Stroke Thrombolysis Training

Dr. Indira NatarajanClinical Lead Acute Stroke and TIA Services

WHO DEFINITION

“ rapidly developing clinical signs (at times global) of disturbance of cerebral function, lasting more than 24 hours with no apparent cause other than that of vascular origin”

This definition includes signs and symptoms of suggestive of

- ischaemic stroke - haemorrhages (intracerebral)

Diagnostic Dilemma

“ Stroke Mimics ” or “ Stroke Syndrome ”

10% - 15% of patients referred with possible stroke have something else

Some uncertainty is inevitable

Stop and Think!

Drowsy and Delirious

Patient with headache

Drowsiness, confusion and headache

Drowsiness / Delirium

SEIZURESMETABOLIC / TOXICSUBDURAL HAEMATOMAUNCONCONSCIOUS

ROSIER ScaleFacial weakness +1Arm weakness +1Leg weakness +1Speech disturbance +1Visual disturbance +1Loss of Consciousness - 1Seizure episode - 1

Diagnostic Dilemma

68 year old

Sudden onset

Right facial arm and leg weakness with speech disturbance

Vascular Risk factors:

Hypertension

Diabetes

.......................

32 year old

Dubious onset

Right facial arm and leg weakness

Stuttering course

No vascular risk factors

? Seizure

? Other causes

Treatments effective within first hours to days

Aspirin

Thrombolysis

Acute Stroke Unit

Hemicraniectomy

Effective treatment for 1 patient to benefit

Numbers treated to

benefit one patient

Propotion of patients

eligible

Asprin 100

70 - 80%

Stroke Unit 20

100%

Thrombolysis 10 10%

Hemicraniectom

y

2 2%

Hyper-acute treatment of Stroke

Re-Canalisation

Modified Rankin Scale

Independent Dependent

1 2 3 4 5

No Mild Moderate Moderately Severe

Severe

TIME IS BRAIN

2 million neurons are lost every minute that treatment is delayed.

Saver JL. Time is brain—quantified. Stroke 2006;37: 263–266.

rt-PA trials meta-analysis. Benefit declines with increasing time to treatment, but

scope for benefit up to 6h (Lancet 2004; 363: 768–74)

Benefit

Harm

3 hours 6 hours

Upper and lower 95% confidence limits

Line of no effect

Benefit of r-tpa at 90 days

Time between

event and

treatment

Odds ratio in favour of

favourable outcome (95%

CI)

Estimated number needed

to treat for favourable

outcome

0-90 minutes 2.55 (1.44 to 4.52) 3.0

91-180 minutes 1.64 (1.12 to 2.40) 7.0

181-270

minutes

1.34 (1.06 to 1.68) 14.1

271-360

minutes

1.22 (0.92 to 1.61) 21.4

Acute Stroke Services... 999

1 hour1 hour

0 - 4.5 hours0 - 4.5 hours

A Patient's Journey.....

1 hour1 hour

ESDESD

Check List

Confirm diagnosisExclude Hypo-glycaemia

Confirm Onset TimeNIHSS scaleEligibility

Contra-indicationsConsent

NIHSS Scale

International ScaleValidated to be used across the worldMainly used to maintain consistency in

all research studiesAlso to assess progress

Stroke Severity - NIHSS

NIHSS < 4

NIHSS 4 - 7

NIHSS 8 – 15

NIHSS >15

NIHSS >24

Eligibility

Age 80 or below Previously fit and independent Onset time known and less than 4.5

hours CT excludes haemorrhage

Exclusions

Recent surgery, biopsies arterial cannaulation Increased bleeding risk Past history of intracranial haemorrhage Any CNS pathology other than current stroke Any past stroke plus diabetes Stroke within 3 months Systolic blood pressure >185 NIHSS < 4 or NIHSS > 25

Benefit of thrombolysis according to age group.....

Mishra. et.al BMJ 2010; 341:c6046

Other ways of saving the Penumbra if beyond 3 - 6 hours Neuro-protection

and Re-perfusion

Saving the Penumbra……..

