Hywel Dda Health Board Stroke Thrombolysis Care Pathway (Pembrokeshire version)

Transcription

1 Hywel Dda Health Board (Pembrokeshire version) Patient Details (attach Addressograph): Number: Name: Address: NHS Number: Date of Birth: / / Telephone Number: Religion: Postcode: Allergies: This pathway should be used to record all care and treatment given in relation to assessment and diagnosis of stroke, and delivery of thrombolysis for acute ischaemic stroke. THIS PATHWAY IS TO BE USED IN ADDITION TO THE STANDARD CLERKING DOCUMENT Lead Directorate/Group: Stroke Services Delivery Group Contact Details: Louise Coombe Stroke CNS Ext 3389 Approved By: Date Approved: Review Date: 1

2 Everyone using this Pathway must sign the Signature Record Date Print Name Signature Initials Designation Bleep No. Guidelines for use 1. Please ensure that your details are on the signature sheet, initial, print and designation. 2. Please ensure all entries in the pathway are signed or initialled and dated. 3. This document will record the care given by the multidisciplinary team. 4. Reasons for discontinuation of the pathway should be recorded on page Once the pathway is completed, it must be filed in the medical records 2

3 Patient with a suspected Ischaemic Stroke Self present at A&E Self referral to GP Self referral to ambulance In Out Patient Dept Assess using FAST A&E medic/nurse, Paramedic, GP +ve FAST and known time of symptom onset within 120 minutes Emergency transfer to A&E as per WAST procedure Ambulance to pre alert A&E A&E to pre alert CCU / bed manager & radiology Commence thrombolysis pathway Arrival in A&E Priority 2 (Orange) Confirm stroke onset time, ROSIER, Urgent Bloods, CXR (if indicated) BP monitoring, Weigh / Estimate weight Max minutes A&E Staff Grade / shop floor Consultant Patient already an inpatient (do not transfer to A&E) Arrange urgent CT brain Confirm ischaemic stroke NIHSS < 25 Confirm inclusion & exclusion criteria met Contact Stroke Physician - Decision to thrombolyse Medical Middle Grade Not suitable for standard thrombolysis >3 hours since onset Suitable for thrombolysis Obtain patient consent / make best interests decision based on discussion with Next of Kin Medical Middle Grade Consider IST3 trial randomisation or transfer to ASU Yes Transfer to CCU Bed available in CCU No Initiate thrombolysis in A&E, transfer to CCU when bed available wait for 2 hours post thrombolysis infusion completed Proceed to thrombolyse with Alteplase 10% stat as a bolus, 90% over 1 hour as infusion Follow Post Thrombolysis section of Pathway 3

4 TO BE COMPLETED BY A&E DOCTOR Acute Stroke Data Dates: Date of admission: Stroke onset date: Times (use 24 hour clock): Symptom onset*: Ambulance called: (Incident No: ) Patient arrived in A&E: Time of assessment: *If more than 3 hours since onset, this pathway should not be used. VITAL SIGNS ON ADMISSION Time Recorded: Temperature: C Glasgow Coma Score Eye movement = Motor = Verbal response = Weight: kgs / stones / llbs (please circle) Measured / Estimated (please circle) Capillary Glucose: mmols Respiratory Rate: min BP: mmhg Pulse: min Regular / Irregular (please circle) 4

5 TO BE COMPLETED BY A&E DOCTOR Assessment Recognition of Stroke in A&E - ROSIER Score Score (1) Has there been loss of consciousness or syncope? Y (-1pt) No (0pts) (2) Has there been seizure activity? Y (-1pt) No (0pts) (3) Is there a NEW ACUTE onset (or on awakening from sleep) in the following: І. Asymmetrical facial weakness Y (+1pt) No (0pts) ІІ. Asymmetrical arm weakness Y (+1pt) No (0pts) ІІІ. Asymmetrical leg weakness Y(+1pt) No (0pts) ІV. Speech disturbance Y(+1pt) No (0pts) V. Visual field defect / ophthalmoplegia Y(+1pt) No (0pts) Total Score: (-2 to +5) NB: A total score of 1 5 is suggestive of stroke. Stroke is unlikely but not excluded if total score is zero. Clinical judgement should be used. Provisional diagnosis: Stroke Non Stroke (specify) Signed : Date: Time : If Non-Stroke is diagnosed, then discontinue pathway and revert to Medical Clerking Proforma. If likely OR confirmed acute stroke on clinical grounds using ROSIER and it is less than 3 hours since onset: Inform Medical Middle Grade Organise Urgent CT Scan Discuss with Radiologist on Extn **** Date and time of call to book CT Scan: Organise ECG Organise blood samples: admission profile, clotting screen, random cholesterol. INFORM BED MANAGEMENT - BED MAY BE REQUIRED IN CCU Bleep

