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STROKE THROMBOLYSIS GUIDELINE (EMERGENCY

DEPARTMENT RUN SERVICE)

1. Aim/Purpose of this Guideline


To deliver safe and effective thrombolysis for acute ischaemic stroke using
robust evidence based clinical criteria. The service has been taken over by the
Emergency Department in November 2013 and this updated guidance reflects
this change in delivery.

2. The Guidance
Contents Page
Reason for change 2
Thrombolysis pathway 3
Clinical Exclusions from thrombolysis 5
Management of hypertension 7
r-tPA dose ready reckoner 8
Consent issues 9
Management of complications after thrombolysis 10
NIH Stroke Scale (full version) 11
ASPECTS score 19
Nursing protocol and care plan 20
References 22
Short NIHSS score sheet 23
Peninsula Heart & Stroke Network Clinical Reference Group 24
statement on thrombolysis
Monitoring and Effectiveness and compliance 27
Governance information 28
Equality Impact Assessment 31

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Reason for change

Referral of Patients with Acute Stroke and Proximal Artery Occlusion for
Consideration of Intra-arterial Treatment at Derriford Hospital

Publication of the MR CLEAN; EXTEND-IA; ESCAPE; and SWIFT PRIME thrombectomy trials.
Taken together, these trials provide compelling evidence that quick, early thrombectomy with
second-generation stent retriever devices is safe and effective for reducing disability when used to
treat patients with stroke caused by proximal large artery occlusions in the anterior circulation [2-5].
The NNT for one additional person to achieve functional independence in these trials ranged from
approximately 3 to 7.5.

Referrals only accepted between the hours of 09:00 and 15:00 Monday to Friday.

Please consider following patients for referral for intra-arterial treatment:

Ischaemic stroke patient-if no improvement within 30 minutes of intravenous


thrombolysis on NIHSS with suspected proximal vessel occlusion (NIHHS>9)

Demonstration of proximal vessel occlusion CT angiogram (terminal ICA, M1,


proximal M2, basilar), considered responsible for the patients presentation

Possibility of clot extraction within 4.5 hours of stroke (time to groin puncture 4
hours).

Exclusion criteria
Any evidence of haemorrhagic transformation (or primary haemorrhage)
Age greater than 80
Hypodensity involving more than 1/3 of middle cerebral artery territory

Significant comorbidities that reduce the likelihood of a good clinical outcome

Opinion of receiving clinician that clot extraction will be impossible in the required time
How to proceed:
ED consultant discusses patient with stroke consultant on Phoenix (ext 2120/via
switch)

ED consultant in charge of patients care requests urgent CT angiogram and


contacts on call stroke neurology registrar at Derriford hospital.

Ensure iv access (2 cannulas)

Urgent transfer of patient by radiographers (main CT scanner)

Patient accompanied to scanner by ED nurse

Images are uploaded PACS as soon as obtained

ED consultant contacts Derriford team once CTA images uploaded and arranges
urgent transfer to Derriford hospital.

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Derriford Hospital # 6171 request the stroke registrar (1908) to arrange bed and
RCHT STROKE THROMBOLYSIS PATHWAY
transfer

PRE-HOSPITAL
Stroke eligible for thrombolysis:
Positive FAST (Face, Arm and Speech Test)
Age 18 or older
Symptoms noted on waking exclude thrombolysis
Symptom onset to thrombolysis within 6h
No seizure at onset

Check BM, confirm time of onset, transport to ED RCHT, with NOK and list of pills if
available. Pre-alert ED ensure name, DOB and AFFECTED SIDE included

EMERGENCY DEPARTMENT
Confirm stroke using ROSIER scale
Book CT on MAXIMS ensure side affected is clear on request
Ring 4444 to alert radiographer/stroke nurse/stroke ward
Transport patient straight to CT on arrival for urgent CT head
Brief medical history to confirm time of onset, inclusion and exclusion criteria
Perform NIHSS examination (National Institute Health Stroke Scale)
Brief general examination, estimate weight
BP both arms, repeat higher arm BP after 15 minutes (manual cuff not dynamap)
Manage high BP as per protocol
iv access x2
Urgent bloods = FBC, U&E, clotting, G&S (INR if on warfarin), lipids, glucose
ECG (and CXR if needed)

CT SCANNER
Radiographer performs scan and informs on call radiologist to report scan using
ASPECTS score

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DECISION TO THROMBOLYSE
Repeat NIHSS to ensure not rapidly improving
Do not delay while waiting for bloods (unless on warfarin or on chemo or known
haematological disorder)
Decision to thrombolyse taken by thrombolysing doctor
Obtain verbal consent if possible
Calculate dose using ready reckoner, give bolus in 10ml syringe over 1-2
minutes then infusion over 1 hour using 50ml syringe driver
Start treatment in ED and organise bed on critical care via site coordinator
(bleep 2634)
If large vessel occlusion suspected (NIHSS >9) please consider referral for intra-
arterial treatment (see first page of guidance)

