Asynchrony EM: Code Stroke

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM, with digital content curated into topic modules following our curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM professional community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.

Click here for more about us and for other curated teaching modules!

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.


This week in Asynchrony, we discuss code stroke.   Recognition of stroke is something ED practitioners must become very good at, however it is hard --and sometimes making the call can be difficult! 

We have a LOT of great #FOAMed content listed -- take your time and enjoy. Stroke mimics, posterior strokes, tPA (both recent data and old controversies, main line and endovascular) -- we've got it all here for you!

But before we wade into the velvet sea of 'code strokes', take a listen to a musical selection that could be aptly described as self-induced stroke symptoms from the consumption of stimulants followed by...whatever:

From EM Docs: how to recognize stroke and develop your ddx highlighting stroke mimics 

From Life in the Fast Lane - a succinct review of must know data & review of literature

"Stroke and TIA: Pearls and Pitfalls", again from EM Docs. Excellent review that helps you organize the management steps of stroke and gives treatment options (along w literature references - BONUS!!) to help streamline your approach 

From REBEL EM - summary of avail  lit to date focusing on effects of TPA

Another option on the data and rational for TPA usage -  from Life in the Fast Lane


Endovascular TPA

a) Drastic changes came to the landscape in 2014, when one of the first major positive trials for endovascular therapy emerged – the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN). This study ushered in the new era in endovascular intervention.

Endovascular Stroke Therapy: The New Standard? - studies showing support for intravascular TPA

b) While the data may have been promising, the truth is that a limited population will actually benefit from the therapy. The trials focused on patients with severe strokes, with large vessel occlusions and salvageable brain tissue -- however this is a small portion of the stroke patients arriving to our EDs. 

A Word of Caution, from PulmCrit

c) Time to get a little wild & crazy... you think risk factors for vascular disease in our pediatric population are unlikely but they can have strokes too --BEWARE!!  - Pediatric Stroke: EM Focused Highlights (EM Docs)

d) The ever challenging and elusive posterior stroke - an EM Crit Podcast

e) Featuring HINTS and more on posterior strokes - Posterior Stroke and HINTS exam, EM Docs

f) HINTS Demo if you need it however if test of skew is your thing, then feel free to jump ahead!

HINTS Demonstration



a) New information, will our stroke management change soon?  Data on the approach via low dose TPA. From EM Crit: The Case of the Non Inferior Inferiority Continues.

b) A bit older information and data you probably know well.  The following links highlight the history of how TPA came to be an accepted treatment for stroke and the very evidence you use to justify your decision in administering this drug...

The Secret of NINDS, from the SGEM - excellent review of the NINDS study that started the whole TPA regime.

c) The fragility of the NINDS - from PulmCrit

d) From 2014, EM Crit  - an animated and entertaining review of NINDS trial and limitations of the trail that has served as the basis for TPA use.  (Discussion of consent.)

e) EM Cases: Information on the ABCD2 score (if you are using it:) and more!

That's it! See you next time in Asynchrony EM  -- happy #FOAMing!