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Stroke Thrombolysis at GRH

Stroke Thrombolysis at GRH. Dr Kate Hellier Consultant Physician Stroke and Elderly Care. Thrombolysis in Stroke. Why do it? The Evidence Who? Patient Selection How? When? The Protocol Where?. Heart attack vs Brain attack. 60,000 vs. 5675. The Evidence: NINDS, NEJM 1995.

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Stroke Thrombolysis at GRH

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  1. Stroke Thrombolysis at GRH Dr Kate Hellier Consultant Physician Stroke and Elderly Care

  2. Thrombolysis in Stroke • Why do it? The Evidence • Who? Patient Selection • How? • When? The Protocol • Where?

  3. Heart attack vs Brain attack 60,000 vs. 5675

  4. The Evidence: NINDS, NEJM 1995 • 624 patients within 3hrs (mean 120mins) • With rtPA 30% less likely to end up dependent rtPA(%) Control (%) • Haemorrhage 6.4 0.6 • Death/dependency 57.4 73.4 • Mortality at 3/12 17 21

  5. The Evidence: Cochrane Review, Wardlaw et al 2004 Disability significantly reduced in survivors For every 1000 patients thrombolysed 43 avoided death or dependency

  6. Beware: Cleveland, Ohio • 50% deviation from national guidelines • Symptomatic haemorrhage rates of 15.7% (vs 6.4% in NINDS) Katzan, JAMA, 2000

  7. Thrombolysis for acute ischaemic stroke Ongoing, unresolved issues • Time • IV within 3 hours • 3-6hours • Age • No trials so far in over 80s • Severity of stroke • Type of stroke IST3

  8. Who, How, When and Where?

  9. Who? • Patients aged 18-80 • Clinically ischaemic stroke • Sudden onset of acute focal neurological deficit – hemiplegia, impairment of language, gaze, vision and/or neglect • Symptoms present for at least 30mins and not improving

  10. When? • Known time of onset • Occurred within last 2 hours • Must be thrombolysed within 3 hours of onset • Beware… waking with symptoms Treatment only available 9am-5pm, Mon-Fri

  11. Who not? • >3 hours, or Time of Onset unknown • Seizure at onset of stroke • Symptoms suggestive of SAH • Full dose heparin within 48 hours • Any Hx of prior stroke AND diabetes • Prior stroke within last 3 months • Significantly increased risk of bleeding • On warfarin with INR >1.4 • Liver disease…

  12. Where? • Gloucestershire Royal Hospital • A+E Department

  13. How? • 999 Ambulance • Tell them possibility of thrombolysis • Pre-Alert A+E • Relatives / Witnesses • Consultant stroke physician to A+E resus • CT • Bolus then 1 hour infusion rTPA • No antiplatelets for 24 hours

  14. Summary • Is it a stroke? • Age 18-80? • Occurred within the last 2 hours? • Call Ambulance to take patient to GRH A+E (not AAU) • Pre alert A+E NB. Service available Mon-Fri 9am-5pm from 6th November 2006 at GRH

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