MONITOR FOR COMPLICATIONS


Watch for signs of neurological deterioration, bleeding, anaphylaxis
Repeat NIHSS at 30 minutes
Manual BP, pulse, GCS, respiratory rate, temperature, SaO2 every 15 min for
2h, then every 30 min for 6 h, then every hour for 18h
Maintain BP Systolic <180 and Diastolic <105, Temperature < 37C.
Avoid urinary catheter, ng tube, im injections for first 24h
Avoid antiplatelets / anticoagulants until repeat CT at 24h excludes bleeding
Inform medical registrar of any concerns
Manage complications as per protocol
Prescribe Intermittent compression stockings for VTE prophylaxis

AT 12 HOURS
Arrange transfer to Phoenix via clinical site coordinator (bleep 2634)

AT 24 HOURS
Repeat routine CT scan and repeat NIHSS at 24h
Start antiplatelet as per protocol if no bleeding on repeat CT

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CLINICAL EXCLUSIONS FROM THROMBOLYSIS
Do not give thrombolysis if you have ticked any YES boxes

YES NO
FROM THE HISTORY

Time of onset unknown


Awoke with symptoms
Seizure at onset
Known bleeding diathesis
Arterial puncture at a non-compressible site, or lumbar
puncture, within the last 7 days
Major surgery within the last 14 days
Gastrointestinal or urinary tract haemorrhage within 21 days
Head injury, intracranial surgery or stroke within the last 3
months
Any history of intracranial haemorrhage, brain tumour,
intracranial AVM or aneurysm
TIME OF ONSET
Within 3h no upper age limit
3 to 4.5h can treat if 18-80y, patients over 80y do not benefit
4.5 to 6h patients 18-80 may benefit needs decision by thrombolysing doctor

ANTICOAGULANTS
Current warfarin treatment is not exclusion if the INR is 1.7 or less.

Current heparin treatment is not an exclusion if the APTT ratio is less than 1.2
Full dose (but not low dose/prophylactic) LMWH is an exclusion
Rivaroxaban/Dabigatran if a patient is on these treatments, 24h or 12h respectively
should elapse before a parenteral anticoagulant is given. This excludes these patients
from thrombolysis for stroke.

PREGNANCY
Pregnancy or women who are post-partum r-tPa is unlicensed for use in pregnancy.
It should not be withheld in pregnant patients with ischaemic stroke, but because
experience is limited, risks and benefits must be carefully weighed and should be
discussed with on-call obstetrician

CHEMOTHERAPY
Some chemotherapy agents may be relative contra-indications to thrombolysis. Or
patients may be cytopaenic. If patient on chemotherapy drugs please ensure bloods
normal first and check with oncology or haematology before giving lysis

CHILDREN
Alteplase is not licensed for <18y. Studies are ongoing in children. Cases should be
discussed by paediatric team with paediatric neurologists at Bristol.

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ON INITIAL ASSESSMENT YES NO

Coma (GCS <8; NIH-SS question 1a = 3)


Minor stroke symptoms Sensory symptoms only
Dysarthria only
Ataxia only
Minimal weakness not
registering on NIHSS
Partial visual field defect
only
Rapidly improving symptoms or signs
Clinical presentation suggestive of subarachnoid
haemorrhage (even if subsequent CT normal)
DBP>140
or BP>180/105 having received more than 2 doses
labetolol (see management of hypertension page 7)
Capillary glucose <2.7 (Treat as per Trust protocol)

YES NO
ON LAB RESULTS
Platelets <100 (only wait for FBC if known haematological
disorder or on chemo)
Current warfarin treatment with INR MORE THAN 1.7
Do not start treatment until INR available
Current heparin treatment and APTT > 1.2
Do not start treatment until APTT available
Current treatment with full dose LMWH
Plasma glucose <2.7 (Treat as per Trust protocol)
ON CT SCAN reported by radiologist

Radiological signs of intracranial haemorrhage


Diffuse swelling of a cerebral hemisphere
ASPECTS score 7 or less is a relative contra-indication; in this instance
consider carefully other factors that may influence the decision to treat or not
to treat

CONFIRM PATIENT ELIGIBLE FOR THROMBOLYSIS YES NO

VERBAL CONSENT? YES NO

SIGNATURE

NAME DATE TIME

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MANAGEMENT OF HYPERTENSION IN POTENTIAL THROMBOLYSIS PATIENTS

Record BP in both arms using Manual cuff


Use arm with highest BP reading thereafter
Repeat after 15 minutes if hypertensive

Blood Pressure < 180 Monitor BP, do not intervene, Thrombolyse if eligible
Systolic <105 Diastolic

Systolic > 220 mmHg


And / Or
Diastolic 121-140 mmHg *Give IV Labetalol 10 mg iv over 1-2 minutes
Repeat same or double dose to bring BP down to 180/105
Or Labetalol Infusion 2-8mg/min

Systolic >180
And/or *Give IV Labetalol 10 mg iv over 1-2 minutes
Diastolic >105 mmHg Repeat same or double dose to bring BP down to 180/105
Or Labetalol Infusion 2-8mg/min

If Diastolic above 140 patient NOT eligible for Thrombolysis


mmHg

*If more than 2 doses of labetolol needed Patient NOT eligible for Thrombolysis
In asthma, cardiac failure or 1st Degree heart block use Isoket infusion (2-10mmHg /hr)

Monitoring of BP after Thrombolysis


Blood Pressure after Thrombolysis should be measured
Every 15 minutes for 2 hours
Every 30 minutes for 6 hours
Hourly for 18 hours
During Thrombolysis and afterwards BP should be managed to below 180/105 using the
above instructions If Blood pressure rises sharply during or after Thrombolysis suspect
Intracranial haemorrhage.