6 TO BE COMPLETED BY MEDICAL MIDDLE GRADE Risk Factors Known History of Hypertension known / new (please circle) MI/Ischaemic Heart Disease Atrial Fibrillation Peripheral Vascular Disease Diabetes - known / new (please circle) Hyperlipidaemia - known / new (please circle) Smoking Stroke Summary No Yes Brief Details On statin - Y / N Never Ex smoker (Quantity and duration) Alcohol excess Previous CVA/TIA Family History of stroke Carotid Bruit GLASGOW COMA SCORE Eye Opening Best Motor Best Verbal 1. Never 1. None 1. None 2. To pain 2. Extend to pain 2. Noises only 3. To sound 3. Abnormal flex to pain 3. Inappropriate 4. Spontaneously 4. Flex to pain 4. Confused 5. Localises to pain 5. Normal 6. Normal TOTAL: Communication Can the patient communicate normally? Yes No (If No specify below) Expressive Dysphasia Receptive Dysphasia Dysarthria Visual Fields Intact Yes No (specify) Visual inattention Yes No (specify) 6

7 TO BE COMPLETED BY MEDICAL MIDDLE GRADE Stroke Summary (continued) Sensation Sensory Loss Yes No (specify) Sensory Inattention Yes No (specify) Power Upper limb - Lower limb Plantar Reflexes Right Left Bladder & Bowel Function on admission Continent: Urine - Yes No Faeces - Yes No Cognitive Status Orientated: Yes No (details) Summary 1. List Neurological Deficits 2. Which side of the brain is involved? - please circle Right side Left side No clear lateralising signs 3. Which clinical syndrome? - please circle TACS = Total Anterior Circulation PACS = Partial Anterior Circulation Stroke Stroke POCS = Posterior Circulation Stroke LACS = Lacunar Stroke 7

8 TO BE COMPLETED BY MEDICAL MIDDLE GRADE Patient name: Date of Birth: NIH STROKE SCALE (TO BE USED BY TRAINED PERSONNEL ONLY) Acute Stroke Unit/Institute of Neurological Sciences Time & Date of symptom onset: : h on / / Time & Date of examination: : h on / / Time from onset: h min 1a. Level of Consciousness 1b LOC Questions Ask patient the month and his/her age 1c. LOC Commands Open & close eyes and grip & release non-paretic hand 2. Best Gaze Horizontal movements only 0 = Alert; keenly responsive 1 = Not alert; but arousable by minor stimulation 2 = Not alert; requires repeated stimulation to attend 3 = Unresponsive; reflex movements only 0 = Answers both questions correctly 1 = Answers one question correctly 2 = Answers neither question correctly 0 = Performs both tasks correctly 1 = Performs one task correctly 2 = Performs neither task correctly 0 = Normal 1 = Partial gaze palsy 2 = Forced Deviation not overcome by oculocephalic manoeuvre 3. Visual Fields 0 = Normal 1 = Partial Hemianopia 2 = Complete Hemianopia 3 = Bilateral Hemianopia (blind including cortical blindness) 4. Facial Palsy 0 = Normal 1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling) 2 = Partial paralysis (total or near total paralysis of lower face) 3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face) 5. Motor Function Arm 0 = Normal; limb holds 90 (or 45) degrees for 10 seconds without drift 1 = Drift; limb holds 90 (or45) degrees but drifts down before full 10 seconds but does not hit bed or other support 2 = Some effort against gravity 3 = No effort against gravity; limb falls 4 = No movement UN= Untestable; joint fused or amputated 6. Motor Function Leg 0 = Normal; leg holds 30 degree position for 5 seconds 1 = Drift; leg falls by end of 5 second period but does not hit bed 2 = Some effort against gravity 3 = No effort against gravity 4 = No Movement UN= Untestable; joint fused or amputated 7. Limb Ataxia Finger/nose & heel/shin both sides. Ataxia disproportionate to weakness only 0 = No Ataxia or paralysed/comatose/does not understand 1 = Present in one limb 2 = Present in two limbs UN= Untestable only if amputation or joint fusion 8. Sensory 0 = Normal; no sensory loss 1 = Mild to moderate sensory loss, aware of touch 2 = Severe to total sensory loss 9. Best Language 0 = No Aphasia 1 = Mild to moderate aphasia; loss of fluency or comprehension 2 = Severe aphasia; fragmented communication 3 = Mute, global aphasia; no useable speech or auditory comprehension 10. Dysarthria 0 = Normal 1 = Mild to moderate dysarthria; slurring of words, at worst can be understood with some difficulty 2 = Severe dysarthria; near unintelligible or unable to speak (out of proportion to aphasia) UN = Untestable due to intubation or other physical barrier 11. Extinction & Inattention 0 = No abnormality 1 = Inattention or extinction to bilateral simultaneous simulation in one sensory modality (visual, tactile, auditory, spatial or personal) 2 = Profound hemi-inattention or extension to more than one modality Score: R L UN R L UN UN Total Score: (NIHSS to be repeated after 48 hours - see page 19) 8

