1. RMH Comprehensive Stroke Centre Thrombolysis and Stroke Units : The Evidence Professor Stephen Davis Royal Melbourne Hospital Comprehensive Stroke Centre University of Melbourne

2. Stroke in Australia 53,000 per year 53,000 per year 15,000 per year with stroke or TIA in Victoria 15,000 per year with stroke or TIA in Victoria Mortality rate of 33% at 12 months Mortality rate of 33% at 12 months Higher than most forms of cancer Higher than most forms of cancer 3 rd most common cause death 3 rd most common cause death Commonest cause of serious adult disability Commonest cause of serious adult disability An increasing challenge with the ageing of our population An increasing challenge with the ageing of our population

3. Without acute reperfusion, strokes grow No Reperfusion Reperfusion

4. Time is brain – Quantified Saver J. Stroke 2006;37:263-266 RMH Comprehensive Stroke Centre

8. Comparison: tPA Vs Placebo Outcome: Death or dependency  3 hours ECASS I28 /4728 /37 0.47 (0.18, 1.23) ECASS II47 /8148 /77 0.84 (0.44, 1.58) NINDS179 /312229 /312 0.49 (0.35, 0.68) ATLANTIS8 /2316 /38 0.73 (0.25, 2.14) Total 262 /463321 /464 0.55 (0.42, 0.73) >3 to 6 hours ECASS I173 /266189 /270 0.80 (0.55, 1.15) ECASS II197 /328200 /314 0.86 (0.62, 1.18) ATLANTIS99 /336105 /336 0.92 (0.66, 1.28) Total 469 /930494 /920 0.86 (0.71, 1.04) tPAPlaceboOROR n/Nn/N(95% CI Fixed)(95% CI Fixed) tPA better Placebo better.1.21510 Thrombolysis RMH Comprehensive Stroke Centre

9. Comparison: tPA Vs Placebo (  3 hours) Outcome: Risk Mortality ECASS I13 /498 /38 1.35 (0.50, 3.70) ECASS II11 /816 /77 1.86 (0.65, 5.30) NINDS54 /31264 /312 0.81 (0.54, 1.21) ATLANTIS4 /232 /38 3.79 (0.64, 22.61) Total 82 /46580 /465 1.01 (0.72, 1.41) All intracranial haemorrhage ECASS I12 /492 /38 5.84 (1.22, 27.94) ECASS II7 /814 /77 1.73 (0.48, 6.15) NINDS34 /31211 /312 3.35 (1.66, 6.73) ATLANTIS3 /230 /3813.15 (0.65,267.05) Total 56 /46517 /465 3.43 (1.98, 5.96) tPAPlaceboOROR n/Nn/N(95% CI Fixed)(95% CI Fixed) tPA betterPlacebo better.1.21510 Thrombolysis RMH Comprehensive Stroke Centre

10. Intravenous rt-PA stroke trials : pooled analysis Global outcome score (mRS, Barthel Index, glascow score at 90 days) The ATLANTIS, ECASS, AND NINDS rt-PA Study group, 2002 Stroke onset to treatment time (OTT) [min] Adjusted odds ratio Thrombolysis N = 2799 RMH Comprehensive Stroke Centre

13. Davis SM, Hand PJ, Donnan GA. MJA 2007;187:548-550

14. MJA, 2003 RMH Comprehensive Stroke Centre

15. The Stroke Trialists' Collaboration BMJ, 1997 RMH Comprehensive Stroke Centre

16. For whom does SU work? Almost everyone! gender, age, severity All types of SCU that provide care lasting >1 week Benefit most apparent in units based in a discrete ward Not mobile teams Cochrane Library, 2003 RMH Comprehensive Stroke Centre

17. The effectiveness of SCU OutcomeStroke UnitControlRisk Difference Home44%38%6 (independent) Home16%16%0 (dependent) Institutional care18%20%-3 Dead21%25%-4 For every 100 patients receiving organised (stroke unit) care: 4 extra survive, 2 avoid NH care, 5 return home Reduction in length of stay by 6 days RMH Comprehensive Stroke Centre

20. Reduction in RMH stroke mortality due to Stroke Care Unit 19922007Fall %% Cerebral infarct 15.25 11.41 25.2 Cerebral haemorrhagic 34.03 27.65 18.8 RMH Comprehensive Stroke Centre

21. 79% hospitals in NSF survey did not have Stroke Care Unit