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RtPA DOSE READY RECKONER

Alteplase, Recombinant tissue plasminogen activator


(Actilyse Boehringer Ingelheim)

Unless the patient or companion knows their recent weight, estimate it to the
nearest 5 kg
The total dose of rt-PA is 0.9 mg/kg or 90 mg, whichever is the lesser (Column 3)
Make up one or two vials of rt-PA using the 50 ml diluent in each drug pack, making
a solution of 1 mg/ml rt-PA
Draw up and give 10% as a bolus over 1-2 minutes (Column 4), using a 10 ml
syringe
Draw up the remaining 90% (the infusion dose, Column 5) into 1 or 2 50ml
syringes and set up the 50ml syringe driver (IVAC) with the corresponding infusion
rate in mls/hr. This infusion is given over 1h.
Do not give the cardiac dose
Do not give more than 90 mg

1 2 3 4 5

Bolus dose Infusion


Estimate of Equivalent Total dose
(mls) dose (mls) =
patients Imperial (mg at 1
given over 1-2 infusion rate
weight (kg) weight mg/ml)
minutes in mls/hr

45 7 st 1 lb 4 36 40
One
50 7 st 12 lb 5 40 45
vial
55 8 st 9 lb 5 44 49
60 9 st 6 lb 5 49 54
65 10 st 3 lb 6 52 58
70 11 st 0 lb 6 57 63
75 11 st 11 lb 7 60 67
Two 80 12 st 8 lb 7 65 72
vials
85 13 st 5 lb 7 69 76
90 14 st 2 lb 8 73 81
95 14 st 13 lb 8 77 85
100 15 st 10 lb 9 81 90

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Information for patients / relatives before giving thrombolysis

Thrombolysis with r-tPA is a licensed treatment for acute ischaemic stroke, so written
consent is not required. If possible there should be agreement from the patient and / or
relative.
When the patient cannot agree because of their impairments and no relative is available,
then treatment can still be given if it is judged to be in the best interests of the patient. Any
explanation might include:

There has been a significant stroke caused by a blocked artery preventing blood
from getting to a part of the brain and causing permanent damage. With or without
treatment there may be some recovery or things could get worse. Stroke is fatal in
about a third of people.
Only one treatment has been shown to prevent damage to the brain. This treatment
dissolves the blood clot blocking the artery and allows blood to get back to the brain.
It only works if given quickly after the stroke starting and the benefit is greater the
sooner it is given
There is a slight increased risk of death within the first week (8.9 vs 6.4%), mostly
due to fatal intracranial bleeding (3.6 vs 0.6%). But after the first week there is a
lower chance of death (11.5 vs 13.6%), so several months later there is no
difference in chance of death overall.
The chances of being alive and independent (Rankin score 0-2) several months later
are higher,
% chance of % chance of Absolute benefit
being alive and being alive and number of extra
independent at 3 independent at patients alive and
months if lysed 3 months if not independent at 3
lysed months per 1000
patients treated
if treated within 3h 40.7% 31.7% 90

If treated 3-6h 47.5% 45.7% 18

if treated within 6h 46.3% 42.1% 42

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MANAGEMENT OF COMPLICATIONS AFTER THROMBOLYSIS

BP commonly drops after initiation of thrombolysis, not necessarily due to bleeding. If this
happens give iv fluid bolus.
Bleeding, by process of de-fibrination, is more common than with heparin (around 3%)

Intracranial bleeding
Should be suspected if there is neurological deterioration, new headache, fall in conscious
level, acute hypertension, seizure, nausea or vomiting

Initial action
Stop infusion of r-tPA, repeat NIHSS, commence iv saline if needed
Arrange urgent CT scan
Check FBC, full coagulation screen, check blood sent for G&S

If CT scan shows bleeding


Is haemorrhage petechial? If so it is unlikely anything other than stopping r-tPA will be
needed. Continue to observe patient closely

Is haemorrhage parenchymal?
Give 20% mannitol 200ml stat (dose may be repeated)
Consider tranexamic acid 10 mg/kg IV and 10 units cryoprecipitate

Further advice is available via the intranet anti-coagulation guidelines and Consultant
Haematologist

Consult neurosurgeon regarding possible transfer for haematoma evacuation

If CT scan shows no bleeding


Recheck patient for other causes of deterioration eg recurrent ischaemic stroke, sepsis,
seizure, metabolic derangement, extracranial bleeding

Extracranial bleeding
Should be suspected if there is shock, drop in BP, evidence of blood loss although a
high index of suspicion is needed as blood loss may not be obvious.

