Complications off-licence. Tom Webb Tharani T-Chandran

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1 Complications off-licence Tom Webb Tharani T-Chandran

2 History 82 yr old collapsed at a restaurant Slumped to the Rt side Vacant and mute No obvious loss of consciousness No stereotypical movements Incontinent of urine

3 History PMHx Hyperlipidaemia, IHD, HTN, AF DHx atorvastatin, ezetemibe, bisoprolol, ramipril, aspirin SHx Retired Managing Director Never smoked Alcohol 14 units/week Pre-stroke Rankin 0

4 Examination O/E BP-176/88 P-67 regular GCS 12/15 Emotionally labile Rt hemiparesis face/arm/leg Severe dysphasia HS ESM radiating to carotids Chest clear Abdo NAD NIHSS 22

5 Clinical diagnosis? Management?

6 CT Head

7 CT Head

8 CT Head Sylvian fissure dot sign Right putaminal lacunar infarct

9 Blood results Bloods: INR 1.0, Hb 12.8, WCC 5.7 Plts 219 U&E s Normal

10 Management? Clinical diagnosis? Possible treatment?

11 What treatment should be offered? 1 hour 15 minutes post onset 1) Intravenous thrombolysis

12 What treatment should be offered? 1 hour 15 minutes post onset 1) Intravenous thrombolysis 2) Intra-arterial thrombolysis

13 What treatment should be offered? 1 hour 15 minutes post onset 1) Intravenous thrombolysis 2) Intra-arterial thrombolysis 3) Aspirin, admission to stroke unit, best medical care

14

15 Management? Clinical diagnosis? Possible treatment? Contraindications?

16 Management? Clinical diagnosis? Possible treatment? Contraindications? Complications discussed?

17 Management Thrombolysed at 75 minutes

18 Management Thrombolysed at 75 minutes 45 minutes into infusion bleeding from his gums.

19

20 What would you do?

21 Management Tongue noted to be swollen on the Rt (paretic) side Swelling spreads to neck Stridor present and decreased saturation commenced oxygen

22 Management Treated iv hydrocortisone, and chlorpheniramine Anaesthetist and ENT Reg contacted BP elevated too 200/100 Commenced on iv GTN infusion BP improved to 160/90 Treated nebulised epinephrine Intubated and transferred to ITU

23 Outcome (radiological)

24 Outcome Several days on ITU Gradual reduction in swelling Extubated Transferred to ASU

25 Outcome 3 Speech improved Walking with assistance of 1 Pureed diet Home with CST

26 Discussion Should angio-oedema be mentioned as a complication when gaining consent? In everyone? In those on ACE inhibitors? Should epinephrine be part of management of angio-oedema? How best to manage BP post thrombolysis?

27

28 Mechanism of action of tpa Alteplase Recombinant Serine protease physiological thrombolytic agent Converts plasminogen to plasmin (fibrinolytic) Plasmin lyses clot by breaking down the fibrinogen and fibrin

29 Complications of Thrombolysis for stroke

30 Complications of Thrombolysis for stroke Haemorrhage (0.7-6%)

31 Complications of Thrombolysis for stroke Haemorrhage (0.7-6%) Anaphylaxis/ angio-oedema

32 Complications of Thrombolysis for stroke Haemorrhage (0.7-6%) Anaphylaxis/ angio-oedema Blood pressure changes(?)

33 Angio-oedema and anaphylaxis Angio-oedema = swelling of dermis, subcutaneous/ submucosal tissue due to vascular leakage Hereditary/ idopathic/ drug-induced Anaphyllactoid/ pseudoanaphyllactoid ACE inhibitors commonly associated

34 tpa and angio-oedema Not unique to stroke (?neurogenic role) 1-5% of patients Up to ~ 14% in those on ACEi? tpa plasmin complement and kinin activation mast cell activation histamine release ACEi inhibit kininases bradykinin

35 Rx of Angio-oedema due to tpa Empirical Antihistamines Corticosteroids (?epinephrine)

36 Use of tpa for stroke in elderly

37 Use of tpa for stroke in elderly Increased concerns re risk of haemorrhage Uncertain if similar benefit IST-3 trial allows randomisation of patients > 80 yrs Biological age > chronological age Reason to give tpa Vs reason not to give

38 Summary Widening licence of tpa for stroke BP management post tpa to reduce risk of haemorrhage Angio-oedema not uncommon Needs prompt identification and treatment Good outcome still possible with complications of tpa

39 Thank you

40 References Raising Awareness of Orolingual Angioedema as a Complication of Thrombolysis in Acute Stroke Patients, Ottomeyer et al, Cerebrovasc Dis 2009;27: Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study, Hill M D et al, CMAJ, MAY 10, 2005; 172 (10) Thrombolysis in Stroke Mimics: Frequency, Clinical Characteristics, and Outcome Ruegg, S et al, Jan 22, 2009; Stroke 2009;40; Benign Angioedema After Thrombolysis For Acute Stroke, Journal of Stroke and Cerebrovascular Diseases, Vol. 9, No. 2 (March-April), 2000: pp Nikolaos I. H. Papamitsakis

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