Barriers of thrombolysis therapy in developing countries

Mechanical Thrombectomy Workshops Improve Procedural Knowledge and Skills Among Neurointerventional Teams in Low- to Middle-Income Countries

BACKGROUND

While mechanical thrombectomy (MT) is proven to be lifesaving and disability sparing, there remains a disparity in its access in low- to middle-income countries. We hypothesized that team-based MT workshops would improve MT knowledge and skills.

METHODS

We designed a 22-hour MT workshop, conducted as 2 identical events: in English (Jamaica, January 2022) and in Spanish (Dominican Republic, May 2022). The workshops included participating neurointerventional teams (practicing neurointerventionalists, neurointerventional nurses, and technicians) focused on acute stroke due to large vessel occlusion. The course faculty led didactic and hands-on components, covering topics from case selection and postoperative management to device technology and MT surgical techniques. Attendees were evaluated on stroke knowledge and MT skills before and after the course using a multiple choice exam and simulated procedures utilizing flow models under fluoroscopy, respectively. Press conferences for public education with invited government officials were included to raise stroke awareness.

RESULTS

Twenty-two physicians and their teams from 8 countries across the Caribbean completed the didactic and hands-on training. Overall test scores (n=18) improved from 67% to 85% (P<0.002). Precourse and postcourse hands-on assessments demonstrated reduced time to completion from 36.5 to 21.1 minutes (P<0.001). All teams showed an improvement in measures of good MT techniques, with 39% improvement in complete reperfusion. Eight teams achieved a Thrombolysis in Cerebral Infarction score of 3 on pre-course versus 15 of 18 teams on post-course. There was a significant reduction in total potentially dangerous maneuvers (70% pre versus 20% post; P<0.002). Universally, the workshop was rated as satisfactory and likely to change practice in 93% Dominican Republic and 75% Jamaica.

CONCLUSIONS

A team-based hands-on simulation approach to MT training is novel, feasible, and effective in improving procedural skills. Participants viewed these workshops as practice-changing and instrumental in creating a pathway for increasing access to MT in low- to middle-income countries.

Developing Systems of Care for Stroke in Resource-limited Settings

Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.

Identifying factors in the provision of intravenous stroke thrombolysis in Malaysia: a multiple case study from the healthcare providers' perspective

BACKGROUND

Translation into clinical practice for use of intravenous thrombolysis (IVT) for the management of ischemic stroke remains a challenge especially across low- and middle-income countries, with regional inconsistencies in its rate. This study aimed at identifying factors that influenced the provision of IVT and the variation in its rates in Malaysia.

METHODS

A multiple case study underpinning the Tailored Implementation for Chronic Diseases framework was carried out in three public hospitals with differing rates of IVT using a multiple method design. Twenty-five in-depth interviews and 12 focus groups discussions were conducted among 89 healthcare providers, along with a survey on hospital resources and a medical records review to identify reasons for not receiving IVT. Qualitative data were analysed using reflective thematic method, before triangulated with quantitative findings.

RESULTS

Of five factors identified, three factors that distinctively influenced the variation of IVT across the hospitals were: 1) leadership through quality stroke champions, 2) team cohesiveness which entailed team dynamics and its degree of alignment and, 3) facilitative work process which included workflow simplification and familiarity with IVT. Two other factors that were consistently identified as barriers in these hospitals included patient factors which largely encompassed delayed presentation, and resource constraints. About 50.0 - 67.6% of ischemic stroke patients missed the opportunity to receive IVT due to delayed presentation.

CONCLUSIONS

In addition to the global effort to explore sustainable measures to improve patients' emergency response for stroke, attempts to improve the provision of IVT for stroke care should also consider the inclusion of interventions targeting on health systems perspectives such as promoting quality leadership, team cohesiveness and workflow optimisation.

Deciphering the contextual barriers to mainstreaming the implementation of stroke thrombolysis in a Ghanaian hospital: Findings from the activate mixed-methods study

BACKGROUND

Each year, stroke-related death and disability claim over 143 million years of healthy life globally. Despite accounting for much of the global stroke burden, acute stroke care in Low-and-Middle-Income Countries remains suboptimal. Thrombolysis, an effective treatment option for stroke, is only received by a minority of stroke patients in these settings.

AIM

To determine the context-specific barriers and facilitators for the implementation of mainstream stroke thrombolysis in a Ghanaian hospital.

METHODS

We employed a mixed-methods approach involving key stakeholders (recipients, providers, and leaders) in the acute stroke care continuum. Surveys were administered to acute stroke patients, and in-depth key informant interviews were conducted with experts in stroke care, including a neurologist, medical director, neurology residents, a stroke nurse, emergency physicians, a radiologist, and a pharmacist. The data collected from these interviews were transcribed and analysed using content analysis with the CFIR (Consolidated Framework for Implementation Research) model as a guiding template. Two independent coders were involved in the analysis process to ensure reliability and accuracy.

