Hyperacute thrombolysis with IV rtPA of acute ischemic stroke: Efficacy and safety profile of 54 patients at a tertiary referral center in a developing country

Statins Therapy Improves Acute Ischemic Stroke in Patients with Cardio-metabolic Disorders Measured by Lipoprotein-Associated Phospholipase A2 (Lp-PLA2): New Focal Point

BACKGROUND

Acute ischemic stroke (AIS) leads to neuronal and endothelial damage that activate the release of proinflammatory mediators such as lipoprotein-associated phospholipase A2 (Lp-PLA2), which lead to the development of brain edema injury. Most of statins produce differential effects on Lp-PLA2 activity and mass with a comparable reduction in low-density lipoprotein (LDL) serum levels.

AIMS

The aim of this study is to evaluate the differential effect of different statins on the mass of level of Lp-PLA2 in patients with AIS.

METHODS

A total of 69 patients with AIS aged 40-70 years compared with matched 39 healthy controls were involved in this case-control study. The AIS patients were divided according to the statins therapy into 39 patients on statins therapy (statins on), and 30 patients were not on the statins therapy (statins off). Anthropometric variables including weight, height, body mass index (BMI), and blood pressure profile were estimated. Besides, biochemical variables including lipid profile[total cholesterol (TC), triglyceride (TG), LDL, very low-density lipoprotein (VLDL), high-density lipoprotein (HDL)], Lp-PLA2 mass levels, high-sensitive C-reactive protein (Hs-CRP) were estimated.

RESULTS

Patients with AIS had high Lp-PLA2 mass levels (P < 0.01) that positively correlated with high Hs-CRP, blood pressure, BMI, TC, TG, VLDL, LDL, and negatively correlated with HDL as compared with healthy controls. As well, statins on patients had lower Lp-PLA2 mass levels (9.82 ± 3.19 IU/mL) compared with statins off patients (16.55 ± 4.72 IU/mL), (P = 0.0001). Regarding the gender differences in the Lp-PLA2 mass level, it was higher in men patients with AIS compared with comparable females (P = 0.03).

CONCLUSIONS

Lp-PLA2 mass level was higher in patients with AIS and linked with underlying poor cardio-metabolic disorders. Therefore, the Lp-PLA2 mass level is observed to be a surrogate biomarker of AIS mainly in patients with poor cardio-metabolic disorders. Statin therapy improves the Lp-PLA2 mass level and the poor cardio-metabolic profile in patients with AIS.

Efficacy and Safety of Intravenous rtPA in Ischemic Strokes Due to Small-Vessel Occlusion: Systematic Review and Meta-Analysis

Intravenous recombinant tissue plasminogen activator (iv-rtPA) has been routinely used to treat ischemic stroke for 25 years, following large clinical trials. However, there are few prospective studies on the efficacy and safety of this therapy in strokes attributed to cerebral small vessel disease (SVD). We evaluated functional outcome (modified Rankin scale, mRS) and symptomatic intracerebral hemorrhage (sICH) using all available data on the effects of iv-rtPA in SVD-related ischemic stroke (defined either using neuroimaging, clinical features, or both). Using fixed-effect and random-effects models, we calculated the pooled effect estimates with regard to excellent and favorable outcomes (mRS=0-1 and 0-2 respectively, at 3 months), and the rate of sICH. Twenty-three studies fulfilled the eligibility criteria, 11 of which were comparative, and there were only 3 randomized clinical trials. In adjusted analyses, there was an increased odds of excellent outcome (adjusted OR=1.53, 95% CI: 1.29-1.82, I2: 0%) or favorable outcome (adjusted OR=1.68, 95% CI: 1.31-2.15,I2: 0%) in patients who received iv-rtPA compared with placebo. Across the six studies which reported it, the incidence of sICH was higher in the treatment group (M-H RR = 8.83, 95% CI: 2.76-28.27). The pooled rate of sICH in patients with SVD administered iv-rtPA was only 0.72% (95% CI: 0.12%-1.64%). We conclude that when ischemic stroke attributed to SVD is considered separately, available data on the effects of iv-rtPA therapy are insufficient for the highest level of recommendation, but it seems to be safe. Although further therapeutic trials in SVD-related ischemic stroke appear to be justified, our findings should not prevent its continued use for this group of patients in clinical practice.

Challenges of Thrombolysis in a Developing Country: Characteristics and Outcomes in Peru

BACKGROUND

The availability of intravenous tissue plasminogen activator (IV-tPA) remains limited worldwide, especially in low-income countries, where the burden of disability due to ischemic stroke is the highest.

AIMS

To evaluate outcomes and safety of IV-tPA at the only Peruvian reference institute for neurologic diseases.

METHODS

We conducted a prospective, observational study of stroke patients who received IV-tPA between 2009 and 2016. We assessed characteristics associated with good outcome (modified Rankine scale 0-2) at 3 months using a multivariate regression model; and factors correlated with clinical improvement (delta National Institute of Health Stroke Scale (NIHSS)) using linear regression.

