Thrombolysis risk prediction : applying the SITS-SICH and SEDAN scores in South African patients : cardiovascular topic

Abstract

At present, the only specific medical treatment for acute ischaemic stroke is intravenous administration of recombinant tissue plasminogen activator within 4.5 hours of stroke onset. In the last year, two scores for risk stratification of intracranial haemorrhage have been derived from multicentric European trial groups, the Safe Implementation of Treatment in Stroke – Symptomatic IntraCerebral Haemorrhage risk score (SITS-SICH) and the SEDAN score. The aim of this study was to pilot their use in a cohort of patients treated at a South African tertiary hospital.Prospectively collected data were used from a cohort of 41 patients who underwent thrombolysis at Groote Schuur Hospital from 2000 to 2012. Computerised tomography brain imaging was available for review in 23 of these cases. The SITS-SICH and SEDAN scores were then applied and risk prediction was compared with outcomes.Two patients suffered symptomatic intracranial haemorrhage (SICH), representing 4.9% (95% CI: 0–11.5%) of the cohort. This was comparable to the SICH rate in both the SITS-SICH (5.1%) and SEDAN (6.5%) cohorts. Patient scores in the Groote Schuur Hospital cohort appeared similar to those of the validation cohorts of both SITS-SICH and SEDAN.With increasing use of thrombolysis in a resource-constrained setting, these scores represent a potentially useful tool in patient selection of those most likely to benefit from intravenous thrombolysis, reducing risk for SICH and with the added benefit of curtailing cost.

Not only the Sugar, Early infarct sign, hyperDense middle cerebral artery, Age, Neurologic deficit score but also atrial fibrillation is predictive for symptomatic intracranial hemorrhage after intravenous recombinant tissue plasminogen activator

“…[10] Moreover, this score was also validated in African and European population. [17,18,23] For safety reason, the rate of sICH after i.v. rt-PA, as recommended by standard guidelines, should not exceed 7% in certified primary stroke center.…”

“…[16] Most of the tool scores have been validated in diverse population, however, the accuracy of the scores is lower than which of the original reports. [10,13,17,18,22,23,33]…”

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

“…Of the four eligible studies, there were no experimental studies; two were retrospective cohort studies [ 41 , 42 ], a prospective cohort study [ 43 ] and a case series study [ 44 ]. Three of the studies reported on thrombolytic therapy using recombinant tissue plasminogen activator [ 42 – 44 ] and the remaining study focused on stroke unit care [ 41 ]. Three of the eligible studies were conducted in South Africa [ 41 – 43 ] and the other in Morocco [ 44 ].…”

“…Despite accounting for confounding factors in the cohort studies, only one study [ 42 ] accounted for it in the analysis. Also, the retrospective nature of two of the cohort studies [ 41 , 42 ], where outcomes were reportedly based on a chart review of medical records, could bias the results by potentially underestimating or overestimating the final outcomes. All included studies contained small and unrepresentative patient samples which limited their generalisability.…”

“…Three studies reported on thrombolytic therapy for acute stroke care, two in South Africa [ 42 , 43 ] and another in Morocco [ 44 ]. The first study evaluated outcomes and safety of thrombolysis among 42 patients thrombolysed using t-PA in a tertiary academic hospital [ 43 ].…”