Stroke thromboysis Benefits and pitfalls by mikeholy

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									       Stroke thrombolysis:
       Benefits and pitfalls

                 Dr Neil Baldwin
Consultant Physician North Bristol NHS Trust
      Clinical lead AGW Stroke Network
  Clinical Lead Acute Stroke NHS Institute
Benefits of Stroke Thrombolysis
   Reduced mortality
   Reduced Disability
       Reduced need for institutional care
       Reduced LOS mean 12 days v 23 days
Intention to treat
Risks of Thrombolysis
   Intracerebral Haemorrhage
       Symptomatic
       Asymptomatic
   Extracranial Haemorrhage
   Anaphylaxis
     Is thrombolysis safe and effective in practice?


SITS-MOST


•ICH at 7 days:                7.3% in SITS-MOST vs 8.6% in RCT’s

•3 month mortality:          11.3% in SITS-MOST vs 17.3% in RCT’s

•Complete recovery at 3 months: 38.9% (SITS-MOST) vs 42.3% (RCT’s)




 Lancet Jan 2007
Pitfalls of Thrombolysis
   Treatment of Stroke mimics
   Delayed treatment
   Not treating
Stroke mimics
Clinical Evaluation
   Five question approach
       Is it a Stroke?
       Which type of stroke?
       Where is the Stroke?
       What caused the Stroke?
       Will thrombolysis be helpful?
        Stroke mimics

   Syncope                        Subarachnoid
   Partial epileptic seizure       haemorrhage
    with Todd’s paresis            Neuroinfection
   Migraine attack (aura)         Neoplasm
   Hypoglycaemia                  Brain injury
   Hysteria                       Multiple sclerosis
   Intoxication                   Peripheral vertigo
Mr BD                                   68yr
   HPC T= 13.45
       Sudden onset left hemiparesis
       Left visual field defect
       Dysarthria
   Risk Factors
       Hypertension on Atenolol
       Ex Smoker
   Past Medical History
       Nil else
Mr BD                                   68yr
       General Exam           Neurological
   Alert GCS 15         Normal commands
   Pulse 80 SR          L VII palsy mild
   BP 175/85            L visual field defect
   BM 5.6mmol/L         L hemiparesis
   Heart normal         Dysarthria



NIHSS = 15
Mr BD                                                   68yr
   Time line
       Onset T0 = 13.45
       ED Arrival =14.20
       CT scan    =14.45
       Stroke team saw pt in Scanner room
       Thrombolysis 15.00
   Outcome
       Fully independent when reviewed 1730
       Repeat CT 24 hrs normal
       Carotid Doppler > 75% Right ICA
       Discharged Following day with plan for Endarterectomy in 2
        Weeks
Benefit of rt-PA for Acute Stroke
                                      mRS 0-1 at day 90
  Adjusted odds ratio with 95 % confidence interval by stroke onset to treatment time (OTT)

   4.0

   3.5
                    <3h                        3 - 4.5 h                     > 4,5h
   3.0              SITS-MOST                    RCT
                                               ECASS III
                                                                except selected patients
   2.5

   2.0

   1.5

   1.0

   0.5

   0.0
         60    90      120      150      180       210       240       270     300    330     360

                                Stroke onset to treatment time (OTT) [min]



  Brott TG. International Stroke Conference 2002; abstract.
Mr PB                                        72yr
   HPC T= 14.20
       Word finding difficulty
       Mild right hemiparesis
       No visual field defect
   Risk Factors
       Hypertension on Atenolol & Bendroflumethazide
       Smoker
       Cholesterol
   Past Medical History
       Previous MI
Mr PB                                   72yr
       General Exam           Neurological
   Alert GCS 15          Normal commands
   Pulse 80 SR           Moderate expressive
   BP 185/85              aphasia
   BM 8.6mmol/L          R VII palsy mild
   Heart clinically      R visual field defect
    enlarged              R hemiparesis mild