9 TO BE COMPLETED BY MEDICAL MIDDLE GRADE Stroke Thrombolysis Pre-Thrombolysis CT Results Pre Thrombolysis CT brain scan: Date: Time: (hrs) (mins) Report Outline: CT consistent with cerebral infarction? Y N (if No then discontinue pathway) 9

10 TO BE COMPLETED BY MEDICAL MIDDLE GRADE Stroke Thrombolysis Criteria for Inclusion Criteria Y N Clinical signs and symptoms of definite acute stroke Clear time of onset AND NOT symptomatic on awakening from sleep Presentation within 3 hours of onset Haemorrhage excluded by CT scan Between years old NIHSS score < 25 Exclusion Criteria Y N Rapidly improving or minor stroke symptoms (eg NIHSS <5) Severe Stroke (NIHSS >25) +/- suggested by CT Stroke or serious head injury within 3 months Major surgery / external heart massage / obstetric delivery within 14 days GI haemorrhage / urinary tract haemorrhage within 21 days History of intracranial haemorrhage, aneurysm, neoplasm, spinal or cranial surgery of haemorrhagic retinopathy Symptoms suggestive of Sub Arachnoid Haemorrhage even if CT normal Systolic BP > 185mmHg and Diastolic BP > 110mmHg (BP reduction for criteria not permitted) Known clotting disorder Patient on heparin or warfarin Blood glucose <3 mmol/i or >22 mmol/l Seizure at start of stroke Premorbid dependency Bacterial endocarditis / pericarditis Acute pancreatitis/ oesophageal varcies/ulcerative GI disease within 3 months/aortic aneurysm/ active hepatitis/cirrhosis Prior stroke and concomitant diabetes Puncture of non-compressible blood vessel last 14 days Could the patient be pregnant? If the patient meets ALL of the inclusion criteria, and NONE of the exclusion criteria then they are suitable for thrombolysis 10

11 TO BE COMPLETED BY MEDICAL MIDDLE GRADE CONSENT TO TREATMENT (NB: All appropriate Yes / No boxes to be completed. At the end of the consent process Yes must be ticked in either box 2, 4, 5b or 7). 1. Does the patient have capacity to consent to treatment? (If Yes go to question 2. If No or Unsure go to question 3) 2. If the patient has capacity, does the patient give verbal consent to treatment? (go to Information section, below) 3. If there is doubt about the patients capacity then assess their capacity by answering questions (i) (iv) below: (i) Can they understand the information about thrombolysis? (ii) Are they able to retain the information long enough to make a decision? (iii) Can they use or weigh the information to make the decision? (iv) Can they communicate their decision in any way? 4. If Yes to all of (i)-(iv), the patient has capacity - Do they consent to treatment? (go to Information section below) If No to any of (i) (iv), then the patient lacks capacity to make this decision: 5a. Is there a relevant documented authority in place for this decision e.g. advance decision / Health & Welfare Lasting Power of Attorney / Court appointed Deputy? (If Yes please circle, then obtain copy for the notes and answer 5b. If No, go to 6. Yes No Unsure 5b. Consent given via advance decision / Health & Welfare Lasting Power of Attorney / Court appointed Deputy? (please circle) 6. If the patient does not have capacity to consent ensure that: The patients past and present wishes and any beliefs and values that may influence their decision are considered and they are involved as much as possible in the decision-making process People close to the patient (unpaid carers / relatives) have been consulted as appropriate Other professionals (multidisciplinary team) have been consulted as appropriate 7. Taking all of the above factors into account, is thrombolysis judged to be in the patients best interests? Information to be given BEFORE administration of Alteplase Any explanation should include: Stroke Diagnosis. This treatment, Alteplase, dissolves the blood clot blocking the artery and allows blood to get back to the brain. Evidence indicates that the drug works if given within 3 hours of the stroke starting. The patient should be informed that they have a 1 in 8 chance of making a significant improvement in their symptoms and there is a 1 in 18 chance of causing a symptomatic intracranial haemorrhage. 11