RESULTS

Only 1.98% (39/1,1962) of patients presenting with ischemic stroke received IV-tPA. Nearly half (41%) were younger than 60 years, 56.4 % were men, and most strokes were cardioembolic (46.2%). The majority (64.1%) were treated within 3-4.5 hours. The median NIHSS on admission and discharge was 9 and 4, respectively; 42.1% of patients had an mRS of 0-1 at 3 months. Three patients (7.7%) developed hemorrhagic conversion, and 1 patient died (2.6%). Patients with good outcomes had lower pretreatment systolic blood pressure (138.9 versus 158.1 mm Hg, P < .007), fewer complications during hospitalization (5 versus 9 events, P < .001), shorter hospital stay (14 versus 21 days, P < .03) and, paradoxically, longer last known well -to-door times (148.3 versus 105 minutes, P < .0022). Clinical improvement was associated with shorter door-to-tPA times and obesity.

CONCLUSIONS

Our findings indicate that IV-tPA has similar safety and outcomes compared to developed countries. All internal metrics (door-to-tPA, door-to-CT, and CT-to-tPA time) improved over time, highlighting areas for future implementation science studies to further expedite the administration of IV-tPA.

Predictors of Postthrombolysis Outcome and Symptomatic Postthrombolysis Hemorrhage following Intravenous Thrombolysis with Alteplase for Acute Ischemic Stroke

Background  Thrombolysis improves the outcome in acute ischemic stroke (AIS), albeit with an increased risk of symptomatic intracranial hemorrhage (sICH). Biomarkers to find patients at risk of sICH, and guide treatment and prognosis would be valuable. Methods  Consecutive patients of AIS thrombolysed between February 2017 and September 2019 at Calcutta National Medical College were studied prospectively for sICH and outcome at 6-month follow-up. We identified the independent risk factors for unfavorable outcomes, mortality, and sICH using multivariate analysis. Prethrombolysis and 24-hour postthrombolysis fibrinogen levels were estimated to evaluate its biomarker role. Results  Out of 180 AIS patients admitted during the study period, 60 patients were thrombolysed. Door to needle time was <3 hours among 24 patients and 3 to 4.5 hours among 36 patients. Favorable outcomes occurred among 76.67% and sICH occurred among 13.33% patients. Upper tertile of National Institute of Health Stroke Scale (NIHSS) had the highest adjusted odds for sICH (17.5 [95% confidence intervals=1.7-178.44]). Total anterior circulation stroke had the highest adjusted odds for unfavorable outcome (19.11 [3.9-92.6]). Following thrombolysis, the mean (standard deviation) fibrinogen level of 449.27 (32.87) decreased 7% to postthrombolysis level of 420 (20.5; p< 0.0001). Higher tertiles of fibrinogen levels had progressively increasing odds for morbidity and sICH. Conclusion  Congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke (double weight), i.e., CHADS2 score >2, low ejection fraction, the occurrence of total anterior circulation stroke and higher mean arterial blood pressure, blood glucose level, NIHSS score, and fibrinogen at admission were the common risk factors significantly predicting postthrombolysis sICH and morbidity. Antiplatelet and anticoagulant therapy, lower ASPECT (Alberta Stroke Program Early CT Score), and higher SEDAN scores also predicted sICH . Fibrinogen levels were significantly higher among those developing sICH and having unfavorable outcome. The performance of thrombolysis within 3 hours or between 3 and 4.5 hours after symptom onset did not affect morbidity, mortality, or the occurrence of sICH.

MRI-Based Predictors of Hemorrhagic Transformation in Patients With Stroke Treated by Intravenous Thrombolysis

Background: Clinical and biological risk factors for hemorrhagic transformation (HT) after intravenous thrombolysis (IT) have been well-established in several registries. The added value of magnetic resonance imaging (MRI) variables has been studied in small samples, and is controversial. We aimed to assess the added value of MRI variables in HT, beyond that of clinical and biological factors. Methods: We enrolled 474 consecutive patients with brain infarction treated by IT alone at our primary stroke center between January 2011 and August 2017. Baseline demographic, clinical, biological, and imaging characteristics were collected. MRI variables were: brain infarction volume in cm3; parenchymal fluid attenuated inversion recovery (FLAIR) hyperintensity; FLAIR hyperintense vessel signs; number of microbleeds; subcortical white matter hyperintensity; and thrombus length. Results: Overall, 301 patients were included out of 474 (64%). The main causes of exclusion were combined thrombectomy (n = 98) and no MRI before IT (n = 44). In the bivariate analysis, HT was significantly associated with the presence of more FLAIR hyperintense vessel signs, thrombus length (>8 mm), and larger brain infarction volume (diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) < 500 × 10-6 mm2/s). In the multivariable analysis, only brain infarction volume was significantly associated with HT. The discrimination value of the multivariable model, including both the DWI volume and the clinical model (area under the receiver operating characteristic curve, 0.80; 95% confidence interval 0.74-0.86), was improved significantly compared with the model based only on clinical variables (P = 0.012). Conclusions: Brain infarction volume on DWI was the only MRI variable that added value to clinico biological variables for predicting HT after IT.

