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Complications following thrombolysis Phil Sanmuganathan Consultant Stroke Physician
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Outline Pharmacological properties How to avoid or minimise complications Intracerebral haemorrhage and bleeding elsewhere Reperfusion cerebral excitability Cerebral oedema Anaphylaxis and angio-oedema Myocardial rupture
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Pharmacology Alteplase is an enzyme Binds to fibrin in clots Converts plasminogen to plasmin Plasmin initiates local fibrinolysis Circulating fibrinogen drops by a third Half life distribution 5 min excretion 40 min
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How to avoid complications Time of onset of symptoms Any seizure activity Severe strokes – NIHSS >20 BP <185/110 MI, Stroke 3/12 GI, urinary bleed 3/52 Major surgery 2/52
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Bleeding complications Symptomatic ICH 6-9% stroke compared to 0.5-0.6% MI thrombolysis Usually massive Multifocal 30 day mortality 60%
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Intracerebral bleeding Destroys and displaces brain tissue Increase ICP Haematoma growth Perihaematoma oedema + ischaemia Secondary intraventricular heamorrhage Hydrocephalus
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Classification HI 1small petechiae infarct margins HI 2confluent petechiae within inf. No SOE PH 1clots exceeding 30% of infarct PH2clots exceeding 30% of infarct with SOE PHr1bleed away from the infarct mild SOE PHr2large bleed away from inf. Sig. SOE
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Symptomatic ICH Parenchymal haemorrhage type 2 on post treatment scan neurological deterioration with 4 point increase in NIHSS
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Parenchymal haematoma Plac.Rt-PA OTT (min) n bleed n bleeds 0-9015001615 91-180315330217 181-270-411739023 271-360508553837
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ICH Analysis # of Risk Factors # of patients treated with t- PA (n=310) # of Symptomatic ICH’s (# of placebo patients with ICH) Percentage (%) 01142 (1)1.8 11447 (1)4.9 > 1521121.2 Baseline NIHSS > 20 Age > 70 years Ischemic changes present on initial CT Glucose > 300 mg/dl (16.7 mmol/L)
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Treatment Stop alteplase infusion Airway, oxygenation, circulation Head 30 0 jugular venous drainage - ICP BP <160/90 over 6hrs Platelet infusion 6-8 units Cryoprecipitate 6-10 bags Tranexemic acid 1 gm iv FFP 15-20 ml/kg
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SBP management SBP >200 Labetalol 50 mg iv followed by 2-8mg/min (max. 200mg) SBP >180 Labetalol 50mg iv Aim to maintain SBP around 160 CPP >60 GTN 50mg in 50ml saline/dex. 0.6-12 ml/h
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Reperfusion oedema Mannitol 1g/kg iv 8 hrly Epileptic fits lorazepam 4mg iv phenytoin 15mg/kg (50mg/min) INTENSIVE CARE
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ITU Intravenous sedation – propofol Hyperventilation Manage cardiopulmonary instability associated with RICP DNAR
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Angio-oedema Common in those on ACEI Usually self limitng Adrenaline 1:1000 nebulised if stridor Oxygen Alteplase infusion can be continued if ABC is not compromised
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Anaphylaxis Laryngeal oedema, bronchospasm, hypotension Stop alteplase infusion Horizontal bed raise foot end Airway patent Adrenaline 1:10,000 five ml -1ml/min Chlorpheniramine 10mg slow iv Hydrocortisone 200 mg iv
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