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The roadmap for trombolysis
in outpatients with acute stroke
Luca Puccetti*, Mirene Anna Luciani***,
Giovanni Orlandi**, Alberto Chiti**
* GP, SMIPG - SIT
** Institute of Neurology, University of Pisa
*** Training physician in family medicine
BACKGROUND
-Intravenous trombolysis (IT) performed within 3 hours
in “suitable” patients with ischemic stroke reduces both
mortality and disability: TIME IS BRAIN
- Although these benefits are evident few patients with stroke
undergo IT (less than 5%), even in best situations, because of:
-UNAWARENESS or INSENSITIVITY
-- DELAY (OUT and IN – Hospital)
OBJECTIVES
-Increase awareness and interest
-REDUCE DELAY
Tasks for community physicians
1) Sharing patient’s medical information (patients summary and EHR)
2) Sensitizing community physicians to realize the benefits associated
with VT in acute stroke and to cooperate to make it possible
3) Training of community physicians on inclusion and exclusion
criteria
4) Tele-consultation with the onboard neurologist or with the
Emergency Center
5) Follow-up
Venous Trombolysis in outpatients
DEDICATED MODIFIED AMBULANCE
•On board specifically formed Team including skilled neurologist;
•On board automated laboratory analyzer (clotting and blood count)
•“Moveable” cranial CT (350 Kg), 8 slices;
•Local first evaluation of imaging by the neurologist on board;
•Sending of images via UMTS-HSPDA/SAT to the Neuroradiological
Center of the AOUP (University of Pisa) for legally refertation;
•Assessment of inclusion and esclusion criteria;
•Trombolysis if indicated and subsequent transport to the Stroke Unit
or to the Neurosurgical Center – ICU if hemorrhagic stroke
INCLUSION CRITERIA of
the PILOT STUDY
1) PATIENTS 18 - 80 YEARS
2) Ischemic STROKE with moderate neurological injuries (NIHSS
5-25) including also isolated aphasia isolate (NIHSS 2-3)
3) IT within 3 hours of onset of symptoms
4) Symptoms for at least 30 minutes and not significantly
improved before treatment
MAJOR ESCLUSION CRITERIA
CLINICAL CRITERIA
LABORATORY CRITERIA
*Stroke with sezures
*Heparin in the last 48 hours
*Subarachnoid hemorrhagic symptoms, although normal
CT imaging
*Actual Anticoagulants with INR > 1,7
*Previous ischemic stroke with disability (mRS >2)
*Platelet count < 100.000/mm3
*Glycemia < 50 o > 400 mg/dl
*Ischemic stroke in the last 3 months
*Previous intracranial hemorrhage
*Diseases with high hemorrhagic risk
*Severe actual or recent bleeding
*Recent (< 10 days) resuscitation manouvres
severe trauma, delivery
*Recent (< 3 months) major surgical procedure
OTHER CRITERIA
*Intracranial , CT evident hemorrage
or early hypodensity in more than
⅓ of the area of medium cerebral artery
*Systolic pressure > 185 mmHg, or
diastolic >110 mmHg, uncontrollable
Critical issues
HEMORRHAGIC STROKE (CT confirmed)
TELE –NEUROSURGICAL-CONSULTATION
FAST SURGICAL PROCEDURES or ICU
FACILITATION of INTRA-ARTERY Thrombolysis
Venous thrombolysis may facilitate the Intra-artery
thrombolysis which is indicated in selected cases
Occlusion of medium cerebral artery within 3-6
hours from the onset of symptoms
Occlusion of basilar artery within 3-6 hours
from the onset of symptoms