Regional differences in ischemic stroke in India (north vs. south)

BACKGROUND

India is a large country with geographically diverse populations and varying risk factors. Identification of regional differences can improve healthcare policy decisions.

AIM

To study regional differences in stroke between North and South India.

METHODS

We analyzed data from the Indo-US Collaborative Stroke Project, a National Institute of Health-funded multicentre prospective study conducted in five academic centers in India with a US-based coordinating center. Risk factors, severity, mechanisms, management, complications, and outcomes among ischemic stroke patients were compared between North and South Indian centers.

RESULTS

Of the 2066 patients enrolled from North (n = 1060) and South India (n = 1006), North Indian patients were significantly older with fewer men and had lower rates of diabetes (32.8% vs. 38.7%, p < 0.01), dyslipidemia (3.5% vs. 25.7%, p < 0.01), tobacco use (27% vs. 38%, p < 0.001), and alcohol use (30.1% vs. 38.6%, p < 0.01). North Indian patients had higher median National Institute of Health stroke scale scores (10 vs. 9, p < 0.01), more frequent large-artery atherosclerosis mechanism (34% vs. 25.6%, p < 0.001), intravenous thrombolysis (14.0% vs. 6.1%, p < 0.001), and lower rates of pneumonia (10.5% vs. 15.1%, p = 0.02). The three-month outcome (modified Rankin Scale score 0-2, 45.8% vs. 50.3%, p = 0.08) did not differ; however, North Indian patients had higher 90-day mortality (23.5% vs. 13.5%, p < 0.0001).

CONCLUSIONS

The substantial regional differences in stroke risk factors and mechanisms may be partly explained by factors such as differing dietary habits and lifestyle, which can be addressed at a national level. Differences in acute and inpatient stroke care suggest a need for better adoption of national stroke management guidelines.

Current status of intravenous tissue plasminogen activator dosage for acute ischaemic stroke: an updated systematic review

The optimal dose of recombinant tissue plasminogen activator (rtPA) for acute ischaemic stroke (AIS) remains controversial, especially in Asian countries. We aimed to update the evidence regarding the use of low-dose versus standard-dose rtPA. We performed a systematic literature search across MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception to 22 August 2016 to identify all related studies. The outcomes were death or disability (defined by modified Rankin Scale 2–6), death, and symptomatic intracerebral haemorrhage (sICH). Where possible, data were pooled for meta-analysis with ORs and corresponding 95% CIs by means of random-effects or fixed-effects meta-analysis. We included 26 observational studies and 1 randomised controlled trial with a total of 23 210 patients. Variable doses of rtPA were used for thrombolysis of AIS in Asia. Meta-analysis shows that low-dose rtPA was not associated with increased risk of death or disability (OR 1.13, 95% CI 0.95 to 1.33), or death (OR 0.86, 95% CI 0.74 to 1.01), or decreased risk of sICH (OR 1.06, 95% CI 0.65 to 1.72). The results remained consistent when sensitivity analyses were performed including only low-dose and standard-dose rtPA or only Asian studies. Our review shows small difference between the outcomes or the risk profile in the studies using low-dose and/or standard-dose rtPA for AIS. Low-dose rtPA was not associated with lower risk of death or disability, death alone, or sICH.

Impact of "Stroke Code"-Rapid Response Team: An Attempt to Improve Intravenous Thrombolysis Rate and to Shorten Door-to-Needle Time in Acute Ischemic Stroke

Objective:

“Stroke code” (SC) implementation in hospitals can improve the rate of thrombolysis and the timeline in care of stroke patient.

Materials and Methods:

A prospective data of patients treated for acute ischemic stroke (AIS) after implementation of “SC” (post-SC era) were analyzed (2015–2016) and compared with the retrospective data of patients treated in the “pre-SC era.” Parameters such as symptom-to-door, door-to-physician, door-to-imaging, door-to-needle (DTN), and symptom-to-needle time were calculated. The severity of stroke was calculated using the National Institutes of Health Stroke Score (NIHSS) before and after treatment.

Results:

Patients presented with stroke symptoms in pre- and post-SC era (695 vs. 610) and, out of these, patients who came in window period constituted 148 (21%) and 210 (34%), respectively. Patients thrombolyzed in pre- and post-SC era were 44 (29.7%) and 65 (44.52%), respectively. Average DTN time was 104.95 min in pre-SC era and reduced to 67.28 min (P < 0.001) post-SC implementation. Percentage of patients thrombolyzed within DTN time ≤60 min in pre-SC era and SC era was 15.90% and 55.38%, respectively.

