Shadowing Practice: Medium Vessel Occlusion: Should We Thrombectomize? - Learn English Speaking with Video

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Hello everyone, my name is Puriya Moshaydi.

I'm a vascular neurologist and neurointerventionist at Tehran University of Medical Sciences.

I'm very honored to be invited on this panel discussing thrombectomies in medium vessel occlusions.

Should we still treat them?

And my take is we should not.

I have no conflict of interest and speaking in front of a group of neurodeterventionists and say that do not do thrombectomy,

giving me a feeling that is best depicted in this slide, how I divide roles between myself and Dr. Al -Rahimi.

So let's first start with talking what is a medium vessel.

So we know what large vessel is.

Large vessel are basilar arteries, internal carotides, and the main branch of middle cerebral artery.

And anything beyond that is considered middle vessel,

medium vessel, including PCAs, ACAs, and MCA branches, M2s.

There are some nuances.

We know that there is an anatomic variability on how M2s are branching.

The main application here is sometimes you have a dominant M2s that you see here.

one m2 is bigger than the other one

and sometimes you have co -dominant m2s and obviously a non -dominant m2

so a dominant m2 is actually a large vessel occlusion as they have been included in other lvo trials

and non -dominant or co -dominant m2s are in fact medium vessels

and the medium vessel occlusion trials published so far include all the medium vessels but majority are m2s so let's

take a step back.

When Dawn trials were underway and it was published, I was a resident at UPMC, we often had this discussion with my mentor,

Tudor Joven, who would argue astonishing number needed to treat of two for any improvement after thrombectomy,

any functional outcome improvement at 90 days may indicate that we own a very effective treatment,

but may also show that we are being very over selective in a group of patients,

meaning that we are able to exclude any patient with lesser likelihood of benefiting from thrombectomy.

And so we usually select patients based on the loss known normal, degree of disability, the location of occlusion, and the infarct volume.

And so the next generation of trials, which the MEVO trials belong to them, is starting to testing those boundaries.

So going beyond the time limits,

the publication by my very good friend Shashva Desai showed that if you select patients that are in the

DAWN criteria would be included, except the time of onset, even going as far as 72 hours, they would have the same benefit as patients in DAWN.

So they successfully crossed the time limit although it's not within our guidelines yet

and then we're all aware of the large core trials uh this is the one by dr saraj

that the number needed to treat drop from 2 .1 to 7 .7

but they still show the benefit for thrombectomies but

so the second line was crossed successfully

but are we able to go from large vessel thrombectomy to medium vessel thrombectomy And even before starting the trials, was it expected to help?

So let's look at the subgroup analysis of the early time point thrombectomy trials and the Hermes meta -analysis.

So I want to draw your attention in the subgroup of M2s, which were included in some of those five trials.

the subgroup of M2s actually did not benefit from thrombectomy.

And also those that their NIH stress scale was less than 10.

So the myelore stroke symptoms.

And this is important because actually looking at the patients with medium vessel occlusions,

the presenting NIH stress scales is an average three points below large vessel occlusion.

So you're dealing with a less disabled group of patients, let's call it.

And then looking at the subgroup analysis of late -time window EVT, this is from diffuse tree, the same thing showed up.

So the subgroup of patients with milder NISOS scale, again, they did not benefit from thrombectomy.

So this is how we entered, um, the the information we have before doing the medium vessel occlusion trials

and there were some studies on the PCAs and ACA showing

that ACA thrombectomy would not change the outcome they were non -randomized

but still I think they're worth mentioning

and then there was a observational study on PCA thrombectomies

that in fact it showed that thrombectomy we call a higher rate of symptomatic ICH and a worse recovery.

So this is how we entered.

So I want to use this nice picture from the publication by Goldberg and colleagues.

We have two published trials, Distal and Escape MVO and Discount, which is not yet published.

Correct me if I'm wrong.

This is the baseline studies.

So what I want to draw your attention to is

that each study was enough powered and And they were trying patients with different time points, less than 12 hours, less than 24 hours, less than 8 hours.

And they were also variable and allowed different devices to be used.

Some obliged the operator to use the stent retriever, some gave them flexibility.

So the results that would come from these trials will have generalizability to different times of onset and different device usage.

The outcome, again, this is part of the baseline characteristics.

You would see that in all the trials, both discount distal and SCAPE -MEVO,

the patients that were included as expected they were presented with mylar stroke symptoms

so you are doing a procedure on a patient

that is much less disabled remember the the average of patient in dawn were

about five or six units higher in an NHSRO scale and then the symptomatic ICH in all the trials

were really considerable and discounted with 12 percent in distal was 5 .9 percent

and 5 .4 percent in escape mevo

and then I want to again compare it with the meta -analysis of large vessel occlusion thrombectomies

that the symptomatic ICH were only 4 .4 percent so you are treating a patient

treating group of patients with milder symptoms with a more risky procedure.

