Stroke thrombolysis: Benefits and pitfalls

1. Stroke thrombolysis: Benefits and pitfalls Dr Neil Baldwin Consultant Physician North Bristol NHS Trust Clinical lead AGW Stroke Network Clinical Lead Acute Stroke NHS Institute

2. Benefits of Stroke Thrombolysis • Reduced mortality • Reduced Disability • Reduced need for institutional care • Reduced LOS mean 12 days v 23 days

3. Intention to treat

4. Risks of Thrombolysis • Intracerebral Haemorrhage • Symptomatic • Asymptomatic • Extracranial Haemorrhage • Anaphylaxis

5. Is thrombolysis safe and effective in practice? • SITS-MOST • ICH at 7 days: 7.3% in SITS-MOST vs 8.6% in RCT’s • 3 month mortality: 11.3% in SITS-MOST vs 17.3% in RCT’s • Complete recovery at 3 months: 38.9% (SITS-MOST) vs 42.3% (RCT’s) Lancet Jan 2007

6. Pitfalls of Thrombolysis • Treatment of Stroke mimics • Delayed treatment • Not treating

7. Stroke mimics

8. Clinical Evaluation • Five question approach • Is it a Stroke? • Which type of stroke? • Where is the Stroke? • What caused the Stroke? • Will thrombolysis be helpful?

9. Syncope Partial epileptic seizure with Todd’s paresis Migraine attack (aura) Hypoglycaemia Hysteria Intoxication Subarachnoid haemorrhage Neuroinfection Neoplasm Brain injury Multiple sclerosis Peripheral vertigo Stroke mimics

10. Mr BD 68yr • HPC T= 13.45 • Sudden onset left hemiparesis • Left visual field defect • Dysarthria • Risk Factors • Hypertension on Atenolol • Ex Smoker • Past Medical History • Nil else

11. General Exam Alert GCS 15 Pulse 80 SR BP 175/85 BM 5.6mmol/L Heart normal Neurological Normal commands L VII palsy mild L visual field defect L hemiparesis Dysarthria Mr BD 68yr NIHSS = 15

14. Mr BD 68yr • Time line • Onset T0 = 13.45 • ED Arrival =14.20 • CT scan =14.45 • Stroke team saw pt in Scanner room • Thrombolysis 15.00 • Outcome • Fully independent when reviewed 1730 • Repeat CT 24 hrs normal • Carotid Doppler > 75% Right ICA • Discharged Following day with plan for Endarterectomy in 2 Weeks

15. 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 60 90 120 150 180 210 240 270 300 330 360 mRS 0-1 at day 90 Adjusted odds ratio with 95 % confidence interval by stroke onset to treatment time (OTT) Benefit of rt-PA for Acute Stroke < 3 h SITS-MOST 3 - 4.5 h RCT ECASS III > 4,5h except selected patients Adjusted odds ratio Stroke onset to treatment time (OTT) [min] Brott TG. International Stroke Conference 2002; abstract.

16. Mr PB 72yr • HPC T= 14.20 • Word finding difficulty • Mild right hemiparesis • No visual field defect • Risk Factors • Hypertension on Atenolol & Bendroflumethazide • Smoker • Cholesterol • Past Medical History • Previous MI

17. General Exam Alert GCS 15 Pulse 80 SR BP 185/85 BM 8.6mmol/L Heart clinically enlarged Neurological Normal commands Moderate expressive aphasia R VII palsy mild R visual field defect R hemiparesis mild Mr PB 72yr NIHSS = 14

20. Mr PB • Time line • Onset T0 = 14.20 • ED Arrival =15.30 • CT scan =1600 • Stroke team saw pt in ED soon afterwards • Marked improvement in NIH =4 • No thrombolysis • Outcome • Fully independent when reviewed next day • CT Carotid Angiogram > 75% L ICA • Discharged Following day with plan for Endarterectomy in 1 Weeks

21. Mrs SS 45yrs • HPC • Sudden onset of L hemiplegia • Drowsy • Severe Dysarthria • Risk Factors • Hypertension

22. General Exam Drowsy GCS 14 Pulse 80 SR BP 165/85 BM 5.6mmol/L Heart clinically enlarged Neurological Abnormal commands Severe Dysarthria L VII palsy severe L visual field defect L hemiplegia Mrs SS 45yr NIHSS = 22

