1. Dr Marc Randall Consultant Neurologist and Stroke Physician Honorary Senior Lecturer University Sheffield

2.  A sudden loss of brain function caused by a blockage (80%) or rupture of a blood vessel supplying the brain. Causing loss of muscular control, diminution or loss of sensation or consciousness, dizziness, slurred speech, or other symptoms that vary with the extent and severty of the damage to the brain.

3. ISCHAEMICHAEMORRHAGIC

4. Hippocrates 430BC Described the first strokes Johann Webfer 1675 “Observationes anatomicae, ex cadaveribus eorum, quos sustulit apoplexia,” Pierre Paul Broca 1824 - 1880

5. 1980 Approval for first stroke therapy IST : Lancet.IST : Lancet. 1997 May 1995 First stroke thrombolytic trials 2002 Approval for first licensed thrombolytic therapy within 3 hours

7. Acute left MCA thrombus

8.  recombinant Tissue Plasminogen Activator  Initiates local thrombolysis

10. Current European licence

11.  Is this Ischaemic ?  Is the presentation compatible with stroke ?  Do I want to try and clear the blocked vessel ?  Do I need to clear the blocked vessel ?  What am I trying to save ?  What are the risks ? Australasian Radiology (2007) 51, 532–537

13.  Well run well trained team of stroke specialists required to deliver thrombolytic. ▪ Ambulance service with clear selection protocols to deliver patients to correct service access point. ▪ Stroke specialist nurse  Protocol driven, selection for rTPA  Drives the process from time of arrival to decision to give rTPA  Constant in the patients care pathway ▪ 24 / 7 radiology back up ▪ Strong stroke unit leadership and training

15.  Most feared complication  Symptomatic ICH has a 45% mortality in patients who have received TPA  4 - 5 % of cases treated with rTPA will have intra cerebral bleeds. ▪ Stroke 2005;36:916  Patient selection and BP control reduce risk.

18.  May extend window of treatment time for those patients who present in 3 – 9 hour time window.  ? reduces potential for intracranial haemorrhage  Possibly more effective in basilar stroke

26.  Small numbers of patients in trials.  Very few randomised trials.  Case by case basis.  Some benefits in posterior circulation stroke with basilar thrombosis.

27. % treated with this intervention Number treated per year Benefit per 1000 treated Number who avoid death or dependency Aspirin80%104000131350 Stroke Unit60%78000564370 Thrombolysis2%208063130 Thrombolysis30%31200471470 Based on 130,000 strokes per year in the UK IST 3 Collaborators

28.  Acknowledgements:  Stroke Specialist Nurses  Nursing staff of the HASU L2 RHH  Staff of the integrated stroke pathway Sheffield Teaching Hospitals.