So have this in mind.

And then in terms of outcomes, so we have the escape mevo and distal,

which showed no benefit in outcome at 90 days.

As you see, the confidence interval will cross the value one,

and the escape mevo in fact showed a higher rate of 90 days mortality

which was significant in interventional group so it shows

that we're not only benefiting but we are at some point harming

so one word of caution that discount results which were preliminary presented in isc

it showed that there was a significant improvement in thrombectomy patients for the MRC score equal less than 2 at 90 days.

But this was this annotation at the bottom after multiple imputation of missing data.

So I don't know what it means.

I don't know what it would turn into when it comes out as a full paper.

So we have to look out for it.

So we are talking about the thrombectomy in a group of patients or in one patient they are facing.

You're doing thrombectomy in a patient which has milder symptoms in a risky procedure.

But I want to also take this discussion into a global health level.

So this is the picture from MT Glasses study,

mission thrombectomy, which shows the access of different countries to thrombectomies.

As you can see, even the good countries are colored in green, only about a third of patients eligible for thrombectomy have access to it.

The situation for other countries is dismal.

Majority of MENA countries have less than 10 % access to thrombectomies.

So what I'm feeling that as neurointerventionists, although we have the duty to bring the best for our patient,

but it seems that we have a more pressing and urgent challenge, meaning that

improving access to thrombectomies for large vessel occlusion you know we are living in a world

that the resources are limited

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so we can invest in finer devices for middle vessel occlusion thrombectomies as we we saw

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that the thrombectomies in this population is more risky

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so maybe we can already our devices is not uh prepared for it

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but we can also invest that time and effort and money in making LVO device thrombectomies more available.

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And that is the subject of grassroots trials,

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bringing a stent retriever in with the lesser cost so that it could widen its coverage.

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It actually came out from the Mission Thrombectomy Initiative.

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And I think it got approval in India, if I'm not wrong, it got approval in Thailand before it.

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So, So as an interventionist, when I'm facing the MEVO study,

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we can talk about like different pieces of information that we have.

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That for MEVO, we are treating patients with milder symptoms.

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Our procedure is more risky, causing higher degree of symptomatic ICH, even mortality.

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We have less successful reperfusion and no proven functional outcome.

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But I think as a next step, if I have a choice of going after improving the devices

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and refining trials for smaller vessels or trying to widen the very dismal global coverage for mechanical thrombectomy for LVO,

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I would definitely choose the second one.

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So, my answer to doing thrombectomies in medium vessel occlusions is no,

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then I'm leaving a stage to my very good colleague, Dr. Rohini.

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This is a picture of Tehran from the hospital that I work with.

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Hopefully, we can all meet there.

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And thank you for your attention.

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אוצר מילים והערות הגייה לשיעור הזה

שיעור הדיבור הזה ברמה C2 מבוסס על הסרטון “Medium Vessel Occlusion: Should We Thrombectomize?”. המילים שחוזרות הכי הרבה: patient, vessel, thrombectomy, trials, occlusion. בסרטון הזה יש 120 משפטים ו-1578 מילים לתרגול Shadowing. הדיבור נמשך 12:00. הדובר שומר על קצב יציב של כ-132 מילים בדקה, קצב נוח לתרגול Shadowing. רק 76% מהמילים נמצאות בין 3,000 המילים הנפוצות ביותר באנגלית, כך שאוצר המילים מאתגר.

אוצר מילים מרכזי בסרטון הזה

12 המילים המתקדמות ביותר בסרטון, עם ההגייה והמשמעות שלהן:

מילה	הגייה	משמעות
symptom שם עצם	/ˈsɪm(p)təm/	תַּסְמִין, סִימְפּטוֹם
artery שם עצם	/ˈɑɹ.təɹ.i/	עוֹרֶק
mortality שם עצם	/mɔɹˈtælɪti/	תְּמוּתָה
distress שם עצם	/dɪˈstɹɛs/	מוּעָקָה
colleague שם עצם	/ˈkɒliːɡ/	עָמִית, עמיתה
astonish פועל	/əˈstɑnɪʃ/	הדהים
criterion שם עצם	/kɹaɪˈtɪɹ.i.ən/	קרִיטֶרִיוֹן
infarct שם עצם	/ɪnˈfɑɹkt/	אוטם
exclude פועל	/ɪksˈkluːd/	לא הכליל
mentor שם עצם	/ˈmɛn.tɔː/	מַנְחֶה, חוֹנֵךְ
characteristic שם עצם	/ˌkæɹ(ə)ktəˈɹɪstɪk/	סממן
flexibility שם עצם	/ˌflɛksɪˈbɪlɪti/	גְּמִישׁוּת