RESULTS

The stroke thrombolysis rate over a 6-month period was 0.83% (2 out of 242), with an average door-to-needle time among thrombolyzed patients being 2 hours, 37 minutes. Only 12.8% of patients (31 out of 242) presented within 4.5 hours of stroke symptom onset. The most significant obstacle to the implementation of acute stroke thrombolysis was related to the characteristics of the individuals involved, notably delays in presenting to the hospital among stroke patients due to a lack of knowledge about stroke symptoms and cultural beliefs. Additionally, a significant bottleneck that contributed to the discrepancy between the number of patients who presented within the 4.5-6 hour window and the number of patients who actually received thrombolysis was the inability to pay for the cost of thrombolytic agents. This was followed by challenges in the implementation processes.

CONCLUSIONS

Addressing challenges related to stroke awareness, and financial constraints via multi-level stakeholder engagement, and enactment of stroke protocols are crucial steps in ensuring a successful implementation of a stroke thrombolysis program in a resource-limited setting.

Stumbling Blocks to Stroke Thrombolysis: An Indian Perspective

Background and purpose

Stroke is a leading cause of morbidity and mortality worldwide. Developing countries, however, still lag behind in providing timely thrombolytic therapy (TLT) to many eligible patients owing to various reasons. This study aims to identify such factors.

Materials and methods

This was a descriptive observational study undertaken over a period of 18 months at a tertiary care teaching hospital and included 252 acute ischemic stroke patients of which 200 were not thrombolyzed. The reasons for nonthrombolysis were recorded and analyzed.

Results

The study included 252 acute ischemic stroke patients of which only 20% were thrombolyzed. Of the 200 nonthrombolyzed patients, 55% arrived out of the window period while patient-related factors were the second biggest factor preventing thrombolysis. Hospital factors at 14% and financial constraints at 4.5% contributed significantly. Delayed consent emerged as an important factor making 6% of the delays.

Conclusion

Stroke thrombolysis still faces various pre- and intrahospital barriers in India. There is an urgent need to improve infrastructure and organizational streamlining to enable eligible patients to receive prompt treatment.

How to cite this article

Shah A, Diwan A. Stumbling Blocks to Stroke Thrombolysis: An Indian Perspective. Indian J Crit Care Med 2023;27(9):616-619.

Comparison of Effectiveness and Safety of Low-Dose Versus Standard-Dose Intravenous Recombinant Tissue Plasminogen Activator in Patients With Acute Ischemic Stroke: A Meta-Analysis

The aim of the present meta-analysis is to compare the efficacy and safety of low-dose and standard-dose recombinant tissue plasminogen activators (r-tPA) in patients with acute ischemic stroke. The present meta-analysis was conducted according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted a systematic search in PubMed, Embase, and the Cochrane Library to identify studies published between January 1, 2010, and January 31, 2023, using the following terms: "stroke," "alteplase," "doses," "efficacy," "tissue plasminogen activator," "r-tPA," and "safety." Primary efficacy outcomes included favorable outcomes (Modified Rankin Scale scores of 0-2), while secondary efficacy outcome was all-cause mortality at 90 days. Safety outcomes included asymptomatic intracerebral hemorrhage (ICH) and symptomatic ICH assessed using the National Institute of Neurological Disorders and Stroke (NINDS) study and the Safe Implementation of Thrombolysis in Stroke-Monitoring (SITS-MOST) study. We also compared parenchymal hematomas as safety outcome between the two groups defined by the authors themselves in their research. A total of 16 studies were included in the present meta-analysis. The meta-analysis did not report any significant difference between low-dose and standard-dose r-tPA in terms of mortality, symptomatic intracranial hemorrhage (SICH), asymptomatic ICH, and parenchymal hematomas. However, the favorable outcome was significantly greater in patients receiving a standard dose of r-tPA.

Childhood stroke

Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.

Quality of acute ischemic stroke care at a tertiary Hospital in Ghana

Background

Information on the quality of acute ischemic stroke care provided in lower-to-middle income countries is limited.

Objective

This study was undertaken to examine the quality of acute ischemic stroke care provided at Tamale Teaching Hospital in Ghana.

Methods

The medical records of patients admitted into the medical ward of the hospital between January to October 2021 were reviewed retrospectively. Extent of compliance to 15 stroke performance indicators were determined.

