stroke thrombolysis benefits and pitfalls l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Stroke thrombolysis: Benefits and pitfalls PowerPoint Presentation
Download Presentation
Stroke thrombolysis: Benefits and pitfalls

Loading in 2 Seconds...

play fullscreen
1 / 78

Stroke thrombolysis: Benefits and pitfalls - PowerPoint PPT Presentation


  • 422 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Stroke thrombolysis: Benefits and pitfalls' - betty_james


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
stroke thrombolysis benefits and pitfalls

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
Benefits of Stroke Thrombolysis
  • Reduced mortality
  • Reduced Disability
    • Reduced need for institutional care
    • Reduced LOS mean 12 days v 23 days
risks of thrombolysis
Risks of Thrombolysis
  • Intracerebral Haemorrhage
    • Symptomatic
    • Asymptomatic
  • Extracranial Haemorrhage
  • Anaphylaxis
is thrombolysis safe and effective in practice
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
Pitfalls of Thrombolysis
  • Treatment of Stroke mimics
  • Delayed treatment
  • Not treating
clinical evaluation
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 mimics9
Syncope

Partial epileptic seizure with Todd’s paresis

Migraine attack (aura)

Hypoglycaemia

Hysteria

Intoxication

Subarachnoid haemorrhage

Neuroinfection

Neoplasm

Brain injury

Multiple sclerosis

Peripheral vertigo

Stroke mimics
mr bd 68yr
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 68yr11
General Exam

Alert GCS 15

Pulse 80 SR

BP 175/85

BM 5.6mmol/L

Heart normal

Neurological

Normal commands

L VII palsy mild

L visual field defect

L hemiparesis

Dysarthria

Mr BD 68yr

NIHSS = 15

mr bd 68yr14
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

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

60

90

120

150

180

210

240

270

300

330

360

mRS 0-1 at day 90

Adjusted odds ratio with 95 % confidence interval by stroke onset to treatment time (OTT)

Benefit of rt-PA for Acute Stroke

< 3 h

SITS-MOST

3 - 4.5 h

RCT

ECASS III

> 4,5h

except selected patients

Adjusted odds ratio

Stroke onset to treatment time (OTT) [min]

Brott TG. International Stroke Conference 2002; abstract.

mr pb 72yr
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 72yr17
General Exam

Alert GCS 15

Pulse 80 SR

BP 185/85

BM 8.6mmol/L

Heart clinically enlarged

Neurological

Normal commands

Moderate expressive aphasia

R VII palsy mild

R visual field defect

R hemiparesis mild

Mr PB 72yr

NIHSS = 14

mr pb
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
Mrs SS 45yrs
  • HPC
    • Sudden onset of L hemiplegia
    • Drowsy
    • Severe Dysarthria
  • Risk Factors
    • Hypertension
mrs ss 45yr
General Exam

Drowsy GCS 14

Pulse 80 SR

BP 165/85

BM 5.6mmol/L

Heart clinically enlarged

Neurological

Abnormal commands

Severe Dysarthria

L VII palsy severe

L visual field defect

L hemiplegia

Mrs SS 45yr

NIHSS = 22

mrs ss
Mrs SS
  • Blood sugar normal
  • Blood Hb 7.9 g/dL
  • MCV 76
  • U+E Normal
mrs ss26
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 45yrs29
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
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 55yr31
General Exam

Alert GCS 15

Pulse 80 SR

BP 140/75

BM 4.6 mmol/L

Heart normal

Neurological

Normal commands

mild facial weakness

Mild left hemiparesis

Speech mild Dysarthria

Mrs SK 55yr

NIHSS = 10

mr sk
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
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
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 72yr36
General Exam

Alert GCS 15

Pulse 80 AF

BP 112/75

BM 4.6 mmol/L

Heart enlarged

Neurological

Normal commands

Mild L facial weakness

Mild left hemiparesis

Speech mild Dysarthria

Mrs GW 72yr

NIHSS = 11

mrs gw 72yr38
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
Mrs SB 52yr
  • HPC
    • Sudden onset of right hemiparesis
    • Right visual loss
  • Risk factors
    • None
  • Past medical history
    • nil
mr sp 44yr carpenter
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

Tattoos

Alert GCS 15

Pulse 100 SR

BP 112/75

BM 4.6 mmol/L

Heart normal

Neurological

Normal commands

Mild R facial weakness

Mild R hemiparesis

Speech mild Dysarthria he said normal for him

Mr SP 44yr

NIHSS = 11

mr sp46
Mr SP
  • Bloods
  • Hb 11.5 g/dL MCV 99
  • Bilirubin 29
  • ALT 67
  • Alk Phos normal
progress
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
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

Alert GCS 15

Looks well

Pulse 70 SR

BP 132/75

BM 4.6 mmol/L

Heart normal

Neurological

Normal commands

Mild L facial weakness

No hemiparesis

Speech mild Dysarthria

Mr AS 75yr

NIHSS = 5

mrs as
Mrs AS
  • Subsequent examination revealed a left Breast mass confirmed to be an Adenocarcinoma
mr bt 59yr
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
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 bt56
General Exam

GCS 14

Pulse 85 AF

BP 132/75

BM 4.6 mmol/L

Heart normal

Neurological

Not obeying commands

R facial weakness

R homonymous hemianopia

R Hemiplegia

Speech Aphasia

Mr BT

NIHSS = 18

mr bt64
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 bt65
Mr BT
  • 24 hr NIH score 11
  • CT scan
  • Discharges at day 8
  • NIHSS 6
mr bt68
Mr BT
  • 24 hr NIH score 11
  • CT scan
  • Discharges at day 8
  • NIHSS 6
mrs mo 62yr
Mrs MO 62yr
  • HPC
    • Sudden onset of right hemiplegia
    • Aphasia
    • NIHSS22
    • Risk factors AF Hypertension
mrs a
Mrs A
  • Thrombolysed
  • Marked improvement
how may we improve diagnostic accuracy
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
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 ?
conclusion78
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