Hurdles in stroke thrombolysis: Experience from 100 consecutive ischemic stroke patients

Badachi, Sagar; Mathew, Thomas; Prabhu, Akshata; Nadig, Raghunandan; Sarma, G.R.K.

doi:10.4103/0972-2327.165460

Cited by 15 publications

(11 citation statements)

References 27 publications

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“…Infrastructure deficiencies and lack of human resources impede stroke care delivery in India. [ 28 ] The government needs to make amends and implement insurance policies so that health-care expenses are not largely out of one's own pocket. [ 29 30 ]…”

Section: Discussionmentioning

confidence: 99%

Factors delaying management of acute stroke: An Indian scenario

Abraham

Krishnan

Thaha

et al. 2017

Int J Crit Illn Inj Sci

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Background and Purpose:The purpose of this study was to assess factors causing delay in treatment of acute stroke in a tertiary care institute in South India.Methods:All clinically suspected cases of acute stroke presenting to the emergency department over a period of 1 year were prospectively followed up and data collected as per a preset pro forma. The various time intervals from stroke onset to definitive management and other pertinent data were collected. The time delays have been evaluated in the decision tree model: Chi-squared Automatic Interaction Detection. Significance was assessed at 5% level of significance (P < 0.05).Results:The mean prehospital time delay for all clinically suspected stroke (n = 361) in our institute was 716 min and the median time 190 min. The mean total in-hospital delay was 94.17 ± 54.5 min and median time being 82 min. The onset of symptoms to first medical contact was the main interval that influenced the prehospital delay. Computed tomographic (CT) diagnosis to stroke unit admission influenced the in-hospital delay the most.Conclusions:Lack of awareness regarding stroke leads to delayed seeking of treatment for the same. The factors that contribute to the in-hospital delay included patient admission procedure delay, lack of staff to transport the patient, and the distance between the stroke unit and CT room. Educating the community with regard to “stroke” and implementation of a better pre- and in-hospital stroke care system is a need of the hour in the country.

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Section: Discussionmentioning

confidence: 99%

Factors delaying management of acute stroke: An Indian scenario

Abraham

Krishnan

Thaha

et al. 2017

Int J Crit Illn Inj Sci

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“…The overall crude prevalence rate of stroke in Egypt is 963/100,000 inhabitants [2]. In 1996, the Food and Drug Administration (FDA) had approved IV r-tPA as the only therapy for early acute ischemic stroke (AIS) management and since this date, many efforts have been spent to reduce the stroke onset/needle time owing to the narrow therapeutic window of the drug [3].…”

Section: Introductionmentioning

confidence: 99%

Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience

Bahnasy

Elhassanien

2019

eNeurologicalSci

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BackgroundThe use of intravenous recombinant tissue plasminogen activator (IV r-tPA) in early acute ischemic stroke (AIS) management faces a lot of difficulties in developing countries due to lessened guideline development with consecutive pre- and intra-hospital delay.ObjectivesThe objective was to identify the barriers facing proper utilization of IV r-tPA for AIS in Tanta University Hospitals.MethodsThe study was conducted on 4124 AIS patients eligible to use IV r-tPA divided to group-I consisting of 442 patients who arrived the hospital within <3.5 h from the stroke onset and group-II consisting of 3682 patients who arrived >3.5 h from the stroke onset. The former group was further subdivided to 238 patients who received IV r-tPA (group-Ia) and 204 patients who did not receive IV r-tPA (group-Ib) due to different obstacles.ResultsThe main causes of pre-hospital onset to arrival delay were stroke unawareness, long travel time, incorrect beliefs, non-available neurologists, stroke onset during sleep and multiple causes (18.2%, 20.5%, 12.7%, 9.1%, 16% and 23.5% of cases, respectively). Causes of non-administration of IV r-tPA in eligible patients includes prolonged door-to-needle time, financial restraints, minor strokes, unavailable beds and fear of complications (41.2%, 26%, 12.7%, 11.3% and 8.8%, respectively).ConclusionIncreasing the chance of utilizing IV r-tPA for AIS patients' needs regular updating of the stroke chain of survival system to get the highest benefits from the available resources.