Results

Under the study period, 105 patients were admitted at the hospital with acute ischemic stroke. The mean (±SD) age was 65 ± 12 years; 38.1% were males; 65.7% had National Health Insurance Scheme coverage. Glasgow Coma Scale was the only functional stroke rating scale used by physicians to rate stroke severity. About a quarter of the patients had CT scan performed within 24 h of admission. Less than a quarter of the patients had a last known well time documented. Rate of thrombolytic administration was 0%. Less than a quarter of the patients were prescribed venous thromboembolism prophylaxis on the day of admission or day after. Only 13.8% of patients had documented reasons for not being prescribed venous thromboembolism prophylaxis. Antiplatelet therapy was prescribed to 33.3% of the patients by the end of day 2 of admission. Anticoagulation was prescribed to all patients who had comorbid condition of atrial fibrillation as part of the discharge medications. More than half of the patients were discharged to go home with statin medications. Documented stroke education was provided to 31.4% caretakers or patients. Slightly less than half of the patients were assessed for or received rehabilitation. Less than a quarter had documented dysphagia screening within 24 h of admission. None of the patient had their stroke severity rated with National Institutes of Health Stroke Scale on arrival. No patient obtained carotid imaging assessment by end of day 2.

Conclusion

There were several gaps in the quality of acute ischemic stroke care provided to patients at the Tamale Teaching Hospital. With the exception of discharging patients on statin medications, there was poor adherence to all other stroke performance indicators.

Outcomes of stroke patients undergoing thrombolysis in Sri Lanka; an observational prospective study from a low-middle income country

BACKGROUND

Stroke related deaths are relatively higher in low- and middle-income countries where only a fraction of eligible patients undergo thrombolysis. There is also limited evidence on post-thrombolysis outcomes of patients from Asian countries in these income bands.

METHODS

This is a single center prospective observational study of a patient cohort with acute ischaemic stroke, undergoing thrombolysis with alteplase (low and standard dose), over a 24-month period in 2019/2020. Modified Rankin scale (mRS) for dependency at 3 months (primary outcome), duration of hospital stay, incidence of symptomatic intracranial haemorrhages and all-cause mortality at 3 months (secondary outcomes) were recorded. Demographic, clinical and treatment related factors associated with these outcomes were explored.

RESULTS

Eighty-nine patients (males - 61, 69%, mean age: 60 years ±12.18) were recruited. Time from symptom onset to reperfusion was 174 min ± 56.50. Fifty-one patients were independent according to mRS, 11 (12.4%) patients died, and 11 (12.5%) developed symptomatic intracranial haemorrhages by 3 months. Functional independence at 3 months was independently associated with National Institutes of Health Stroke Scale (NIHSS) on admission (p < 0.05). Thrombolysis with low dose alteplase did not lead to better or worse outcomes compared to standard dose.

CONCLUSIONS

On admission NIHSS is predictive of functional independence at 3 months post-thrombolysis. Low dose alteplase may be as efficacious as standard dose alteplase with associated cost savings, but this needs to be confirmed by a prospective clinical trial for the Sri Lankan population.

Treatment Outcome and Its Determinants among Patients Admitted to Stroke Unit of Jimma University Medical Center, Southwest Ethiopia

Background

Stroke is a public health problem in Ethiopia. Despite the high prevalence of stroke in Ethiopia, there is a paucity of data with regard to drug treatment, treatment outcome, and risk factors of poor treatment outcome of stroke. Hence, this study is aimed at assessing treatment outcome and its determinants among patients admitted to stroke unit of Jimma University Medical Center (JUMC).

Methods

A two-year hospital-based retrospective cross-sectional study was employed to analyze the medical records of patients admitted with stroke to stroke unit of Jimma University Medical Centre from February 1^st, 2016 to March 30^th, 2018. Data was entered by Epidata manager version 4.0.2 and analyzed by SPSS version 24. Multivariable logistic regression analysis with the backward stepwise approach was done to identify independent predictors of poor treatment outcome of stroke. Variables with P value less than 0.05 were considered as statically significant determinants of poor treatment outcome.

Results

Of 220 patients with stroke admitted to the Jimma University, 67.30% were male. Nearly two thirds (63.18%) of them had poor treatment outcomes. Dyslipidimics were administered to 60% of the patients, and the most popular antiplatelet used was aspirin, which was prescribed to 67.3% the patients. Age ≥ 65 adjusted odd ratio ((AOR): 2.56; 95% CI: 1.95-9.86, P = 0.001), presence of comorbidity (AOR: 5.25; 95% CI: 1.08-17.69, P < 0.001), admission with hemorrhagic stroke (AOR: 18.99; 95% CI: 7.05-42.07, P < 0.001), and admission to the hospital after 24 hour of stroke onset (AOR: 4.98; 95% CI: 1.09-21.91, P = 0.03) were independent predictors of poor treatment outcomes.

Conclusion

Substantial numbers of stroke patients had poor treatment outcomes. Elderly patients, patients diagnosed with hemorrhagic stroke, patients with comorbidity, and those with delayed hospital admission were more likely to have poor treatment outcome. Hence, frequent monitoring and care should be given for the aforementioned patients. Awareness creation on the importance of early admission should be delivered particularly for patients who have risk factors of stroke (cardiovascular diseases).