Initial action
Stop infusion of r-tPA
Check FBC, full coagulation screen, check blood sent for G&S and/or arrange cross match
depending on situation
Commence iv saline or blood transfusion depending on situation
If patient fails to respond to simple measures or there is severe haemorrhage, consider
tranexamic acid 10 mg/kg IV and 10 units cryoprecipitate
Further advice is available from intranet, on call geriatrician and haematologist as above.

Anaphylaxis
Anaphylactic reactions to r-tPA can occur but are rare. If an urticarial rash, peri-orbital
swelling or tongue swelling occur, the r-tPA should be stopped and the patient reviewed by
a doctor urgently.

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NIH STROKE SCALE full version and master copy please record patient scores on quick version
(see page 23)

INSTRUCTION SCALE DEFINITION SCORE SCORE


1 2
1a. Level of Consciousness: 0 = Alert; keenly responsive.
The investigator must choose a response, 1 = Not alert, but rousable by minor
even if a full evaluation is prevented by stimulation to obey, answer, or respond.
such obstacles as an endotracheal tube, 2 = Not alert, requires repeated
language barrier, orotracheal trauma/ stimulation to attend, or is obtunded and ----------- -----------
bandages. A 3 is scored only if the patient requires strong or painful stimulation to
makes no movement (other than reflexive make movements (not stereotyped).
posturing) in response to noxious 3 = Coma; Responds only with reflex
stimulation. motor or autonomic effects, or totally
unresponsive, flaccid, areflexic.
1b. LOC Questions: 0 = Answers both questions correctly.
The patient is asked the month and his/her 1 = Answers one question correctly.
age. The answer must be correct - there is 2 = Answers neither question correctly.
no partial credit for being close. Aphasic
and stuporous patients who do not ----------- -----------
comprehend the questions will score 2.
Patients unable to speak because of
endotracheal intubation, orotracheal
trauma, severe dysarthria from any cause,
language barrier or any other problem not
secondary to aphasia are scored 1. It is
important that only the initial answer be
graded and that the examiner not help the
patient with verbal or non-verbal cues.
1c. LOC Commands: 0 = Performs both tasks correctly.
The patient is asked to open and close the 1 = Performs one task correctly.
eyes and then to grip and release the 2 = Performs neither task correctly.
nonparetic hand. Substitute another one
step command if the hands cannot be used. ----------- -----------
Credit is given if an unequivocal attempt is
made but not completed due to weakness.
If the patient does not respond to
command, the task should be demonstrated
to them (pantomime) and score the result
(i.e., follows none, one, or two commands).
Patients with trauma, amputation, or other
physical impediments should be given
suitable one-step commands. Only the first
attempt is scored.
2. Best Gaze: 0 = Normal
Only horizontal eye movements will be 1 = Partial gaze palsy. This score is
tested. Voluntary or reflexive given when gaze is abnormal in one or
(oculocephalic) eye movements will be both eyes, but where forced deviation or
scored but caloric testing is not done. If the total gaze paresis are not present. ----------- -----------
patient has a conjugate deviation of the 2 = Forced deviation, or total gaze
eyes that can be overcome by voluntary or paresis not overcome by the
reflexive activity, the score will be 1. If a oculocephalic manoeuvre
patient has an isolated peripheral nerve
paresis (CN III, IV, OR VI) score a 1. Gaze
is testable in all aphasic patients. Patients
with ocular trauma, bandages, preexisting
blindness or other disorder of visual acuity
or fields should be tested with reflexive
movements and a choice made by the

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investigator. Establishing eye contact and
then moving about the patient from side to
side will occasionally clarify the presence of
a gaze palsy.

3. Visual: 0 = No visual loss.


Visual fields (upper and lower quadrants) 1 = Partial hemianopia.
are tested by confrontation, using finger 2 = Complete hemianopia.
counting or visual threat as appropriate. 3 = Bilateral hemianopia (blind including
Patient must be encouraged, but if they cortical blindness). ----------- -----------
look at the side of the moving fingers
appropriately, this can be scored as normal.
If there is unilateral blindness or
enucleation, visual fields in the remaining
eye are scored. Score 1 only if a clear-cut
asymmetry, including quadrantanopia is
found. If patient is blind from any cause
score 3. Double simultaneous stimulation
is performed at this point. If there is
extinction patient receives a 1 and the
results are used to answer question 11.
4. Facial Palsy: 0 = Normal symmetrical movement.
Ask, or use pantomime to encourage the 1 = Minor paralysis (flattened nasolabial
patient to show teeth or raise eyebrows or fold, asymmetry on smiling).
close eyes. Score symmetry of grimace in 2 = Partial paralysis (total or near total
response to noxious stimuli in the poorly paralysis of lower face). ----------- -----------
responsive or non-comprehending patient. 3 = Complete paralysis (absence of facial
If facial trauma/bandages, orotracheal tube, movement in the upper and lower face).
tape, or other physical barrier obscures the
face, these should be removed to the extent
possible.
5&6. Motor Arm and Leg: Arm
The limb is placed in the appropriate 0 = No drift, arm holds 90 (or 45) degrees
position: extend the arms 90 degrees (if for full 10 seconds.
sitting) or 45 degrees (if supine) and the leg 1 = Drift, arm holds 90 (45) degrees, but
30 degrees (always tested supine). Drift is drifts down before full 10 seconds; does
scored if the arm falls before 10 seconds or not hit bed or other support.
the leg before 5 seconds. The aphasic 2 = Some effort against gravity, limb
patient is encouraged using urgency in the cannot get to or maintain (if cued) 90 (or
voice and pantomime but not noxious 45) degrees, drifts down to bed, but has
stimulation. Each limb is tested in turn, some effort against gravity.
beginning with the nonparetic arm. Only in 3 = No effort against gravity, arm falls.
the case of amputation or joint fusion at the 4 = No movement.
shoulder or hip may the score be 9 and 9 = Amputation, joint fusion -explain:
the examiner must clearly write the
explanation for scoring as a 9. 5a = Right Arm ----------- -----------