12 TO BE COMPLETED BY MEDICAL MIDDLE GRADE Final Pre-Thrombolysis Checklist Less than 3 hours since symptom onset (p.4) Confirmed acute stroke (ROSIER completed p.5) Standard investigations completed (p5) (admission profile, coagulation screen, glucose, random cholesterol, ECG, CXR (if indicated)) Ascertained full history (p.6-7) Neurological exam (p.7) NIHSS completed, with score between 5 24 (p.8) CT Scan done and ischaemic stroke confirmed (p9) Inclusion criteria met (p.10) Verbal consent obtained / Best interests decision made (p.11) Bed arranged/confirmed in CCU IV access obtained (green cannula both arms) Once all of the above are confirmed contact the Stroke Consultant via bleep**** to obtain agreement to thrombolyse Agreement to thrombolyse obtained from Consultant: Yes No If Yes to Thrombolysis: Transfer arranged to CCU or No bed available in CCU, therefore proceeding to thrombolyse in A&E Neuro-protective measures initiated (BM/Temp/O 2 /BP/Hydration Control) Continuous cardiac monitoring commenced No Aspirin, heparin, warfarin, dipyridamole, clopidogrel, or NSAIDs No Central or arterial lines No NG tube 12

13 Prescribing and administration instructions for alteplase (tpa) in acute stroke Prescribing - total alteplase (tpa) dose = 0.9mg per kg; 10% of this dose to be given as loading dose, the remainder infused over 60 minutes via syringe pump. P1. Using patient's estimated body weight, read across chart below to identify doses to prescribe. P2. Prescribe the loading dose in the "stat doses" section of the chart. P3. Prescribe the infusion in the "intravenous infusions" section of the chart. Administration A1. Add 50ml water for injection to 50mg alteplase vial to give 1mg in 1ml solution (Use diluents and transfer set provided). Agitate gently to reconstitute - DO NOT SHAKE vial. A2. Let vial stand for 2-3 minutes to allow large bubbles to dissipate (slight foaming is common). A3. Draw up loading dose into 10ml syringe and administer intravenously over 2-3 minutes A4. Draw up infusion dose into 1 or 2 x 60ml syringes as per table. A5. Label infusion syringes with "Drug added" labels. A6. Administer infusion dose over 60 minutes via syringe pump. Set infusion rate according to table below. Patient weight (kg) Patient weight (st and lb) Loading dose (mg) Loading dose (ml) 1 hour infusion dose (mg) 1 hour infusion dose (ml) Number of 50mg vials to reconstitute Number of infusion syringes Volume in syringe 1 (ml) Volume in syringe 2 (ml) Infusion rate (ml per hour) 30 4st 10lb vial st 7lb vial st 4lb vial st 1lb vial st 12lb vial st 9lb vial st 6lb vials st 3lb vials st vials st 11lb vials st 8lb vials st 5lb vials st 2lb vials st 13lb vials st 10lb vials > 100 > 15st 10lb vials Maximum total dose to be given is 90mg Dose to be prescribed: 13

14 TO BE COMPLETED BY MEDICAL MIDDLE GRADE Thrombolysis commenced: Thrombolysis Administration Dose given: Date: Location: CCU / A&E (please circle) Time: hrs/ mins 15 minute observations of blood pressure & pulse, SaO2 & temperature commenced 15 minute Neuro obs commenced Continuous cardiac monitoring commenced Thrombolysis completed: Date: Time: hrs/ mins Thrombolysis discontinued due to complications (see overleaf): Date: Time: hrs/ mins Reason for discontinuation (see p.15): 14

