1. Update on Stroke GP Update Course RSCH October 2010 Dr Adrian Blight

2. Plan Thrombolysis in acute ischaemic stroke –Background –Practical considerations –Cases –Controversial issues –Future developments Importance of the whole stroke pathway

3. Thrombolysis for Ischaemic Stroke Attractive in principle Around for years Difficult in practice Various agents NINDS trial 1995 tPA

4. Effect of thrombolysis with rt-PA <3 hours Outcome: death or dependency (Rankin 3-5) at 3 months Brott 2002

5. Global Good Outcome at Day 90 (mRS 0-1, BI 95-100, NIHH 0-1) Lancet, 2004 Adjusted odds ratio with 95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776) SITSECASS III

6. Overall: One in 3 chance of a better outcome One in thirty chance of a worse outcome 1-2% chance of important intracranial haemorrhage BUT – few stroke patients receive tPA in UK Need to aim for 15%

7. How does it work in practice?

8. In Practice Rapid assessment of neurological deficit Assessment proforma – inclusion / exclusion criteria NIHSS Collateral history and witness Pre morbid function Early consultation with stroke consultant on call

9. Acute call Baseline observations –HR/BP/bm/O2 sats Bloods IV access ECG CT head

10. Hypodensity of –Lentiform nucleus –Insular cortex Focal mass effect –Sulcal effacement –Compression lateral ventricles

11. Hyperdensity of vessels –Proximal MCA –Sylvian dot sign

12. Decision to treat Options: 1.Stroke for thrombolysis 2.Stroke but not for thrombolysis 3.Not a stroke – (Stroke mimic)

13. FAST +ve mimics Hypoglycemia Migraine Post-ictal paralysis Brain Tumours Subarachnoid hemorrhage Subdural haemorrhage Cervical myelopathy Hypertensive encephalopathy Peripheral nerve palsies Musculoskeletal injuries Intracerebral abscess Functional Acute illness in pt with old stroke / cerebrovascular disease

14. Fast –ve strokes Cerebellar strokes Occipital infarcts Non-dominant parietal lesions Sensory strokes Frontal infarcts causing just leg weakness

15. Decision to treat Consent Alteplase –Dose 0.9 mg/kg body weight –10% given as initial bolus dose and rest infused over one hour IV One to one care throughout infusion BP observations every 15mins for 2 hours every 30 mins for 4 hours Hourly for 18 hours Acute Stroke bed Complete proforma

16. No catheter / NGT 24 hours BP and glucose control Any deterioration in GCS / neurological status merits repeat CT head ? haemorrhage Local haemorrhage (gums/bruising) Anaphylaxis (lip/tongue swelling) Post stroke governance issues

17. Time is brain….. 1.9 million neurons die every minute after a stroke Thrombolysis given in first 90 minutes is twice as effective as when given in first 180 minutes Thrombolysis needs to be delivered as part of a comprehensive pathway for stroke - NOT in isolation

18. 75yr old man Collapsed 11.10am SECAMB “?TIA/CVA” GCS 10 BP 145/75 BM 7.5 Left hemiparesis Dense Left hemineglect Eyes deviated Tolerating NP airway NIHSS 20

20. TPA bolus given 2 hrs 35 after stroke onset Uneventful infusion No complications NIHSS 2

23. Excellent recovery Home after a few days with ESD team Took part in local TV and newspaper articles to help raise awareness

24. 78yr old man - GB Found collapsed in front garden Dense right hemiparesis Mute NIHSS 19 Little initial other history

26. Developments… Gardening all morning Found collapsed at 12.55 Estimated time of onset – 12.45 CABG / HT – no warfarin Investigations for anaemia “a few years ago” Normally fit and well Ex professional double-bassist

27. Decision to treat “in best interests” tPA at 2 hrs 5 mins since estimated onset Uneventful infusion

28. At 24 hrs NIHSS - 2

29. Made excellent recovery Fluent speech On going follow up at Epsom

30. Difficult decisions….. Mrs KB 46yr old lady. Acute left hemiparesis Witnessed by husband No vascular risk factors No apparent contraindications NIHSS 9

31. CT at approx 2 hours

32. About to administer bolus tPA Hb result now rung through: Hb 5.6g Now what?

33. CT 23 hours later

34. DWI MRI

35. Mrs KB OGD normal. Large fibroid with menorrhagia No cause for infarct indentified - cryptogenic stroke

36. 62 yr old man Playing golf Developed acute dysphasia and left sided weakness

38. Background 3 previous infarcts over last 25 yrs Subsequent PFO and closure Excellent recovery After discussion –felt that tPA is indicated and worthwhile

41. Mr GC 70 yr old Acute dysphasia

42. Acute CT brain

43. Controversies in thrombolysis What is the time window for treatment? Should all the licensed criteria be stuck to rigidly? What about patient age? Who should deliver it? Where is it best delivered?

44. Service Models Who? –Huge variety Where? –Every acute hospital? –Ambulance primary divert for all stroke patients and a limited number of HASUs (London) –Primary diversion for selected cases How? –“Hands-on” specialist –Using remote video enabled teleconference technology (“telemedicine”)

45. Telemedicine in Stroke

46. Interventional neuroradiology

47. The importance of the whole stroke pathway Hyperacute stroke service Direct to stroke unit (NOT MAU) –High quality MDT- inc weekends Specialist inpatient rehabilitation Early supported discharge Long term support –Structured FU and annual review –Rehabilitation / adaption –Spasticity / continence etc –Financial support –Vocational rehabilitation

48. Thank you