Thrombolysis in acute ischemic stroke: Experience from a tertiary care centre in India

Abstract

The management of acute ischemic stroke has undergone a sea of change with the introduction of intravenous thrombolysis (IVT). Current guidelines state that the window period for IVT using rTPA is 4.5 hours. The MERCI, Multi Merci, and Penumbra trials in which patients with acute ischemic stroke were treated using endovascular treatment demonstrated better recanalisation in patients having a large vessel occlusion. However, recently published data from the three large trials IMS 3, Synthesis Expansion, and MR rescue, which compared endovascular treatment with intravenous therapy, failed to demonstrate superiority of endovascular treatment over IVT. In these trials, stent retrievers were used in very few patients. We present our results from a tertiary care center in India where patients are treated using intravenous as well as endovascular modalities. Among the 53 patients with acute ischemic stroke treated between 2010 and 2012, 23 were treated with IVT and 30 with endovascular methods. Stent retriever was used in majority of the endovascular cases.Aims:To compare the outcomes of acute ischemic stroke patients treated with IVT versus those who were managed using endovascular therapy. To evaluate outcomes of patients with acute ischemic stroke with a large vessel occlusion in whom endovascular modalities were used and to compare them with those of patients who were treated with IVT in presence of a large vessel occlusion.Settings and Design:Data of patients who underwent thrombolysis at our centre was collected over a 3-year period, that is, from 2010 to 2012. Endovascular treatment was done by an interventional neurologist.Materials and Methods:Data of patients with acute ischemic stroke who underwent IVT or endovascular treatment at our centre between 2010 and 2012 was analyzed. Parameters included age, National Institutes of Health Stroke Scale (NIHSS) on admission, door to needle time, stroke subtype, modality of treatment, outcome based on modified Rankin Scale (mRS) Score at 90 days follow up and mortality rates at 90 days.Statistical Analysis:Tabulated results were analysed using INSTAT Graphpad analyser. Data were analysed using paired and unpaired t-test, Chi-square test, and Fishers test as applicable. P value was considered significant when it was <0.05.Results:Upon comparison of the outcomes of patients with acute ischemic stroke and large vessel disease treated with endovascular therapy with those treated with IVT, it was found that the former group had better outcomes. We also found that in spite of there being a significant difference in the NIHSS on admission and a significant difference in the door to needle time, the outcomes of patients treated using intravenous or endovascular therapy were similar. There was no statistically significant difference in mortality rates between intravenous and endovascular groups.Conclusions:IVT is currently the standard of care in the management of acute ischemic stroke. Endovascular treatment during the window period is reserved for those patients with contraind...

Congenital macrothrombocytopenia is a heterogeneous disorder in India

“…Data were analysed using INSTAT Graphpad analyser (graphpad.com/scientific-software/instat/) using Spearman's rank correlation method. P-values < 0.05 were considered significant [13].…”

Thrombolytic or endovascular therapy for acute ischemic stroke: Time is brain

“…Authors showed that patients with acute ischemic stroke and large vessels occlusion with no evidence of cross flow through circle of Willis collaterals benefit more from endovascular treatment in comparison with systemic trombolysis. [ 4 ]…”

“…This observation was confirmed in the study of Huded and coworkers. [ 4 ] Namely, patients who underwent intravenous thrombolysis with documented large vessel disease, with no cross flow on angiogram (insufficient collateral circulation), had less favorable early and delayed outcome as compared to patients treated with endovascular modalities.…”

“…Authors showed that the “door to needle” time in the endovascular group was significantly longer (218 minutes) compared with the IV tPA group (137 minutes). [ 4 ]…”

Commentary

“…This approach led to improve acute stroke management proposing the broad using of reperfusion therapies and recommend acute stroke care in the setting of stroke units. [ 3 4 5 ]…”