15 Complications of Thrombolysis & Appropriate Intervention STOP THE ALTEPLASE INFUSION IF ANY OF THE FOLLOWING OCCUR COMPLICATION INTERVENTION ANAPHYLAXIS ABC / Assess for shock / Two large venflons Rapid fall in BP, FBC, U+E, Cr, PT, PTT, fibrinogen, group and save. Urticarial rash, new Administer: IV volume replacement with crystalloid 500ml fluid wheezing or challenges after simple measures have failed breathlessness Give Hydrocortisone 200mg and Chlorpheniramine 10mg IV If circulatory collapse and IV access give 100micrograms (1ml) to 200micrograms (2ml) of 1 in 1,000 IM Epinephrine then review response.) HYPOTENSION BP systolic < 100mmHg UNCONTROLLED HYPERTENSION BP systolic rises to > 185/ 105mmHg sustained after 5 minutes, or associated with neuro deterioration of any sort Inform Consultant Often transient Oxygen therapy, head tilt if BP < 100 systolic Consider IV fluid challenge and monitor closely 2 readings, 5-10 minutes apart Target BP <185/105 Repeat and monitor every 15 minutes If Systolic >185 mmhg or Diastolic > 105mmHg First Line: Labetalol 10mg IV over 2 minutes. May repeat or double every 10 minutes to a total dose of 150mg Or: Give initial dose then infusion at 2mg/min, titrated to 8mg/min as needed LIKELY PRIMARY INTRACEREBRAL HAEMORRHAGE Major systemic bleeding Neuro deterioration of 2 points on GCS eye/motor scale FOR URGENT CT SCAN Second line: Administer GTN 10 micrograms/min & titrate Suspect if headache, nausea and vomiting, fall in GCS, new focal neurological signs or acute hypertension Discontinue alteplase infusion if still running Basic resuscitation and check for new neurological deficit Check fibrinogen, PT, PTT, FBC, group and save Arrange urgent CT scan If bleed confirmed (for Intracerebral OR Life - threatening Systemic bleeding) give the following: 10 units cryoprecipitate if fibrinogen < 1.5g/l. This should be ordered immediately while a coagulation screen is underway. This comes from Blood Bank and takes 30 minutes to thaw. 1-2 ATU (Adult Therapeutic Doses) of platelets, if count < 100. These come from Blood Centre Discuss with Consultant Haematologist for further intervention & management /possible Recombinant Factor VII administration 15

16 TO BE COMPLETED BY NURSING STAFF Monitoring & Nursing Care Protocol for Patients Receiving Thrombolysis (Alteplase) Monitoring requirement 1.Continous Cardiac Monitoring for 24 hours 2.Blood Pressure & Pulse Monitoring 15min x 2hrs 30min x 6hrs 60min x 24hrs Via hand held manual sphygmomanometers 3.Neuro Obs Monitoring for first hours Frequency the same as indicated with BP & Pulse monitoring 4. Bed Rest for 24 Hours 5. No Arterial Punctures or Central Lines 6. No Naso-Gastric Tube for 24 hours Sign to confirm done Rationale Monitoring allows early warning of cardiac complications e.g. Atrial fibrillation Myocardial Infarction Monitoring of BP allows early recognition of complications arising from administration of alteplase & allows further administration of drugs to combat hyper / hypotension. If any cause for concern, report to medical team, document and increase observations accordingly. The evidence suggests that blood pressure cuffs can some times cause petechial subcutaneous bleeding; therefore automated BP machines should be avoided. The GCS should be part of a minimum nursing assessment and documented accordingly. Any deterioration in GCS during thrombolysis may be attributed to suspected major bleeding or intracranial haemorrhage, prompting discontinuation of alteplase infusion and calling the Medical Team Urgently. An urgent CT scan should be performed. Although alteplase has a short half life in the circulation (minutes), the drug will continue to act in a thrombosis for many hours. Reduces the risk of injury during the active life of the alteplase. Lowers the risk of extensive uncontrolled bleeding from vulnerable sites. An exception may be made if continuous arterial monitoring is required following the administration of some antihypertensive drugs (Sodium Nitroprusside). Increased risk of oesophageal haemorrhage when passing a NGT whilst alteplase is active. 16

17 TO BE COMPLETED BY NURSING STAFF Monitoring & Nursing Care Protocol for Patients Receiving Thrombolysis (Alteplase) (continued) Monitoring requirement 7. No Urinary Catheterisation (for first 30 minutes of thrombolysis administration) 8. No Aspirin, Dipyridamole, Clopidogrel, Heparin, Warfarin or NSAIDs 9. Obtain Second CT Brain Scan between hours post thrombolysis Sign to confirm done Rationale During the first 30 minutes following administration of alteplase, there is a great risk of causing trauma and haemorrhage during catheterisation. Despite this it may be necessary to catheterise a patient to help measure diuresis accurately, if this is likely then whenever possible the patient should be catheterised prior to Thrombolysis. Heparin, Clopidogrel, Dipyridamole, Aspirin and Warfarin prevent platelet aggregation and should be avoided to lower the risk of over anticoagulation. NSAIDs should be avoided due to gastrointestinal side effect which may cause bleeding. To help exclude any intracranial bleeding complications. Once CT is completed /no bleeding complications, aspirin is usually started (or recommenced). 17

