implementation.

Materials and Methods

Using a mixed research design, the SIG was implemented for four months in a rehabilitation hospital. The frequency with which clinicians addressed sexuality and their level of comfort pre-post implementation was measured. Perceived factors influencing implementation were determined through individual interviews and focus groups with five stroke clients, 15 clinicians and a coordinator. A paired-specimen Wilcoxon test was used to explore differences in pre- post-level of comfort. Qualitative data was analyzed by two independent evaluators using thematic analysis.

Results

The SIG was used 28 times and clinicians' level of comfort in addressing sexuality improved significantly (p = 0.001). The factors perceived as influencing implementation were: the acceptability of the SIG, the individual characteristics, the context of the rehabilitation hospital and the implementation process.

Conclusion

This study showed that the SIG can be used in stroke rehabilitation and that, with sufficient financial and human resources, and training for clinicians, it would be feasible to implement it in usual care.

• Implications for rehabilitation

• The Sexuality Interview Guide (SIG) can be used in stroke rehabilitation and helps clinicians to target stroke clients who want to include sexuality in their rehabilitation.

• The best time to approach sexuality using the SIG, according to all participants, was in outpatient rehabilitation.

• For inpatient clients, it was more appropriate to use the SIG as they approach a weekend home trial or rehabilitation discharge.

• Training for clinicians working in post-stroke sexual rehabilitation, administrative policies and procedures and access to a sexual health specialist for consultation or referral purpose, would be important facilitators in integrating sexuality into clinical practices.

 

Author Interview: Dr. Mayank Goyal on “Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging”

 Notice what is not discussed! 100% RECOVERY. That is how bad our stroke medical world is. Not understanding that the only goal in stroke is 100% recovery and no one is talking about that. They all need to be fired.

My comments on the original article are here:

Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging 

The latest here:

Author Interview: Dr. Mayank Goyal on “Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging”

A conversation with Mayank Goyal, MD, PhD, Professor of Radiology and Clinical Neurosciences, University of Calgary.

Interviewed by Saurav Das, MD, Fellow in Vascular Neurology, Washington University School of Medicine, St. Louis.

They will be discussing the topical review “Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging,” published in October 2020 issue of Stroke. 

Dr. Das: Dr. Goyal, the Blogging Stroke team is happy to have you for an author interview today. Thanks for this provocative paper, which disrupts several currently accepted ideas that guide decision-making in stroke patients to make way for new innovation.

Let’s start by discussing the context in which this paper was conceptualized. The paper has a line-up of great authors, many considered visionaries in vascular neurology, across countries. Please tell us more about how this collaboration came into being.

Dr. Goyal: I have been thinking about the problem of defining ischemic core on baseline imaging for a long time. I noticed patients with a really bad-looking baseline CT, patients in which you would be inclined to call the whole MCA territory “core.” But when these patients went on to endovascular treatment and we managed to re-open the occluded vessel quickly, many of those did well, and their follow-up MRI scans showed that much of the parenchyma thought to be “core” was not actually damaged. More importantly, many of these patients did well clinically, resulting in a clinical-imaging mismatch. In addition, I was quite convinced that the so called “core” on CT perfusion was quite an exaggeration of the truth. In some ways, when many of the trials were being designed, they came in the aftermath of the Interventional Management of Stroke (IMS) 3 trial, and hence, people were over-conservative in their selection criteria. I then started talking to several of my collaborators and friends from all over the world, to see whether they felt the same way. This is when this collaboration was formed.

Dr. Das: The authors make strong arguments regarding the ambiguity associated with the term ischemic “core.” They propose it be replaced with the term “severely ischemic tissue with uncertain viability” (SIT-uv). Where will “penumbra,” tissue with Tmax > 6s on CT Perfusion scan, fall in this proposed lexicon?

