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Stroke : Acute Intervention

Dr Marc Randall Consultant Neurologist and Stroke Physician Honorary Senior Lecturer University Sheffield. Stroke : Acute Intervention. Stroke.

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Stroke : Acute Intervention

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  1. Dr Marc Randall Consultant Neurologist and Stroke Physician Honorary Senior Lecturer University Sheffield Stroke : Acute Intervention

  2. Stroke • A sudden loss of brain function caused by a blockage (80%) or rupture of a blood vessel supplying the brain. Causing loss of muscular control, diminution or loss of sensation or consciousness, dizziness, slurred speech, or other symptoms that vary with the extent and severtyof the damage to the brain.

  3. haemorrhagic Stroke ISCHAEMIC 15 % 80 %

  4. Timeline of knowledge Hippocrates 430BC Johann Webfer 1675 Pierre Paul Broca 1824 - 1880 • “Observationes anatomicae, ex cadaveribus eorum, quos sustulit apoplexia,” Described the first strokes

  5. 1980 Approval for first stroke therapy 1995 First stroke thrombolytic trials 2002 Approval for first licensed thrombolytic therapy within 3 hours IST : Lancet. 1997 May

  6. Middle Cerebral Artery Stroke Acute left MCA thrombus

  7. rTPA – Alteplase • recombinant Tissue Plasminogen Activator • Initiates local thrombolysis

  8. Thrombolysis – rTPA for stroke Current European licence

  9. Treatment decision • Is this Ischaemic ? • Is the presentation compatible with stroke ? • Do I want to try and clear the blocked vessel ? • Do I need to clear the blocked vessel ? • What am I trying to save ? • What are the risks ? Australasian Radiology (2007) 51, 532–537

  10. The aim

  11. Time is of the essence • Well run well trained team of stroke specialists required to deliver thrombolytic. • Ambulance service with clear selection protocols to deliver patients to correct service access point. • Stroke specialist nurse • Protocol driven, selection for rTPA • Drives the process from time of arrival to decision to give rTPA • Constant in the patients care pathway • 24 / 7 radiology back up • Strong stroke unit leadership and training

  12. Intracranial bleeding • Most feared complication • Symptomatic ICH has a 45% mortality in patients who have received TPA • 4 - 5 % of cases treated with rTPA will have intra cerebral bleeds. • Stroke 2005;36:916 • Patient selection and BP control reduce risk.

  13. What is significant bleeding

  14. Deterioration ?

  15. Intra-arterial thrombolysis • May extend window of treatment time for those patients who present in 3 – 9 hour time window. • ? reduces potential for intracranial haemorrhage • Possibly more effective in basilar stroke

  16. 30 year old male presents with neck pain

  17. 3 days later sudden collapse

  18. urgent angiography

  19. after 25 mgs. IA t-PA (90 mins)

  20. 3 hours later

  21. MRI 4 days later – patient ‘doing well’

  22. Merci and Penumbra

  23. Intra arterial intervention • Small numbers of patients in trials. • Very few randomised trials. • Case by case basis. • Some benefits in posterior circulation stroke with basilar thrombosis.

  24. How many stroke patients per year in UK* might avoid being ‘dead or dependent’ with each treatment? Based on 130,000 strokes per year in the UK IST 3 Collaborators

  25. Thank you • Acknowledgements: • Stroke Specialist Nurses • Nursing staff of the HASU L2 RHH • Staff of the integrated stroke pathway Sheffield Teaching Hospitals.

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