Developing Acute Stroke Services Diagnosing Screening Acute Care pathways Thrombolysis Dr C. Roffe Clinical Lead Shropshire and Staffordshire Heart and Stroke Network

Blue-light FAST positive potential strokes to A&E Patient or bystander recognizes stroke Dial 999 Ambulance response Blue-light FAST positive potential strokes to A&E Fits thrombolysis criteria pre alert A&E Does not fit thrombolysis criteria Immediate assessment Thrombolysis pathway and CT within 15 min Stroke pathway and CT within 1 hour Thrombolysis Admit to ASU within 4 h of presentation

Diagnosing Stroke and TIA

F A S T Face–Arm–Speech Test F Facial weakness: Can the person smile? Has their mouth or an eye drooped? A Arm weakness: Can the person raise both arms? S Speech problems: Can the person speak clearly and understand what you say? T Time to call 999.

ROSIER Recognizing Stroke in the Emergency Room Only count new symptoms Exclude hypo by BM stix Unilateral facial weakness? y (1) n (0) Unilateral arm weakness? y (1) n (0) Unilateral leg weakness? y (1) n (0) Speech disturbance ? y (1) n (0) Visual field defect? y (1) n (0) Any loss of consciousness or syncope y (-1) n (0) Any seizures? y (-1) n (0) Rosier >0 suggests ischaemic stroke and potential thrombolysis case

Stroke or TIA? Symptoms still present => Stroke Symptoms gone =>TIA

WHO DEFINITION OF STROKE A NEUROLOGICAL DEFICIT OF Sudden onset With focal rather than global dysfunction In which, after adequate investigations, symptoms are presumed to be of non-traumatic vascular origin and last for >24 hours Sudden: Sudden onset out of full health DD post MI, endocarditis, vasculitis, mets Focal: intoxication, vasculitis, encephalitis, hysteria, >24 hrs: TIA, Todd’s, migraine Presumed non-traumatic vascular origin: exclude head trauma, neck trauma, whiplash, systemic vascultitis, cardiac source of emboli AF, but also endocarditis, post MI, hypotension

Stroke onset Witness? Woke with hemiparesis? Found collapsed? Sudden/gradual/ stuttering

ABCD2 Scoring for all new TIAs Symptom Score Age > 60 years 1 point Blood pressure > 140/80 Clinical (neurological deficit) 2 points for hemiparesis 1 point for speech problem without weakness Duration 2 points for >60 minutes 1 point for 10-60 min Diabetes Stroke risk at 2 days, 7 days, and 90 days: Scores 0-3: low risk 1% at 2 d, 1.2% at 7 d and 3.1% at 90d Scores 4-5: moderate risk 4.1% at 2 d, 5.9% at 7 d, 9.85 at 90d Scores 6-7: high risk 8.1% at 2 d, 11.7% at 7d and 17.8% at 90d. Stroke risk within 1 week 6% for scores 4-5, 12% for scores >5 Admit all with score 5 or above.

TIA management Do not allow any TIA patient to leave the department without having administered the first dose of antiplatelet ABCD 4 or above admit or ensure TIA clinic appointment (and Doppler) within 24 hours. Endarterectomy within 48 h for patients with symptomatic stenosis ABCD <4 see in TIA clinic within 1 week. Endarterectomy within 14 days for patients with symptomatic stenosis This will reduce strokes within 1 week by 80%!!!