Phrasal verbs שתשמעו

מילה	הגייה	משמעות
come out פועל	/ˌkʌm ˈaʊt/	יָצָא

דקדוק בסרטון הזה

המבנים שהדובר משתמש בהם הכי הרבה, עם המילים המדויקות מהסרטון:

מבנה	בסרטון
סביל (Passive voice) be + past participle — הדגש הוא על מה שקורה, לא על מי שעושה את הפעולה	be invited · is considered · have been included
משפטי זיקה (Relative clauses) who / which + clause — מידע נוסף על אדם או דבר	Discount, which is · results which were · patient which has

הגייה ששווה לשים לב אליה

הדובר משתמש ב-14 קיצורים וצורות מקוצרות, כמו I'm, don't, we're. אמרו אותם בצורה הקצרה, כפי שאתם שומעים אותם.

הצלילים של “sh” ו-“zh”: occlusion /əˈkluː.ʒən/, annotation /ˌæn.əˈteɪ.ʃən/, astonish /əˈstɑnɪʃ/, imputation /ˌɪm.pjʊˈteɪ.ʃən/, interventional /ˌɪn.təɹˈvɛn.ʃə.nəl/
מילים ארוכות — שימו לב להטעמה: symptomatic /ˌsɪmp.təˈmæt.ɪk/, mortality /mɔɹˈtælɪti/, anatomic /ˌæn.əˈtɑ.mɪk/, annotation /ˌæn.əˈteɪ.ʃən/, criterion /kɹaɪˈtɪɹ.i.ən/

צלילים שדוברי עברית מתקשים בהם:

/w/ — שפתיים מעוגלות, לא /v/: widen /ˈwaɪdn̩/, underway /ʌndəɹˈweɪ/
/æ/ — פתוח יותר מה-“אֶ” העברית, לא כמו “a” ב-“cup”: symptomatic /ˌsɪmp.təˈmæt.ɪk/, mortality /mɔɹˈtælɪti/, anatomic /ˌæn.əˈtɑ.mɪk/, annotation /ˌæn.əˈteɪ.ʃən/, basilar /ˈbæz.əl.ɚ/
/r/ — הלשון לא נוגעת בשום מקום, לא ה-“ר” הגרונית: subgroup /ˈsʌbˌɡɹuːp/, risky /ˈɹɪski/, retriever /ɹiˈtɹivəɹ/, artery /ˈɑɹ.təɹ.i/, mortality /mɔɹˈtælɪti/

איך לתרגל עם הסרטון הזה

הקשיבו לכל הסרטון פעם אחת בלי לדבר, ורשמו את המילים שאתם לא מכירים.
תרגלו Shadowing משפט אחר משפט במהירות רגילה, וחזרו על כל משפט עד שהקצב שלכם תואם את הדובר.
הקליטו את עצמכם והשוו למקור, תוך תשומת לב למילים כמו symptom, artery, mortality.

מהי טכניקת השאדואינג?

שאדואינג היא טכניקת למידת שפה מבוססת מדע שפותחה במקור להכשרת מתורגמנים מקצועיים ופופולרית על ידי הפוליגלוט ד"ר אלכסנדר ארגואלס. השיטה פשוטה אך עוצמתית: אתה מקשיב לאודיו באנגלית ילידית וחוזר עליו בקול רם מיד — כמו צל העוקב אחרי הדובר עם עיכוב של 1–2 שניות בלבד. בניגוד להאזנה פסיבית או תרגילי דקדוק, שאדואינג מכריח את המוח והשרירים בפה לעבד ולשחזר דפוסי דיבור אמיתיים בו זמנית. מחקרים מראים שזה משפר משמעותית את דיוק ההגייה, האינטונציה, הקצב, הדיבור המחובר, הבנת השמיעה ושטף הדיבור — מה שהופך אותו לאחת השיטות היעילות ביותר להכנה לIELTS Speaking ולתקשורת באנגלית בעולם האמיתי.

טכניקת Shadowing: קרא את המדריך המלא שלב אחר שלב →

Shadowing Practice: Medium Vessel Occlusion: Should We Thrombectomize? - Learn English Speaking with Video

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אוצר מילים והערות הגייה לשיעור הזה

אוצר מילים מרכזי בסרטון הזה

Phrasal verbs שתשמעו

דקדוק בסרטון הזה

הגייה ששווה לשים לב אליה

איך לתרגל עם הסרטון הזה

מהי טכניקת השאדואינג?