Acute Thrombolysis Stroke Service at NNI

Dr Rajinder Singh, Consultant, Department of Neurology, National Neuroscience Institute

In 2006, the National Neuroscience Institute (NNI) Neuroradiology Department became the first imaging centre in Singapore to provide 24-hour MRI scanning for acute stroke patients. Using fast imaging techniques, the department can complete a scan in half the time usually needed for MRI stroke protocol – a scan can even be completed in five minutes. This service enables doctors to decide on the most appropriate management for the stroke patients. With short scanning times, patients diagnosed with an acute stroke in the Emergency Department of Tan Tock Seng Hospital (TTSH) can get an MRI scan done promptly at the department, en route to the acute ward or Neuro Intensive Care Unit.

With further improvement of our acute stroke service, the NNI now provides acute thrombolysis treatment for all patients admitted to its Tan Tock Seng Seng Hospital campus with ischemic stroke under three hours of symptom onset. Such treatment can be critical for some stroke patients because acute thrombolysis given within a few hours after onset has been shown to improve outcome with potential for significant or even complete reversal of neurological deficits. In addition, all patients admitted for stroke receive magnetic resonance imaging scans as the primary neuroimaging modality round the clock. With almost 1900 scans performed in 2006, this has changed the paradigm of care, with improvement in accuracy of diagnosis, streamlining of further tests and treatment strategies.

Thrombolytic Therapy for Acute Ischemic Stroke at NNI-TTSH Campus

Intravenous TPA for thrombolysis of acute stroke was licensed for use in Singapore in 2004. Its use was initiated at NNI-TTSH campus, with the implementation of the acute stroke service, for  all eligible patients with acute ischemic stroke. In line with this, an Acute Stroke Thrombolysis Protocol, adapted from the American Heart Association (AHA) Guidelines for Thrombolytic Therapy for Acute Stroke, was developed by our team of doctors.
 
Speed is of the essence as treatment for acute stroke is often time-dependent. The emergency department at TTSH triages patients who present with acute stroke within two hours of onset of symptoms and activates the acute stroke service at the time of the patient’s arrival. The acute stroke service, which comprises the stroke neurologist and resident-oncall, assess eligibility of patients with acute ischemic stroke for intravenous thrombolytic therapy based on inclusion and exclusion criteria as per protocol. An NIH Stroke Scale (NIHSS) scoring is also performed at this point in time. CT scan brain interpretation is done by the attending resident and stroke neurologist.

Patients with hemorrhagic strokes, mild or rapidly improving deficits and contraindications to thrombolytic therapy are excluded from treatment. Intravenous tissue plasminogen activator (TPA) is administered to eligible patients after informed consent is obtained. During discussion with the patient and family, they are informed that there may be no clear benefit seen at Day 1, but treated patients are 30% more likely to have minimal or no disability at 3 months. To date, 47 patients have received TPA since the start of the thrombolysis service.

National Neuroscience Institute Tel : 6357 7153 Fax : 6357 7103
Website : http://www.nni.com.sg