Dr. Goyal: The reason for us to advise against using the word “core” is that current imaging techniques that are used in the acute stroke setting are just not able to accurately distinguish between severely ischemic yet viable tissue and irreversibly damaged tissue. We all agree that what we currently call “penumbra” on baseline imaging, i.e., tissue with Tmax > 6 sec. but largely preserved CBF, is viable. And, frankly, It is all about core. Knowing the penumbra is not critical to decision making. If the patient has significant symptoms and a small core, of course they are going to have a penumbra … you don’t need to see it or measure it. I do think that just like “core” measurement, the one of “penumbra” is also flawed (for the same reasons as described in the paper) but is not as critical for decision making. It becomes trickier when we start looking at what current perfusion softwares call “core,” for example, tissue with relative CBF <30%. As we have outlined in our manuscript, a single time blood flow measurement is not sufficient to reliably identify irreversible tissue damage. Numerous studies in cell cultures, animals, and humans have shown that brain tissue with relative cerebral blood flow far below 30% can survive, if the duration of ischemia is short. And there are, of course, all the additional issues as described in the paper: selective tissue loss; gray vs. white matter; other factors such as microangiopathic disease, diabetes, etc.

Dr. Das: How do you believe any discordance between the SIT-uv probabilities across different imaging modalities should be addressed, especially, in the absence of a gold standard to determine cell death within the SIT-uv? Will there ever be a gold standard, and what research may lead us there?

Dr. Goyal: This is certainly a central question in acute stroke imaging: What should be our gold standard? The honest answer is that we currently do not have one. Diffusion weighted imaging is often used as a reference standard, but DWI-reversal is a well-described phenomenon. One might think that pathologists would be able to examine the tissue and provide us with a definitive answer, but even they struggle with identifying tissue infarction since the transition from complete, central infarction to peripherally spared areas is gradual and non-linear rather than sharply demarcated, with interspersed areas of incomplete infarction between both extremes. Selective neuronal loss, i.e., death of single neurons with preserved glial cells and extracellular matrix, are other, complicating factors. In short, I do not expect us to have a reliable “gold standard” in the near future, but that does not mean we cannot work towards a better understanding of the pathophysiology of tissue infarction.

However, for an emergent situation like acute stroke, one does need to take a pragmatic viewpoint. The key issue is decision making: Should I go forward with therapy xx or yy, or not? If I say no, am I missing an opportunity to help this patient from an otherwise devastating disease? If I say yes, am I taking unnecessary risk? Am I spending valuable resources of what is clear to have a bad outcome? From that perspective, we need not have a “gold standard.” We just need to do better than what we are doing right now … and the first step is to acknowledge our current limitations on imaging.

Dr. Das: It is proposed in the paper that the consideration of eloquence, grey vs white matter involvement, selective neuronal loss, etc., in the SIT-uv might contribute to clinical outcomes. Using automated tissue characterization, we will achieve more granularity in defining these parameters in threshold-free probabilistic approaches. However, on the other hand, we are still using a gross six point modified Rankin scale to categorize clinical outcomes, which might not be an equally sensitive comparator. What are your thoughts?

Dr. Goyal: I completely agree with you. Clearly, the mRS scale is limited in its ability to capture more subtle functional deficits. mRS is also heavily weighted towards motor function, but nowadays, at least in Western countries, this becomes less of an issue, with modern technology allowing us to talk to our friends, family, and business partners via Zoom or Facetime without actually having to leave the house. The problem with outcome scales is that they have to go through a process of calibration, internal and external validation, and lastly, they have to be widely accepted and used. All these things are true for the mRS. Developing a new, more meaningful stroke outcome scale would definitely be desirable, but it is nothing that can be done overnight. It will require several years, and then there is still the question whether it will be accepted and adopted by the stroke community or not. For these reasons, I personally believe that we will keep up using mRS at least for the next several years.

