You've heard of thrombolysis? We are here to deliver anxiolysis when it comes to learning about stroke. We are a Stroke Educational podcast originally developed by a keen group of doctors in the Neurology program in Toronto. We are also the official podcast of the Canadian Stroke Consortium and will be releasing episodes with the prefix "CSC" to designate those podcasts. Ideas and opinions are our own and not any institution or hospital, and this podcast is not a substitute for expert medical advice. The purpose of this podcast is medical education. https://www.stroke.fm/disclaimer
Chat & Tap: screening for ELVO at the 6-24 Hrs, the ACT-FAST Protocol
Episode Title: The 6-24 Hour Window: Screening, "Chat & Tap," and WorkflowHosts: Dr. Houman Khosravani (Stroke Neurologist) & Dr. Christine Hawkes (Stroke Neurologist & Neuro-Interventionist)Location: Stroke FM Studios, Toronto
The Original paper, ACT-FAST (https://www.ahajournals.org/doi/10.1161/STROKEAHA.117.019307) was a pre-hospital tool for detecting ELVO. This is now used in the ED as a first-pass clinical screen, that leads to acute CT/CTA Head and Neck.
In this episode of Stroke FM, we unpack the specific screening protocols for identifying stroke patients in the extended 6 to 24-hour window who may be eligible for Endovascular Thrombectomy (EVT). Unlike the standard "FAST" screen, this protocol aims to identify Large Vessel Occlusions (LVOs)—severe strokes caused by major clots that require mechanical removal.
We discuss the critical importance of accurate timestamps, how to clinically test for cortical signs (the "Chat and Tap"), and the essential workflow for emergency physicians to confirm candidacy before activating the regional stroke team.
The Rule: The 6-24 hour window is calculated from when the patient was last seen completely normal, not when symptoms were discovered.
Wake-Up Strokes: For patients waking up with symptoms, the clock starts when they went to sleep or were last seen well by family.
No "Resets": Hearing a patient move or hearing a fall is not sufficient to reset the clock; there must be a confirmed interaction where the patient was at their neurological baseline. However, if the patient self-reports - definitely consider that.
Protocol for Emergency Physicians or Emergency Department Nurses - in a RN-led model:
The initial screening (using ACT-FAST or similar LVO tools) should be performed locally by the Emergency Physician. If the clinical screen is positive, the following workflow applies:
Local Imaging First: Order a CT Head and CTA (Angiogram) of the Head & Neck immediately at your site.
Confirm the LVO: Review the imaging to confirm the presence of a Large Vessel Occlusion.
Activate: Only once an LVO is confirmed on imaging should you call the Regional Stroke Centre or activate the "Code Stroke" transfer.
Note: In our network, once the call is made MD-to-MD and accepted, the transfer coordination is streamlined through a nursing-led model to expedite care.
Disclosures and Disclaimers
Medical Education Only: This podcast is for educational purposes only. It does not constitute medical advice, create a physician-patient relationship, or establish a duty of care.
Not a Substitute for Care: This content should not replace competent medical assessment, professional clinical judgment, or advice from a licensed physician.
Views & Opinions: The views expressed are solely those of the hosts and guests and do not reflect the positions of their affiliated universities or hospitals.
Patient Privacy: All cases discussed are fictionalized or significantly altered for educational purposes; no real-life patient data is used.
Verification: While references are provided, the audience should independently verify all information and consult the primary literature for full details.
8 Dec 2025
Mastering your Fitness Metrics: Interview with intervals.icu David Tinker
Intervals.icu (https://intervals.icu/) is a Stellar platform to track your metrics, your fitness, whether you are a cyclist or love another sport.
In this episode, Mr. David Tinker, founder and primary developer of this platform shares some key insights. Knowledge is power and metrics are important. It is also important to be able to integrate data across different devices such as wearables. David shares his journey from a software developer to the creator of Intervals.icu, a platform designed for sport analytics. He discusses the importance of user feedback, the integration of AI, and the challenges of maintaining data accuracy. The conversation also touches on the growth of the cycling community, the significance of coaching, and the future of open-source hardware in fitness technology. David emphasizes the platform's commitment to user data accessibility and the ongoing development of features to enhance user experience.
