Thrombolysis of stroke in Emergency Department

1. Acute Ischemic Stroke
Dr Swarupa Tandel
DNB Emergency medicine
6/3/2023

2. Case presentation-
73 years old female,
K/C/O IHD-->post PTCA in 2017
K/c/O RVHD--->post MVR done in 2020 on tab Acitrom 2mg & 1mg every
alternate day
K/C/O HTN on tab Losartan ,tab Met XL,T.DILZEM SR 90 MG 1-0-0
T.DIGOXIN 0.25 MG 1-0-0(5/7)
Brought to ER
H/o Right sides weakness in both upper limb & lower limb since 1 hour.(9
a.m.)
H/o aphasia++
H/O facial deviation to the left++
O/E -
conscious
P-130/min,sinus tachy+
BP-152/90mmhg
RR-18/min
SPO2-98% on RA
distal pulse+

3. S/E-
RS-AEBE,b/l wheezing+
CVS-S1S2+
P/A-soft,NT
CNS-conscious,obeys simple commnads
moves left side spontaneorusly
right side power-RUL-0/5---->3/5
RLL-0/5------->2/5
pupils-BLERTL
BSL-127mg/dl
NIHSS: 7
MRI Brain findings:
Acute infarct seen in left middle cerebral artery territory involving left
fronto-parietal temporal lobe , peri insular cortex and left gangliocapsular
regions.
Rx given in ER:
INJ. ACTILYSE--40.5 MG --->TOTAL--->4.05 ML IV BOLUS F/B---36 ML IN 1
HR.

4. 1 in
6 MILLION
WORLDWIDE, NEARLY
6 MILLION PEOPLE DIE
EACH YEAR FROM A
STROKE1,2
1 IN 6
WORLDWIDE, 1 IN 6
PEOPLE ON AVERAGE
WILL SUFFER A STROKE
IN
THEIR LIFETIME1
EVERY 6
SECONDS
EVERY 6 SECONDS,
SOMEONE DIES FROM
A STROKE1,2

5. 1. Lozano R, et al. Lancet 2012;380:2095-2128.
2. Hankey G. Lancet 2013;1:e239-e240.
3. Roger VL, et al. Circulation 2011;123:e18-e209.
www.who.int/mediacentre/factsheets/fs310/en
STROKE IS THE
SECOND MOST
COMMON CAUSE
OF DEATH IN THE
WORLD1,2
APPROXIMATELY
ONE THIRD OF
PATIENTS WITH A
NEW STROKE
WILL DIE3
7.4M
6.7M
3.1M
3.1M
1.6M
1.5M
1.5M
1.5M
1.3M
1.1
M
ISCHAEMIC HEART
DISEASE
STROKE
COPD
LOWER RESPIRATORY
INFECTIONS
TRACHEA BRONCHUS,
LUNG CANCERS
HIV/AIDS
DIARRHOEAL DISEASES
DIABETES MELLITUS
ROAD INJURY
HYPERTENSIVE
HEART DISEASE
www.who.int/mediacentre/factsheets/fs310/en

6. .
AN UNTREATED PATIENT LOSES APPROXIMATELY
1.9 MILLION NEURONS EVERY MINUTE IN THE
ISCHAEMIC AREA1
REPERFUSION OFFERS THE
POTENTIAL TO REDUCE THE EXTENT OF
ISCHAEMIC INJURY3
PENUMBRA
(SALVAGEABLE
BRAIN AREA)2
ISCHAEMIC CORE
(BRAIN TISSUE
DESTINED TO
DIE)2