5b = Left Arm ----------- -----------


Leg
0 = No drift, leg holds 30 degrees position
for full 5 seconds.
1 = Drift, leg falls by the end of the 5
second period but does not hit bed.
2 = Some effort against gravity, leg falls
to bed by 5 seconds, but has some effort
against gravity.
3 = No effort against gravity, leg falls to
bed
immediately.
4 = No movement.
9 = Amputation, joint fusion -explain:
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----------- -----------
6a = Right Leg
----------- -----------
6b = Left Leg

7. Limb Ataxia: 0 = Absent.


This item is aimed at finding evidence of a 1 = Present in one limb.
unilateral cerebellar lesion. Test with eyes 2 = Present in two limbs.
open. In case of visual defect, ensure
testing is done in intact visual field. The
finger-nose-finger and heel-shin tests are
performed on both sides, and ataxia is
scored only if present out of proportion to
weakness. Ataxia is absent in the patient
who cannot understand or is hemiplegic.
Only in the case of amputation or joint
fusion may the item be scored 9, and the
examiner must clearly write the explanation
for not scoring. In case of blindness, test
by touching nose from extended arm
position.
8. Sensory: 0 = Normal; no sensory loss.
Sensation or grimace to pinprick when 1 = Mild to moderate sensory loss; patient
tested, or withdrawal from noxious stimulus feels pinprick is less sharp or is dull on
in the obtunded or aphasic patient. Only the affected side; or there is a loss of
sensory loss attributed to stroke is scored superficial pain with pinprick but patient is ----------- -----------
as abnormal and the examiner should test aware he/she is being touched.
as many body areas [arms (not hands), 2 = Severe to total sensory loss; patient is
legs, trunk, face] as needed to accurately not aware of being touched.
check for hemisensory loss. A score of 2,
severe or total, should only be given when
a severe or total loss of sensation can be
clearly demonstrated. Stuporous and
aphasic patients will therefore probably
score 1 or 0. The patient with brainstem
stroke who has bilateral loss of sensation is
scored 2. If the patient does not respond
and is quadriplegic, score 2. Patients in
coma (item 1a=3) are arbitrarily given a 2
on this item.

9. Best Language: 0 = No aphasia, normal.


A great deal of information about 1 = Mild to moderate aphasia; some
comprehension will be obtained during the obvious loss of fluency or facility of
preceding sections of the examination. The comprehension, without significant
patient is asked to describe what is limitation on ideas expressed or form of ----------- -----------
happening in the attached picture, to name expression. Reduction of speech and/or
the items on the attached list of sentences. comprehension, however, makes
Comprehension is judged from responses conversation about provided material
here as well as to all of the commands in difficult or impossible. For example, in
the preceding general neurological exam. If conversation about provided materials
visual loss interferes with the tests, ask the examiner can identify picture or naming
patient to identify objects placed in the card from patients response.
hand, repeat, and produce speech. The 2 = Severe aphasia; all communication is
intubated patient should be asked to write. through fragmentary expression; great
The patient in coma (question 1a = 3) will need for inference, questioning, and
arbitrarily score 3 on this item. The guessing by the listener. Range of
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examiner must choose a score in the information that can be exchanged is
patient with stupor or limited cooperation limited; listener carries burden of
but a score of 3 should be used only if the communication. Examiner cannot identify
patient is mute and follows no one step materials provided from patient response.
commands. 3 = Mute, global aphasia; no usable
speech or auditory comprehension.

10. Dysarthria: 0 = Normal.


If the patient is thought to be normal, an 1 = Mild to moderate; patient slurs at least
adequate sample of speech must be some words and, at worst, can be
obtained by asking patient to read or repeat understood with some difficulty.
words from the attached list. If the patient 2 = Severe; patients speech is so slurred ----------- -----------
has severe aphasia, the clarity of as to be unintelligible in the absence of or
articulation of spontaneous speech can be out of proportion to any dysphasia, or is
rated. Only if the patient is intubated or has mute/anarthric.
other physical barrier to producing speech 9 = Intubated or other physical barrier -
may the item be scored 9", and the explain:
examiner must clearly write an explanation
for not scoring. Do not tell the patient why
he/she is being tested.
11. Extinction and Inattention 0 = No abnormality.
(formerly Neglect) 1 = Visual, tactile, auditory, spatial, or
Sufficient information to identify neglect personal inattention or extinction to
may be obtained during the prior testing. If bilateral
the patient has severe visual loss simultaneous stimulation in one of the ----------- -----------
preventing visual double simultaneous sensory modalities.
stimulation, and the cutaneous stimuli are 2 = Profound hemi-inattention or hemi-
normal, the score is normal. If the patient inattention to more than one modality.
has aphasia but does appear to attend to Does not recognize own hand or orients
both sides, the score is normal. The to only one side of space.
presence of visual spatial neglect or
anosagnosia may also be taken as
evidence of neglect. Since neglect is
scored only if present, the item is never
untestable.
Total Total
Max Max
score 42 score 42