Conclusion:

Implementation of SC helped us to increase thrombolysis rate in AIS and decrease DTN time.

Interventions for acute stroke management in Africa: a systematic review of the evidence

BACKGROUND

The past decades have witnessed a rapid evolution of research on evidence-based acute stroke care interventions worldwide. Nonetheless, the evidence-to-practice gap in acute stroke care remains variable with slow and inconsistent uptake in low-middle income countries (LMICs). This review aims to identify and compare evidence-based acute stroke management interventions with alternative care on overall patient mortality and morbidity outcomes, functional independence, and length of hospital stay across Africa.

METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. An electronic search was conducted in six databases comprising MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Academic Search Complete and Cochrane Library for experimental and non-experimental studies. Eligible studies were abstracted into evidence tables and their methodological quality appraised using the Joanna Briggs Institute checklist. Data were analysed and presented narratively with reference to observed differences in patient outcomes, reporting p values and confidence intervals for any possible relationship.

RESULTS

Initially, 1896 articles were identified and 37 fully screened. Four non-experimental studies (three cohort and one case series studies) were included in the final review. One study focused on the clinical efficacy of a stroke unit whilst the remaining three reported on thrombolytic therapy. The results demonstrated a reduction in patient deaths attributed to stroke unit care and thrombolytic therapy. Thrombolytic therapy was also associated with reductions in symptomatic intracerebral haemorrhage (SICH). However, the limited eligible studies and methodological limitations compromised definitive conclusions on the extent of and level of efficacy of evidence-based acute stroke care interventions across Africa.

CONCLUSION

Evidence from this review confirms the widespread assertion of low applicability and uptake of evidence-based acute stroke care in LMICs. Despite the limited eligible studies, the overall positive patient outcomes following such interventions demonstrate the applicability and value of evidence-based acute stroke care interventions in Africa. Health policy attention is thus required to ensure widespread applicability of such interventions for improved patients' outcomes. The review findings also emphasises the need for further research to unravel the reasons for low uptake.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016051566.

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review

Background: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. Aims and Objectives: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. Methods: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. Results: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. Conclusion: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.

Risk Factors for Hemorrhagic Transformation After Intravenous Thrombolysis in Acute Cerebral Infarction: A Retrospective Single-Center Study

OBJECTIVE

To investigate the risk factors for hemorrhagic transformation (HT) after intravenous thrombolysis using a recombinant tissue plasminogen activator (r-tPA) in acute cerebral infarction.

METHODS

Patients with acute cerebral infarction receiving r-tPA thrombolysis in Shanghai Eastern Hospital were retrospectively studied. Based on the cranial computed tomography or magnetic resonance imaging examination, after the intravenous thrombolysis, the patients were divided into 2 groups: an HT group and a non-HT group. The information was collected before or after thrombolysis.

RESULTS

A total of 162 patients were included in the analysis. The age ranged from 25 to 86 years, with an average age of 65.6 ± 10.6 years. The average time from disease onset to thrombolysis was 188 ± 53.1 minutes. Cranial computed tomography or magnetic resonance imaging showed that 20 patients (12.3%) had HT after thrombolysis. Using univariate analysis, history of atrial fibrillation, positive expression of urinary protein, and high National Institutes of Health Stroke Scale (NIHSS) score before thrombolysis, we found that there was a significant difference between the HT and non-HT group (P < 0.05) in the level of mean systolic pressure (MSP) 24 hours after thrombolysis. Multivariate logistic regression analysis indicated that age ≥80 years, MSP ≥140 mm Hg, NIHSS score, and fibrinogen concentration before thrombolysis were risk factors for HT after thrombolysis in patients with acute cerebral infarction.

CONCLUSIONS

Age, MSP, NIHSS score, and fibrinogen concentration before thrombolysis are risk factors for HT after thrombolysis in acute cerebral infarction. These 4 factors should be carefully taken into account before thrombolysis.

Quality Indicators of Intravenous Thrombolysis from North India

Background:

Data on intravenous (IV) thrombolysis using tissue plasminogen activator (tPA) are limited from low- and middle-income countries. We aimed to assess the quality indicators of IV thrombolysis in our stroke unit.

Methods:

All stroke patients admitted in our hospital from October 2008 to April 2017 were included in this study. Data were collected prospectively by trained research staff in a detailed case record form. Outcome was assessed using modified Rankin Scale (mRS, 0–1 good outcome).

Results:

Of the total 4720 stroke patients seen, 944 (20%) came within window period (<4.5 h). Of these, 214 (4.5%) were eligible for thrombolysis and 170 (3.6%) were thrombolysed, relatives of 23 (23/214, 10.7%) patients denied consent, and 21 (9.8%) patients could not afford tPA. The mean age of thrombolysed patients was 58.4 (range 19–95) years. Median NIHSS at admission was 12 (interquartile range 2–24). Average onset-to-door (O-D) time was 76.8 (5–219) min, door-to-examination (D-E) time was 17.8 (5–105) min, door-to-CT (D-CT) time was 48 (1–205) min, and door-to-needle (D-N) time was 90 (20–285) min. At 6 months, 110 (64.7%) patients were contactable and 82 (74.5%) patients had good outcome (mRS 0–1).

