The Grampian Stroke
Acute Stroke Unit
Patient has stroke/TIA
Red is BAD
A&E NHS 24 GP
Stroke bleep notified Clinic
Decant/ Acute Stroke Unit
Ward 6 WE Ward 12 WE Home Care home/ hospitals
CHSS nurse follow up GP and primary care Clinic review Horizons etc
Getting it right from the beginning
• CHSS FAST campaign due to begin in
• May have implications for patient
numbers and review in A&E
• GPs need to be aware of stroke
symptoms and thrombolysis service
• NHS24 are reviewing stroke protocol
Outcome for placebo, rt-PA in clinical trials and SITS-MOST
SITS is a register of thrombolysis in clinical practice
Proportion of patients with good outcomes (0-2) is higher
in SITS group than placebo group from clinical trials
(Just in case you need evidence!)
Outcome following rt-PA
Earlier is better
Assessment of Stroke Patients in A&E
Patients who have a neurological deficit may be suitable for thrombolysis if they are scanned within 4.5 hours of symptom onset.
Has the patient got an ongoing neurological deficit?
e.g. Facial weakness
Speech disturbance (dysphasia or dysarthria)
YES NO If resolved anterior circulation
symptoms and/or AF, discuss with
stroke bleep holder re urgent
Refer other patients to neurovascular
clinic (fax letter to 559506)
Known time since onset <4.5 hours? Time since onset >4.5 hours or
No contraindication to thrombolysis?**
Arrange urgent CT scan Contact stroke team to arrange admission
contact stroke bleep via switchboard
(If no response, contact Dr Macleod on page 3132, tel 645250 or 07771631243)
**Contraindications to thrombolysis
Minor neurological deficit or symptoms rapidly improving before start of infusion.
Symptoms of ischaemic attack began more than 4 hours prior to referral, or when time of symptom onset is unknown.
Severe stroke as assessed clinically (e.g. NIHSS>25) and/or by appropriate imaging techniques.
Seizure at onset of stroke.
Symptoms suggestive of subarachnoid haemorrhage, even if the CT-scan is normal.
On warfarin therapy, or administration of heparin within the previous 48 hours and a thromboplastin time exceeding the upper limit of normal for laboratory.
Patients with any history of prior stroke and concomitant diabetes.
Prior stroke within the last 3 months.
Platelet count of below 100,000/mm3 (if available).
Systolic blood pressure >185 mmHg or diastolic blood pressure >110 mmHg, or aggressive management (IV medication) necessary to reduce BP to these limits.
Blood glucose <3 or > 20 mmol/L.
Known haemorrhagic diathesis, manifest or recent severe or dangerous bleeding, known history of or suspected intracranial haemorrhage.
Thrombolysis in Grampian
• Approx 20 patients so far this year
• Still only about 2-3% of patients
• Recent audit suggested most appropriate
patients offered therapy (i.e. most are
arriving too late)
Example patient 1
• 54 year old off shore worker from Kilmarnock
• Walking along Market St prior to joining ship
• Developed dense left sided weakness
• Arrived A&E within thirty minutes
• Reviewed within one hour
• CT scan and thrombolysed within 1 ½ hours
• Initial dramatic improvement, but symptoms returned at
approx 1 hr after thrombolysis
• Internal capsule infarct on repeat scan at 24 hours
• Good progress with physiotherapy/OT
• Transferred back to Kilmarnock for rehab
Example patient 2
• 71 year old
• History of HBP, IHD
• 0530 at Montrose harbour, about to go prawn
fishing with brother
• Hauling creels
• Suddenly collapsed: right sided weakness and
aphasia by arrival in A&E at 0700
• Reviewed 0720
• CT scan showed L intracerebral bleed
• Slow progress, still on ward three weeks later
awaiting transfer to slow stream rehab.
Even if not suitable for thrombolysis………
• Early review of patients is associated with
• Early scanning
• Immediate management protocol
• Secondary prevention protocol
• Early carotid intervention
Why are we proud of the ASU?
We are a TEAM!!
Social work CHSS nurses Links with Woodend
Speech & Language
Mobile stroke team Occupational therapy
How can we make the pathway better?
• All appropriate patients coming to ASU
– (would allow redeployment of MST)
• Quicker ‘run off’ to Wards 12, 6 and interim care
• Improve links with Radiology (new CT scanner in March 08 will allow
perfusion CT/angiography which aids in diagnosis and decision
• Implement SIGN guidelines
• Continue to aim towards QIS standards
• Development of early supported discharge team