Stroke

1. Acute Stroke Protocol and
Thrombolysis in Stroke
By: Dr. Rahul Jankar
Specialist: Neurology
MBBS, MD, DM (NIMHANS)
AIMS hospital Dombivli.

2. Importance of Door to Needle time:
Simplifying Treatment Protocols

3. Canadian Stroke Strategy 2011. Paramedic
Prompt Card; Issue 110.
The situation at large
First medical contact is
physician
The earlier treatment is
initiated, the better the
outcome
Diagnosis requires
stroke expertise
Treatment carries a risk and
requires monitoring
Thrombolysis is underused Resources are often limited
!

4. How are strokes classified?
Ischaemic stroke
The blood supply to an area of the
brain is completely blocked, causing
tissue death and neurological
damage
Transient ischaemic attack
(TIA)
The blood supply to an area of the
brain is temporarily interrupted but
is restored within 60 min and the
patient returns to normal
Haemorrhagic stroke
Bleeding in the brain can prevent
the normal flow of blood to the
tissue beyond the damage and
causes neurological symptoms
ISCHAEMIC STROKE IS THE
COMMONEST FORM OF
STROKE
A stroke can be due to a blockage in one of the arteries (ischaemic stroke) or
bleeding in the brain (haemorrhagic stroke)

5. FAST is the most commonly used
stroke screening tool

7. Stroke- an Emergency
Act FAST
Time is still a Brain......

8. Evidence for DTN time

9. ED response times
NINDS recommendations
Door-to-MD 10 minutes
Door-to-Stroke
Team Notification
Door-to-CT Scan 25 minutes
Door-to-Needle
(80% threshold)
Door-to-Admission 3 hours
15 minutes
60 minutes
ED, Emergency Department
Bock. NINDS Stroke symposium proceedings 1996; Updated 2011.

10. Factors associated with DTN time

11. Why DTN is <60 minute?

12. NIHSS Scale
Monitoring and quantification

13. What is the NIHSS and Why Do We Need It?
• Standardized stroke severity scale to describe
neurological deficits in acute stroke patients
• Allows us to:
– Quantify our clinical exam
– Determine if the patients’ neurological status is improving
or deteriorating
– Provide for standardization
– Communicate patient status

14. The Neurological Examination & NIHSS
Neurological Examination
• LOC
• Mental status and
cognitive function
• Cranial nerves
• Motor system
• Sensory function
• Cerebellar system
(coordination and gait)
• Reflexes
NIHSS
• LOC
• Best gaze
• Visual field testing
• Facial paresis
• Arm & leg motor function
• Limb ataxia
• Sensory
• Best language
• Dysarthria
• Extinction & inattention

15. NIHSS and Patient Outcomes
• Total scores range from 0-42 with higher values representing
more severe infarcts
– >25 Very severe neurological impairment
– 15-24 Severe impairment
– 5-14 Moderately severe impairment
– <5 Mild impairment
Adams, HP, et al. (1999). Neurology: 53: 126-131.
• A 2-point (or greater) increase on the NIHSS administered
serially indicates stroke progression. It is advisable to report
this increase.

16. Online NIHSS Certification
• Online NIHSS Certification available free
through the American Stroke Association.
• The online program provides detailed
instructions and demonstration scenarios for
practice in scoring the NIHSS.
• Certification is completed by scoring different
patient scenarios.
www.strokeassociation.org

17. Acute Stroke Care & IV
Thrombolysis

18. What has not changed since IV Alteplase is on
the stroke scene
 Thrombolysis is still underused
 The majority of patients who receive tPA have a DTN time ≥ 60
min
 Ongoing effort to overcome delays
 Reducing rtPA treatment times is the single most important
modifiable factor to improve patient outcomes from hyper-acute
stroke care
rt-PA for Stroke
Treatment
1995-2015

19. What is rtPA?
• rtPA is a thrombolytic drug also known as Alteplase
– Used for Acute Ischemic Stroke (AIS), AMI, PE.
– The dosage for AIS is less than the dosing for AMI or PE
• rtPA disrupts the integrity of a thrombus, plaque or emboli
within a blood vessel
– Other Thrombolytics had unacceptably high
hemorrhage rates or were not tested extensively to
establish risk versus benefits.

20. Treat the patient with Actilyse®
Boehringer Ingelheim. Actilyse® Summary of Product Characteristics
In acute ischaemic stroke, the recommended dose of Actilyse®
is 0.9 mg/kg body weight (maximum 90 mg)1
• 10% of the 0.9 mg/kg dose is given as an initial intravenous bolus
• The remaining 90% are infused intravenously over 60 minutes

21. Treatment of AIS: Administration of Alteplase
Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 min,
with 10% of the dose given as a bolus over 1 min.
Admit the patient to ICU or stroke unit for monitoring.
If the patient develops severe headache, acute
hypertension, nausea, or vomiting or has a worsening
neurological examination, discontinue the infusion and
obtain emergency head CT scan.
Measure BP and perform neurological assessments every
15 min during and after IV alteplase infusion for 2 h, then
every 30 min for 6 h, then hourly until 24 h after IV
alteplase treatment.
Increase the frequency of BP measurements if SBP is >180
mm Hg or if DBP is >105 mm Hg;
administer antihypertensive medications to maintain BP
at or below these levels