Conclusion:

Thrombolysis rate has steadily increased at the center without undue adverse effects even in the elderly. D-E and D-CT times have reduced, but O-D and D-N times need further improvement. More patients could be thrombolysed if the cost of tPA is reduced and the consent process is waived.

Intravenous recombinant tissue plasminogen activator for acute ischemic stroke: a feasibility and safety study

Background

In developing countries, intravenous thrombolysis (IVT) is available at a limited number of centers. This study aimed to assess the feasibility and safety of IVT at Tabriz Imam Reza Hospital.

Methods

In a prospective study, over a 55-month period, any patient at the hospital for whom stroke code had been activated was enrolled in the study. Data on demographic characteristics, stroke risk factors, admission blood pressure, blood tests, findings of brain computed tomography (CT) scans, time of symtom onset, time of arrival to the emergency department, time of stroke code activation, time of CT scan examination, and the time of recombinant tissue plasminogen activator administration were recorded. National Institutes of Health Stroke Scale assessments were performed before IVT bolus, at 36 hours, at either 7 days or discharge (which ever one was earlier), and at 3-month follow-up. Brain CT scans were done for all patients before and 24 hours after the treatment.

Results

Stroke code was activated for 407 patients and IVT was done in 168 patients. The rate of functional independence (modified Rankin Scale [mRS] 0–1) at 3 months was 39.2% (62/158). The mortality rate at day 7 was 6% (10/168). Hemorrhagic transformation was noted in 16 patients (9.5%). Symptomatic intracranial hemorrhage occurred in 5 (3%), all of which were fatal. One case of severe urinary bleeding and one other fatal case of severe angioedema were observed.

Conclusion

During the first 4–5 years of administration of IVT in the hospital, it was found to be feasible and safe, but to increase the efficacy, poststroke care should be more organized and a stroke center should be established.

Factors influencing nonadministration of thrombolytic therapy in early arrival strokes in a university hospital in Hyderabad, India

BACKGROUND

It is a well-known fact that very few patients of stroke arrive at the hospital within the window period of thrombolysis. Even among those who do, not all receive thrombolytic therapy.

OBJECTIVE

The objectives of this study were to determine the proportion of early arrival ischemic strokes (within 6 h of stroke onset) in our hospital and to evaluate the causes of nonadministration of intravenous and/or intraarterial thrombolysis in them.

MATERIALS AND METHODS

Data of all early arrival acute stroke patients between January 2010 and January 2015 were included. Factors determining nonadministration of intravenous and/or intraarterial thrombolysis in early arrival strokes were analyzed.

RESULTS

Out of 2,593 stroke patients, only 145 (5.6%) patients presented within 6 h of stroke onset and among them 118 (81.4%) patients had ischemic stroke and 27 (18.6%) patients had hemorrhagic stroke. A total of 89/118 (75.4%) patients were thrombolyzed. The reasons for nonadministration of thrombolysis in the remaining 29 patients were analyzed, which included unavoidable factors in 8/29 patients [massive infarct (N = 4), hemorrhagic infarct (N = 1), gastrointestinal bleed (N = 1), oral anticoagulant usage with prolonged international normalized ratio (INR) (N = 1), and recent cataract surgery (N = 1)]. Avoidable factors were found for 21/29 patients, include nonaffordability (N = 7), fear of bleed (N = 4), rapidly improving symptoms (N = 4), mild stroke (N = 2), delayed neurologist referral within the hospital (N = 2), and logistic difficulty in organizing endovascular treatment (N = 2).

CONCLUSION

One-fourth of early ischemic stroke patients in our study were not thrombolyzed even though they arrived within the window period. The majority of the reasons for nonadministration of thrombolysis were potentially preventable, such as nonaffordability, intrahospital delay, and nonavailability of newer endovascular interventions.

Fifty years of stroke researches in India

Currently, the stroke incidence in India is much higher than Western industrialized countries. Large vessel intracranial atherosclerosis is the commonest cause of ischemic stroke in India. The common risk factors, that is, hypertension, diabetes, smoking, and dyslipidemia are quite prevalent and inadequately controlled; mainly because of poor public awareness and inadequate infrastructure. Only a small number of ischemic stroke cases are able to have the benefit of thrombolytic therapy. Benefits from stem cell therapy in established stroke cases are under evaluation. Presently, prevention of stroke is the best option considering the Indian scenario through control and/or avoiding risk factors of stroke. Interventional studies are an important need for this scenario.