Role of Paramedics Establish working diagnosis of stroke/TIA Identify potential thrombolysis candidates Prealert A&E if thrombolysis an option Establish onset time Bring a witness Airway Breathing Circulation Exclude Hypo BM Prevent aspiration Get patient to nearest hyper acute stroke centre

Investigations and tests in the early stages

CT Head scan Intracerebral haemorrhage Cerebral Infarct Cerebral infarct not visible early on Hyperdense right MCA suggests occlusion Intracerebral haemorrhage Correct abnormal INR or low platelets immediately Neurosurgical referral Cerebral Infarct Thrombolysis or immediate antiplatelet treatment

Early signs of infarction Loss of insular ribbon 14.jpg SW, day 1

Early signs of infarction Effacement of sulci 16.JPG 1648:21 Sylvia Walker day 1 Early infarct with flattening of sulci, but no distinct hypoattenuation yet. SW, day 1

CT angiogram

Diffusion Perfusion CT

Other tests FBC U&E INR Glucose ECG Carotid Doppler

Thrombolysis

Why?

DH A New Ambition for Stroke A consultation document for a National Stroke strategy Dec 2008 If 10% of stroke patients in the UK were given thrombolysis, 1000 people less would be dead or dependent in one year. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081062

NINDS trial of rt-PA for acute ischaemic stroke 633 patients recruited Rt-PA 0.9 mg/kg (10% bolus the rest over 1 h) given within 3 hrs of symptom onset BP<185/110 Not on warfarin or heparin, platelets and coagulation normal Blood glucose 2.7-22 mmol/L No seizure at onset Quasi intensive care environment Aggressive BP control 16,000 screened to recruit 633 N Engl J Med 1995;333:1581-1587. Baseline differences in stroke severity favoured alteplase

NINDS rt-PA trial 1995 Improvements in dependency (modified Rankin Scale: mRS) Mean Score 2.8 for rt-PA and 3.3 for control : difference 0.5 mRS points* Number needed to treat to improve by 1 point is 2* Number needed to treat to improve by 1 or more points is 3** Number needed to treat to make one patient more independent =5* Needs No help Wheelchair Dead Normal INDEPENDENT DEPENDENT Rankin > 2 49.4% on tpa and 61.5% for control Absolute difference 11.9% Relative difference (11.9/ 0.615)=19.3% Cave: baseline imbalanced favoured alteplase. * My own calculation bases on the original paper ** Saver. Arch Neurol, Jul 2004; 61: 1066 - 1070.

Eligibility Age 80 or below Previously fit and independent Onset time known and less than 3 hours CT excludes haemorrhage

Exclusions Recent surgery, biopsies arterial cannulation 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

Alteplase (rt-Pa) 0.9 mg/kg body weight 10% as bolus over 2 min 90% as infusion over 1 hour No heparin for 24 hours

Post thrombolysis Care Needs trained team / ASU Neurological observations (NIHSS) Blood pressure Observation for complications Scan at 24 h Prevent recurrence Early Doppler/ CTangio in recovered cases

The acute stroke pathway How can I make sure my patient will do well?

Most complications of stroke develop in the first 24 hours Management in the first few hours has a major effect on outcome and LOS

Important factors for successful early stroke rehabilitation Mobilise ASAP The probability of returning home decreases by 20% for each day the patient is not mobilized Maintain normal haemodynamic and biochemical environment Prevent complications Keep patient and family informed

1. Transfer to ASU within 4 h or less of admission

2. Prevent Aspiration Swallow screen on arrival on ASU Sit up Drowsy patients in recovery position Antiememtics for haemorrhages and patients who feel sick All members of staff have at least basic knowledge of the diagnosis and management of swallowing problems

3. Prevent hypotension and dehydration IV saline Sufficient fluids by mouth or ngt

4. Prevent pneumonia Mobilization

Mouthcare Dysphagic patients have impaired oral movements resulting in debris, pooled secretions and tongue coating.

5. Prevent hospital acquired infections MRSA/ ESBL/ C.Difficile Avoid catheters at all costs Hand hygiene Bed spacing Appropriate antibiotics

6. Prevent starvation

7. Prevent stagnation and deterioration Time does not cure strokes Give at least 45 min of each therapy needed every day 7/7

7. Detect and treat problems early 72 hour monitoring Neurological scores (NIHSS/SSS) Daily consultant ward rounds 7/7