This study analyzed outcomes of emergency department-based thrombolysis for stroke performed at Scarborough Acute Trust in the UK between 2004-2009. 110 patients received thrombolysis for acute ischemic stroke. 79 patients treated through the emergency department had an average treatment time of 2.7 hours and 6-month mortality of 15%. 19 patients treated from hospital wards had a treatment time of 3.4 hours and 12% mortality. Outcomes were similar to other European cohorts. The study concluded that thrombolysis for acute ischemic stroke is achievable and safe in district general hospital settings.

1. JOURNAL PRESENTATION FROM :
BRITISH MEDICAL JOURNAL.
By A P Volans, Emergency Department,
Scarborough Acute Trust. U.K.
Published in June 2011.

2. AN ANALYSIS OF OUTCOMES OF
EMERGENCY PHYSICIAN/DEPARTMENT
– BASED THROMBOLYSIS FOR STROKE

4. INTRODUCTION
• For many years, stroke was a condition that was
primarily diagnosed by emergency physicians, but
only few effective interventions were available in
the emergency department to reduce the burden of
the disease.
• Intravenous thrombolysis has been recommended
for the treatment of ischaemic stroke with in 3 to 4
½ hours of onset of symptoms.

5. • There is a difficulty in delivery of effective
thrombolysis across the system.
• There is a need for timely intervention in
stroke and to develop services for stroke
patients across the country.

6. AIM OF THE STUDY
• To describe the services and the outcomes of
thrombolysis in stroke in District hospital
setting.
• To study the outcome and complications in the
treated cohort.

7. METHOD AND METHODOLOGY
• Study done at Scarborough Acute Trust- a 320
bedded DGH.
• The emergency department has 42,000
patients and 25,000 minor cases are seen at
periphery minor injury units.

8. • It is equipped with CCU and CT scanning is
available 24hrs a day.
• Scarborough had introduced stroke
thrombolysis in 2004.
• Initially it was done under the auspices of the
Safe Implementation of Thrombolysis in Stroke
– Monitoring Study (SITS-MOST).

9. • Patients presenting to emergency department at
Scarborough were entered into SITS-MOST
registry, and the national and the international
comparisons were made.
• This database collects demographic, physiological,
clinical and radiological data at presentation and
records initial stroke severity using NIH Stroke
Scale(NIHSS) score and determines outcome at 7
days using a Global Score and at three months
using Rankin Scale.

10. • For presentation of the local results of stroke
outcome, patients were categorized at
discharge into:
• 1. Good responders- improvement in multiple
areas of neurological loss.
• 2. Partial responders- improvement one area.
• 3. Poor responders- no improvement.

11. • Complications related to treatment (significant
intra-cerebral bleeding) – obtained from
patient notes.
• Mortality was determined at 6 months after
presentation.

12. Scarborough thrombolysis model

13. RESULTS
• Between 2004-09 Jan, Scarborough treated 110
cases of stroke with thrombolysis and data of 98
patients was available.
• Age of the patients ranged between 39-91 yrs.
• 79 patients were treated through ED-pathway, with
average time of treatment of 2.7hrs and cohort
6months mortality of 15%.
• 19 cases from wards, admitted for other diagnoses
including TIA, were treated with treatment of
3.4hrs and a cohort mortality of 12%.

14. • Early deaths occurred in 7patients, all in non
responsive group.
• 5 patients died on day 1, CT of 4 showed massive
cerebral oedema. 5th died before a repeat CT, and
could be due post-thrombolysis intra-cerebral
haemorrhge .
• 5th oedema death was 5 days after stoke onset.
• Late deaths were associated with failure to
rehabilitate and had complications of stroke
recorded.

16. DISCUSSION
• Thrombolysis in stroke could be provided
outside hyper acute stroke centers.
• The outcomes of thrombolysis are similar to
European based cohort.
• The use of objective coding systems like NIHSS
and availability of neurologists and stroke care
has made the decision of thrombolysis in
difficult cases much easier.
• Support of radiology is essential.

19. CONCLUSION
• Thrombolysis for acute ischaemic stroke is
achievable and safe within DGH settings.
• A DGH based thrombolysis service could
potentially offer thrombolysis to 10% of
patients presenting with an acute stroke.
• Thrombolysis should be available at the place
where patients with acute ischaemic stroke
present.
• Outcomes can be compared with different
settings.

20. Related studies
• Emergency department – focused thrombolysis
for acute ischaemic stroke: done at Department
of Emergency Royal United Hospital, Combe
Park, Bath, UK.
• Conclusion of this study:
• It is possible to provide ED- focused service for
thrombolysis of acute ischaemic stoke with
initial management and thrombolysis decisions
made with in the ED.

21. Continued…
• An ED stroke thrombolysis protocol can be
relatively easily instituted with in large district
hospital provided there is support.
• It is possible that the results of ECASS3
supporting the extension of thrombolytic
therapy up to 4.5hrs after the onset of stroke
may change impact and may increase public
awareness.

22. Continued..
• An ED stroke thrombolysis protocol seem to be the
most efficient and effective means of delivering this
treatment.
• The impact of public information campaign has
been minimal. However there is likely to be an
increase in the numbers of patients presenting in
the acute potential thrombolysis window in the
near future.
• There also a need to develop a sustainable service
24X7.

23. Positive Results Number Percentage
No. of patients presenting with acute stroke
between June 2008-June 2009
298 100%
Eligible for thrombolysis 24 8%
Thrombolysed 16 5%
Treated by emergency physician and stroke
physician
8 50%
Treated by emergency physicians autonomously 8 50%

25. Indian studies
• Jeyaraj Durai Pandian
• Department of Neurology, Stroke Unit, Betty
Cowan Research and Innovation Centre,
Christian Medical College, Ludhiana - 141 008,
Punjab, India
• Re-canalization in acute ischemic stroke: The
strategies

26. • Re-canalization is an important predictor of stroke
outcome in all the modalities of thrombolysis.
• Thrombolysis in acute ischemic stroke evolved from
clinical trials with intravenous (IV) tissue plasminogen
activator (tPA) to combination treatments with Intra-
arterial (IA)/mechanical reperfusion techniques.
• The combined approach reduces time to initiation of
treatment and may increase re-canalization and chances
of a good clinical outcome.

27. • . In IV thrombolysis overall re-canalization rate
is 46.2% during the first 6-24 hrs.
• Intra-arterial thrombolysis has higher early re-
canalization rate, 63.2%.
• The highest re-canalization rate is seen with
mechanical thrombolysis, 83.6%.

29. Other related study
• From Neurology Update Mumbai 2012
• Off label thrombolytic therapy : when and why.
By Peter Schillenger
• Most common limitations of Iv-rtPa are :
• Time window from onset of symptoms and
presentation, patient age, stroke severity on
lower and the end, history of diabetes and prior
stroke, and blood pressure management.

31. The Modified Rankin Scale (mRS)
• The scale runs from 0-6, running from perfect health without symptoms to
death.
• 0 - No symptoms.
• 1 - No significant disability. Able to carry out all usual activities, despite
some symptoms.
• 2 - Slight disability. Able to look after own affairs without assistance, but
unable to carry out all previous activities.
• 3 - Moderate disability. Requires some help, but able to walk unassisted.
• 4 - Moderately severe disability. Unable to attend to own bodily needs
without assistance, and unable to walk unassisted.
• 5 - Severe disability. Requires constant nursing care and attention,
bedridden, incontinent.
• 6 - Dead.

35. THANK YOU