Transcript The South London Stroke Register

Thrombolysis: The Evidence
Barry Moynihan
Stroke Physician, St. George’s Hospital
SITS/BASP Thrombolysis Nursing Training Day
March 26th 2012
Outline
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Pathophysiology
Case Study
Evidence available
Unanswered questions
Without thrombolysis
2 hr
Follow
up
A cerebral artery blocks with a clot
Over the next few hours the infarct grows
Open the blocked artery
- reduce the brain damage
Randomised trials of thrombolysis vs
control in acute myocardial infarction
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Total no. patients by 1994!
58,600
Randomised trials of thrombolysis vs
control in acute ischaemic stroke
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Total (all agents)
6,284
(recombinant tisse plasminogen activatort, streptokinas, desmoteplase, urokinase)
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rt-PA
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rt-PA < 3hrs
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rt-PA aged > 80 years
3,977
930
42
Even if the EU approval for thrombolysis
is extended to 4.5 hrs, who else might
benefit?
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Are aged > 80 years
‘very mild stroke’
or NIHSS > 25
Posterior circulatory stroke
Prior stroke within the last 3 months
Have a history of prior stroke + Diabetes
Presenting outside the time window of 4.5 hours
Other relative contraindications specified in the
licence (e.g. ‘extensive infarction’, which is not
defined in any way)
Key Messages
• Thrombolysis is the only cure for ischaemic stroke
• IV thrombolysis is associated with improved
outcome up until 4.5 hours
• Any benefit from IV rTPA between 4.5-6 hours is
likely to be less and needs demonstrating in
clinical trials
Time is brain!