1) Minocycline, a tetracycline antibiotic, may reduce hemorrhagic transformation after acute ischemic stroke when given intravenously with tPA. 2) Endovascular approaches such as intra-arterial thrombolysis and thrombectomy are promising options for treating large vessel occlusions in acute ischemic stroke beyond the current treatment window of 4.5 hours. 3) Pre-hospital administration of therapies such as magnesium may expand the treatment window for acute ischemic stroke if given soon after symptom onset in the field before hospital arrival.

1. ED Stroke Update
DAVID BLACKER
Neurologist & stroke
physician,
Sir Charles Gairdner
Hospital
Clinical Professor of
Neurology
University of WA
Medical Director
WA Neuroscience Research
Institute
No disclosures

2. ?Best Rx for large clots

4. Logistic regression curve representing an estimate of the probability for successful
recanalization of occluded vessels by intravenous thrombolysis (IVT) depending on thrombus
length.
Riedel C H et al. Stroke 2011;42:1775-1777
Copyright © American Heart Association

5. Solitaire FR Stentriever
possibly the preferred option

6. Basilar thrombosis- SCGH case

7. Very early thrombectomy combined with intravenous
tPA for acute ischaemic stroke; the Sir Charles
Gairdner Hospital (SCGH) experience
SSA 2011 Blacker DJ, Phatouros C, Singh TJ, McAuliffe W, Bynevelt M, Triplett J, Bukhari W,
Musuka T

14. Recent transfer to SCGH
 Initially registrar to registrar contact
 Wrong hospital
 NOT a stroke
 Distress to patient
 Delays on return
 $$$$$$
 How do we do better?

15. Is transfer required
 For stroke?
 For neurological evaluation
Who is to benefit from the transfer?
 Patient?
 Family?
 Doctors?

16. Stroke Units
 In Utopia
 All patients should be managed in a stroke unit, since
the evidence suggests better outcomes.

17. Stroke Units
Stroke Unit benefits
 Benefit 5.6/100
 reduced mortality (22% v 26%)
 reduced dependency (56% v 62%)
 reduced cost of care ($10-16 000 savings)
 LOS reduced 2-11 days

18. Stroke Units
Stroke unit features
 geographically distinct
 comprehensive assessment
 co-ordinated MDT
 early mobilisation (avoid bed rest)
 staff with interest; ongoing training and education
 team meetings (DC planning)
 encourage patient participation in rehab

19. Stroke Units
Reasons for benefit
 application of proven treatments
 ?more intense monitoring of physiology
 anticipation, early recognition, and treatment of
complications
 volume of practice
 audit, review, QA, research
 enthusiastic, expert staff

20. Stroke Unit- Physician role
 Knowledge of stroke and TIA
 Accurate determination of mechanism
 Institution of appropriate Rx;
eg anti-coagulation for AF
CEA -symptomatic high grade stenosis
Correct Dx of mimics

21. Patients to transfer to teritary or
“quaternary” centres
1. Acute therapy for ischaemic stroke; depends on system
of care
2. Most cases of ICH (if active treatment planned)
3. Young massive MCA, candidates for decompression.
4. Cerebellar infarct > 3cm, candidate for decompression.
5. Carotid revascularization.
6. Dx unclear, advanced workup required (neuro opinion,
MRI, TOE, LP)

22. Consultant to consultant
discussion
 Early advice on Dx
 Early advice on interventions
 In the future; IV tPA
 “Big picture” discussion on goals of transfer
 Chance for education

23. ACUTE STROKE- EVERY MINUTE COUNTS
1 minute= 1.9 million neurons
14 billion synapses
7.5 miles of myelinated fibres

25. IV tPA meta-analysis – level 1 evidence
Lees et al Lancet 2010
NNT
4.5 9 14.1
Time is BRAIN!
Treatment effect
p<0.001
Interaction with
time p=0.03
4.5 hours

