Update on Stroke

GP Update Course RSCH October 2010 Dr Adrian Blight

Plan

• Thrombolysis in acute ischaemic stroke – Background – Practical considerations – Cases – Controversial issues – Future developments • Importance of the whole stroke pathway

Thrombolysis for Ischaemic Stroke

• Attractive in principle • Around for years • Difficult in practice • Various agents • NINDS trial 1995 tPA

Effect of thrombolysis with rt-PA <3 hours Outcome: death or dependency (Rankin 3-5) at 3 months

Brott 2002

Global Good Outcome at Day 90 (mRS 0-1, BI 95-100, NIHH 0-1)

Adjusted odds ratio with 95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776) SITS ECASS III

Lancet, 2004

Overall:

• One in 3 chance of a better outcome • One in thirty chance of a worse outcome • 1-2% chance of important intracranial haemorrhage • BUT – few stroke patients receive tPA in UK • Need to aim for 15%

How does it work in practice?

In Practice

• Rapid assessment of neurological deficit • Assessment proforma – inclusion / exclusion criteria • NIHSS • Collateral history and witness • Pre morbid function • Early consultation with stroke consultant on call

Acute call

• Baseline observations – HR/BP/bm/O2 sats • Bloods • IV access • ECG • CT head

• Hypodensity of – Lentiform nucleus – Insular cortex • Focal mass effect – Sulcal effacement – Compression lateral ventricles

• Hyperdensity of vessels – Proximal MCA – Sylvian dot sign

Decision to treat Options:

1. Stroke for thrombolysis 2. Stroke but not for thrombolysis 3. Not a stroke – (Stroke mimic)

FAST +ve mimics

• Hypoglycemia • Migraine • Post-ictal paralysis • Brain Tumours • Subarachnoid hemorrhage • Subdural haemorrhage • Cervical myelopathy • Hypertensive encephalopathy • Peripheral nerve palsies • Musculoskeletal injuries • Intracerebral abscess Functional Acute illness in pt with old stroke / cerebrovascular disease

Fast –ve strokes

• Cerebellar strokes • Occipital infarcts • Non-dominant parietal lesions • Sensory strokes • Frontal infarcts causing just leg weakness

Decision to treat

• Consent • Alteplase – Dose 0.9 mg/kg body weight – 10% given as initial bolus dose and rest infused over one hour IV • One to one care throughout infusion • BP observations • every 15mins for 2 hours • every 30 mins for 4 hours • Hourly for 18 hours • Acute Stroke bed • Complete proforma

• No catheter / NGT 24 hours • BP and glucose control • Any deterioration in GCS / neurological status merits repeat CT head ? haemorrhage • Local haemorrhage (gums/bruising) • Anaphylaxis (lip/tongue swelling) • Post stroke governance issues

Time is brain…..

• 1.9 million neurons die every minute after a stroke • Thrombolysis given in first 90 minutes is twice as effective as when given in first 180 minutes • Thrombolysis needs to be delivered as part of a comprehensive pathway for stroke - NOT in isolation

75yr old man

• Collapsed 11.10am

• SECAMB “?TIA/CVA” • GCS 10 BP 145/75 BM 7.5

• Left hemiparesis • Dense Left hemineglect • Eyes deviated • Tolerating NP airway • NIHSS 20

• TPA bolus given 2 hrs 35 after stroke onset • Uneventful infusion • No complications • NIHSS 2

• Excellent recovery • Home after a few days with ESD team • Took part in local TV and newspaper articles to help raise awareness

78yr old man - GB

• Found collapsed in front garden • Dense right hemiparesis • Mute • NIHSS 19 • Little initial other history

Developments…

• Gardening all morning • Found collapsed at 12.55

• Estimated time of onset – 12.45

• CABG / HT – no warfarin • Investigations for anaemia “a few years ago” • Normally fit and well • Ex professional double-bassist

• Decision to treat “in best interests” • tPA at 2 hrs 5 mins since estimated onset • Uneventful infusion

At 24 hrs NIHSS - 2

• Made excellent recovery • Fluent speech • On going follow up at Epsom

Difficult decisions…..

• Mrs KB 46yr old lady. • Acute left hemiparesis • Witnessed by husband • No vascular risk factors • No apparent contraindications • NIHSS 9

CT at approx 2 hours

• About to administer bolus tPA • Hb result now rung through: • Hb 5.6g

• Now what?

CT 23 hours later

DWI MRI

Mrs KB

• OGD normal. • Large fibroid with menorrhagia • No cause for infarct indentified cryptogenic stroke

• 62 yr old man • Playing golf • Developed acute dysphasia and left sided weakness

Background

• 3 previous infarcts over last 25 yrs • Subsequent PFO and closure • Excellent recovery • After discussion –felt that tPA is indicated and worthwhile

• 70 yr old • Acute dysphasia

Mr GC

Acute CT brain

Controversies in thrombolysis

• What is the time window for treatment?

• Should all the licensed criteria be stuck to rigidly?

• What about patient age?

• Who should deliver it?

• Where is it best delivered?

Service Models

• Who? – Huge variety • Where? – Every acute hospital?

– Ambulance primary divert for all stroke patients and a limited number of HASUs (London) – Primary diversion for selected cases • How? – “Hands-on” specialist – Using remote video enabled teleconference technology (“telemedicine”)

Telemedicine in Stroke

Interventional neuroradiology

The importance of the whole stroke pathway • Hyperacute stroke service • Direct to stroke unit (NOT MAU) – High quality MDT- inc weekends • Specialist inpatient rehabilitation • Early supported discharge • Long term support – Structured FU and annual review – Rehabilitation / adaption – Spasticity / continence etc – Financial support – Vocational rehabilitation

Thank you