A systematic review of the cost-effectiveness of emergency interventions for stroke in low- and middle-income countries

Background

Stroke is a leading cause of death and disability globally, with an increasing incidence in low- and middle-income countries (LMICs). The successful treatment of acute stroke requires an organized, efficient and well-resourced emergency care system. However, debate exists surrounding the prioritization of stroke treatment programs given the high costs of treatment and the increased incidence of hemorrhagic stroke in LMICs. Economic data is helpful to guide evidence-based priority setting in health systems development, particularly in low-resource settings where scarcity requires careful stewardship of resources. This systematic review surveys the existing evidence surrounding the cost-effectiveness of interventions to address acute stroke in LMIC settings.

Methods

The authors conducted a PRISMA style systematic review of economic evaluations of interventions to address acute stroke in LMICs. Five databases were systematically searched for articles, which were then reviewed for inclusion.

Results

Of the 153 unique articles identified, 11 met the inclusion criteria. Four studies demonstrate the heavy economic burden on patients and households due to stroke. Two studies estimate that preventive measures are more cost-effective than acute treatments. Four studies directly examine the cost-effectiveness of thrombolysis and thrombectomy in three middle-income countries (Iran, China, and Brazil) with results ranging from roughly $2578 to $34,052 (2019 USD) per quality adjusted life-year saved. These results are similar to the cost-effectiveness ratios estimated in high-income settings. Finally, one study examined a care bundle that included acute treatment elements.

Conclusions

The findings reinforce the need for additional research support informed decision-making. The available evidence suggests that preventive measures should be prioritized over emergency treatment for acute stroke, particularly in settings of resource scarcity. Cost-effectiveness ratios do not compare favorably to estimates for other emergency care interventions in LMICs, such as basic emergency care training, implementation of triage systems, and basic trauma care. Cost-effectiveness is also likely to vary depending on local epidemiology. Overall, decision-makers should balance the economic evidence alongside social, political and cultural priorities when making resource allocation choices.

Barriers to the implementation of prehospital thrombolysis in the treatment of ST-segment elevation myocardial infarction in South Africa: An exploratory inquiry

INTRODUCTION

Evidence-based guidelines advocate percutaneous coronary intervention (PCI) as the mainstay reperfusion strategy for ST-segment elevation myocardial infarction (STEMI). However, the South African health system is not well positioned to provide PCI as a 'mainstay strategy'. In response, the Health Professions Council of South Africa approved the use of prehospital thrombolysis (PHT) for emergency care practitioners in 2009. However, since its approval, prehospital thrombolysis has failed to reach a level of systematic uptake indicative of successful implementation. The current study aimed to explore, through a qualitative inquiry, barriers to PHT for the treatment of myocardial infarction within a South African context.

METHODS

A qualitative single-case study design was used where a series of semi-structured interviews were conducted involving purposefully selected participants. The case comprised a nationalised private emergency medical service, and participants were selected in view of relevant experience and knowledge. Requisite data was conceptualised through the consolidated framework for implementation research, and thematic analysis outlined the data coding procedures of the study.

RESULTS

The study identified potential barriers to the implementation of PHT. These comprised cost, logistics, inter-professional collaboration, leadership engagement, and beliefs or scepticism associated with PHT.

CONCLUSION

A lack of strategic implementation has resulted in a poor introduction of evidenced-based prehospital cardiac care, affecting vulnerable populations who may have otherwise benefited from receiving this level of care. Given the time-sensitive nature of STEMI management, and severely limited access to 'primary reperfusion', PHT resembles not only a logical but also appealing solution in the South African context.

Former antiplatelet drug administration and consequences of intravenous thrombolysis in acute ischemic stroke

BACKGROUND

One of the concerns in patients with acute ischemic stroke with former history of taking antiplatelet drugs is the risk of intracerebral hemorrhage following venous thrombolysis. The purpose of this study was to evaluate the effect of previous administration of antiplatelet drugs on adverse outcomes of recombinant tissue plasminogen activator (tPA) in patients with acute ischemic stroke.

METHODS

In this study, 46 patients with the diagnosis of acute ischemic stroke were recruited. Patients were assessed in a period of three hours after stroke and received the standard dose of tPA (0.9 mg/kg). History of antiplatelet drugs, risk factors, demographic information and stroke severity were collected. The severity of the stroke was determined by the National Institutes of Health Stroke Scale (NIHSS). The outcome was assessed using the Modified Rankin Scale (MRS) and Barthel Index (BI) in the days one, 14 and 90.

RESULTS

Patients with history of antiplatelet drugs had an increased rate of intracranial hemorrhage [odds ratio (95% CI) = 7.3 (1.3-40.5)]. Stroke severity scores were higher in patients receiving antiplatelet drugs than the other group at discharge day and day 90. In both groups, the severity of the disease decreased with time. Mortality rate was 42.1% in patients received antiplatelet drugs and 18.5% in the other group (P> 0.05).