Anitplatelets Aspirin and DipyridamoleHydration use normal saline first 24 hTemperature keep below 37.5Oxygenation treat if saturation <92%Blood glucose keep < 10 mmol/lNutrition maintainPain Control Analgesics Blood pressure Target 160-180/90-100 in

normotensives Target 180/100-105 in hypertensives

European Stroke Initiative 2003 (http://www.eusi-stroke.com/recommendations) unchanged in 200

Getting the right patient to the right place......

Admitting patient to the Acute Stroke Unit within 4 hours

Management of Management of ComplicationsComplications

Copyright ©2008 BMJ Publishing Group Ltd.

Derex, L et al. J Neurol Neurosurg Psychiatry 2008;79:1093-1099

Figure 1 European Cooperative Acute Stroke Study (ECASS) classification of intracerebral haemorrhage (ICH) following thrombolysis (from Berger and colleagues38). (A) HI-1; (B) HI-2; (C)

PH-1; (D) PH-2

Intracranial Haemorrhage

Stop alteplase infusion

Immediate non contrast CT head

ImmediatePT, APTT, fibrinogen FBC/Group and save

Prepare 6 units cryoprecipitate

Prepare6 units platelets

Haemorrhage on CT?

Check lab resultsGive cryoprecipitate and plateletsNotify Neurosurgeons

Resume alteplase infusion

YES NO

Khaja, Lancet 2007; 396:319-330.

Intracranial haemorrhage within Intracranial haemorrhage within 36 h36 h

7 % risk of Intracranial Haemorrhage7 % risk of Intracranial Haemorrhage

(2 %of which were fatal)(2 %of which were fatal)

Asymptomatic 5%Asymptomatic 5%

Risk of haemorrhage depends on Risk of haemorrhage depends on stroke severitystroke severity

NIHSS> 20 => haemorrhage risk 17%NIHSS> 20 => haemorrhage risk 17%

NIHSS <10 => Haemorrhage risk 3%NIHSS <10 => Haemorrhage risk 3%

Stroke 1997;28(11):2109-2118.Stroke 1997;28(11):2109-2118.

Extracranial bleeding

Stop alteplase infusion

Immediate PT, APTT, fibrinogen, FBC, group and save

Use mechanical compression, if possible, to control bleeding form puncture sites

Support circulation with fluids and blood transfusion, as appropriate

For severe life threatening bleeding tranexamic acid 1 g i.v. over 15 min, repeated at 8 h if needed

Consider transfusion of FFP and/or cryoprecipitate depending on the results of the coagulation screen

Reperfusion cerebral oedema

Elevate the head to 30 degrees

Correct hyperthermia, hypoxia, hyperglycaemia, hypotension

AHA/ASA Stroke 2007;38:1655-1711. *as used by C. Roffe in Stoke, not in AHA/ASA guidance

If symptoms improve with mannitol reduce dose/frequency gradually

Mannitol 0.25-0.5 mg/kg over 20 min i.v., repeat q 6-8 h, if necessaryDexamethasone 4 mg iv qds*

Frusemide 20-40 mg iv*

Avoid antihypertensives, especially vasodilators

Consider decompressive hemicraniectomy (once clotting correct/corrected)

Orololingual Angiooedema

Stop alteplase infusion

Antihistamines (clorpheniramine 10 mg i.v.)

Hydrocortisone 200 mg i.v.

Khaja, Lancet 2007; 396:319-330.

Observe vital for signs of progression, dyspnoea, anaphylactic shock

If sx are mild and non-progressive, alteplase can be restarted under close observation

Anaphylaxis

Stop alteplase infusion

Adrenaline 0.5 -1 ml 1:1000 im or sc (not iv)

Clorpheniramine 10 mg i.v.Hydrocortisone 200 mg i.v.Salbutamol nebulizer 5 mg

Urgent medical assessment: Airway, Breathing, Circulation

If shocked i.v. saline and consider repeat doses of adrenaline

Any Questions ?

Thank you