1. ACUTE CARE and THROMBOLYSIS
STROKE
ACUTE CARE and THROMBOLYSIS
Adrian Pace
Neurology SpR
Derriford Hospital

2. Types of Stroke Stroke is several different disease processes:
Small vessel disease (atherosclerosis)
Large vessel disease (carotid atheroma embolism)
Cardio-embolic disease (AF; PFOs; LVF)
Cerebral haemorrhage (aneurysms; HTN)

3. Acute care in a nutshell
Oxygen, glucose, blood pressure
Sa02 should be maintained at >=95%
Blood glucose should be maintained between 4 – 11 mmol including use of insulin for known diabetics
Blood pressure should allowed to find its normal level by ensuring normal fluid balance
Low pressure will mean low cerebral perfusion pressure and limit recovery so that is always bad
High pressure increases risk of repeat stroke or bleed so that is only potentially bad
Guidelines are to maintain that persons “natural” pressure by maintaining a normal fluid balance with IV fluids.
Anti-hypertensive treatment in people with acute stroke is recommended only if there is a hypertensive emergency or one or more of the following
hypertensive encephalopathy
hypertensive nephropathy
hypertensive cardiac failure/myocardial infarction
aortic dissection
pre-eclampsia/eclampsia
intracerebral haemorrhage with systolic pressure over 200.

4. Also in first 24 hours… Admit to an acute stroke unit direct from ED
Aspirin 300 mg
Swallow screen and SALT referral
Keep temperature down (fan, paracetamol)
Early mobilisation and PT referral
Avoid catheters unless in retention

5. National guidelines
Everything you need is in the
Royal College of Physicians National Clinical Guidelines for Stroke (3rd Edition) 2008
This includes a comprehensive evidence-based guide to acute stroke care – what works, what is pointless, what is still being tested

6. THROMBOLYSIS
FOR
ISCHAEMIC STROKE

7. Ischaemic cascade in stroke
Process of stroke injury
at cellular level.
Irreversible damage begins
immediately at the core
(Umbra).
The surrounding area (Penumbra) is an ischaemic zone with CBF of 25-50% of normal and loss of autoregulation.
Viability of penumbra is preserved if perfusion is restored with in a critical time period.

8. Ischaemic Penumbra
Maintain blood flow to penumbra
Maintain cerebral blood flow

9. Thrombolysis is the process of breaking up and dissolving intravascular blood clots by pharmacological means.
Some commonly used thrombolytics are:
Streptokinase
Urokinase
Recombinant tissure plasminogen activators (rt-PA).
Thrombolysis is used for minimising tissue damage following myocardial infarction, stroke, massive pulmonary embolism and acute limb ischaemia.
Thrombolysis reduces risk of long term disability after stroke by 30%
But only 0.2% received thrombolysis in UK in 2006 compared with 10% in Australia. Derriford currently at about 1.5% of acute stroke admissions.
NAO estimate:
- cost of thrombolysis for 9% strokes to be £9.9 million
- saving of £26.4 million in care costs

10. EFFICACY AND SAFETY OF THROMBOLYSIS

11. Benefit vs Harm with Thrombolysis
For every 100 patients treated with rt-PA: - 32 have a better final outcome - 3 have a worse final outcome - 65 have an unchanged outcome NNT = 3.1 NNH = 30.1 Likelihood of being helped rather than harmed LHH = 30/3 = 10 Intravenous rt-PA is 10 times more likely to help than harm eligible patients with acute ischaemic stroke.

12. Risk of Cerebral Haemorrhage with rt-PA
6.4% risk of symptomatic ICH within 24hrs (ie, clinical worsening due to new ICH) vs 0.6% without rt-PA.
1.5% risk of large haemorrhage with significant space occupying effect likely to prove fatal and not usually amenable to surgery.
At three months mortality was not significantly different between the two groups

13. NINDS trial – 3 months outcome

14. ELIGIBILITY FOR
THROMBOLYSIS

15. Eligibility Criteria for treatment with rt-PA
Age 18 to 80 years
Clinical diagnosis of ischaemic stroke
Stroke must cause a measureable
neurological deficit (NIHSS >4)
Time of symptom onset is known
Sufficient time in 3 hours therapeutic
window to assess and treat
No clear contraindication to
thrombolysis.