NIHSS = 14
Mr PB
   Time line
       Onset T0 = 14.20
       ED Arrival =15.30
       CT scan    =1600
       Stroke team saw pt in ED soon afterwards
       Marked improvement in NIH =4
       No thrombolysis
   Outcome
       Fully independent when reviewed next day
       CT Carotid Angiogram > 75% L ICA
       Discharged Following day with plan for Endarterectomy in 1
        Weeks
Mrs SS                                 45yrs
   HPC
       Sudden onset of L hemiplegia
       Drowsy
       Severe Dysarthria
   Risk Factors
       Hypertension
Mrs SS                                   45yr
      General Exam            Neurological
   Drowsy GCS 14         Abnormal commands
   Pulse 80 SR           Severe Dysarthria
   BP 165/85             L VII palsy severe
   BM 5.6mmol/L          L visual field defect
   Heart clinically      L hemiplegia
    enlarged


NIHSS = 22
Mrs SS
   Blood sugar normal
   Blood Hb 7.9 g/dL
   MCV 76
   U+E Normal
Mrs SS   45yrs
Mrs SS   45yrs
Mrs SS
   Time line
       Onset T0 = 16.30
       ED Arrival =18.45
       CT scan    =1900
       Stroke team saw pt in ED soon afterwards
       Discussion about menohhagia DW Gynae
       Thrombolysis given 2.45 hrs after onset
   Outcome
       when reviewed next day no change in NIHSS
       3 days after admission sudden deterioration in condition GCS
        7
       CT Repeat
Mrs SS   45yrs
Mrs SS   45yrs
Mrs SS                                        45yrs
   Malignant Middle Cerebral Artery Ischaemic
    Syndrome
       Non dominant hemisphere
   Very High mortality
   Referred to Neurosurgeons
       Uncertainty about benefits of decompression
       Underwent hemi-craniotomy
   Died few days later
Mrs SK                                               55yr
   HPC
       Sudden onset left hemiparesis
       Loss vision in Left eye
       Severe headache with mild photophobia
   Risk Factors
       No BP/ Cholesterol/ Diabetes / Vascular disease /
        Non Smoker / Ex HRT
   Past Medical History
            Hysterectomy 35 yr HRT for 5 yrs only
            Migraine since childhood
Mrs SK                                 55yr
       General Exam          Neurological
   Alert GCS 15         Normal commands
   Pulse 80 SR          mild facial weakness
   BP 140/75            Mild left hemiparesis
   BM 4.6 mmol/L        Speech mild
   Heart normal          Dysarthria



NIHSS = 10
Mrs SK   55yr
Mr SK
   Time line
       Onset T0 = 0850
       ED Arrival =1015
       CT scan     =1045
       Stroke team saw pt in ED soon afterwards
       History of headache explored long history of classical
        migraine
            fortification spectra & Scotoma
            GI Disturbance
            Hemicranial headache
            1 previous episode of weakness
       Not Thrombolysed
Mrs SK
    Subsequent investigations
         No evidence of atherosclerosis
         Bubble contrast ECHO confirmed a PFO
         Strong Relationship between PFO and Migraine
         Small increase in risk of Stroke
Mrs GW                                       72yr
   HPC
       Got up and was well
       After breakfast husband noticed a left
        facial weakness and Dysarthria
   Risk Factors
       Atrial Fibrillation / Hypertension
   PMH
       none
Mrs GW                                  72yr
       General Exam          Neurological
   Alert GCS 15         Normal commands
   Pulse 80 AF          Mild L facial
   BP 112/75             weakness
   BM 4.6 mmol/L        Mild left hemiparesis
   Heart enlarged       Speech mild
                          Dysarthria


NIHSS = 11
Mrs GW
Mrs GW                         72yr
   Seen in ED
   CT showed Chronic Subdural
   No History of Falls or Head Trauma
   Transfer to Neurosurgeons
   Good recovery 3 months later
Mrs SB                                      52yr
   HPC
       Sudden onset of right hemiparesis
       Right visual loss
   Risk factors
       None
   Past medical history
       nil
Mr SP                             44yr carpenter
   HPC
       Monday 26th November 2007
       At work collapsed no recall of the prodrome he thought LOC
        5 minutes
       On recovery right sided weakness
       Slurred speech
   Risk Factors
       Smoker 30 day / hypertension poor compliance
   Past Medical History
       Previous admission with blackout 2 yrs ago
   Social History
       Drinks 3-4 cans per day more at weekends
Mr SP                               44yr
       General Exam          Neurological
   Tattoos              Normal commands
   Alert GCS 15         Mild R facial
   Pulse 100 SR          weakness
   BP 112/75            Mild R hemiparesis
   BM 4.6 mmol/L        Speech mild
   Heart normal          Dysarthria he said
                          normal for him