But coming to the question that you are asking, I don’t think that in the near future mRS will be the limiting factor for making progress on the SIT-uv concept. There are several low-ASPECTS trials that are running currently. Irrespective of their outcomes, those datasets will provide an excellent opportunity to further validate the concepts. As you know, we are soon starting ESCAPE-NEXT (in follow-up to ESCAPE-NA1). It will be interesting in how the relatively biggish “cores” do with neuro-protection and fast reperfusion.

Dr. Das: Dr. Goyal, apart from replacing the erstwhile ischemic “core” with the term “SIT-uv” and being sensitive to the fact that all cells within the SIT-uv may not be already dead, what other practice recommendations do you have for stroke clinicians in light of this paper?

Dr. Goyal: What I would really like to recommend to all the physicians out there treating acute stroke patients is: Never forget that we are treating patients, not images. Look at the bigger picture, consider all the factors, including patient and family wishes. Keep in mind that our imaging techniques can only provide us with a rough estimate of tissue viability; do not over-rely on them. We need to understand that: (a) ischemic stroke due to LVO is a dismal disease; (b) we have a super-powerful treatment; (c) we have to recognize the limitations of our current imaging and continue to strive to make it better; and lastly, (d) please participate in trials to continue to move towards evidence-based (as opposed to opinion-based) medicine.

Dr. Das: Thanks again for your time, Dr. Goyal! It was a pleasure chatting with you.

 

What did your doctor, therapists and stroke hospital do when you didn't 100% recover?

The answer to that tells you how fucking incompetent they were and have been for years. No analysis into what went wrong? Standard of care is not the answer you lazy bastards. Nor is; 'All strokes are different, all stroke recoveries are different'.
I didn't have an exit interview and I bet you didn't either.

I leave my rants open ended because they keep going forever

Prognostication of long-term outcomes after subarachnoid hemorrhage: The FRESH-score

You can see for yourself that the telephone interview for cognitive status questions really have little objective correlation with where the damage is located.
The Rankin scale has no useful discrimination at all except for no. 6 - dead.
See page 3 and 4 here for Sickness Impact Profile questionnaire. Nothing objective about that since the patient is answering the questions.
Hunt & Hess Classification of Subarachnoid Hemorrhage doesn't look at anything objective at all except for the coma part and would they be able to tell the difference between coma and locked in?
 At least the apache ii acute physiology score seems to contain objective measurements.
No looking at all at 3d representations of the dead and damaged areas.  Does anyone have two neurons to rub together in stroke?
Do you really trust prediction scores based on this for your loved one?

Prognostication of long-term outcomes after subarachnoid hemorrhage: The FRESH-score

Witsch J¹, Frey HP¹, Patel S¹, Park S¹, Lahiri S¹, Schmidt JM¹, Agarwal S¹, Falo MC¹, Velazquez A¹, Jaja B², Macdonald RL², Connolly ES³, Claassen J¹.

Author information

Abstract

OBJECTIVE:

To create a multi-dimensional tool to prognosticate long-term functional, cognitive, and quality-of-life outcomes after spontaneous subarachnoid hemorrhage (SAH) using data up to 48 hours after admission.

METHODS:

Data were prospectively collected for 1619 consecutive patients enrolled in the SAH-outcome-project 07/1996-03/2014. Linear models (LM) were applied to identify factors associated with outcome in 1526 patients with complete data. 12-months functional, cognitive, and quality-of-life outcomes were measured using the Modified-Rankin-scale (mRS), Telephone-Interview-for-Cognitive-Status and the Sickness-Impact-Profile. Based on the LM-residuals, we constructed the FRESH-score (Functional Recovery Expected after Subarachnoid Hemorrhage). Score performance, discrimination and internal validity were tested using the area under the receiver-operating-characteristic-curve (AUC), Nagelkerke's and Cox/Snell's R-Squares, and bootstrapping. For external validation we used a control population of SAH-patients from the CONSCIOUS-1-study (n=413).