16. Contraindications to Thrombolysis (1)
HISTORY
Haemorrhagic retinopathy
Known or suspected history of intracranial bleed
HI or stroke within last 3/12
Major surgery/trauma within last 3/12
Peptic ulcer
Recent puncture of a non-compressible blood vessel
Recent (<10/7) traumatic CPR or childbirth
Severe liver disease
Neoplasm with increased bleeding risk
Prior stroke with concomitant diabetes

17. Contraindications to Thrombolysis (2)
CURRENT
Symmptoms suggestive of SAH
Evidence of intracranial bleed on CT
Seizure at onset of stroke
SBP of >185mmHg or DBP >110mmHg
Symptoms rapidly improving before rt-PA
Anticoagulants (except warfarin if INR <1.4)
Platelet count below 100x103
Clinically mild stroke (NIHSS <4)
Clinically severe stroke (NIHSS >25)
Severe stroke as assessed on CT (>1/3 MCA territory;)
Previous functional status (Rankin score 3 or more)

18. ACUTE
MANAGEMENT
IN HOSPITAL

19. Time is brain!

20. NINDS recommended targets for time
• Door to Doctor minutes
• Access to Neurological expertise minutes
• Door to CT completion minutes
• Door to CT interpretation minutes
• Door to treatment minutes
• Admission to monitored bed hours

21. ***IS THE PATIENT A CANDIDATE FOR THROMBOLYSIS?***
Acute Management
Vitals:
A : Is the airway secure?
B : O2 saturation > 95%?
(put all patients on an oxygen mask)
C : BP? Too high or too low? Is patient in AF?
History:
- Symptom onset or time last seen normal
- Correlate times (alarms, work, drive time TV)
- Corroborate with any available witness
- Prodromal or previous symptoms/TIAs
- Exclude stroke mimics
***IS THE PATIENT A CANDIDATE FOR THROMBOLYSIS?***

22. Thrombolysis in the ED IDENTIFY POTENTIAL CANDIDATE
IMMEDIATELY CONTACT STROKE PHYSICIAN
Take bloods (FBC, U&Es, glucose, clotting)
Acquire a 12-lead ECG
IV access x 2 (preferably large gauge)
Document observations every 15 minutes
Check capillary BM
Administer O2 at 2-10 L/min
If BP consistently >185 SBP or >110 DBP - labetolol
ORGANISE IMMEDIATE CT SCAN

23. Stroke Physician Assessment
Examine patient and confirm diagnosis
Discuss risks/benefits with patient/relatives
Obtain informed consent
Review and confirm inclusion/exclusion criteria
Complete NIHSS and Rankin scores
Obtain weight estimate
Review blood results and CT images
Calculate dose of rt-PA
- 0.9 mg/kg (max. 90mg)
- 10% dose stat over 1 min
- remaining 90% over 1 hour
Patient admitted to Level 1 area

24. POST-THROMBOLYSIS
ASSESSMENT AND
MONITORING

25. Post Thrombolysis (1): The ‘DOs’
Check observations:
- every 15 minutes for 2 hours
- every 30 minutes for 6 hours
- every 60 minutes for 16 hours
NIHSS at 2 hrs, 24 hrs and 7 days ( or discharge)
Maintain oxygenation
Treat pyrexia aggressively
Manage blood glucose actively
Prompt swallowing assessment
IV fluids if needed
Nurse with head and trunk at 30 degrees in bed

26. Post Thrombolysis (2): The ‘DON’Ts’
For the first 24 hours (unless absolutely necessary):
No urinary catheters
No NG tubes
No aspirin / dipyridamole / clopidogrel
No heparin (not even prophylactic doses
Avoid central venous and arterial lines

27. 24 hours Post-Treatment Likelihood of rt-PA complications reduced
Usual stroke aftercare resumes:
1. aspirin 300mg after repeat scan
2. NG tube if required
3. Investigations of stroke aetiology as indicated
4. Secondary prevention therapy
5.Begin normal rehabilitation

28. BP Management Post-Thrombolysis
Significant HTN post-treatment is potentially hazardous due to haemorrhagic transformation.
SBP >180 or DBP >105 on two occasions over 5 minutes:
Labetolol 10-20mg IV stat
Repeated dose Labetolol can be used
Consider Labetolol infusion
GTN infusion (as per cardiac dosing)
Avoid Ca+ channel blockers
Na+ nitroprusside infusion on ITU

29. Neurological Deterioration Post Thrombolysis
ICH may be signalled by acute HTN,
headache, neurological deterioration, and N&V.
Inform Stroke team immediately
Repeat CT head
Contact neurosurgeons if haemorrhage
- stop rt-PA infusion!
- check FBC and clotting
- Give FFP, cryoprecipitate, platelets
Treatment is usually conservative

30. BARRIERS TO
RAPID ACUTE
STROKE CARE

31. Patient inability to recognise stroke symptoms
- 40% of stroke patients cannot name a single sign or symptom or
stroke risk factor.
- 60% of patients would contact their GP or NHS Direct if having a
stroke
- 75% of stroke patients misinterpret their symptoms.
- 86% of patients believe that their symptoms are not serious enough
to seek urgent care.
Just over half of GPs said they would refer someone with a suspected
stroke immediately.
3. Hospital physicians’ lack of experience with stroke thrombolysis and therefore reluctance to ‘risk’ treatment.
< 12% of hospitals have protocols in place with ambulance services for
the rapid referral of those with suspected stroke.
< 50% of hospitals with acute stroke units have access to brain
scanning within three hours of admission to hospital.

32. UK thrombolysis use in research (IST-3)and practice (SITS)