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Developing Acute Stroke Services Diagnosing Screening Acute Care pathways Thrombolysis Dr C. Roffe Clinical Lead Shropshire and Staffordshire Heart and Stroke Network . Patient or bystander recognizes stroke. Dial 999. Ambulance response Blue-light FAST positive potential strokes to A&E.

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Developing Acute Stroke ServicesDiagnosingScreeningAcute Care pathwaysThrombolysisDr C. RoffeClinical Lead Shropshire and Staffordshire Heart and Stroke Network


Patient or bystander recognizes stroke

Dial 999

Ambulance response

Blue-light FAST positive potential strokes to A&E

Fits thrombolysis criteria pre alert A&E

Does not fit thrombolysis criteria

Immediate assessment

Thrombolysis pathway and CT within 15 min

Stroke pathway and CT within 1 hour


Admit to ASU within 4 h of presentation

f a s t

Face–Arm–Speech Test

F Facial weakness: Can the person smile? Has their mouth or an eye drooped?

A Arm weakness: Can the person raise both arms?

S Speech problems: Can the person speak clearly and understand what you say?

T Time to call 999.

rosier recognizing stroke in the emergency room
ROSIERRecognizing Stroke in the Emergency Room

Only count new symptoms

Exclude hypo by BM stix

Unilateral facial weakness? y (1) n (0)Unilateral arm weakness? y (1) n (0) Unilateral leg weakness? y (1) n (0) Speech disturbance ? y (1) n (0) Visual field defect? y (1) n (0) Any loss of consciousness or syncope y (-1) n (0) Any seizures? y (-1) n (0)

Rosier >0 suggests ischaemic stroke and potential thrombolysis case

stroke or tia
Stroke or TIA?
  • Symptoms still present => Stroke
  • Symptoms gone =>TIA
who definition of stroke


  • Sudden onset
  • With focal rather than global dysfunction
  • In which, after adequate investigations, symptoms are presumed to be of non-traumatic vascular origin
  • and last for >24 hours
stroke onset
Stroke onset
  • Witness?
  • Woke with hemiparesis?
  • Found collapsed?
  • Sudden/gradual/ stuttering
abcd2 scoring for all new tias
ABCD2 Scoring for all new TIAs

Stroke risk within 1 week 6% for scores 4-5, 12% for scores >5

Admit all with score 5 or above.

tia management
TIA management
  • Do not allow any TIA patient to leave the department without having administered the first dose of antiplatelet
  • ABCD 4 or above admit or ensure TIA clinic appointment (and Doppler) within 24 hours.
  • Endarterectomy within 48 h for patients with symptomatic stenosis
  • ABCD <4 see in TIA clinic within 1 week. Endarterectomy within 14 days for patients with symptomatic stenosis

This will reduce strokes within 1 week by 80%!!!

role of paramedics
Role of Paramedics
  • Establish working diagnosis of stroke/TIA
  • Identify potential thrombolysis candidates
  • Prealert A&E if thrombolysis an option
  • Establish onset time
  • Bring a witness
  • Airway Breathing Circulation
  • Exclude Hypo BM
  • Prevent aspiration
  • Get patient to nearest hyper acute stroke centre
ct head scan
CT Head scan
  • Intracerebral haemorrhage
  • Correct abnormal INR or low platelets immediately
  • Neurosurgical referral
  • Cerebral Infarct
  • Thrombolysis or
  • immediate antiplatelet treatment
other tests
Other tests
  • FBC
  • U&E
  • INR
  • Glucose
  • ECG
  • Carotid Doppler
dh a new ambition for stroke a consultation document for a national stroke strategy dec 2008
DH A New Ambition for StrokeA consultation document for a National Stroke strategy Dec 2008

If 10% of stroke patients in the UK were given thrombolysis, 1000 people less would be dead or dependent in one year.

ninds trial of rt pa for acute ischaemic stroke
NINDS trial of rt-PA for acute ischaemic stroke
  • 633 patients recruited
  • Rt-PA 0.9 mg/kg (10% bolus the rest over 1 h) given within 3 hrs of symptom onset
  • BP<185/110
  • Not on warfarin or heparin, platelets and coagulation normal
  • Blood glucose 2.7-22 mmol/L
  • No seizure at onset

Quasi intensive care environment

Aggressive BP control

16,000 screened to recruit 633

N Engl J Med 1995;333:1581-1587.

ninds rt pa trial 1995 improvements in dependency modified rankin scale mrs
NINDS rt-PA trial 1995Improvements in dependency (modified Rankin Scale: mRS)

Mean Score 2.8 for rt-PA and 3.3 for control : difference 0.5 mRS points*

Number needed to treat to improve by 1 point is 2*

Number needed to treat to improve by 1 or more points is 3**

Number needed to treat to make one patient more independent =5*









* My own calculation bases on the original paper ** Saver. Arch Neurol, Jul 2004; 61: 1066 - 1070.

  • Age 80 or below
  • Previously fit and independent
  • Onset time known and less than 3 hours
  • CT excludes haemorrhage
  • Recent surgery, biopsies arterial cannulation
  • Increased bleeding risk
  • Past history of intracranial haemorrhage
  • Any CNS pathology other than current stroke
  • Any past stroke plus diabetes
  • Stroke within 3 months
  • Systolic blood pressure >185
alteplase rt pa
Alteplase (rt-Pa)
  • 0.9 mg/kg body weight
  • 10% as bolus over 2 min
  • 90% as infusion over 1 hour

No heparin for 24 hours

post thrombolysis care
Post thrombolysis Care
  • Needs trained team / ASU
  • Neurological observations (NIHSS)
  • Blood pressure
  • Observation for complications
  • Scan at 24 h
  • Prevent recurrence
  • Early Doppler/ CTangio in recovered cases
most complications of stroke develop in the first 24 hours

Most complications of stroke develop in the first 24 hours

Management in the first few hours has a major effect on outcome and LOS

important factors for successful early stroke rehabilitation
Important factors for successful early stroke rehabilitation
  • Mobilise ASAP

The probability of returning home decreases by 20% for each

day the patient is not mobilized

  • Maintain normal haemodynamic and biochemical environment
  • Prevent complications
  • Keep patient and family informed
2 prevent aspiration
2. Prevent Aspiration
  • Swallow screen on arrival on ASU
  • Sit up
  • Drowsy patients in recovery position
  • Antiememtics for haemorrhages and patients who feel sick
  • All members of staff have at least basic knowledge of the diagnosis and management of swallowing problems
3 prevent hypotension and dehydration
3. Prevent hypotension and dehydration
  • IV saline
  • Sufficient fluids by mouth or ngt

Dysphagic patients have impaired oral movements resulting in debris, pooled secretions and

tongue coating.

5 prevent hospital acquired infections mrsa esbl c difficile
5. Prevent hospital acquired infectionsMRSA/ ESBL/ C.Difficile

Avoid catheters at all costs

Hand hygiene

Bed spacing

Appropriate antibiotics

7 prevent stagnation and deterioration
7. Prevent stagnation and deterioration
  • Time does not cure strokes
  • Give at least 45 min of each therapy needed every day 7/7
7 detect and treat problems early
7. Detect and treat problems early
  • 72 hour monitoring
  • Neurological scores (NIHSS/SSS)
  • Daily consultant ward rounds 7/7