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Category: Volume 08 Issue 10 October 2020
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Title: Thrombolysis with Alteplase in Acute Ischemic Stroke: A Case Series from A Tertiary Care Centre in Bangladesh

Authors: Dr Ghulam Kawnayn, Dr Humayun Kabir

 DOI: https://dx.doi.org/10.18535/jmscr/v8i10.02

Abstract

Background: Alteplase is the only licensed thrombolytic agent for the treatment of acute ischemic stroke. The body of evidence to date suggests that it reduces the number of stroke patients who are dead or dependent at follow up, despite the risk of intracranial hemorrhage.

Objective: The objective of this study was to report our early experience of thrombolysis with alteplase in a case series of acute ischemic stroke.

Material and Methods: In this case series, profile of patients, onset to hospital time, onset to needle time and door to needle time, and effectiveness and safety of thrombolysis with standard dose (0.9 mg/kg) of alteplase in acute ischemic stroke is reported. Effectiveness of thrombolysis was evaluated by assessing change in National Institutes of Health Stroke score (NIHSS) score. Safety and tolerability of alteplase was evaluated by recording adverse events.

Results: A total of 10 patients (male n=6, female n=4) with mean age of 63.8 (range 38-84) years were included in this series. Hypertension, diabetes and ischemic heart disease was present in 7(70%), 5(50%) and 2(20%) cases. The mean onset to hospital time, mean onset to needle time and mean door to needle time was 83 (range 0-150) minutes, 187(range 75-240) and 104(range 40-195) minutes. The mean pre-thrombolysisscore was 25.8 which decreased to 8.8 after thrombolysis. Alteplase was well tolerated without any serious adverse event.

Conclusion: Our initial results with standard dose of alteplase (0.9 mg/kg) as thrombolytic agent are promising. Alteplase was found to be effective in improvement of NIHSS score without risk of serious adverse events.

Keywords: Alteplase, ischemic stroke, thrombolysis.

References

  1. GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol2019; 18: 439–58
  2. Islam MN, Moniruzzaman M, Khalil MI, Basri R, Alam MK, Loo KW. Burden of stroke in Bangladesh. Int J Stroke 2013; 8:211-3
  3. Katan M, Luft A. Global burden of stroke. SeminNeurol2018; 38:208-11
  4. Mamin FA, Islam MS, Rumana FS, Faruqui F. Profle of stroke patients treated at a rehabilitation centre in Bangladesh. BMC Res Notes 2017; 10:520
  5. Giang KW, Mandalenakis Z, Nielsen S, Bjorck L, Lappas G, Adiels M, et al. Long-term trends in the prevalence of patients hospitalized with ischemic stroke from 1995 to 2010 in Sweden. PLoS ONE 2017;12: e0179658
  6. Feigin VL, Florouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet. 2014; 383: 245–254
  7. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007; 38:967-73
  8. Kassem-Moussa H, Graffagnino C. Nonocclusion and spontaneous recanalization rates in acute ischemic stroke: a review of cerebral angiography studies. Arch Neurol2002; 59:1870-3
  9. Fugate JE, Rabinstein AA. Absolute and relative contraindications to IV rt-PA for acute ischemic stroke. The Neurohospitalist2015; 5:110-21
  10. Dhillon S. Alteplase: a review of its use in the management of acute ischaemic stroke. CNS Drugs 2012; 26:899-926
  11. Syalaja PN, Dong W, Grotta JC, Miller MK, Tomita K, Hamilton S, et al. Safety outcomes of alteplase among acute ischemic stroke patients with special characteristics. Neurocrit Care 2007; 6:181-5
  12. Anderson CS, Robinson T, Lindley RI, Arima H, Lavados PM, Lee TH, et al. Low-dose versus standard-dose intravenous alteplase in acute ischemic stroke. N Engl J Med 2016; 374:2313-23
  13. Chao AC, Han K, Lin SF, Lin RT, Chen CH, Chan L, et al. Low-dose versus standard-dose intravenous alteplase for octogenerian acute ischemic stroke patients: A multicenter prospective cohort study. J NeurolSci2019; 399:76-81
  14. Yamaguchi T, Mori E, Minematsu K, Nakagawara J, Hashi K, Saito I, et al. Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT). Stroke 2006; 37:1810-5
  15. Bahnasy WS, Ragab OAA, Elhassanien ME. Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience. eNeurologicalSci 2019;14: 68–71
  16. Ma AJ, Dong Z, Li G. Prevalence rates and risk factors on stroke among 50 - 79 years-olds in Beijing, 2011. Zhonghua Liu Xing Bing XueZaZhi2012; 33:645-8
  17. Micieli G, Marcheselli S, Tosi PA. Safety and efficacy of alteplase in the treatment of acute ischemic stroke. Vac Health Risk Manag2009; 5:397-409Owais M, Panwar A, Valupadas C, Veeramalla M. Acute ischemic stroke thrombolysis with tenecteplase: an institutional experience from South India. Ann Afr Med 2018; 17:90-3
  18. Miller DJ, Simpson JR, Silver B. Safety of thrombolysis in acute ischemic stroke: A review of complications, risk factors, and newer technologies. The Neurohospitalist 2011; 1:138-147
  19. Lindley RI, Wardlaw JM, Whiteley WN, Cohen G, Blackwell L, Murray GD, et al. Alteplase for acute ischemic stroke: outcomes by clinically important subgroups in the Third International Stroke Trial. Stroke 2015; 46:746-56
  20. William AG, Pannu A, Kate MP, Jaison V, Gupta L, Bose S, et al. Quality indicators of intravenous thrombolysis from North India. Ann Indian AcadNeurol2017; 20:393-98.
  21. Lees KR, Emberson J, Blackwell L, Bluhmki E, Davis SM, Donnan GA, et al. Effects of alteplase for acute stroke on the distribution of functional outcomes: a pooled analysis of nine trials. 2016; 47: 2373–2379
  22. Mehta A, Mahale R, Buddaraju K, Majeed A, Sharma S, Javali M, et al. Intravenous thrombolysis for acute ischemic stroke: Review of 97 patients. J Neurosci Rural Pract2017; 8:38-43
  23. Zinkstok SM, Beenen LF, Luitse JS, Majoie CB, Nederkoorn PJ, Roos YB. Thrombolysis in Stroke within 30 Minutes: Results of the Acute Brain Care Intervention Study. PLoS ONE 2016;11: e0166668. doi:10.1371/journal. pone.0166668
  24. Gurav SK, Zirpe KG, Wadia RS, Naniwadekar A, Pote PU, Tungenwar A, et al. 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. Indian J Crit Care Med 2018; 22:243-48

Corresponding Author

Dr Ghulam Kawnayn

Lt Colonel, FCPS (Medicine), Classified Specialist, CMH, Dhaka, Bangladesh