The document discusses the benefits of integrated stroke care and evidence for intravenous thrombolysis for acute ischemic stroke. Integrated stroke care can reduce mortality, improve recovery rates, and reduce time to carotid surgery. Intravenous tPA is an effective treatment for ischemic stroke and works through recanalization, though it carries some risk of bleeding; newer endovascular treatments are also showing promise. The benefits of both integrated stroke care and thrombolysis are supported by evidence from systematic reviews, international registries, and clinical trials.

1. Reza Mofidi MB MCh MSc MBA FRCS
Peng Wong MD FRCS
James Cook University Hospital Middlesbrough,
United Kingdom
Integrated stroke care services,
The evidence for thrombolysis

2. • Value based healthcare
• Developed by Harvard economist Michael Porter
• Structural and process changes
• Delivery of disease/pathology specific care
• Placed under a single organizational entity
• Benefits
• Improve outcome
• Practice Evidence based medicine
• Reduce costs
Integrated Healthcare

4. Regional Stroke Care Centres
Regional
Stroke Care
Centre
Timely Diagnosis Protocolized care
Improved Outcomes

5. Time is brain
0 10
arrival
Clinical
Evaluation
30
CT scan
45 60
Stroke team evaluation
Thrombolysis
Carotid Duplex
MR Angiogram
Diffusion weighted MRI
Daily TIA clinics
Within 24 hours
Same day imaging
Vascular Surgeon review
Within 48 hours Within 2 weeks
Carotid endarterectomy
All cases discussed in MDT

6. Organised inpatient (stroke unit) care for stroke (Mortality)
Cochrane Database of Systematic Reviews
11 SEP 2013 DOI: 10.1002/14651858.CD000197.pub3
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000197.pub3/full#CD000197-fig-0004

7. Organised inpatient (stroke unit) care for stroke
Cochrane Database of Systematic Reviews
11 SEP 2013 DOI: 10.1002/14651858.CD000197.pub3
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000197.pub3/full#CD000197-fig-0005

8. Organised inpatient (stroke unit) care for stroke
Cochrane Database of Systematic Reviews
11 SEP 2013 DOI: 10.1002/14651858.CD000197.pub3
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000197.pub3/full#CD000197-fig-0006

9. Proportion of patients known to be dead after the index stroke and cumulative difference
between stroke unit and control subjects.
Stroke Unit Trialists’ Collaboration Stroke. 1997;28:2139-
2144
Copyright © American Heart Association, Inc. All rights reserved.

10. Proportion of patients living at home after the index stroke and cumulative difference between
stroke unit and control subjects.
Stroke Unit Trialists’ Collaboration Stroke. 1997;28:2139-
2144
Copyright © American Heart Association, Inc. All rights reserved.

12. Benefits of Integrated Stroke care
Time to thrombolysis

13. Peter M. Rothwell, and Charles P. Warlow Neurology
2005;64:817-820
©2005 by Lippincott Williams & Wilkins

14. Benefits of Integrated stroke care
Time to carotid endarterectomy

15. Integrated Practice Unit
Mofidi R, Wong P, Gatenby T, Milburn S. Value based healthcare and delivery of vascular surgery services in the United
Kingdom. Reviews in Vascular Medicine. 2016 Sep 30;6:1-9.

20. Evidence for intravenous Thrombolysis
for acute ischaemic stroke

21. Thrombolysis /ischaemic stroke
Evidence
Systematic reviews
International registries
• Level 1 evidence
• Effect?
• Size of effect?
Practicalities of treatment
How does evidence fair in practice

22. Time to thrombolysis

26. 90 Day Mortality

27. Information obtained from thrombolysis Registries

29. SITS-ISTR Registry data

32. • Dense Hemiparesis
• Occluded MCA
4 hours later

33. Figure 2. Relationship of recanalization vs nonrecanalization to good outcome at 3 months.
Joung-Ho Rha, and Jeffrey L. Saver Stroke. 2007;38:967-
973
Copyright © American Heart Association, Inc. All rights reserved.

34. Figure 3. Relationship of recanalization vs nonrecanalization to death within 3 months.
Joung-Ho Rha, and Jeffrey L. Saver Stroke. 2007;38:967-
973
Copyright © American Heart Association, Inc. All rights reserved.

35. Figure 1. Drawing of the L5 device (top) and X6 device (bottom) engaging a clot.
Wade S. Smith et al. Stroke. 2008;39:1205-1212
Copyright © American Heart Association, Inc. All rights reserved.

36. Subject disposition. mRS indicates modified Rankin Scale.
Vitor M. Pereira et al. Stroke. 2013;44:2802-2807
Copyright © American Heart Association, Inc. All rights reserved.

37. Distribution of mRS at 90 days. mRS indicates modified Rankin Scale.
Vitor M. Pereira et al. Stroke. 2013;44:2802-2807
Copyright © American Heart Association, Inc. All rights reserved.

40. Take home message
• Integrated stroke care
• Reduce Mortality
• Improves chances of recovery and independent living
• Improves time to surgery in patients requiring carotid
endarterectomy

41. Take home message
• Intravenous tPA is a treatment for acute ischaemic stroke
• The earlier it is started the more effective it will be
• Still effective over 80 years of age
• Most effective in patients with Dense stroke (High NIHSS Scores)
• 55% of patients return to independent living
• Risk of bleeding 2-7% (depending on the definition used)
• Thrombolysis works through recanalization
• New modalities such as thrombectomy, intra-arterial lysis