Host: @neuroccm (https://x.com/neuroccm) (X) @neuroccm (https://bsky.app/profile/neuroccm.bsky.social) (BlueSky)
Guest: @david_tinker (https://x.com/david_tinker) (X) davidtinker.bsky.social (https://bsky.app/profile/davidtinker.bsky.social) (BlueSky)
6 Dec 2025
A Swell Simulation!
Topic: Simulation Debrief – Airway Management in the CT Scanner
Host: Dr. Houman Khosravani
Guests: Dr. Nicole Kester-Greene, Lowyl Notario (APN), Miranda Lamb (Clinical Educator, now our *stellar* Patient Care Manager for our ED!)
Patient: 67-year-old presenting with full Left MCA syndrome (Right hemiplegia/aphasia).
History: Hypertension, Diabetes, on Ramipril (ACE Inhibitor).
Initial Action: CT Head (Aspects 7, no hemorrhage) $\rightarrow$ tPA administered in the CT scanner.
The Complication: Post-tPA, the patient developed hypoxia (sats low 90s) and significant tongue/lip swelling.
Note: Angioedema can be precipitated by the combination of tPA and ACE inhibitors.
The team discussed the critical decision-making process when a "Code Stroke" turns into a "Code Airway."
Immediate Treatment:
Epinephrine: The team opted for 0.5 mg IM Epinephrine.
Debate: There was a discussion regarding IV vs. IM Epi. The consensus was to avoid IV bolus Epi in a stroke patient (due to hypertension risks) unless hypotensive, sticking to IM for the allergic reaction while monitoring BP.
Adjuncts: Methylprednisolone (125 mg) and Benadryl (50 mg).
Airway Strategy:
The Challenge: Assessing whether to intubate immediately or observe. Given the progression, the decision was to intubate.
The Method: Awake Intubation (using Ketamine/Lidocaine/Phenylephrine) was chosen over RSI (Rapid Sequence Intubation) to avoid cardiovascular collapse and maintain spontaneous respiration in a difficult airway.
The debrief heavily focused on Human Factors and inter-departmental communication.
The "CT Trap": The patient was isolated in the scanner. Managing an airway in the CT control room/scanner is dangerous due to lack of space and equipment.
The Move: A critical decision was made to move back to the ED Resus room.
Communication Gap: There was confusion regarding where the patient was going, highlighting the need for closed-loop communication before moving a critical patient.
The Transition: The Stroke Team leader initially managed the code but recognized the need to hand over the airway to the EM physician.
Explicit Handover: The importance of clearly stating, "I am handing over the airway to you," to avoid the "two cooks in the kitchen" scenario.
Dr. Kester-Greene introduced a specific communication framework to align the team during chaos:
Initial Summary: When the team arrives (Status, Diagnosis, Treatment so far).
Priority Summary: Mid-resuscitation (Re-evaluating what is most important right now).
Pre-Transfer Summary: Before moving the patient (Where are we going? Do we have the right equipment?).
"Speaking Up": The nurse noted early signs of anaphylaxis but felt unheard initially.
"Listening Up": Leaders must create space for team members to voice concerns (e.g., "Does anyone see anything I missed?").
The group established that for future cases involving angioedema in the scanner:
Secure the Airway: If imminent failure, manage on-site (or immediate vicinity).
Stable but Concerned: Transport immediately to the Resus room where equipment and space are optimized.
Clear Terminology: Use "Airway Emergency" to trigger the correct mindset shift from "Stroke Protocol."
Dr. Houman Khosravani – Stroke Physician
Dr. Nicole Kester-Greene – Director of Emergency Dept Simulation
Lowyl Notario – Advanced Practice Nurse / Patient Care Manager
Miranda Lamb – Interim Clinical Educator--> Now our Stellar Patient Care Manager
Podcast Authority Score: 42 / 100
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