Stroke Thrombolysis

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					       Stroke
It’s an Emergency
                    MR X
 63 previously fit and well. Works as a
  telephone engineer
 0700
 Sitting on toilet, suddenly developed
  difficulty speaking, and difficulty co-
  ordinating all four limbs
 Called ambulance at 0738
 Arrived in department 0838
           The cost of stroke

 56000 death in England and Wales in 99

 11% of all deaths

 ½ of survivors are dependent on others

 Costs economy £7 billion a year
 Potential Emergency Treatment
 Most strokes are due
  to blockage of an
  artery in the brain by a
  blood clot

 Plausible that
  thrombolysis could
  help patients with
  acute ischaemic stroke
                The evidence

 Meta-analysis of 18
  trials involving 5675
  patients
     Results of Meta-analysis
Outcome        Control   Thrombolysis

Death from all  9.4%     14.9%
causes at 7-
10days
Death from all  15.2%    16.2%
causes at 3
months
Death or        58%      53.3%
dependency at 3
months
            The evidence
  Patients treated within 3 hours of
                stroke.

Outcome        Control   Thrombolysis


Death or        60.3%    49.7%
dependency at 3
months
              The Evidence
 Patients treated within 3 hours with rtPA



 55 fewer dead or dependent patients for
  every 1000 treated

 NNT 18
Bottom Line


   Patients presenting
    with symptoms of a
    stroke within 3 hours of
    onset may benefit from
    thrombolysis.
What's happening in
       Bath?
Pre - hospital
              Our protocol
 Age 18-80
 Clinical diagnosis of a stroke causing a
  measurable neurological difference
 Time of symptom onset is known
 Sufficient time in 3 hour therapeutic window
  to assess and treat patient
 No clear contra-indications to thrombolysis
              Our protocol
 Contra-indications
  – Intracranial haemorrhage on CT scan
  – > 3 hours since onset of stroke
  – Improving symptoms
  – Seizure at onset
  – BM <2.7 or >22
  – Bleeding disorder
  – Active cancer
      Relative contra-indications
   Age <18 and >80
   Warfarin Rx with INR >1.6
   NIHSS <4 or > 25
   CT showing early ischaemic change
            Mr X continued
 Symptoms of stroke and possible eligibility
  for thrombolysis recognised by paramedics
  and patient rung through
 Seen within 10mins of arrival by emergency
  physician
 In CT scanner 0915
     Stroke thrombolysis so far
 Started July 2008
 3 emergency physicians and 3 stroke
  physicians trained up
 Currently offer a 9-5 Monday to Friday
  service
  Data from July – September 2008

 68 patients arrived with stroke

 8 patients were eligible for thrombolysis

 3 were thrombolysed
         The ineligible patients
   37 were too old (>80)
   5 patients had NIHSS >25
   4 were excluded on CT findings
   1 patient showed spontaneous improvement
   4 patients either woke up with a stroke or
    had no timings
 9 patients presented at > 3hrs
Eligible patients who did not receive
             thrombolysis
 4 were out of hours
 1 thrombolysis not considered
 Working up 3 patients a month

 Thrombolysing 1 patient a month
               The Future
 Public awareness campaign

 Increase the number of doctors trained to
  deliver stroke thrombolysis

 Extend the hours over which stroke
  thrombolysis is available
                The latest
 ECASS 3
 Thrombolysis with alteplase (rtPA) at 3-4.5
  hours
 Suggests that those thrombolysed were less
  likely to be disabled at 3 months than those
  receiving placebo
                   Mr X
 Thrombolysed at 0959

 Discharged from hospital 3 days later with
  no residual deficit
                    Summary
 Evidence for stroke
  thrombolysis

 Narrow time frame

 Current service

 Areas for development

				
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posted:7/26/2011
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