7. TREATING FAST CAN MAKE A DIFFERENCE
TIME IS BRAIN

8. A STROKE CAN BE DUE TO A BLOCKAGE IN ONE OF THE ARTERIES (ISCHAEMIC STROKE) OR
BLEEDING IN THE BRAIN (HAEMORRHAGIC STROKE)
THE BLOOD SUPPLY TO AN AREA OF THE
BRAIN
IS TEMPORARILY INTERRUPTED BUT IS
RESTORED WITHIN 60 MIN AND THE PATIENT
RETURNS
TO NORMAL
TRANSIENT ISCHAEMIC ATTACK (TIA) HAEMORRHAGIC STROKE
ISCHAEMIC STROKE
BLEEDING IN THE BRAIN CAN PREVENT
THE NORMAL FLOW OF BLOOD TO THE TISSUE
BEYOND THE DAMAGE AND CAUSES
NEUROLOGICAL SYMPTOMS
THE BLOOD SUPPLY TO AN AREA OF THE
BRAIN IS COMPLETELY BLOCKED, CAUSING
TISSUE DEATH AND NEUROLOGICAL DAMAGE
ISCHAEMIC STROKE IS THE
COMMONEST FORM OF STROKE

9. Albers G, et al. Chest 200
4;126 (3 Suppl):438S-512S.
Haemorrhagic
12%
Other
5%
Cryptogenic
30%
Cardiac embolism
20%
Small vessel
Disease “lacunes”
25%
Atherosclerotic
cerebrovascular
disease
20%

11. * See notes
* DTN, door to needle time, refers to in-hospital management
NINDS NIH website. Stroke symposium proceedings 1996. Updated 2011.
DTN* ≤60 MIN - FOR EVALUATING AND TREATING ACUTE STROKE
Suspected stroke
patient arrives at stroke
unit
Initial evaluation by physician
(including patient history, lab work
initiation, & NIHSS)
Stroke team notified
(including neurologic
expertise)
CT scan initiated CT & labs interpreted rt-PA* given if patient
is eligible
IDEALLY pre-hospital

12. TAKE BLOOD* FOR
COMPLETE BLOOD COUNT & PLATELET COUNT
PROTHROMBIN TIME / INR
PARTIAL THROMBIN TIME
SERUM ELECTROLYTES
BLOOD GLUCOSE
BLOOD GROUP AND CROSS MATCH
HEPATIC AND RENAL CHEMICAL ANALYSIS
ESTABLISH TIME OF SYMPTOM ONSET…..NIHSS SCORE
MRI/CT BRAIN
DETERMINE OR ESTIMATE PATIENT'S WEIGHT
INSERT TWO 18 GAUGE INTRAVENOUS CANNULAS Put Foleys catheter
RULEOUT CONTRAINDICATIONS FOR THROMBOLYSIS

13. * Please refer to angels NIHSS protocol
1. Kasner SE, et al. Stroke 1999;30:1534-1537.
2. Fonarow GC, et al. J Am Heart Assoc 2012;1:42-50.
Reliable and reproducible assessment of
neurological status1
Used to monitor changes in
neurological status
Predicts functional outcome and
mortality risk after ischaemic stroke2
11-item analysis, scored from 0-42
Scores are based only on the patient’s
responses and not on the investigator’s
interpretation
Can be performed in 10 minutes
by trained staff
MOTOR ARM
LIMB ATAXIA
VISUAL FIELDS
BEST GAZE
LEVEL OF CONCIOUSNESS
FACIAL PALSY
MOTOR LEG
LANGUAGE
EXTINCTION & INATTENTION
SENSORY
DYSARTHRIA
NIHSS 11-ITEM ANALYSIS*

15. Fonarow GC, et al. J Am Heart Assoc 2012;1:42-50.
Muir KW, et al. Stroke 1996;27:1817-1820.
ASSESSMENT OF NEUROLOGICAL STATUS
0-1 NORMAL
1-4 MINOR STROKE
5-15 MODERATE STROKE
16-20 MODERATELY SEVERE STROKE
>20 SEVERE STROKE
PREDICTION OF MORTALITY
0 POINTS: RISK OF 30-DAY MORTALITY 2.3%1
≥40 POINTS: RISK OF 30-DAY MORTALITY >75%1
PREDICTION OF LONG-TERM CARE NEEDS
≥14 POINTS: LONG-TERM CARE IS LIKELY
6-13 POINTS: ACUTE INPATIENT REHABILITATION
≤5 POINTS: 80% OF PATIENTS DISCHARGED HOME