23. Mrs SS • Blood sugar normal • Blood Hb 7.9 g/dL • MCV 76 • U+E Normal

24. Mrs SS 45yrs

25. Mrs SS 45yrs

26. Mrs SS • Time line • Onset T0 = 16.30 • ED Arrival =18.45 • CT scan =1900 • Stroke team saw pt in ED soon afterwards • Discussion about menohhagia DW Gynae • Thrombolysis given 2.45 hrs after onset • Outcome • when reviewed next day no change in NIHSS • 3 days after admission sudden deterioration in condition GCS 7 • CT Repeat

27. Mrs SS 45yrs

28. Mrs SS 45yrs

29. Mrs SS 45yrs • Malignant Middle Cerebral Artery Ischaemic Syndrome • Non dominant hemisphere • Very High mortality • Referred to Neurosurgeons • Uncertainty about benefits of decompression • Underwent hemi-craniotomy • Died few days later

30. Mrs SK 55yr • HPC • Sudden onset left hemiparesis • Loss vision in Left eye • Severe headache with mild photophobia • Risk Factors • No BP/ Cholesterol/ Diabetes / Vascular disease / Non Smoker / Ex HRT • Past Medical History • Hysterectomy 35 yr HRT for 5 yrs only • Migraine since childhood

31. General Exam Alert GCS 15 Pulse 80 SR BP 140/75 BM 4.6 mmol/L Heart normal Neurological Normal commands mild facial weakness Mild left hemiparesis Speech mild Dysarthria Mrs SK 55yr NIHSS = 10

32. Mrs SK 55yr

33. Mr SK • Time line • Onset T0 = 0850 • ED Arrival =1015 • CT scan =1045 • Stroke team saw pt in ED soon afterwards • History of headache explored long history of classical migraine • fortification spectra & Scotoma • GI Disturbance • Hemicranial headache • 1 previous episode of weakness • Not Thrombolysed

34. Mrs SK • Subsequent investigations • No evidence of atherosclerosis • Bubble contrast ECHO confirmed a PFO • Strong Relationship between PFO and Migraine • Small increase in risk of Stroke

35. Mrs GW 72yr • HPC • Got up and was well • After breakfast husband noticed a left facial weakness and Dysarthria • Risk Factors • Atrial Fibrillation / Hypertension • PMH • none

36. General Exam Alert GCS 15 Pulse 80 AF BP 112/75 BM 4.6 mmol/L Heart enlarged Neurological Normal commands Mild L facial weakness Mild left hemiparesis Speech mild Dysarthria Mrs GW 72yr NIHSS = 11

37. Mrs GW

38. Mrs GW 72yr • Seen in ED • CT showed Chronic Subdural • No History of Falls or Head Trauma • Transfer to Neurosurgeons • Good recovery 3 months later

39. Mrs SB 52yr • HPC • Sudden onset of right hemiparesis • Right visual loss • Risk factors • None • Past medical history • nil

42. Mr SP 44yr carpenter • HPC • Monday 26th November 2007 • At work collapsed no recall of the prodrome he thought LOC 5 minutes • On recovery right sided weakness • Slurred speech • Risk Factors • Smoker 30 day / hypertension poor compliance • Past Medical History • Previous admission with blackout 2 yrs ago • Social History • Drinks 3-4 cans per day more at weekends

43. General Exam Tattoos Alert GCS 15 Pulse 100 SR BP 112/75 BM 4.6 mmol/L Heart normal Neurological Normal commands Mild R facial weakness Mild R hemiparesis Speech mild Dysarthria he said normal for him Mr SP 44yr NIHSS = 11

44. Mr SP

45. Mr SP

46. Mr SP • Bloods • Hb 11.5 g/dL MCV 99 • Bilirubin 29 • ALT 67 • Alk Phos normal

47. Progress • Reviewed in the ED • Not thrombolysed as I felt likely to be due to a seizure • Subsequent review of old noted previous admission thought to be a withdrawal seizure

48. Mrs AS 75yr • HPC • Sudden onset of a left visual field defect whilst driving her car • Managed to get home • Daughter thought she had a left facial weakness • Risk factors • hypertension

49. General Exam Alert GCS 15 Looks well Pulse 70 SR BP 132/75 BM 4.6 mmol/L Heart normal Neurological Normal commands Mild L facial weakness No hemiparesis Speech mild Dysarthria Mr AS 75yr NIHSS = 5

50. Mrs AS 75yr