CONCLUSION

Based on the results of this study, patients with acute ischemic stroke and history of taking antiplatelet drugs have poor outcome following administration of standard dose of tPA.

30-day and 60-day rates and predictors of mortality among adult stroke patients: Prospective cohort study

Stroke is one of the most common medical emergencies and the leading cause of preventable death and long-term disability worldwide. A prospective cohort study was conducted at the stroke unit of Jimma university medical center for four consecutive months (from March 10 to July 10, 2017). Of the total 116 study patients, 60 (51.7%) had an ischemic stroke. At 30-day follow-up, 81 (69.8%) patients were alive, 34 (29.3%) were died, and one patient (0.9%) was lost to follow-up. Elevated alanine aminotransferase (ALT) level (AHR: 3.77, 95% CI: 1.34-10.57), diagnosis of stroke clinically alone (AHR: 3.90, 95 CI: 1.49-10.26), brain edema (AHR: 4.28, 95% CI: 1.61-11.37), and National Institute of Health Stroke Scale (NIHSS) ≥ 13 during hospital arrival (AHR: 6.49, 95% CI: 1.90-22.22) were the independent predictors of 30-day mortality. At 60-day follow-up, 68 (58.6%) patients were alive, 46 (39.7%) were died, and 2 (1.7%) were lost to follow-up. Discharge against medical advice (AHR: 6.40, 95% CI: 2.31-17.73) and severe modified Rankin score/mRS (4-5) at discharge (AHR: 3.64, 95% CI: 1.01-13.16) were the independent predictors of 60-day mortality. The median (IQR) length of survival after hospital admission for patients died within 30 and 60 days were 4.65 (2.34-11.80) and 9.3 (3.93-33) days, respectively. Stroke significantly affects the morbidity and mortality in Ethiopia. There is a need to provide better care and future planning for stroke patients as an emergency diagnosis and treatment to minimize mortality and disability.

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.

Management protocols and encountered complications among stroke patients admitted to stroke unit of Jimma university medical center, Southwest Ethiopia: Prospective observational study

Objectives

The number of stroke patients receiving recombinant tissue plasminogen activator (r-tPA) in developing world is extremely low. Pre-hospital delay, financial constraints and lack of infrastructure are the main barriers. Additionally, various medical, neurological and psychological complications are allied to stroke patients after the acute attack. Hence, the study was aimed to identify management protocols and encountered complications among stroke patients admitted to stroke unit of Jimma university medical center (JUMC).

Patients and methods

Prospective observational study was conducted at stroke unit of JUMC from March 10 to July 10, 2017. All eligible consecutive stroke patients of ≥18 years were included. Data was entered to Epi data version 3.1 and analyzed using SPSS version 20.

Results

A total of 116 eligible stroke patients were followed with mean age of 55.14 ± 14.04 years and males comprised of 62.9%. Using world health organization (WHO) criteria, 60 (51.7%) patients had ischemic while 56 (48.3%) had hemorrhagic stroke. During admission, 93 (80.2%) patients had developed at least one complication. The most complication was brain edema (increased intracranial pressure) detected in about one third of the patients (30.2%) followed by urinary incontinence (28.4%) and aspiration pneumonia (19.8%). Almost half of the patients (52.5%) had at least one past medication history. During hospitalization, 111(95.7%) of patients had received at least one medication and the median start time of the medications after hospital arrival was 15 h. The most common medication given for the patients during hospitalization were antiplatelets and statins for 63 (54.3%) patients. During discharge, about 78 (67.2%) patients had received medications and antihypertensives were the prominent medications prescribed for half of the discharged patients.

Conclusion

Both neurologic and medical complications were common in majority of stroke patients. But the management protocol for stroke patients was sub-optimal and lagging behind the recommended guidelines due to lack of skilled personnel, appropriate treatment and diagnostic agents. The clinical team involved in the care of stroke patients should make preparations to take preventive measures that will save a lot of lives.

Burden, clinical outcomes and predictors of time to in hospital mortality among adult patients admitted to stroke unit of Jimma university medical center: a prospective cohort study

Background

The global burden of stroke epidemiology is changing rapidly. Over the 1990–2013 periods, there was a significant increase in the absolute number of deaths and incident events of stroke. The burden of stroke varies in Ethiopia between regions and over time. Hence, this study was aimed to assess the burden, clinical outcomes and predictors of time to in hospital mortality among stroke patients.

Methods

A prospective cohort study was carried at stroke unit of Jimma University Medical Center (JUMC) from March 10–July 10, 2017. The outcome of interest was mortality and time to death. Data was analyzed using SPSS version 20. Multivariable Cox regression was used to identify the predictors of in hospital mortality and time to death from hospital arrival. Predictor variable with P < 0.05 was considered statistically significant.