Thrombolysis for acute ischemic stroke by tenecteplase in the emergency department of a Moroccan hospital

INTRODUCTION

Thrombolysis has radically changed the prognosis of acute ischemic stroke. Tenecteplase is a modified form of rt-PA with greater specificity for fibrin and a longer half-life. We report the experience of a Moroccan tertiary hospital in thrombolysis using Tenecteplase.

METHODS

We conducted an open prospective study of all patients who were treated with Tenecteplase for an acute ischemic stroke admitted to our emergency department. Tenecteplase was administered intravenously at a dose of 0.4 mg/kg single bolus. The primary outcome measure was the proportion of patients achieving significant early neurological recovery defined as an improvement of 4 or more points on the NIHSS score at 24h.

RESULTS

13 patients had been treated by intravenous thrombolysis. 31% were women. Mean age was 63 years old. The mean NIHSS score at admission was 14.3 and 24h after was at 9.1. The right middle cerebral artery was involved in 69% of cases. The carotid atherosclerosis was predominant 63.3% and the cardio embolic etiology 27%. The mean time to the first medical contact after the onset of symptoms was 3h 30 min. One patient presented a capsulo-lenticular hematoma of 5 mm(3) in the same side of the ischemic stroke.

CONCLUSION

Tenecteplase is a more interesting thrombolytic than alteplase, it seems to be more suitable for thrombolysis in our center.

Cost of stroke in low and middle income countries: a systematic review

BACKGROUND

There is limited information available from low and middle-income countries regarding the cost of stroke treatment. Hence, we aimed to review the costs of stroke in low and middle-income countries.

SUMMARY OF REVIEW

The literature search was done using databases: PubMed/Medline, Ovid, EconLit and Google Scholar from 1966 until January 2014 using key words 'economic impact of stroke', 'cost of illness in low and middle income countries' and 'cost of stroke'. With these key words, 10/184 articles were retained for this review. The cost data were converted to 2013 currency values using a web-based tool (CCEMG-EPPI-centre cost converter). Most of the included studies were conducted in Asia. The design of these studies was retrospective and conducted predominantly in multicenter private hospitals. The highest mean direct medical cost of stroke was US$ 8424 in Nigeria. The lowest mean cost of stroke was in Senegal (US$ 416). The average length of hospital stay was longest (20 days) in China. The main predictors of higher costs appeared to be due to differences in length of stay and stroke severity.

CONCLUSION

Costs of stroke are variable because of heterogeneous healthcare systems prevailing in low and middle-income countries. Length of hospital stay and stroke severity appear to be the main predictors of cost. Understanding the costs of stroke in low and middle-income countries is important. However, the evidence remains limited because there is a lack of standardized research. Future research should focus on using a uniform method across low and middle-income countries for estimating the costs of stroke.

Eligibility assessment for intravenous thrombolytic therapy in acute ischemic stroke patients; evaluating barriers for implementation

Background:

Intravenous thrombolysis is an approved treatment method for patients with acute ischemic stroke (AIS) and is recommended by multiple guidelines. However, it seems that it is less frequently used in the developing countries compared to the developed countries.

Objectives:

The purpose of this study was to estimate the percentage of patients with AIS, eligible for intravenous thrombolytic therapy, at the main referral center in Northwest Iran and to determine the main barriers for implementation of this method.

Patients and Methods:

Over one year, 647 patients who were admitted to the emergency department and met the Cincinnati Stroke Scale were enrolled into the study. The center to which patients were admitted, is a tertiary university hospital that has the required infrastructure for thrombolytic therapy in AIS. Factors recorded were neurological examinations and time between onset of symptoms and hospital arrival, hospital arrival and performance of brain computed tomography (CT) scanning, and hospital arrival to complete the investigations. Patients eligible for intravenous thrombolytic therapy were identified according to the American Heart Association (AHA) guidelines.

Results:

Mean time interval between hospital arrival and completion of brain CT scanning was 91 minutes (range: 20–378 minutes) and mean time from hospital arrival to completion of investigations was 150 minutes (range: 30–540 minutes). A total of 159 (31.3%) patients arrived at hospital within 3 hours of the onset of symptoms (early enough for intravenous thrombolytic therapy). However, 81.7% (130/159) of these patients missed thrombolytic therapy due to delayed performance of brain CT scanning and laboratory tests and 38.3% (61/159) had contraindications. The remaining 16 patients (10% of those who arrived within 3 hours and 3.1% of all cases) were eligible for thrombolytic therapy.

Conclusions:

The major barriers for thrombolytic therapy for patients with AIS in this setting were delays in the provision of in-hospital services, like initial patient assessment, CT scans or laboratory studies. These results were in contrast with previous reports.

