Stroke Thrombolysis Training Dr. Indira Natarajan Clinical Lead Acute Stroke and TIA Services.
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Transcript of Stroke Thrombolysis Training Dr. Indira Natarajan Clinical Lead Acute Stroke and TIA Services.
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Stroke Thrombolysis Training
Dr. Indira NatarajanClinical Lead Acute Stroke and TIA Services
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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)
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Diagnostic Dilemma
“ Stroke Mimics ” or “ Stroke Syndrome ”
10% - 15% of patients referred with possible stroke have something else
Some uncertainty is inevitable
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Stop and Think!
Drowsy and Delirious
Patient with headache
Drowsiness, confusion and headache
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Drowsiness / Delirium
SEIZURESMETABOLIC / TOXICSUBDURAL HAEMATOMAUNCONCONSCIOUS
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ROSIER ScaleFacial weakness +1Arm weakness +1Leg weakness +1Speech disturbance +1Visual disturbance +1Loss of Consciousness - 1Seizure episode - 1
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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
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Treatments effective within first hours to days
Aspirin
Thrombolysis
Acute Stroke Unit
Hemicraniectomy
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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%
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Hyper-acute treatment of Stroke
Re-Canalisation
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Modified Rankin Scale
Independent Dependent
1 2 3 4 5
No Mild Moderate Moderately Severe
Severe
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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.
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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
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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
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Acute Stroke Services... 999
1 hour1 hour
0 - 4.5 hours0 - 4.5 hours
A Patient's Journey.....
1 hour1 hour
ESDESD
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Check List
Confirm diagnosisExclude Hypo-glycaemia
Confirm Onset TimeNIHSS scaleEligibility
Contra-indicationsConsent
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NIHSS Scale
International ScaleValidated to be used across the worldMainly used to maintain consistency in
all research studiesAlso to assess progress
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Stroke Severity - NIHSS
NIHSS < 4
NIHSS 4 - 7
NIHSS 8 – 15
NIHSS >15
NIHSS >24
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Eligibility
Age 80 or below Previously fit and independent Onset time known and less than 4.5
hours CT excludes haemorrhage
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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
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Benefit of thrombolysis according to age group.....
Mishra. et.al BMJ 2010; 341:c6046
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Other ways of saving the Penumbra if beyond 3 - 6 hours Neuro-protection
and Re-perfusion
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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
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Getting the right patient to the right place......
Admitting patient to the Acute Stroke Unit within 4 hours
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Management of Management of ComplicationsComplications
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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
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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.
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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%
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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.
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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
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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)
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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
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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
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Any Questions ?
Thank you