Thrombolysis East of England Forum Diana Day Consultant Nurse for Stroke

What is thrombolysis Clot buster Lyse (breaks up) clots Drug is called Alteplase (rt-Pa) Aim to restore blood supply to the brain in the early hours of stroke

Global Good Outcome at Day 90 (mRS 0-1, BI 95-100, NIHS 0-1) (N=2776) SITS database 12/12/2007 http://www.acutestroke.org/index.php

SITS-MOST vs RCTs – mRS 3/12 19 20 13 19,9 22 16 15,9 8 11 14,7 14 13,9 12 5,3 7 11,4 18 SITS-MOST RCT active rt-PA RCT placebo mRS 0 mRS 1 mRS 2 mRS 3 mRS 4 mRS 5 mRS 6 0% 20% 40% 60% 80% 100% Dead Recovered +10% +4,8% Red colours: independent Blue colours: dependent Black colour: dead Lancet 2007; 369: 275-282.

Time is brain Around1.9 million neurons lost a minute

Time to treat Target 2hrs (30-45mins) Max 4.5 hours Recognise React Respond Refer Treat Target 2hrs (30-45mins)

Journey time 30 – 45mins (60mins review) Act F.A .S.T Recognise /React Respond Journey time 30 – 45mins (60mins review)

Refer and Assess Assess Event history NIHSS,PMH, meds Glucose / bloods Pre alert stroke team

Treat with thrombolysis?

Telemedicine Providing regional access to stroke expertise out of hours

Who can we treat? Inclusion criteria Clinical S&S of definite acute stroke Clear time of onset Presentation within 4.5 hrs of acute onset Haemorrhage excluded by CT scan Age 18 and over NIHSS less than 25 Consent discussion

Exclusion Criteria Increase bleeding risk Greater than 4.5hrs Rapidly improving or minor stroke symptoms Stroke or serious head injury 3 months Major surgery, obstetrical delivery, external heart massage last 14 days, Seizure at onset of stroke Severe haemorrhage last 21/7 History of central nervous damage Hypo / hyper glycaemia Warfarin (unless INR below 1.5) BP > 180/110mmHg (and other exclusions)

Potential for thrombolysis

Conditions Hyper Acute stroke unit Under the care of stroke physician /neurologist Care at level 2 (HDU) Physiological monitoring Nurses trained in thrombolysis & acute skills Protocols & guidelines for care Access to immediate imaging (24hrs) Protocols of care

Staffing Nursing 1:1 – whilst thrombolysing 1:2 – 1:4 first 24-48 hrs of care Competency based training NIHSS trained

Mimics Seizure Migraine Sub /extra dural Tumour MS Hyperglycaemia Non organic Cerebral abscess /infection Unlikely to be stroke Felt funny & shaking Visual disturbance Pins & needles Fluctuating symptoms

Exclude stroke mimics Vascular event sudden onset Maximal at onset Fits within vascular territory

Case 1 72 yr old gentleman well this morning Went to his car at 8.30am Dropped his keys, and fell to the ground His wife noticed right sided weakness Unable to talk properly Rang 999

Assessment – 10.02 He has PMH high blood pressure He is being investigated for AF No previous hospital admissions BP 179/95, P 114, sats 94%, glu 7.8mmols NIHSS 21 (aphasic, RSW fal, HH)

Early CT scan : time 10:23

CT Perfusion Cerebral Blood Flow Time to peak

Infusion Alteplase 0.9mg/kg/body weight, up to max of 90mg. Diluted with sterile water to 1mg/ml 10% of infusion as bolus 90% as infusion using syringe pump over 1 hour.

Post Thrombolysis

Potential complications Haemorrhage Intracerebral Systemic Reperfusion hypotension Improvement then deterioration Nausea / vomiting

Haemorrhagic Complications of t-PA 30 mins into infusion he starts talking again, weakness improves Then becomes drowsy GCS 15 -13 Stop infusion Call medical team CT scan Neurosurgical opinion

Post CT scan

Management of Bleeding Complications If bleeding is suspected stop infusion of a thrombolytic drug immediately. Send FBC, APTT, PT/INR, and fibrinogen. Grouped and matched if transfusions are needed 4 to 6 U of cryoprecipitate or fresh frozen plasma, platelets These therapies should be made available for urgent administration.

Allergic reaction anaphylactoid reaction, laryngeal oedema, orolingual angioedema, rash, and urticaria usually respond to conventional therapy – antihistamine and hydrocortison if caught early – otherwise full anaphylaxis protocol many of these patients received concomitant ACEI therapy Most cases resolved with prompt treatment; there have been rare fatalities as a result of upper airway haemorrhage from intubation trauma Other Adverse Reactions Nausea and/or vomiting, hypotension and fever have also been reported – Treat symptoms

Patient 2 : Right hemilingual angioedema

Time is Brain Impact of thrombolysis 30 20 10 0 2 4 6 Time (hours) Number making full recovery per 100 treated 30 20 10 Benefit Harm 0 2 4 6 Time (hours) Saver, Stroke 2006

First 24 hours of care Monitored bed on stroke unit Thrombolysis pathway 24-36 hour repeat CT scan No antiplatelets for 24 hours No IM injections, catheterisations or invasive procedure unless unavoidable. Bed rest for 24 hrs IV access

Research areas Time window (DIAS) Dose (Enchanted) Other medications (DIAS III) Intra arterial (PISTE) Clot retrieval Awakening stroke (WAKE UP) Anticoagulation thrombolysis

Summary Thrombolysis is effective if used within hyperacute unit setting Time is Brain, rapid treatment improves outcome There are risks of bleeding can differ between cases Appropriate place is for all strokes is hyperacute stroke unit There are outstanding research questions

The End Questions?