Results

A total of 116 eligible stroke patients were followed over 4 months. The mean age of patients was 55.1 + 14.0 years and males comprised of 73 (62.9%). Stroke accounted for 16.5% of total medical admissions. Among the 116 patients with stroke, 91 (78.4%) were discharged alive making in hospital mortality rate of 25 (21.6%). The median time of in hospital mortality and length of hospital stay after admission of the patients were 4.38 days and 9.21 days, respectively. The prominent suspected immediate cause for in hospital mortality was increased intracranial pressure in 17 (68.0%) followed by respiratory failure secondary to aspiration pneumonia in 11 (44.0%) patients. Brain edema (AHR: 6.27, 95% CI: 2.50–15.76), urine incontinence (AHR: 3.48, 95% CI: 1.48–8.17), National Institute of Health Stroke Scale (NIHSS) > 13 during hospital arrival (AHR: 22.58, 95% CI: 2.95–172.56) and diagnosis of stroke clinically alone (AHR: 4.96, 95% CI: 1.96–12.54) were the independent predictors of time to in hospital mortality.

Conclusions

The mortality rate of stroke in this setup was comparable with other low- and middle-income countries (LMICs). There is an urgent need to establish well equipped and staffed stroke units in the country in addition to strengthening the already existing one’s. Furthermore, future work must be designed to identify the barriers to improve stroke outcomes and recovery.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1439-7) contains supplementary material, which is available to authorized users.

Public knowledge of people visiting Imam Reza hospital regarding stroke symptoms and risk factors

Background

Early recognition of stroke symptoms results in a lower time period after stroke onset to treatment with a better outcome. This depends on the awareness of patients, family members, and the general public.

Objective

The aim of this study was to evaluate public awareness about stroke risk factors, warning symptoms, and treatments.

Methods

This cross-sectional study was conducted as a hospital-based survey on 2712 people who visited clinics or emergency department of Imam Reza hospital for any reason, from March 2015 to February 2016. All subjects were interviewed face-to-face by four trained physicians and a structured, pre-tested questionnaire was filled.

Results

The mean age of participants was 41.0 ± 12.1 years old. Considering Cincinnati prehospital stroke scale (CPSS) as the main diagnostic system, the percentage of participants that mentioned face asymmetry, speech disturbances, and arm paralysis as a symptom of stroke was 7, 1.5, and 7.9%, respectively. Meanwhile, 71.2% of participants could not mention any of the stroke symptoms. Among participants, 20.2% did not know any of stroke risk factors although 35.1, 27.8, and 17.3% could name one, two and three or more risk factors, respectively. Among participants, only 1.1% were aware of thrombolytic therapy (t-PA) as a first-line drug for stroke treatment.

Conclusion

In this study, public knowledge regarding stroke symptoms, risk factors, and therapy approaches was low. Taken together, public education is necessary to reduce the time for recognition of stroke symptoms and subsequently prompt and proper proceeding seems to be necessary for the community.

Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units

In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs-especially in rural and remote settings-with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.

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

BACKGROUND

The 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.

OBJECTIVES

The objective was to identify the barriers facing proper utilization of IV r-tPA for AIS in Tanta University Hospitals.

METHODS

The 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.

RESULTS

The 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).

CONCLUSION

Increasing 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.

Selection of essential medicines for the prevention and treatment of cardiovascular diseases in low and middle income countries

BACKGROUND

The incidence and mortality of cardiovascular diseases (CVDs) in low and middle income countries (LMICs) have been increasing, while access to CVDs medicines is suboptimal. We assessed selection of essential medicines for the prevention and treatment of CVDs on national essential medicines lists (NEMLs) of LMICs and potential determinants for selection.

METHODS

Only operational NEMLs were considered eligible for this study. A selection of medicines listed under "cardiovascular medicines" or "blood products and plasma substitutes" in the NEMLs were included if they were present on international guidelines for the prevention and treatment of CVDs (hyperlipidemia, hypertension, platelet inhibition, ischemic stroke, stable ischemic heart disease, acute coronary syndromes, heart failure, atrial fibrillation, peripheral arterial disease and acute limb ischemia). The number and diversity of essential medicines selected for CVDs were studied. Moreover, determinants of selection of essential medicines for CVDs at a national level were explored. Data analysis was done using univariate linear regression and non-parametric tests.

RESULTS

All medicine groups listed by the international guidelines were selected by the majority of the 34 countries studied with the exception of adenosine diphosphate receptor inhibitors which appeared on less than half of the NEMLs studied (41% of countries). The total number of essential medicines for the prevention and treatment of cardiovascular diseases (median 24 (range 16-50)) differed significantly across income levels (median range: 19.5-25, p = 0.014) and across regions (median range: 20-32, p = 0.049). When recommendations of the international guidelines were considered, over 75% of the NEMLs contained essential medicines for the majority of CVDs.