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“…While seamless processes to ensure efficiency in initial brain scanning have already been established in high-income countries, limitations in resources and logistics are still problematic most especially in rural areas of low to middle-income countries (48, 49). For example, a tertiary centre in India identified that the lack of neuroimaging facilities posed as one of the most important barriers for thrombolysis, with even the out of pocket cost for CT scan contributing to this limitation (50). It is also practical for other countries such as Sri Lanka, Serbia(51), South Africa and Malaysia not to put too much weight on neurovascular imaging as inaccessibility to neuro-interventionists and comprehensive stroke centres, as well as the high cost of treatment for this sophisticated procedure(51, 52), is still one of the identified problems in most developing countries (53).…”

Section: Resultsmentioning

confidence: 99%

Scoping Review of Existing Stroke Guidelines; Argument for a Value-Added Change

Wijeratne

Sales

Jakovljević

et al. 2021

Preprint

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Background and Purpose: Stroke represents one of the most important causes of morbidity (eighty million patients with disabling of ongoing effects of stroke at a given time, globally) and mortality (the second leading cause of death) worldwide. Innovative systems biology-based approach is likely to increase the understanding of the underpinning of acute stroke promise to enhance stroke prevention, acute treatment, and neurorehabilitation. Recent growing body of evidence with shared pathobiology with COVID-19 and the critically important role of inflammation in the context of stroke points to far-reaching consequences of acute stroke, just as in the case of COVID-19 ( post-acute event issues as well as long term issues ). So far, stroke typically defined by late-appearing disease manifestation by the range of stroke subtypes as defined by the WHO or American Stroke Association. This definition neglects the underlying pathobiological mechanisms such as low-grade chronic inflammation and already compromised vascular system. Diseases such as stroke is hardly a simple result of a single problem, but rather a complex cascade of pathobiological processes and interactions in a complex biochemical environment. The evidence of changes in innate immunity and adaptive immunity during the index event of acute stroke and recovery over next 3-12 months can be easily elicited with simple bedside blood tests such as neutrophil-lymphocyte ratio (NLR) with well over 300 published papers including several systematic reviews and meta-analyses confirming this. Global standard operating procedures (SOP) of stroke care dictated by the national and international stroke guidelines at present. It is imperative to explore the evidence of systems biology approach in current stroke guidelines. This is likely to be a key turning point in managing stroke across the continuum (prevention, management of acute event and rehabilitation). Methods: We systematically searched for guideline recommendation on the day-to-day use of peripheral inflammatory markers such as NLR published in the English language between January 1, 2005, and December 2020. Any other evidence of systems biology-based approach or recommendation was explored within the selected guidelines for this scoping review. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 4 authors to determine clinical scenarios explained/given, scientific evidence used, and recommendations presented in the context of systems biology. Results: The scoping review found 3,830 (3830) titles with 119 guidelines from 46 countries included for this review (Figure 1; PRISMA diagram). Stroke-related organizations wrote Sixty-five per cent of the guidelines while national ministries wrote a fewer number of guidelines. We were primarily interested in recommendations for acute management in AIS published in the English language. Fifteen eligible guidelines were identified from 15 different countries/regions. None of the guidelines recommended the routine use of peripheral markers of inflammation, such as NLR, among their acute assessment and management recommendations. None of the existing guidelines explored the systems biology approach to one of the most complex diseases affecting the human brain, stroke. Conclusions: This systematic review has identified a significant evidence-practice gap in all existing national stroke guidelines published in English medium as of October 2020. These guidelines included the only current living stroke guidelines, Stroke Guidelines from Australia with a real opportunity to modernize the living stroke guidelines with systems biology approach and provide 2020 vision towards better stroke care globally. Investigation of complex disease such as stroke is best served through a systems biology approach. One of the easiest places to start is simple blood tests such as total white cell count and NLR. Systems biology approach point us towards simple tools such immune-inflammatory index (SII), Sunshine Prognostic Score (SPS) which should pave the way for the stroke physician community address the challenges in systems biology approach in stroke care. These challenges include translating bench research to the bedside, managing big data ( continuous pulse, blood pressure, sleep, Oxygen saturation, progressive changes in NLR, SII, SPS, etc.). Working with an interdisciplinary team is also provide a distinct advantage.

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Hurdles in stroke thrombolysis: Experience from 100 consecutive ischemic stroke patients

Cited by 15 publications

References 27 publications

Factors delaying management of acute stroke: An Indian scenario

Factors delaying management of acute stroke: An Indian scenario

Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience

Scoping Review of Existing Stroke Guidelines; Argument for a Value-Added Change

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