1. THROMBOLYSIS Alteplase: indications and contra-indications Dr Ken Fotherby, New Cross Hospital

2. Thrombolysis: Yes? No? Ischaemic stroke (not bleed or mimic) Within 3h onset No ^^risk bleeding (BP>185/110 warfarin/heparin recent stroke recent surgery) Minor/rapidly improving stroke

3. New Cross experience DGH serving ~250,000 pop Thrombolysis service 9am-5pm:May 07 Assessed 21 patients  12 thrombolysed ie. ~1/wk assessed ~1/fortnight treated

4. Alteplase for ischaemic stroke N.N.T. to prevent death/severe dependency?

5. Alteplase for ischaemic stroke N.N.T. to prevent death/severe dependency? 6 (NINDS) 9 (NICE ) and 3 to reduce dependency (NINDS)

6. Alteplase for ischaemic stroke N.N.H. (ie cause symptomatic intra-cranial haemorrhage)?

7. Alteplase for ischaemic stroke N.N.H. (ie cause symptomatic intra-cranial haemorrhage)? 17 6% NINDS 4-7% SITS-MOST,CASES,STARS (16% in Cleveland) ( ~1% for MI)

8. Thrombolysis: Yes? No? Ischaemic stroke (not bleed or mimic) Within 3h onset No ^^risk bleeding (BP>185/110 warfarin/heparin recent stroke recent surgery) Minor/rapidly improving stroke

9. Thrombolysis: ?is ischaemic stroke -Clinical diagnosis but CT scan to exclude bleed -Exclude stroke mimics: epileptic fit hypoglycaemia

10. Thrombolysis: ?within 3 hours Clear time onset ( or when last well) Usually need eye-witness paramedics report “Time is Brain”

11. Thrombolysis: ?too risky ^ risk intra-cranial bleeding: -BP>185/110 (reassure,?labetalol or GTN patch) -Abnormal clotting (warfarin,heparin,haemodialysis) (INR 1.4 or less OK) -?Massive infarct (NIHSS>25) -?Old age (>80yr) -Prior stroke within 3months (but TIA OK) -Any i/c bleed in past -major surgery, G-I bleed, haematuria past 3 weeks

12. Thrombolysis: ?too risky Prognosis “too good”: -Small stroke (NIHSS 4 or less) but ? lone dysphasia

13. Thrombolysis: Yes? No? Ischaemic stroke (not bleed or mimic) Within 3h onset No ^^risk bleeding (BP>185/110 warfarin/heparin recent stroke recent surgery) Minor/rapidly improving stroke

14. Putting it all together! spouse nurse paramedic BP + BM arrange clinical venflon CTscan assessment bloods porter DOCTOR-PATIENT relatives arrange assent/consent bed NIHSScore weight/dose BP (again) read CT scan start drug

15. Thrombolysis: how often? Best = 20% of acute stroke patients (and 2006 NSentinelStroke Audit:39% admitted <2h) strokes/year = 530 /250,000 pop = c400 admitted (excl MAU discharges) = c250 “ “ “ “ “ and aged <80yrs - 40% of 400 = 160 assessments/y or 3/wk 20% 400 = 80 thrombolyses/y or 1-2/wk

16. Thrombolysis: an effective & safe service? Written protocols within an (established) pathway. ( licence & NICE:”only by a physician trained and experienced in the management of acute stroke and in a centre with appropriate facilities”)

17. Pathways and Protocols for thrombolysis paramedics I A&E I CT scanning I Stroke Unit (9am-5pm)

18. Pathways and Protocols for thrombolysis G.P.s/community I paramedics paramedics I I A&E A&E I I CT scanning CT scanning I I Stroke Unit Stroke Unit (9am-5pm) (8am-8pm+)