INITIAL EXPERIENCE WITH INTRAVENOUS THROMBOLYSIS (r-TPA)

Dr A. Hassan (Consultant Neurologist, Leeds Teaching Hospital NHS Trust)

Having been recently appointed as a consultant neurologist and stroke physician it was apt to be asked to make an assessment on thrombolysis in a stroke patient on my first day.  Intravenous alteplase (r-TPA) has been available in Europe since 2002 for acute stroke within 3 hours under strict licensing conditions. The terms of the license included a program of accreditation to administer treatment and participation in a post marketing surveillance study ‘Safe Implementation of Thrombolysis’ (SITS). The latter was designed to control the rate of symptomatic intracerebral haemorrhage to levels comparable with randomised trials. Results from the pivotal thrombolytic trials had indicated 1 fewer dead or dependent patient at follow up per 10 treated with r-TPA. Approximately 1 in 14 patients were seen to have symptomatic haemorrhage, but this was not associated with an excess mortality with treatment over placebo.

There is now a growing awareness amongst medical professionals and the public of stroke as a medical emergency and the availability of thrombolysis as an effective treatment. This in turn means that more patients are likely to attend hospital within the 3 hour therapeutic time window and be potentially eligible for treatment.

In preparation for this in Leeds, a thrombolysis pathway has been developed and will be implemented in the near future. It is envisaged that the service would operate during working hours and the workload shared by the stroke consultants at the LGI. In the mean time, treatment could still be offered to appropriate patients on a case by case basis.

In this initial patient, the signs of stroke were recognised very quickly by his work colleagues who brought the patient to the emergency dept within 50 minutes. The potential for thrombolysis was appreciated by the admitting doctors and the appropriate bloods and brain scan were organised within 30 minutes. The brain scan excluded an intracerebral haemorrhage, but demonstrated thrombus in the middle cerebral artery and early ischaemic changes in the right hemisphere. I was called down to the CT scanner room, where the films were reviewed and the patient assessed clinically and the NIH stroke severity scale completed. A major problem was that the patient was dysphasic and no immediate family members were available to provide medical details or discuss the risks and benefits of treatment. Luckily they were eventually contactable by phone. There was no contraindication to thrombolysis and the family were in agreeement with treatment administration. There was a  further short delay whilst the drug was located and 150 minutes after stroke onset thrombolysis was administered in the A+E department. Fortunately there were no complications of treatment although the TPA did not prevent major stroke from which the patient is recovering.

 
This initial experience has provided some valuable lessons about the practicalities of implementing thrombolysis in a rapid seamless manner within 3 hours, which have been fed back to various teams. However, it has also demonstrated that thrombolysis can be undertaken safely if strict protocols are followed. Hopefully this treatment can be made available to more stroke patients in Leeds in the future. 

Dr Ahamad Hassan
Consultant Neurologist/Stroke Physician
Leeds Teaching Hospital