16.  Total dose: 0.9mg/kg. MAXIMUM DOSE IS 90 MG.
 10% of total dose given as an I.V. push over 2 minutes supervised by a Doctor
experienced in stroke thrombolysis
 Give remaining 90% of dose I.V over 60 minutes via infusion pump
 Observe patient for any deterioration during infusion.
A NON-CONTRAST CT BRAIN SHOULD BE PERFORMED 24-36 HOURS POST
THROMBOLYSIS FOR ALL PATIENTS. IF NO BLEEDING, ASPIRIN CAN BE STARTED
POST STROKE THROMBOLYSIS CARE
General management
 Pulse oximetry - maintain O2 saturations above 95%.
 Maintain normal temperature. Paracetamol if temp > 37˚C.
 Blood Glucose: Maintain blood glucose < 10 mmol/l using IV insulin if necessary.
 DVT prophylaxis –ideally with automatic spontaneous compression devices.
 Mobilise in first 24 hours if tolerated
 Risks and benefits of all invasive procedures should be carefully considered.
 No urinary catheters for at least 1 hour after infusion ended if possible.
 Falls Risk Assessment & Prevention measures.
 No aspirin, clopidogrel, dipyridamole or anticoagulant (heparin, warfarin, NOAC’s)
for 24 hours.
 Hydration / Nutrition

17. 1. Ringelstein EB, et al. Akt Neurol 2005;32:314-317.
CONTINUE TO MONITOR THE PATIENT, SPECIFICALLY LOOKING OUT FOR
COMPLICATIONS
BLOOD PRESSURE CHANGES AND CARDIAC FUNCTION
SWALLOWING DIFFICULTIES
START SECONDARY PREVENTION, TO REDUCE THE INCIDENCE
OF RECURRENT STROKE
RECURRENT STROKE
INITIATE EARLY REHABILITATION MEASURES
ADMINISTER PROPHYLAXIS AND TREAT ANY COMPLICATIONS
NEUROLOGICAL (E.G. SECONDARY HAEMORRHAGE)
MEDICAL (E.G. ASPIRATION)
COMPETENCE
IS BRAIN1

19. 1. European Stroke Organisation (ESO). Cerebrovasc Dis 2008;25(5):457-507.
2. ESO Guidelines 2009 Update. http://www.eso-stroke.org/pdf/ESO_Guideline_Update_Jan_2009.pdf
In patients with suspected TIA or stroke,
urgent cranial CT (Class I),or alternatively MRI (Class II),
is recommended (Level A)1
I.V. rt-PA (0.9 mg/kg body weight, max. 90 mg), with 10% of the dose
given as a bolus followed by a 60-minute infusion, is recommended
within 4.5 hours of onset of ischaemic stroke
(Class I, Level A)2
The use of multimodal imaging may be useful for patient selection for
thrombolysis but is not recommended for routine clinical practice
(Class III, Level C)2

20. In patients
eligible for IV rt-PA,
benefit of therapy is time
dependent, and
treatment should be
initiated as quickly as
possible. The door-to-
needle time (time to
bolus administration)
should be within 60 min
from hospital arrival
(Class I, LOE A), New
recommendation
IV rt-PA
(0.9 mg/kg,
maximum 90 mg) is
recommended for
selected patients
within 3 hours of
onset of ischaemic
stroke (Class I,
LOE A)
IV rt-PA
(0.9 mg/kg,
maximum 90 mg) is
recommended for
administration to
eligible patients who
can be treated in the
time period of 3 to 4.5
hours after stroke
onset (Class I,
LOE B)

21. THANK YOU.....