Acute ischemic stroke: comparison of low-dose and standard-dose regimes of tissue plasminogen activator

Intravenous tissue plasminogen activator (IV-TPA), administered within 4.5 h of symptom onset, is the only therapeutic agent approved for achieving arterial recanalization in acute ischemic stroke. Current major guidelines recommend the use of a standard dose (0.9 mg/kg bodyweight; maximum 90 mg) of IV-TPA. However, comparable efficacy of IV-TPA was demonstrated in the observational studies from Japan when a lower dose (0.6 mg/kg bodyweight; maximum 60 mg) was used and later approved by the regulatory authorities. Although limited in numbers, considerable variations in the dose of IV-TPA are noted in recent publications from Asia, with variable results and optimal dose of TPA in Asia remains controversial. The authors present a systemic review of the existing literature and compare the efficacy and safety of standard-versus the low-dose IV-TPA therapy in acute ischemic stroke.

Thrombolysis for acute ischemic stroke in South Africa

BACKGROUND

Stroke is an important cause of death and disability in sub-Saharan Africa. Thrombolysis with recombinant tissue plasminogen activator (tPA) is the only effective therapy for acute ischaemic stroke. Essential requirements for stroke thrombolysis include availability of CT scanning and arrival at hospital within 4.5 hours of symptom onset. However, in developing countries where the prerequisites are met at certain centres, the efficacy and safety of thrombolysis have not been firmly established.

AIMS

We aimed to evaluate the early outcomes and safety of stroke thrombolysis in a South African setting.

METHOD

We conducted a prospective observational study of all stroke patients receiving tPA for thrombolysis over the period January 2000 to February 2011. The primary outcome measure was the proportion of patients achieving significant early neurological recovery defined as an improvement of four or more points on the NIHSS score at discharge. The safety endpoint was the rate of symptomatic intracranial haemorrhage (SICH) and death.

RESULTS

Forty-two patients received thrombolysis over the study period. Sixty-seven percent achieved significant neurological improvement. The majority of patients (53.8%) were discharged home, and by the time of discharge 17 (40.5%) were functionally independent. SICH occurred in 2 (4.8%) patients with an overall mortality rate of 7.1%.

CONCLUSIONS

Our findings indicate that the use of thrombolysis in routine clinical practice in a South African setting has similar safety and early efficacy outcomes to developed and other developing countries.

Postthrombolysis Outcomes in Acute Ischemic Stroke Patients of Asian Race-Ethnicity

Background

Race-ethnic differences may influence postthrombolysis outcomes in acute ischemic stroke patients. Guidelines for thrombolytic therapy to treat Asian stroke patients are based mostly on extrapolated western data.

Aims

We undertook to examine outcomes among Asians by comparing a propensity-matched cohort of thrombolyzed patients from a tertiary center in Singapore with nonthrombolyzed Asian comparators collated from Virtual International Stroke Trials Archives (control).

Methods

We identified propensity scores-matched patients between thrombolyzed and control Asian patients lodged in the Virtual International Stroke Trials Archives by employing propensity scores method. We compared matched patients for their distributions of three-month functional (modified Rankin scores) and neurological outcomes (National Institute of Health Stroke Scale) by employing Cochran–Mantel–Haenszel test and proportional odds logistic regression analysis. We report odds ratio and 95% confidence interval for improved outcomes on day 90.

Results

Virtual International Stroke Trials Archives and National University Hospital, Singapore, contributed 517 and 133 patients of Asian race-ethnicity ( n = 650), respectively. After propensity matching, sample size reduced to 237 patients; 104 were from Virtual International Stroke Trials Archives. Age (59·7 vs. 61·5 years, P = 0·2) and mean baseline National Institute of Health Stroke Scale scores were similar ( 14 ) between thrombolyzed and control. The odds ratio for shift toward improved modified Rankin scores and National Institute of Health Stroke Scale distributions after tissue plasminogen activator therapy were 2·8 (95% confidence interval 1·8–4·5, P < 0·0001, n = 233; Cochran–Mantel–Haenszel P < 0·0001) and 2·8 (95% confidence interval 1·7–4·7, P = 0·0008, n = 201; Cochran–Mantel–Haenszel P = 0·0001).

Conclusions

Our data indicate that Asian patients derive benefit from thrombolytic therapy.

Intravenous thrombolysis for acute ischemic stroke in Asia

Data regarding thrombolysis for acute ischemic stroke in Asia are scarce and only a small percentage of patients are thrombolysed. Clinical trials that led to the recommended dose of intravenously administered tissue plasminogen activator (IV-tPA) included predominantly Caucasian patients. However, the single-arm case-controlled observational studies in Japanese patients suggested the clinical efficacy and safety of low-dose IV-tPA (0.6 mg/kg bodyweight; maximum 60 mg) comparable with standard dose (0.9 mg/kg bodyweight; maximum 90 mg). There has been no randomized clinical trial for determining the dose, efficacy or safety of IV-tPA in Asia. Accordingly, the dose of IV-tPA in Asia remains controversial. Reduced treatment cost, lower symptomatic intracerebral hemorrhage risk and comparable efficacy encouraged many Asian centers to adopt low-dose or even variable-dose IV-tPA regimens. We present the current status of thrombolysis for acute ischemic stroke in Asia.

