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

2. 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

3. Diagnosing Stroke and TIA

4. 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.

5. 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

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

7. 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

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

9. 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 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.

10. 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%!!!

11. 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

12. Investigations and tests in the early stages

13. 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

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

15. 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

16. CT angiogram

17. Diffusion Perfusion CT

18. Other tests
FBC
U&E
INR
Glucose
ECG
Carotid Doppler

19. Thrombolysis

20. Why?

21. 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.

22. 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 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:
Baseline differences in stroke severity favoured alteplase

23. 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 > % 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:

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

25. 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

26. 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

27. 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

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

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

30. 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

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

32. 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

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

34. 4. Prevent pneumonia
Mobilization

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

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

37. 6. Prevent starvation

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

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