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ASPECTS score

This is a topographic score for dividing middle cerebral artery territory into 10 regions. It is
calculated from 2 standard axial CT cuts, one at the level of the basal ganglia and one at
the corona radiate / centrum semiovale level. Subcortical structures are allotted 3 points
and cortical structures 7 points.
For each of these 10 areas a point is subtracted if there is evidence of ischemic damage
there (eg reduced attenuation, loss of grey-white matter differentiation, focal swelling).
A scan with no ischaemia in the MCA territory would score 10 and a scan with diffuse
involvement of all MCA territory would score 0.
An ASPECTS score 7 or less is a relative contra-indication to thrombolysis, with increased
risk of haemorrhage; in this instance consider carefully other factors that may influence the
decision to treat or not to treat

M1 = anterior MCA cortex, M2 = MCA cortex lateral to insular ribbon


M3 = posterior MCA cortex, M4, M5, M6 are anterior, lateral and posterior MCA territories
immediately superior to M1, M2, M3
C = caudate, L = lentiform, IC = internal capsule, I = insular ribbon

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Nursing Protocol
Nursing Care Following Thrombolysis for Stroke
1. Patient to be nursed in identified bed space that allows for continuous observation.

2. Oxygen, Suction, Cardiac Monitor, Sphygmomanometer, O2 Saturation machine should be


available at the bed side. Capillary blood glucose machine, Anaphylaxis box should be
easily accessible.

3. Initiate post administration thrombolysis care plan on arrival

4. Perform patient observations as indicated and record a baseline ECG

5. If there are any concerns, medical review is essential. Report, review, document and
increase frequency of observations accordingly.

6. Pyrexia > 37C should be treated with PR or PO Paracetamol (1g 4-6 hourly. No more
than 4g in 24 hours)

7. If haemorrhage is suspected, report immediately and arrange for urgent medical


review. Send urgent FBC, clotting and group and save

8. If anaphylaxis is suspected (Tachypnoea, dyspnoea, tachycardia, swelling, rash) Stop


infusion and employ anaphylaxis protocol. Arrange for urgent medical review or
perform a crash call (2222)if required

9. Avoid catheterisation for 24 hours following thrombolysis infusion to minimise the risk of
trauma and bleeding. If essential, consult with medical team.

10. Do not insert naso gastric tubes for 24 hours post thrombolysis infusion to minimise the
risk of trauma and bleeding

11. IM injections should be avoided for 48 hours post thrombolysis infusion to minimise the
risk of excessive bruising

12. Avoid giving heparin / warfarin. Refer to medical staff before commencing any anti
coagulant or antiplatelet therapy (only given if CT at 24h shows no bleeding).

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Observations following administration of
thrombolysis for stroke

Manual BP, Pulse, Temperature, Respirations,


GCS and Oxygen Saturations (MEWS Score Refer to local
Guidelines)

Every 15 minutes for 2 hours

Every 30 minutes for 6 hours

Hourly for 18 hours

Maintain BP < Systolic 180 / Diastolic 105

Temperature not to exceed 37C.

Observe for signs of raised intracranial pressure or intracranial


bleeding
Unequal pupils
Sudden drop in GCS
Onset of drowsiness
Onset of nausea, vomiting (photophobia)
Rising BP and falling pulse

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Short NIHSS scoring sheet
This is master copy patient packs
include this sheet which should be filed
in medical notes with completed
inclusion/exclusion checklist

National Institute for Health Stroke Scale (NIHSS)

REFER TO LAMINATED FULL GUIDANCE FOR SCORING

Score Score Score Score

Date and Time

1a. LOC
Score 0-3
1b. LOC Response to Questions
Score 0-2
1c. LOC Response to Commands
Score 0-2
2. Best gaze
Score 0-2
3. Visual fields
Score 0-3
4. Facial palsy
Score 0-3
5. Right Arm motor
Score 0-4 or X if untestable
6. Left Arm motor
Score 0-4 or X if untestable
7. Right Leg motor
Score 0-4 or X if untestable
8. Left leg motor
Score 0-4 or X if untestable
9. Ataxia
Score 0-2 or X if untestable
10. Sensory
Score 0-2
11. Best language
Score 0-3
12. Dysarthria
Score 0-2 or X if untestable
13. Neglect/Inattention
Score 0-2
Total Score (0-42)

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Consensus statement on mechanical thrombectomy in acute ischemic stroke
ESO-Karolinska Stroke Update 2014 in collaboration with ESMINT and ESNR.

