THROMBOLYSIS
Alteplase: indications
and contra-indications
Dr Ken Fotherby, New Cross Hospital
Thrombolysis: Yes? No?
• Ischaemic stroke (not bleed or mimic)
• Within 3h onset
• No ^^risk bleeding (BP>185/110
•
•
•
warfarin/heparin
recent stroke
recent surgery)
• Minor/rapidly improving stroke
New Cross experience
• DGH serving ~250,000 pop
• Thrombolysis service 9am-5pm:May 07
• Assessed 21 patients12 thrombolysed
ie. ~1/wk assessed
~1/fortnight treated
Alteplase for ischaemic stroke
• N.N.T. to prevent death/severe
dependency?
Alteplase for ischaemic stroke
• N.N.T. to prevent death/severe
dependency?
6 (NINDS)
9 (NICE )
and 3 to reduce dependency (NINDS)
Alteplase for ischaemic stroke
• N.N.H. (ie cause symptomatic intra-cranial
haemorrhage)?
Alteplase for ischaemic stroke
• N.N.H. (ie cause symptomatic intra-cranial
haemorrhage)?
17
6% NINDS
4-7% SITS-MOST,CASES,STARS
(16% in Cleveland)
( ~1% for MI)
Thrombolysis: Yes? No?
• Ischaemic stroke (not bleed or mimic)
• Within 3h onset
• No ^^risk bleeding (BP>185/110
•
•
•
warfarin/heparin
recent stroke
recent surgery)
• Minor/rapidly improving stroke
Thrombolysis: ?is ischaemic stroke
- Clinical diagnosis
but CT scan to exclude bleed
- Exclude stroke mimics: epileptic fit
hypoglycaemia
Thrombolysis: ?within 3 hours
• Clear time onset (or when last well)
• Usually need eye-witness
paramedics report
“Time is Brain”
Thrombolysis: ?too risky
^ risk intra-cranial bleeding:
- BP>185/110
(reassure,?labetalol or GTN patch)
- Abnormal clotting (warfarin,heparin,haemodialysis)
(INR 1.4 or less OK)
-
?Massive infarct
(NIHSS>25)
?Old age
(>80yr)
Prior stroke within 3months (but TIA OK)
Any i/c bleed in past
major surgery, G-I bleed, haematuria past 3 weeks
Thrombolysis: ?too risky
Prognosis “too good”:
- Small stroke (NIHSS 4 or less)
but ? lone dysphasia
Thrombolysis: Yes? No?
• Ischaemic stroke (not bleed or mimic)
• Within 3h onset
• No ^^risk bleeding (BP>185/110
•
•
•
warfarin/heparin
recent stroke
recent surgery)
• Minor/rapidly improving stroke
Putting it all together!
spouse
paramedic
nurse
BP + BM
arrange
CTscan
clinical
assessment
venflon
bloods
porter
arrange
bed
DOCTOR-PATIENT
relatives
assent/consent
NIHSScore
weight/dose
BP (again)
read CT scan
start drug
Thrombolysis: how often?
• Best = 20% of acute stroke patients
(and 2006 NSentinelStroke Audit:39% admitted <2h)
• strokes/year
/250,000 pop
= 530
= c400 admitted (excl MAU discharges)
= c250 “ “ “ “ “ and aged <80yrs
- 40% of 400 = 160 assessments/y or 3/wk
20% 400 = 80 thrombolyses/y or 1-2/wk
Thrombolysis: an effective & safe
service?
• Written protocols within an (established)
pathway.
( licence & NICE:”only by a physician trained and
experienced in the management of acute stroke and in a
centre with appropriate facilities”)
Pathways and Protocols
for thrombolysis
paramedics
I
A&E
I
CT scanning
I
Stroke Unit
(9am-5pm)
Pathways and Protocols
for thrombolysis
paramedics
I
A&E
I
CT scanning
I
Stroke Unit
(9am-5pm)
G.P.s/community
I
paramedics
I
A&E
I
CT scanning
I
Stroke Unit
(8am-8pm+)