18 TO BE COMPLETED BY STROKE TEAM Post Thrombolysis CT brain scan: Post Thrombolysis Outcome This should be done between hours post-thrombolysis (NB: requires new CT referral form to be completed) Date: Time: (hrs) (mins) Report Outline: Antiplatelet medication (if no haemorrhage on post thrombolysis CT) Aspirin 300mg daily prescribed NIHSS Score NIHSS repeated at 48 hours post thrombolysis (see overleaf) Pre Thrombolysis NIHSS Score: Post Thrombolysis NIHSS Score: Comment on patient outcome: 18

19 TO BE COMPLETED BY MEDICAL MIDDLE GRADE Patient name: Date of Birth: NIH STROKE SCALE (TO BE USED BY TRAINED PERSONNEL ONLY) Acute Stroke Unit/Institute of Neurological Sciences Time & Date of thrombolysis: : h on / / (p.14) Time & Date of examination: : h on / / Time since thrombolysis: h min (To be undertaken 48 hours post-thrombolysis.) 1a. Level of Consciousness 1b LOC Questions Ask patient the month and his/her age 1c. LOC Commands Open & close eyes and grip & release non-paretic hand 2. Best Gaze Horizontal movements only 0 = Alert; keenly responsive 1 = Not alert; but arousable by minor stimulation 2 = Not alert; requires repeated stimulation to attend 3 = Unresponsive; reflex movements only 0 = Answers both questions correctly 1 = Answers one question correctly 2 = Answers neither question correctly 0 = Performs both tasks correctly 1 = Performs one task correctly 2 = Performs neither task correctly 0 = Normal 1 = Partial gaze palsy 2 = Forced Deviation not overcome by oculocephalic manoeuvre 3. Visual Fields 0 = Normal 1 = Partial Hemianopia 2 = Complete Hemianopia 3 = Bilateral Hemianopia (blind including cortical blindness) 4. Facial Palsy 0 = Normal 1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling) 2 = Partial paralysis (total or near total paralysis of lower face) 3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face) 5. Motor Function Arm 0 = Normal; limb holds 90 (or 45) degrees for 10 seconds without drift 1 = Drift; limb holds 90 (or45) degrees but drifts down before full 10 seconds but does not hit bed or other support 2 = Some effort against gravity 3 = No effort against gravity; limb falls 4 = No movement UN= Untestable; joint fused or amputated 6. Motor Function Leg 0 = Normal; leg holds 30 degree position for 5 seconds 1 = Drift; leg falls by end of 5 second period but does not hit bed 2 = Some effort against gravity 3 = No effort against gravity 4 = No Movement UN= Untestable; joint fused or amputated 7. Limb Ataxia Finger/nose & heel/shin both sides. Ataxia disproportionate to weakness only 0 = No Ataxia or paralysed/comatose/does not understand 1 = Present in one limb 2 = Present in two limbs UN= Untestable only if amputation or joint fusion 8. Sensory 0 = Normal; no sensory loss 1 = Mild to moderate sensory loss, aware of touch 2 = Severe to total sensory loss 9. Best Language 0 = No Aphasia 1 = Mild to moderate aphasia; loss of fluency or comprehension 2 = Severe aphasia; fragmented communication 3 = Mute, global aphasia; no useable speech or auditory comprehension 10. Dysarthria 0 = Normal 1 = Mild to moderate dysarthria; slurring of words, at worst can be understood with some difficulty 2 = Severe dysarthria; near unintelligible or unable to speak (out of proportion to aphasia) UN = Untestable due to intubation or other physical barrier 11. Extinction & Inattention Total Score: 0 = No abnormality 1 = Inattention or extinction to bilateral simultaneous simulation in one sensory modality (visual, tactile, auditory, spatial or personal) 2 = Profound hemi-inattention or extension to more than one modality Score: R L UN R L UN UN 19

20 REASON FOR DISCONTINUING PATHWAY ( TO BE COMPLETED BY PERSON DISCONTINUING PATHWAY) Date/Time of Reason for discontinuation discontinuation Comments: More than 3 hours since onset of symptoms Non-stroke diagnosed Not ischaemic stroke Inclusion criteria not met Patient does not consent Procedure not in patients best interests Patient died before thrombolysis completed 20