RESULTS:

The FRESH-score was composed of: Hunt&Hess and APACHE-II-physiologic scores on admission, age, and aneurysmal rebleed within 48 hours. Separate scores to prognosticate 1-year cognition (FRESH-cog) and quality-of-life (FRESH-quol) were developed controlling for education and premorbid disability. Poor functional outcome (mRS4-6) for score-levels 1 through 9 respectively was present in 3, 6, 12, 38, 61, 83, 92, 98 and 100% at 1-year-follow-up. Performance of FRESH (AUC 0.90), FRESH-cog (AUC 0.80) and FRESH-quol (AUC 0.78) was high. External validation of our cohort using mRS as endpoint showed satisfactory results (AUC 0.77). To allow for convenient score calculation we built a smartphone-app available for free download.

INTERPRETATION:

FRESH is the first clinical tool to prognosticate long-term outcome after spontaneous SAH in a multidimensional manner. This article is protected by copyright. All rights reserved.

What should have been asked in Interview with Dr. Stephan Davis - WSO

An email I sent to

sarah@researchmedia.eu

Every communication with the stroke world should ask what they are doing to solve these problems. If you are going to interview someone like that you could at least ask some decent questions. Which of these 7 major problems in stroke is being worked on and what progress is there? 1. There is no fast, easy and objective way to diagnose a stroke. Maybe when the Qualcomm Tricorder X Prize is available. A number of friends have waited hours in ERs until stroke symptoms have visibly manifested themselves. 2. Only 10% get to almost full recovery. http://www.ninds.nih.gov/disorders/stroke/stroke_rehabilitation.htm 3. 12% tPA efficacy http://wrkf.org/.../more-stroke-patients-now-get-clot-busting-drug 4. Nothing being done to stop the neuronal cascade of death during the first week. http://newswire.rockefeller.edu/2009/01/15/discovery-could-help-scientists-stop-the-death-cascade-after-a-stroke/ 5. No one knows how to cure spasticity. 6. No one knows how to cure fatigue. 7. No one knows how neuroplasticity exactly works to make it repeatable. Every neurologist and stroke doctor should know about all of these and be working to solve them. All the WSO does is issue press releases. I'm just a simple stroke addled 8 year survivor. Cheers, Dean Reinke

Interview - Professor Stephen Davis, President, World Stroke Organization

This was an appalling interview, any survivor could have asked more hard hitting questions. I could have had him blubbering, wondering what hit him.
http://www.research-europe.com/index.php/2013/09/professor-stephen-davis-president-world-stroke-organization/
And you can't comment to tell them how badly they did.

NYU Langone Experts Available to Discuss Causes, Treatment and Prevention of Stroke

If any of you are reporters please contact them to do an interview with their experts. You should be able to easily stump them.
http://www.newswise.com/articles/nyu-langone-experts-available-to-discuss-causes-treatment-and-prevention-of-stroke
May is Stroke Awareness Month, and NYU Langone experts are available to comment or discuss the latest research and clinical advances in stroke identification, care and recovery (including imaging, drug and surgical treatments and motor recovery). They are available, preferably with advanced notice, to do phone, in-person taped or in-studio interviews:
Keith Siller, MD is an assistant professor of neurology at NYU Langone Medical Center, and medical director for the Comprehensive Stroke Care Center.
Ira Rashbaum, MD, is professor of rehabilitation medicine at NYU Langone Medical Center, and chief of the Rusk Stroke Rehab Medical Unit.
Please contact Craig Andrews at 212-404-3511 or craig.andrews@nyumc.org to schedule an interview.
Questions here:
 What are you doing to stop the neuronal cascade of death in the first week?
http://oc1dean.blogspot.com/2010/08/what-my-doctor-should-have-told-me.html
 http://www.oc1dean.blogspot.com/2011/02/marijuana-and-stroke-rehab.html
http://oc1dean.blogspot.com/2013/03/what-i-am-going-to-insist-i-get-after.html
http://oc1dean.blogspot.com/2010/09/stroke-research-questions.html