NIHSS = 11
Mr SP
Mr SP
Mr SP
   Bloods
   Hb 11.5 g/dL MCV 99
   Bilirubin 29
   ALT 67
   Alk Phos normal
Progress
   Reviewed in the ED
   Not thrombolysed as I felt likely to be
    due to a seizure
   Subsequent review of old noted
    previous admission thought to be a
    withdrawal seizure
Mrs AS                                       75yr
   HPC
       Sudden onset of a left visual field defect
        whilst driving her car
       Managed to get home
       Daughter thought she had a left facial
        weakness
   Risk factors
       hypertension
Mr AS                             75yr
       General Exam          Neurological
   Alert GCS 15         Normal commands
   Looks well           Mild L facial
   Pulse 70 SR           weakness
   BP 132/75            No hemiparesis
   BM 4.6 mmol/L        Speech mild
   Heart normal          Dysarthria


NIHSS = 5
Mrs AS   75yr
Mrs AS   75yr
Mrs AS   75yr
Mrs AS
   Subsequent examination revealed a left
    Breast mass confirmed to be an
    Adenocarcinoma
Mr BT                    59yr
   0950 Great Western Ambulance call
    patient in Malmsbury can we bring for
    thrombolysis
   1105 Arrived in ED
       Sudden onset Right hemi paresis @ 0930
        according to Ambulance crew
       Found by wife in bedroom last seen just
        after 0900
Mr BT
   Risk factors
       Hypertension
       Arial Fibrillation
       Was on Warfarin until 6 weeks ago but
        stopped by GP as the patient was not
        happy on Warfarin.
Mr BT
      General Exam          Neurological
   GCS 14              Not obeying
   Pulse 85 AF          commands
   BP 132/75           R facial weakness
   BM 4.6 mmol/L       R homonymous
   Heart normal         hemianopia
                        R Hemiplegia
                        Speech Aphasia
NIHSS = 18
120 minutes after symptom onset
120 minutes after symptom onset
120 minutes after symptom onset
120 minutes after symptom onset
CT Angiogram
CT Angiogram
CT Angiogram
Mr BT
   Time line
       Onset T0 = 0900 - 0930
       ED Arrival =1105
       CT scan     =1115
       Stroke team saw pt in CT room 1128
       Thrombolysis given 1140
Mr BT
   24 hr NIH score 11
   CT scan
   Discharges at day 8
   NIHSS 6
24 hours post thrombolysis
24 hours post thrombolysis
Mr BT
   24 hr NIH score 11
   CT scan
   Discharges at day 8
   NIHSS 6
Mrs MO                    62yr
   HPC
       Sudden onset of right hemiplegia
       Aphasia
       NIHSS22

       Risk factors AF Hypertension
MA
MA
Mrs A
   Thrombolysed
   Marked improvement
How may we improve diagnostic accuracy?

   The early diagnosis of acute stroke is difficult
    and relies on clinical experience
   Diagnostics can help with the exclusion of
    haemorrhage and alternative brain disorders
   The frequency of cases suitable for
    thrombolysis is at best 10% of all ischaemic
    stroke and at present in UK is used in <0.2%.
   Individual ED clinician experience will be low
   There are relatively few Stroke Consultants in
    the UK and 10 in AGW
Conclusion
   Important steps are
       Is it a stroke/ be aware of stroke mimics?
       Is the stroke an infarct or haemorrhage CT is
        sensitive?
       If ischaemic stroke does the NIHSS fall within the
        selection range?
            < 5 likely to recover without thrombolyis so no benefit
             from treatment except aphasia or hemianopia
            > 25 very high risk of bleeding
       Is there another exclusion criteria
       Is there a significant improvement in NIHSS
       Can the thrombolysis treatment be given within
        4.5 hours ?
Conclusion
   Give rt-PA if no Contra-indication
       More likely to do good than harm
   Transfer to Stroke unit
   Standardised observation
       Be aware of neurological deterioration
            Not all bleeding

								
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