26. Future strategies
 Can thrombectomy be expanded to more patients?

27. Slowing the clock
Expanding the time window

28. Neuroprotective agents in the field

29. Figure 1 The stroke emergency mobile unit with CT scanner on boardNote the CT scanner in
the back of the cabin and the separated shielded workstation on the right behind the door.
Weber J E et al. Neurology 2013;80:163-168
© 2013 American Academy of Neurology

30. Pre-hospital therapies
 Jeff Saver California
 Unique pre-hospital stroke trial
 Ethics considerations
 Magnesium IV
 1700 patients

31.  72% enrolled < 60 mins post Sx onset
 >150 enrolled < 30 mins
 62% ischaemic stroke
 22% haemorrhage
 13% TIAs
 3% mimics
 Neutral results
 Model for the future

32. Neuroprotective agents in the
field
 Peptides
 Hypothermia
 Minocycline
 Combinations
 Physical methods- TCD
Head positioning

33. Neuroprotection
Poly-arginine and arginine rich peptides are
neuroprotective in stroke models
Bruno Meloni et al
J Cerebral Blood Flow and Metabolism 2015 Feb 11th

34. The Perth Intravenous Minocyline
Stroke Study PIMSS
David Blacker
David Prentice
Edith Kohler
Tim Bates
Graeme Hankey
RPH, SCGH,
Swan Districts Hospital, UWA

35. van Heerden and David Blacker
Edith Kohler, David A. Prentice, Timothy R. Bates, Graeme J. Hankey, Anne Claxton, Jolandi
Meta-Analysis
Intravenous Minocycline in Acute Stroke : A Randomized, Controlled Pilot Study and
Print ISSN: 0039-2499. Online ISSN: 1524-4628
Copyright © 2013 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke
published online July 18, 2013;Stroke.
http://stroke.ahajournals.org/content/early/2013/07/18/STROKEAHA.113.000780
World Wide Web at:
The online version of this article, along with updated information and services, is located on the
http://stroke.ahajournals.org//subscriptions/
is online at:StrokeInformation about subscribing toSubscriptions:
http://www.lww.com/reprints
Information about reprints can be found online at:Reprints:
document.Permissions and Rights Question and Answerprocess is available in the
Request Permissions in the middle column of the Web page under Services. Further information about this
Once the online version of the published article for which permission is being requested is located, click
can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.Strokein
Requests for permissions to reproduce figures, tables, or portions of articles originally publishedPermissions:
by GRAEME HANKEY on July 23, 2013http://stroke.ahajournals.org/Downloaded from

36. The West Australian Intravenous
Minocycline and tPA Stroke Study
(WAIMATSS)
A pilot study of a strategy to reduce
haemorrhagic transformation
David Blacker
Mike Bynevelt
David Prentice
Graeme Hankey
Tim Bates
Andrew Kelly
Tony Alvaro

37. 20% STROKE: ICH

38. ICH 30 day Mortality
Broderick et al
9177>60
744930-60
44190-30
GCS 8 or
less
GCS>8Volume
(mls)

39. Stereotactic ICH Aspiration

40. ICH is Dynamic

41. Figure CT scans Baseline noncontrast CT shows heterogeneous right deep parenchymal
hemorrhage (A).
Bermejo P G et al. Neurology 2010;75:834-834
©2010 by Lippincott Williams & Wilkins

42. Figure 1 Symptomatic hypertensive hemorrhage and multiple microbleeds Transversal CT
scan (A) and T2*-weighted 7-T MRI scan (B) with the symptomatic temporal lobe hemorrhage.
Biessels G et al. Neurology 2010;75:572-573
©2010 by Lippincott Williams & Wilkins

44. ? An endovascular approach
to ICH
Perforator stroke following intracranial stenting. A
sacrifice for the greater good?
Levy E, Chaturvedi S.
Neuology 2006;66:1803-4. Editorial

49. Instead of ...

50. “Star Trek” approach
 Stereotactic DXRT, or US to “cauterise” the
bleeder; activated microbubbles+ haemostatic
drug?

51. Other issues
 Secondary prevention strategies
 Novel rehabilitation techniques
 Organisation of services
 Basic sciences
 Psychology