1. Thrombolysis East of England Forum
Diana Day
Consultant Nurse for Stroke

2. 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

3. Global Good Outcome at Day 90 (mRS 0-1, BI 95-100, NIHS 0-1) (N=2776)
SITS database 12/12/2007

4. SITS-MOST vs RCTs – mRS 3/1219 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:

5. Time is brain
Around1.9 million neurons lost a minute

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

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

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

9. Treat with thrombolysis?

10. Telemedicine
Providing regional access to stroke expertise out of hours

11. 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

12. 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)

13. Potential for thrombolysis

14. 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

15. Staffing Nursing 1:1 – whilst thrombolysing
1:2 – 1:4 first hrs of care
Competency based training
NIHSS trained

16. 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

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

18. 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

19. 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)

20. Early CT scan : time 10:23

21. CT Perfusion
Cerebral Blood Flow
Time to peak

22. 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.

23. Post Thrombolysis

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

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

26. Post CT scan

27. 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.

28. 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

29. Patient 2 : Right hemilingual angioedema

30. 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
Time (hours)
Saver, Stroke 2006

31. 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

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

33. 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

34. The End
Questions?