Well, thanks to the speakers for such an enriching session. I know this was a lot of content to cover in the brief time that we had. We have a few speakers that are present live, so I'm going to address questions placed by the audience. And I do apologize we ran over, but this is a lot to cover. The first question I have is for Dr. Mainali. If you're able to come on the speaker, can you clarify the rationale for using bolus hypertonic therapy versus continuous infusion of hypertonic saline? I think you mentioned this in the talk, and Dr. Swor also mentioned this in her talk, basically to prevent rebound-stable edema, but can you please clarify? Great. Can you hear me, Dr. Sarwal? Yes, loud and clear. That's a great question. Generally, there is no clear guideline on you should do specific bolus versus continuous therapy. But really, in clinical experience, bolus therapy does seem to work better in most of our clinical experience. And mostly, the rationale for that really is if you try to keep someone's osmolarity high in a sustained manner, there is reflex mechanisms within the body, within the cells that generates osmoles, like heterogenic proteins that tries to create a state of equilibrium between the intercellular compartment and the osmolarity in the blood. So, over time, the gradient, the difference in osmolarity between the cell and the blood becomes narrower as the body tries to achieve the equilibrium. So, trying to sustain a hyperosmolar state for a prolonged period is likely to be less effective than using that acute bolus therapy at the time of need, so you can create that large osmolar gradient between the intracellular and extracellular compartments, so there could be more water diffusing out of the cells. Does that make sense? Thank you so much. I really appreciate it. The next question is for Dr. Nobelza. The two questions that are directed towards your talk are, is the INR over 2 a contraindication to TPA? I'll go with that first. Yes. So, based on the contraindications, the INR of greater than 1.7, especially if the patient is using anticoagulation, that is a contraindication. And the second question for you was, in the setting of ischemic stroke and atrial fibrillation, when is it appropriate to start full-dose anticoagulation following TPA or endovascular thrombectomy? So, the decision to start anticoagulation after these acute stroke interventions largely depends on really a lot of factors. So, we look at the infarct burden, so typically if someone needs anticoagulation after those therapies, we typically wait for an imaging such as an MRI to just show us whether or not there's a big stroke that can potentially lead to a higher risk of bleeding, or if they have hemorrhagic conversion even after that acute stroke therapy that might preclude us from starting anticoagulation. So, it's a lot of factors that we consider, and then depending on the indication, if it's atrial fibrillation, we might have to wait a week or two depending on those factors. Thank you so much. The next question was, what sorts of questions can we expect about cerebrovascular anatomy? Can you give any examples? I think I can probably take that. You know, this is a kind of review course geared towards a lot of people taking the boards. You will be asked, at least what we've seen in last year, and based on the organization of the outline published that the major vascular syndromes corresponding to major vessels, you will be asked about that. You will need to know how to identify those major vessels related to major clinical syndromes on an angiogram. So, say there's an angiogram that would be, you know, your patient has MC syndrome, and you will be expected to know how to look at the MC on the angiogram. So, very bread and butter, nothing out of the blue, nothing, you know, nobody's going to ask you to find the recurrent artery of Hubler. On an oblique view of the angiogram, it's going to be very bread to butter, but basic anatomy that is day-to-day necessary for evaluation and management of patients. The second question was about reviewing interpretation of CT perfusion scans. If you don't mind going back to the neuroimaging primer number two that I covered, I covered CT perfusion interpretation pretty much in detail, and Dr. Novelza also kind of reviewed a primer of that again in her ischemic stroke talk, so I would guide you to review that content again. And in case we end up, I see a lot of questions coming in, in case we end up missing any questions that we have not addressed, we will create a Word document and then share with all the attendees, so just make sure that, keep your questions posted, we will address all of them one by one. The next question is for Dr. Swor regarding TBI. In the setting of the QTBI, the first 24 hours, is there an upper limit for the systolic blood pressure for which an antihypertensive agent should be started? Dr. Swor? I don't hear her coming in, so at this point there is no published guideline that would help you go for the highest blood pressure. We typically follow the lowest systolic blood pressure of more than 100 or 90 based on Seattle VTF guidelines. The lower pressures have been more debated, primarily because most of these patients have polytrauma or suffer from hypotension that is presumed to be more harmful. There have been talks about this auto-regulated patients suffering from hyperemic injury or reperfusion injury in settings of too much hypertension, but in the cases of traumatic bleeds, the upper limit has not been distinguished. Now again, it all depends upon what other comorbidities the patient has. If they have a dissection along with it, that can help you guide the high blood pressure goals. If they have a significant hematoma component in their QTBI, you can extrapolate these spontaneous guidelines, but in general, there are no established high pressure guidelines in TBI and we go with 160, 180 or 140 depending on other comorbidities that the patient presents with. The next question is, is there a blood pressure goal after a ruptured endorhyzema prior to securing? I think current guidelines recommend a blood pressure goal of 140 and below. There are previous versions that have talked about 150 or 160, but in general, aggressive control of hypertension to less than 140, 150 has been the hallmark of unprotected endorhyzema management. The next question I have is for anybody in the speakers, maybe Dr. O'Fallon can answer this. How long after ICH do you typically wait to start aspirin or Plavix for any indications of endosymbiotic therapy for underlying conditions? I think that depends on the type of intracranial hemorrhage and the reason for the aspirin. I think you have to take every case individually and look at the size of the hemorrhage and the need for the aspirin. If somebody is having an urgent need for aspirin, they're embolizing from someplace and you think that it's potentially immediately harmful to them, then you'll have a lower threshold to start that as opposed to resuming aspirin that's for something chronic and not an immediate harm. Thank you for that. The next question is, what is the best location for A-line transducer placement to decide on the CPPs of 50s to 60s versus 60 to 70? Nikhil, you want to take that question? The two options are the Axilla or the EAC. As far as I recall, there's very few places that actually place the transducer at the EAC. Baylor may be one of them. I don't know, Arti, if you know of anybody else that routinely does that. I think for consistency, because it's pretty rare to place it at the EAC to look at the frame and magnum and have ICPs be referred to that, I think the Axilla is the standard. I think the Y. Olson actually published a survey on calibration practices, whether it was calibrated to fourth ventricular tragus and found almost like a half and half division, but it is accepted consensus that unless otherwise specified, the CPPs usually measured at the left atrium being the baseline for systemic blood pressure and the tragus being the baseline for EBD, which does create a mathematical challenge. That's why we need more standardized procedures. What is the indication for thrombectomy with a sinus venous thrombosis? Dr. Patel, do you want to take that question? I know we quite didn't cover CVD yet. So I think that there's one major trial that has looked at this question called the two-act trial. They looked at question of whether mechanical thrombectomy versus just medical management with anticoagulation helps improve outcomes in patients with cerebral venous thrombosis. I believe the answer is equivocal based on that trial. It was a relatively small study. I don't think that this is a routine practice amongst most centers, especially without a trial of anticoagulation at first. Certainly, it could be considered in patients that have high-risk thrombosis and that have potential clot propagation, especially if they have a clot in the deep vein venous system. But it's certainly not a routine practice. Thank you for that. I think to respect everybody's time, we'll close out the session here. Like I said, I sincerely apologize for running over the time, but this was a lot of content to cover. We will address all these questions in a written word format and share it with all the attendees this week. Please be sure to complete the evaluation for today's session. It's extremely important for us to get your feedback. I know there was a couple audio problems that you've identified that we'll try to fix going forward, but please do let us know some constructive feedback on how to make this course better for you guys. That concludes our session. Enjoy studying. See you next week on Tuesday.

bolus hypertonic therapy

continuous infusion

TPA

INR

intracranial hemorrhage