Treatment recommendations

Mechanical thrombectomy, in addition to intravenous thrombolysis within 4.5 hours


when eligible, is recommended to treat acute stroke patients with large artery
occlusions in the anterior circulation up to 6 hours after symptom onset (Grade A, Level
1a, KSU Grade A). - new

Mechanical thrombectomy should not prevent the initiation of intravenous thrombolysis


where this is indicated, and intravenous thrombolysis should not delay mechanical
thrombectomy (Grade A, Level 1a, KSU Grade A). - changed

Mechanical thrombectomy should be performed as soon as possible after its indication


(Grade A, Level 1a, KSU Grade A).

For mechanical thrombectomy, stent retrievers approved by local health authorities


should be considered (Grade A, Level 1a, KSU Grade A). - new

Other thrombectomy or aspiration devices approved by local health authorities may be


used upon the neurointerventionists discretion if rapid, complete and safe
revascularisation of the target vessel can be achieved (Grade C, Level 2a, KSU Grade
C) - new

If intravenous thrombolysis is contraindicated (e.g. Warfarin-treated with therapeutic


INR) mechanical thrombectomy is recommended as first-line treatment in large vessel
occlusions (Grade A, Level 1a, KSU Grade A) changed and updated level of
evidence.

Patients with acute basilar artery occlusion should be evaluated in centres with
multimodal imaging and treated with mechanical thrombectomy in addition to
intravenous thrombolysis when indicated (Grade B, Level 2a, KSU Grade C);
alternatively they may be treated within a randomized controlled trial for thrombectomy
approved by the local ethical committee - new

The decision to undertake mechanical thrombectomy should be made jointly by a


multidisciplinary team comprising at least a stroke physician and a
neurointerventionalist and performed in experienced centres providing comprehensive

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stroke care and expertise in neuroanesthesiology (Grade C, Level 5, GCP, KSU Grade
C).

Mechanical thrombectomy should be performed by a trained and experienced


neurointerventionalist who meets national and/or international requirements (Grade B,
Level 2b, KSU Grade B) changed in level of evidence.

The choice of anesthesia depends on the individual situation; independently of the


method chosen, all efforts should be made to avoid thrombectomy delays (Grade C,
Level 2b, KSU Grade C) changed.

Patient selection

Intracranial vessel occlusion must be diagnosed with non-invasive imaging whenever


possible before considering treatment with mechanical thrombectomy (Grade A, Level
1a, KSU Grade A) - new.

If vessel imaging is not available at baseline, a NIHSS score of 9 within three, and
7 points within six hours may indicate the presence of large vessel occlusion (Grade B,
Level 2a, KSU Grade B) - new.

Patients with radiological signs of large infarcts (for ex. using the ASPECTS score) may
be unsuitable for thrombectomy (Grade B, Level 2a, KSU Grade B) - new

Imaging techniques for determining infarct and penumbra sizes can be used for patient
selection and correlate with functional outcome after mechanical thrombectomy (Grade
B, Level 1b, KSU Grade B) - new.

High age alone is not a reason to withhold mechanical thrombectomy as an adjunctive


treatment (Grade A, Level 1a, KSU Grade A) new

References

1. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke


2. NEJM 2008; 359: 3517-29

3. The benefits and harms of intravenous thrombolysis with recombinant tissue


plasminogen activator within 6 h of acute ischaemic stroke (the third international
stroke trial [IST-3]): a randomised controlled trial
4. Lancet 2012 ;379 :2352-63

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5. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated
systematic review and meta-analysis
6. Lancet 2012; 379: 2364-72

7. NICE Guidance TA 122 - Alteplase for the treatment of acute ischaemic stroke

8. National Stroke Strategy, Department of Health 2007

9. Validity and reliability of a quantitative computed tomography score in predicting


outcome of hyperacute stroke before thrombolytic therapy
10. Lancet 2000; 355:1670-1674

11. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for Assessing CT
Scans in Patients with Acute Stroke
12. Am J Neuroradiol 2001; 22:153442

13. Importance of Early Ischemic Computed Tomography Changes Using ASPECTS in


NINDS rtPA Stroke Study Stroke 2005; 36:2110-15

14. Berkhemer OA et al. Mr CLEAN Investigators. A randomized trial of intraarterial


treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11

15. Goyal M et al, ESCAPE Trial Investigators. Randomized assessment of rapid


endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019.

16. Saver JL et al. SWIFT PRIME Investigators. Stent-retriever thrombectomy after


intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285

17. Campbell BC et al. Endovascular therapy for ischemic stroke with perfusion-
imaging selection. EXTEND-IA Investigators. N Engl J Med. 2015;372(11):1009.

