1. Thrombolysis: The Evidence Barry Moynihan Stroke Physician, St. George’s Hospital SITS/BASP Thrombolysis Nursing Training Day March 26 th 2012

2. Outline Pathophysiology Case Study Evidence available Unanswered questions

4. Without thrombolysis 2 hr Followup

5. A cerebral artery blocks with a clot

6. Over the next few hours the infarct grows

7. Open the blocked artery - reduce the brain damage

9. Randomised trials of thrombolysis vs control in acute myocardial infarction Total no. patients by 1994!58,600 Randomised trials of thrombolysis vs control in acute ischaemic stroke Total (all agents) 6,284 (recombinant tisse plasminogen activatort, streptokinas, desmoteplase, urokinase) rt-PA 3,977 rt-PA < 3hrs 930 rt-PA aged > 80 years 42

24. Even if the EU approval for thrombolysis is extended to 4.5 hrs, who else might benefit? Are aged > 80 years ‘very mild stroke’ or NIHSS > 25 Posterior circulatory stroke Prior stroke within the last 3 months Have a history of prior stroke + Diabetes Presenting outside the time window of 4.5 hours Other relative contraindications specified in the licence (e.g. ‘extensive infarction’, which is not defined in any way)

26. Key Messages Thrombolysis is the only cure for ischaemic stroke IV thrombolysis is associated with improved outcome up until 4.5 hours Any benefit from IV rTPA between 4.5-6 hours is likely to be less and needs demonstrating in clinical trials

27. Time is brain!