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THROMBOLYSIS. Alteplase: indications and contra-indications Dr Ken Fotherby, New Cross Hospital. Thrombolysis: Yes? No?. Ischaemic stroke (not bleed or mimic) Within 3h onset No ^^risk bleeding (BP>185/110 warfarin/heparin

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thrombolysis

THROMBOLYSIS

Alteplase: indications

and contra-indications

Dr Ken Fotherby, New Cross Hospital

thrombolysis yes no
Thrombolysis: Yes? No?
  • Ischaemic stroke (not bleed or mimic)
  • Within 3h onset
  • No ^^risk bleeding (BP>185/110
  • warfarin/heparin
  • recent stroke
  • recent surgery)
  • Minor/rapidly improving stroke
new cross experience
New Cross experience
  • DGH serving ~250,000 pop
  • Thrombolysis service 9am-5pm:May 07
  • Assessed 21 patients12 thrombolysed

ie. ~1/wk assessed

~1/fortnight treated

alteplase for ischaemic stroke
Alteplase for ischaemic stroke
  • N.N.T. to prevent death/severe dependency?
alteplase for ischaemic stroke1
Alteplase for ischaemic stroke
  • N.N.T. to prevent death/severe dependency?

6 (NINDS)

9 (NICE )

and 3 to reduce dependency (NINDS)

alteplase for ischaemic stroke2
Alteplase for ischaemic stroke
  • N.N.H. (ie cause symptomatic intra-cranial

haemorrhage)?

alteplase for ischaemic stroke3
Alteplase for ischaemic stroke
  • N.N.H. (ie cause symptomatic intra-cranial

haemorrhage)?

17

6% NINDS

4-7% SITS-MOST,CASES,STARS

(16% in Cleveland)

( ~1% for MI)

thrombolysis yes no1
Thrombolysis: Yes? No?
  • Ischaemic stroke (not bleed or mimic)
  • Within 3h onset
  • No ^^risk bleeding (BP>185/110
  • warfarin/heparin
  • recent stroke
  • recent surgery)
  • Minor/rapidly improving stroke
thrombolysis is ischaemic stroke
Thrombolysis: ?is ischaemic stroke
  • Clinical diagnosis

but CT scan to exclude bleed

  • Exclude stroke mimics: epileptic fit

hypoglycaemia

thrombolysis within 3 hours
Thrombolysis: ?within 3 hours
  • Clear time onset (or when last well)
  • Usually need eye-witness

paramedics report

“Time is Brain”

thrombolysis too risky
Thrombolysis: ?too risky

^ risk intra-cranial bleeding:

  • BP>185/110 (reassure,?labetalol or GTN patch)
  • Abnormal clotting (warfarin,heparin,haemodialysis)

(INR 1.4 or less OK)

  • ?Massive infarct (NIHSS>25)
  • ?Old age (>80yr)
  • Prior stroke within 3months (but TIA OK)
  • Any i/c bleed in past
  • major surgery, G-I bleed, haematuria past 3 weeks
thrombolysis too risky1
Thrombolysis: ?too risky

Prognosis “too good”:

  • Small stroke (NIHSS 4 or less)

but ? lone dysphasia

thrombolysis yes no2
Ischaemic stroke (not bleed or mimic)

Within 3h onset

No ^^risk bleeding (BP>185/110

warfarin/heparin

recent stroke

recent surgery)

Minor/rapidly improving stroke

Thrombolysis: Yes? No?
putting it all together
Putting it all together!

spouse nurse

paramedic BP + BM

arrange clinical venflon

CTscan assessment bloods

porter DOCTOR-PATIENT relatives

arrange assent/consent

bed NIHSScore

weight/dose

BP (again)

read CT scan start drug

thrombolysis how often
Thrombolysis: how often?
  • Best = 20% of acute stroke patients

(and 2006 NSentinelStroke Audit:39% admitted <2h)

  • strokes/year = 530

/250,000 pop = c400 admitted (excl MAU discharges)

= c250 “ “ “ “ “ and aged <80yrs

- 40% of 400 = 160 assessments/y or 3/wk

20% 400 = 80 thrombolyses/y or 1-2/wk

thrombolysis an effective safe service
Thrombolysis: an effective & safe service?
  • Written protocols within an (established)

pathway.

( licence & NICE:”only by a physician trained and experienced in the management of acute stroke and in a centre with appropriate facilities”)

pathways and protocols for thrombolysis
Pathways and Protocols for thrombolysis

paramedics

I

A&E

I

CT scanning

I

Stroke Unit

(9am-5pm)

pathways and protocols for thrombolysis1
Pathways and Protocolsfor thrombolysis

G.P.s/community

I

paramedics paramedics

I I

A&E A&E

I I

CT scanning CT scanning

I I

Stroke Unit Stroke Unit

(9am-5pm) (8am-8pm+)