Current Status of Intravenous Thrombolysis for Acute Ischemic Stroke in Asia

Background

Data regarding thrombolysis for acute ischemic stroke in Asia are scarce and only a small percentage of patients are thrombolysed. The dose of intravenous tissue plasminogen activator (IV-tPA) in Asia remains controversial. Case-controlled observation studies in Asia included only Japanese patients and suggested the clinical efficacy and safety of low-dose IV-tPA (0·6 mg/kg body weight; max 60 mg) comparable to standard dose (0·9 mg/kg body weight; max. 90 mg). Reduced treatment cost, lower symptomatic intracerebral hemorrhage risk and comparable efficacy encouraged many Asian centers to adopt low-dose or even variable-dose IV-tPA regimens. We evaluated various Asian thrombolysis studies and compared with SITS-MOST registry and NINDS trial.

Methods

We included the published studies on acute ischemic stroke thrombolysis in Asia. Unadjusted relative risks and 95% Confidence intervals were calculated for each study. Pooled estimates from random effects models were used because the tests for heterogeneity were significant.

Results

We found only 18 publications regarding acute ischemic stroke thrombolysis in Asia that included total of 9300 patients. Owing to ethnic differences, stroke severity, small number of cases in individual reports, outcome measures and tPA dose regimes, it is difficult to compare these studies. Functional outcomes were almost similar (to Japanese studies) when lower-dose IV-tPA was used in non-Japanese populations across Asia. Interestingly, with standard dose IV-tPA, considerably better functional outcomes were observed, without increasing symptomatic intracerebral hemorrhage rates.

Conclusions

Variable dose regimens of IV-tPA are used across Asia without any reliable or established evidence. Establishing a uniform IV-tPA regimen is essential since the rapid improvements in health-care facilities and public awareness are expected to increase the rates of thrombolysis in Asia.

Hospital-based management of acute ischemic stroke following intravenous thrombolysis

Timely administration of proven therapies remains the primary goal in acute stroke care. Following reperfusion therapy with intravenous thrombolysis, medical and neurological complications may develop in the hospitalized patient with acute ischemic stroke. Medical complications may include deep venous thrombosis, pulmonary embolism, aspiration, systemic infections and neuropsychiatric disturbances. Neurologic complications may include symptomatic intracranial hemorrhage, cerebral edema with elevated intracranial pressure, and post-stroke seizures. Early initiation of preventative strategies and proper management of common complications may improve both short-term and long-term outcomes. Here we review evidence-based management strategies for hospitalized acute ischemic stroke patients following intravenous thrombolysis.

Barriers of thrombolysis therapy in developing countries

The developing world carries the highest burden of stroke mortality and stroke-related disability. The number of stroke patients receiving r-tPA in the developing world is extremely low. Prehospital delay, financial constraints, and lack of infrastructure are main barriers of thrombolysis therapy in developing countries. Until a cheaper thrombolytic agent and the proper infrastructure for utilization of thrombolytic therapy is available, developing countries should focus on primary and secondary stroke prevention strategies. However, governments and health systems of developing countries should efforts exerb for promotion of their infrastructure of stroke care.

Hyperacute thrombolysis with recombinant tissue plasminogen activator of acute ischemic stroke: feasibility and effectivity from an Indian perspective

Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries like India, especially in areas such as western Utter Pradesh, where it is overly crowded and there is poor affordability.

AIM

This study was done to evaluate recombinant tissue plasminogen activator r-tpa in acute ischemic stroke in hyper acute phase, in selected patients of western Utter Pradesh, in terms of feasibility and effectivity.

DESIGN

Open, non randomized study.

MATERIALS AND METHODS

Thirty two patients were classified using Trial of ORG 10172 in Acute Stroke treatment (TOAST) criteria (large artery atherosclerotic = 8; cardio embolic = 6; small vessel occlusion = 14; other determined etiology = 2; undetermined etiology = 2). The mean time to reach the hospital was 2 h (1.15-3.0), the mean door to CT scan 20 min (10-40) and door to r-tpa injection was 30 min (24-68). The National Institute of Health Stroke Scale (NIHSS) scores ranged from 11-22 (mean 15.5 +2.7). The dose of r-tpa administered was 0.9 mg/kg.

RESULTS

Twenty one patients (65.6%) showed significant improvement on the NIHSS score, at 48 h (4 points). (Mean change = 10; range = 4-17). At one month, 25 (78%) recorded improvement on the Barthel index (mean change = 45%). One developed frontal lobe hemorrhage and another developed recurrent stroke; one died of aspiration; and four showed no improvement. Modified Rankin score (m RS) was administered at the end of three months to 28 patients (90%); however, the rest could not be directly observed. The average modified Rankin Score was 1.2 (0-2).

CONCLUSIONS

Hyperacute thrombolysis was found feasible and effective in selected patients with AIS from western Utter Pradesh and who had poor affordability.