CONCLUSION

The main medicine classes for the management of CVDs were represented on NEMLs. Consequently, for the majority of CVDs, evidence-based guideline-recommended treatment is possible as far as selection of essential medicines is concerned. Selection will therefore not be the limiting step in access to medicines for cardiovascular diseases.

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.

Assessment of neurologists' knowledge regarding intravenous fibrinolytic therapy for acute stroke in Shanxi province in China

Background

Limitations in physicians’ knowledge regarding fibrinolytic therapy for acute ischemic stroke may contribute to low rate of fibrinolytic therapy in China. Here physicians’ knowledge was surveyed on intravenous fibrinolytic therapy for acute ischemic stroke.

Methods

Neurologists (n = 175) from 27 major general hospitals in Shanxi province, P. R. China, were invited to complete questionnaires regarding their basic knowledge of intravenous fibrinolytic therapy for acute ischemic stroke. The questionnaire contained 12 multiple-choice questions. One point was assigned for a correct answer and zero point for a false or unanswered question.

Results

One hundred and thirty-one neurologists (74.9%) responded to the questionnaires. The mean accuracy rate of 12 questions was 54.9 ± 25.01% (range 0.8–96.2%). The mean total score for respondents was 6.59 ± 2.03 (range 2–11). More years of experience and higher academic degrees were independent factors related to the total scores (P = 0.000 and P = 0.004, respectively).

Conclusions

The neurologists in this study were knowledge deficient in the area of intravenous fibrinolytic therapy for acute ischemic stroke. This partially accounts for the low rate of fibrinolytic therapy in China.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2300-6) contains supplementary material, which is available to authorized users.

The need for a population-based, dose optimization study for recombinant tissue plasminogen activator in acute ischemic stroke: A study from a tertiary care teaching hospital from South India

Context:

The guideline recommended dose of intravenous (i.v) recombinant tissue-type plasminogen activator (rt-PA) for acute ischemic stroke is 0.9 mg/kg in the European and American populations. In Asiatic population, some studies have shown that a lower dose of i.v rt-PA is equally efficacious.

Aims:

To assess if there is a need for a dose optimization for i.v rt-PA study among Indians.

Setting and Design:

A prospective, observational database of acute stroke cases that presented to a tertiary care institute over a period of 1 year was made.

Methods:

The data procured using a prestructured elaborate pro forma. Based on the dose of rt-PA received, the individuals were divided into three groups; Group 1 (0.6–0.7 mg/kg), Group 2 (0.7–0.8 mg/kg), and Group 3 (0.8–0.9 mg/kg). Improvement was assessed in each group and between the thrombolysed and nonthrombolysed individuals.

Statistical Analysis Used:

The nonparametric Mann–Whitney U-test (Wilcoxon rank-sum test) was applied for assessing improvement of National Institutes of Health Stroke Scale score with significance level of α < 0.05 (P < 0.012) and compliance level at 95%.

Results:

Between the thrombolysed (n = 46) and nonthrombolysed (n = 113) group, there was a statistically significant neurological improvement in the thrombolysed group. Clinical improvement was noted in 75%, 85.7%, and 66.7% of individuals receiving rt-PA in Groups 1, 2, and 3, respectively. Four out of the five who developed a clinically significant intracranial hemorrhage were thrombolysed at a dose of 0.8–0.9 mg/kg rt-PA (Group 3).

Conclusion:

There is a need for a properly randomized, dose optimization study of i.v rt-PA in the Indian subcontinent.

Towards best practice in acute stroke care in Ghana: a survey of hospital services

Background

Stroke and other non-communicable diseases are important emerging public health concerns in sub-Saharan Africa where stroke-related mortality and morbidity are higher compared to other parts of the world. Despite the availability of evidence-based acute stroke interventions globally, uptake in low-middle income countries (LMIC) such as Ghana is uncertain. This study aimed to identify and evaluate available acute stroke services in Ghana and the extent to which these services align with global best practice.

Methods

A multi-site, hospital-based survey was conducted in 11 major referral hospitals (regional and tertiary - teaching hospitals) in Ghana from November 2015 to April 2016. Respondents included neurologists, physician specialists and medical officers (general physicians). A pre-tested, structured questionnaire was used to gather data on available hospital-based acute stroke services in the study sites, using The World Stroke Organisation Global Stroke Services Guideline as a reference for global standards.

Results

Availability of evidence-based services for acute stroke care in the study hospitals were varied and limited. The results showed one tertiary-teaching hospital had a stroke unit. However, thrombolytic therapy (thrombolysis) using recombinant tissue plasminogen activator for acute ischemic stroke care was not available in any of the study hospitals. Aspirin therapy was administered in all the 11 study hospitals. Although eight study sites reported having a brain computed tomographic (CT) scan, only 7 (63.6%) were functional at the time of the study. Magnetic resonance imaging (MRI scan) services were also limited to only 4 (36.4%) hospitals (only functional in three). Acute stroke care by specialists, especially neurologists, was found in 36.4% (4) of the study hospitals whilst none of the study hospitals had an occupational or a speech pathologist to support in the provision of acute stroke care.