Stroke Thrombolysis Guideline Extended Age and Treatment Window


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3. Monitoring compliance and effectiveness
Element to be Outcome of thrombolysis for individual patients
monitored
Lead Dr Katja Adie

Tool Sentinel Stroke National Audit Programme (SSNAP) from the Royal
College of Physicians

Frequency Each thrombolysed patients details and outcomes are entered on


to SSNAP

Reporting Dr Adie reports outcome locally to the eldercare governance and


arrangements Emergency Department meeting monthly
SSNAP data is collected as part of the Trust Clinical Audit &
Outcomes Programme on an ongoing basis
SSNAP data is reported and published nationally and monitored by
the Clinical Commissioning Group
Acting on Dr Adie, Dr Harrington
recommendations
and Lead(s)
Change in Required changes to practice will be identified and actioned within
practice and six months. Dr Adie and Dr Harrington as lead members of the
lessons to be team will take each change forward where appropriate.
shared

4. Equality and Diversity


4.1 This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement.

4.2 Equality Impact Assessment


The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information
Stroke Thrombolysis Guideline (Emergency
Document Title
Department run service)
Date Issued/Approved: 1 Sep 13

Date Valid From: 1 Sep 13

Date Valid To: 1 Sep 15

Directorate / Department responsible Dr Frances Harrington, Consultant


(author/owner): Physician, Eldercare RCHT

Contact details: 01872 253290

Guideline for the administration of


Brief summary of contents thrombolysis for acute ischaemic stroke
service taken over by ED
Suggested Keywords: Stroke, Thrombolysis, Alteplase
RCHT PCH CFT KCCG
Target Audience

Executive Director responsible for
Medical Director
Policy:
Date revised: 02/10/15
Clinical guideline to deliver safe and
This document replaces (exact title of effective thrombolysis for acute ischaemic
previous version): stroke using robust evidence based clinical
criteria
Approval route (names of Acute Stroke Group, Radiologists,
committees)/consultation: SWAST
Divisional Manager confirming
Mr A Virr
approval processes
Name and Post Title of additional
Not Required
signatories
Signature of Executive Director giving
{Original Copy Signed}
approval
Publication Location (refer to Policy
on Policies Approvals and Internet & Intranet Intranet Only
Ratification):
Document Library Folder/Sub Folder Clinical / Neurology and Stroke
Links to key external standards NICE Guidance TA122 - Alteplase for the
treatment of acute ischaemic stroke
Advanced Stroke Management Pathway
Acute Stroke Management
Related Documents:
Stroke and TIA Multidisciplinary Care
Pathway
Stroke Thrombolysis Guideline Extended Age and Treatment Window
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Secondary Prevention after Stroke or TIA
Yes. Learning and Development
Training Need Identified?
department have been informed.

Version Control Table

Version Changes Made by


Date Summary of Changes
No (Name and Job Title)
Initial Issue
July 2008 V1.0 Dr F Harrington

December
V2.0 Amendment to 24/7 service Dr F Harrington
2010

3/9/12 V3.0 Extended age and treatment window Dr F Harrington

Change of service provision from Eldercare to


21/1/14 V4.0 Dr F Harrington
Emergency Department team

Dr F Harrington
2/10/2015 V5.0 Availability of intraarterial treatment Dr K Adie
A James

All or part of this document can be released under the Freedom of Information
Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.

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Appendix 2. Initial Equality Impact Assessment Form
Name of service, strategy, policy or project (hereafter referred to as policy) to be
assessed: Stroke Thrombolysis Guideline Extended Age and Treatment Window
Directorate and service area: Is this a new or existing Procedure? existing
Name of individual completing Telephone: 01872 253290
assessment: Dr F Harrington
1. Policy Aim* To safely administer thrombolytic agent to acute ischaemic
stroke patients using updated, clearly defined criteria
2. Policy Objectives* Safe administration of emergency drug therapy
Clear advice and guidance for staff involved in the
administration of emergency treatment and aftercare of
patients who have undergone thrombolysis for stroke
3. Policy intended As above
Outcomes*
4. How will you measure Patient response to treatment
the outcome? Audit ongoing local and RCP National Sentinel Stroke
Audit
Inclusion in international SITS-MOST register (Safe
implementation of thrombolysis in stroke)
5. Who is intended to Patients: through the promotion of safe, effective, evidence
benefit from the Policy? based practice
6a. Is consultation Yes
required with the
workforce, equality
groups, local interest
groups etc. around this
policy?

b. If yes, have these Yes


groups been consulted?

c. Please list any groups


who have been consulted Acute Stroke Group, SERCO, SWAST
about this procedure.

7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Rationale for Assessment / Existing Evidence
Age Removal of upper age limit for stroke thrombolysis based
on recent randomised controlled trials
Sex (male, female, trans-
gender / gender
reassignment)

Race / Ethnic
communities /groups

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Disability -
Learning disability, physical
disability, sensory impairment
and mental health problems
Religion /
other beliefs
Marriage and civil
partnership
Pregnancy and maternity

Sexual Orientation,
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
You have ticked Yes in any column above and
No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
Major service redesign or development
8. Please indicate if a full equality analysis is recommended. Yes No

9. If you are not recommending a Full Impact assessment please explain why.

Signature of policy developer / lead manager / director Date of completion and submission

Names and signatures of 1.


members carrying out the 2.
Screening Assessment

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD

A summary of the results will be published on the Trusts web site.

Signed _______________

Date ________________

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