Hyperacute stroke care

1
Hyperacute stroke care

• Dr Richard Perry
• Consultant Neurologist
• University College Hospital NHS Foundation Trust

2
Plan

• Hyperacute stroke care now HfL plan
• Stroke thrombolysis a case
• Stroke thrombolysis the evidence
• Neurosurgery stroke a case
• Neurosurgery stroke the evidence
• The future
• Conclusion

3
Hyperacute care now

• We can improve mortality, morbidity
• Nothing beats care on a stroke unit!
• Stroke thrombolysis, now and future
• Neurosurgery in hyperacute stroke care
• (Quick 2ary prevention)
• HfLs plan for HASUs

4
Case 1 a mute swan
5
Case 1 background

• 36 y.o. R handed lady
• Brought in by LAS, mute, weak R side
• LAS were called by partner
• Saw her at 6am, well
• Called her at 10am, she could not speak
• Background of back pain depression

6
Case 1 first AE doctor

• Alert but poor eye contact
• Not speaking much
• Keeps looking to left side
• ?Seen to scratch nose/ cover mouth with R
  handwhen yawned
• ?Psychiatric

7
Case 1 another AE doctor

• Leaning to L side
• Cant move R arm/leg
• R facial droop
• Not obeying commands
• Not dysarthric but dysphasic
• Thrombolysis call

8
Case 1 stroke team

• Aphasia
• Probable R homonymous hemianopia
• Not able to look to R, not very aware of R
• R UMN facial droop
• Tongue deviates to R
• R arm and leg 0/5 power, ? reflexes on R
• BP104/86, resp/cardio/abdo exam normal

9
CT
10
CTA
11
CTP
12
Phone call to GP from scan room

• Seen previous day
• R sided weakness, a few minutes
• Complete recovery
• Ex-smoker, occasional alcohol (lipids not known)
• Depression
• Fall 9 years ago, fractured coccyx
• No thrombolysis exclusion criteria

13
Case 1 thrombolysis

• Alteplase bolus given in CT recovery room
• Then 1 hour tPA infusion
• No clear evidence of improvement
• Was there any more that we could do?
• Interventional radiologist get MRI

14
MRI (DWI)
15
DWI and CTP
16
What was the aetiology?
17
Contrast-enhanced MRA
18
Case 1fat-saturatedT1 sequence
19
Case 1 more info outcome

• Partner remembered Ehlers-Danlos
• L sided headache for 2/52
• No further intervention
• 5/52 later on Rehab Unit at Queen Square
• Speaking, not yet very fluent
• Walking around
• Flicker of activity in R hand

20
Stroke thrombolysis evidence
21

• NINDS 2
• 168 tPA vs 165 control
• Favourable outcome (mRS 0-1) at 3/12

22
Favourable outcome at 3/12(i.e. Modified
Rankin 0 or 1)
Pooled analysis of ATLANTIS, ECASS NINDS rt-PA
stroke trials
23
Case 2 pain in the eye
24
Case 2 initial history

• 51 y.o. man, 20 cigs/day, no other risks
• Sore throat 5/7 ago
• 6.50am Brighton to London
• Working on laptop
• Light flashing into eyes
• Left eye and facial pain

25
Case 2 attack of slurred speech

• 9am, spoke to colleague
• Slurred speech
• L side of face felt weak
• Arms clumsy
• Lasted 20 mins
• Eye pain continued

26
Case 2 AE

• 13.45 hr seen by medical SHO on-call
• No abnormal signs
• No carotid bruits
• Impression likely TIA
• Urgent CT booked
• Called TIA Nurse Specialist

27
Case 2 acute deterioration

• 15.20 hr, during assessment with TIA nurse
• Completely aphasic
• R homonymous hemianopia, R neglect
• Not obeying commands
• Not moving right side of body
• R plantar?, L plantar?
• Urgent CT on thrombolysis protocol

28
Case 2 CT lower slices
29
Case 2 CT middle slices
30
Case 2 CT upper slices
31
Case 2 carotidultrasound on ward
32
Case 2 post IV thrombolysis

• IV thrombolysis at 95 mins
• No recovery of function
• Not suitable for interventional radiology

33
CT at 12 hours huge MCA infarct
34
Deterioration on day 3

• Drowsy but rousable
• Handover each night
• 2 hourly neuro obs
• Day 2 more alert
• But on day 3

GCS
M
E
V
35
CT day 3 (lower)
36
CT day 3 (upper)
37
Emergency management

• Called relatives
• Called neurosurgeons

38
Post-operative CT (middle)
39
Post-operative CT (upper)
40
Time series
30 min
12 hours
3 days
1 month
41
Neurosurgery in malignant MCA

• Young strokes with large MCA infarcts
• High mortality
• No medical treatment effective
• Case series benefit of neurosurgery?
• Surgeons not generally keen, until

42
Early Decompressive Surgery
43
Vahedi et al. (2007)

• Pooled analysis from 3 trials
• Patients 18-60 years
• Large MCA infarcts clinically and on CT
• Not alert (item 1a NIHSS)
• Inclusion within 45 hours of onset
• Surgery 51 Conservative 42

44
Vahedi et al. (2007) results _at_12/12
45
The future
46
When iv rtPA fails
47
Conclusion hyperacute stroke

• Exciting times in stroke management
• Patients need to get to hospital immediately
• HASU arrangement in London
• Things that we can do now
• More on offer very soon
• (TIA recognise, refer, prevent a stroke)

48
Thank you for your attention