Rankin scale          Stroke protocol 

 

A Thrombolysis Stroke is a blood clot blocking the blood supply to part of the brain. This clot can lead to some permanent damage. Six months after a stroke about half of all patients will still have disability, with some fatalities. Medicines like Alteplase are used in frontline treatment of thrombolysis stroke. These treatments improve blood supply to the brain and improve chances of a better recovery. Research suggests treatment has to be given as soon as possible and no later than 4./5hrs of onset of the stroke.

Benefits:

Reverse the effect

Reducesthe amount of disability

One person in ten or 10% treated with Alteplase will make a better recovery.

Alteplase appears to increase the number of people who are able to manage without help.

To confirm a stroke from a transient ischaemic attack (TIA) doctors follow a strict protocol listed below to determine which route to take:

Side effects

Serious side effects from a risk of bleeding from the first day after treatment.

Some bleeding risks are minor (EG: bleeding from injection site).

Most severe bleeding in the brain making the stroke worse.

Small number (3 in 100) will be fatal.

This bleeding can also occur naturally without receiving Alteplase.

 

 

Sudden onset of focal neurological deficit If subacute onset, look for typical syndrome Seizure (e.g. limb twitching) at onset makes ischaemic

stroke less likely but does occur.  It is more common in intracerebral haemorrhage. Loss of consiousness is unusual in stroke.  Look for signs of brainstem dysfunction. For diagnostic scores e.g. ROSIER

Ongoing symptoms and less than 3 hours from symptom onset? IF SO, STOP HERE, DO NOT GIVE ASPIRIN, and start THROMBOLYSIS PROTOCOL

NHS Fife Stroke Thrombolysis pathway & Protocol

There is an (in hours) and (out of hours) pathway in place.

Timescale starts when patient arrive with CT request in place within 5 mins of patient arrival. Ideally patient is in CT scanner 15mins after arrival, with 15 mins CT to treatment.

Patient assessed using the ROSIER guide and stroke team and CT advised.

ROSIER score is a measurement of consciousness, seizure activity, speech, weakness in the face, arm and leg. This is measured using a +1/0 scale. The score determines the likeliness of a stroke or Tran ischemic Attack (TIA).

Once a patient has agreed to Treatment, the clock is stopped at the onset of treatment. Optimal timescale is arrival to treatment within 30 minutes.

Treatment is done by IV bolus and infusion doses of Alteplase based on patient weight.  Alteplase is a fibrinolytic drug that acts as thrombolytic by activating plasminogen to form plasmin, which degrades fibrin and so breaks up thrombi.(NICE guidelines).This is done over an hour and the patient monitored over the next 24hrs.

Overview

Strokes

9000 per year

1000 eligable for IV+PA injections

300 severe due to large artery occlusion

Intracranial stent

STEMI

cagnard LINNC 2015

Jeffery L Saver neurosurgeon – Rankin Scale (time of onset)

Aspect score

CT perfusion

 

Ineligible for TPA

Time from wake up – 76hr stroke

Time = brain quality

Role of the acute stroke is:

Exclude contraindications/haemorrhage

Establish diagnosis

Other pathologies SAH SDH Abscess

 

CT pitfalls

Inaccurate at early stages

Insensitive for small lesions

Insensitive for old bleeds

Insensitive for posterior fossa

However enough to exclude

Hyperacute 0-6hrs

Late 6-12hrs

 

Hyperdense artery sign

Insular ribbon sign

Odema takes hrs

CT fogging?????

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