Thrombolysis East of England Forum

Diana DayConsultant Nurse for Stroke

What is thrombolysis

Clot busterLyse (breaks up) clotsDrug is called Alteplase (rt-Pa)Aim to restore blood supply to the brain

in the early hours of stroke

Global Good Outcome at Day 90 (mRS 0-1, BI 95-100, NIHS 0-1) (N=2776)

SITS database 12/12/2007 http://www.acutestroke.org/index.php

SITS-MOST vs RCTs – mRS 3/12

Red colours: independentBlue colours: dependentBlack colour: dead

19

20

13

19,9

22

16

15,9

8

11

14,7

14

14

13,9

12

20

5,3

7

7

11,4

18

18

SITS-MOST

RCT active rt-PA

RCT placebo

mRS 0

mRS 1

mRS 2

mRS 3

mRS 4

mRS 5

mRS 6

0% 20% 40% 60% 80% 100%

DeadRecovered

+10%

+4,8%

Lancet 2007; 369: 275-282.

Time is brain

Around1.9 million neurons lost a minute

Recognise React Respond Refer Treat

Max 4.5 hours

Target 2hrs (30-45mins)

Time to treat

Act F.A .S.T

Recognise /React Respond

Journey time 30 – 45mins (60mins review)

Refer and Assess

Pre alert stroke team

Assess Event history NIHSS,PMH, meds Glucose / bloods

Treat with thrombolysis?

Telemedicine

Providing regional access to stroke expertise out of hours

Who can we treat?Inclusion criteria

Clinical S&S of definite acute stroke Clear time of onset Presentation within 4.5 hrs of acute

onset Haemorrhage excluded by CT scan Age 18 and over NIHSS less than 25 Consent discussion

Exclusion Criteria Increase bleeding risk Greater than 4.5hrs Rapidly improving or minor stroke symptoms Stroke or serious head injury 3 months Major surgery, obstetrical delivery, external heart

massage last 14 days, Seizure at onset of stroke Severe haemorrhage last 21/7 History of central nervous damage Hypo / hyper glycaemia Warfarin (unless INR below 1.5) BP > 180/110mmHg (and other exclusions)

Potential for thrombolysis

Conditions

Hyper Acute stroke unit Under the care of stroke physician

/neurologist Care at level 2 (HDU) Physiological monitoring Nurses trained in thrombolysis & acute skills Protocols & guidelines for care Access to immediate imaging (24hrs) Protocols of care

Staffing

Nursing 1:1 – whilst thrombolysing

1:2 – 1:4 first 24-48 hrs of care

Competency based training

NIHSS trained

Mimics

Seizure Migraine Sub /extra dural Tumour MS Hyperglycaemia Non organic Cerebral abscess

/infection

Unlikely to be stroke

Felt funny & shaking Visual disturbance Pins & needles Fluctuating

symptoms

Exclude stroke mimics

Vascular event sudden onsetMaximal at onsetFits within vascular territory

Case 1

72 yr old gentleman well this morningWent to his car at 8.30amDropped his keys, and fell to the groundHis wife noticed right sided weaknessUnable to talk properlyRang 999

Assessment – 10.02

He has PMH high blood pressureHe is being investigated for AFNo previous hospital admissionsBP 179/95, P 114, sats 94%, glu

7.8mmolsNIHSS 21 (aphasic, RSW fal, HH)

Early CT scan : time 10:23

Cerebral Blood Flow Time to peak

CT Perfusion

Infusion Alteplase

0.9mg/kg/body weight, up to max of 90mg.

Diluted with sterile water to 1mg/ml10% of infusion as bolus90% as infusion using syringe pump

over 1 hour.

Post Thrombolysis

Potential complications

Haemorrhage IntracerebralSystemic

Reperfusion hypotensionImprovement then deteriorationNausea / vomiting

Haemorrhagic Complications of t-PA

30 mins into infusion he starts talking again, weakness improves

Then becomes drowsy GCS 15 -13

Stop infusion

Call medical team

CT scan

Neurosurgical opinion

Post CT scan

Management of Bleeding Complications

If bleeding is suspected stop infusion of a thrombolytic drug immediately.

Send FBC, APTT, PT/INR, and fibrinogen. Grouped and matched if transfusions are needed 4 to 6 U of cryoprecipitate or fresh frozen plasma,

platelets These therapies should be made available for

urgent administration.

Allergic reaction

anaphylactoid reaction, laryngeal oedema, orolingual angioedema, rash, and urticaria

usually respond to conventional therapy – antihistamine and hydrocortison if caught early – otherwise full anaphylaxis protocol

many of these patients received concomitant ACEI therapy

Most cases resolved with prompt treatment; there have been rare fatalities as a result of upper airway haemorrhage from intubation trauma

Other Adverse Reactions

Nausea and/or vomiting, hypotension and fever have also been reported – Treat symptoms

Patient 2 : Right hemilingual angioedema

Saver, Stroke 2006

0 2 4 6

30

20

10

0

Number making full recovery per 100 treated

Impact of thrombolysis

Time (hours)

Benefit

Harm

Time is Brain

First 24 hours of care

Monitored bed on stroke unitThrombolysis pathway24-36 hour repeat CT scanNo antiplatelets for 24 hoursNo IM injections, catheterisations or

invasive procedure unless unavoidable.Bed rest for 24 hrsIV access

Research areas

Time window (DIAS)Dose (Enchanted)Other medications (DIAS III)Intra arterial (PISTE)Clot retrievalAwakening stroke (WAKE UP)Anticoagulation thrombolysis

Summary

Thrombolysis is effective if used within hyperacute unit setting

Time is Brain, rapid treatment improves outcome There are risks of bleeding can differ between

cases Appropriate place is for all strokes is hyperacute

stroke unit There are outstanding research

questions

The End

Questions?