Conclusion

This study confirms previous reports of limited and variable provision of evidence based stroke services and the low priority for stroke care in resource poor settings. Health policy initiatives to enhance uptake of evidence-based acute stroke services is required to reduce stroke-related mortality and morbidity in countries such as Ghana.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2061-2) contains supplementary material, which is available to authorized users.

Factors delaying management of acute stroke: An Indian scenario

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.

Intravenous thrombolysis with rt-PA in stroke: experience of the moroccan stroke unit

The majority of strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred. We report the case series of all patients who were treated with rt-PA at Stroke Unit of HASSAN II University hospital between 2010 and 2013. There were 52 patients treated with intravenous rtPA during the study period. The mean age was 63 years with the no gender predominance (sex ratio 1.02). Hypertension was the most common vascular risk factor (31%) and 17% of patients suffered from atrial fibrillation. 17 of 52 patients (32.7%) were treated within a 3 hours window of stroke onset and 35 of 52 (67.3%) patients were treated within 3-4.5 h. Twenty five patients (48%) had significant early improvements within 24 hours and twenty one (40.3%) patients had good outcomes at 3 months and fifteen patients (29%) died within the same period.

Feasibility and efficacy of thrombolysis in acute ischemic stroke: A study from National Institute of Neurological and Allied Sciences, Kathmandu, Nepal

Background:

Stroke is the major cause of morbidity and mortality worldwide. The number of stroke patients receiving recombinant tissue plasminogen activator (rt-PA), also known as Alteplase, in the developing world is extremely low. We aim to study the feasibility and efficacy of thrombolysis for the 1^st time in our country.

Materials and Methods:

In this retrospective study (July 2012-August 2015), acute ischemic stroke patients who were thrombolyzed within 3 h of stroke onset were included. Their demographic profiles, clinical profiles, risk factors, type of thrombolytic used, and outcomes were systematically recorded and analyzed.

Results:

A total of 9 patients were thrombolyzed. The mean time from the onset of stroke symptoms to first dose of rt-PA (onset to treatment) was 1.2 h. Six patients had good neurological outcome as measured by modified Rankin Scale (mRS). The median mRS at discharge was 3. Thrombolysis-related post treatment complication was noted in 44.4%, of which nonfatal intracranial bleed occurred only in 2 patients (22.2%). None of the patients receiving intravenous tenecteplase had thrombolysis-related complications, and none of the patients had fatal intracranial bleed.

Conclusion:

This study clearly demonstrates the beginning of a feasible and effective thrombolysis in the treatment of acute ischemic stroke in Nepal.

Development and validation of an indirect competitive ELISA for quantification of recombinant staphylokinase in rabbit plasma: Application to pharmacokinetic study

The relatively short circulatory half-life (2-3 min) of staphylokinase is a major drawback in the development of SAK- (staphylokinase) based thrombolytic drug. A rapid and sensitive method, based on indirect competitive ELISA, was developed and validated for quantitative determination of SAK in rabbit plasma. The dynamic range of the assay varied between 0.41 ± 0.16 μg/L and 9.03 ± 0.38 μg/L (R(2) = 0.98) for SAK in rabbit plasma. There were no dilution linearity issues apparent with this assay. The precision (% CV) ranged from 4.6-9.7% for the intraassay and from 17.1-19.3% for interassay. This validated method was successfully employed for evaluation of various pharmacokinetic parameters of SAK in rabbit.

TIME OF PRESENTATION OF STROKE PATIENTS FOR CT IMAGING IN A NIGERIAN TERTIARY HOSPITAL

BACKGROUND

Neuroimaging is the cornerstone for guiding thrombolytic and interventional therapy for stroke. Beneficial outcome can only be obtained within a rather short time of less than 3-4.5 hours of symptom onset. Challenges in developing countries like Nigeria often lead to delayed presentation of stroke patients in hospitals. We sought to study the time and pattern of presentation of stroke patients for CT imaging in a Nigerian tertiary hospital.

METHODS

Of the 271 stroke patients who had cranial CT between 2008 and 2010, eighty-three (30.6%) with full retrievable CT records, were included in this study. They were categorized into six time groups cross-tabulated with their CT findings.

RESULTS

Forty-two patients (50.6%) had cerebral infarction while 23 (27.7%) had haemorrhagic stroke. However, 18 (21.7%) patients had apparently normal CT findings. The mean presentation time for CT imaging was 70 hours (SD ±94 hours). Only 31% of all stroke patients presented for CT imaging within 12 hours, and none, within 3 hours. Forty-six percent did not present within 24 hours of symptom onset. Significantly more patients with ischemic stroke (72.3%) than hemorrhagic stroke (27.7%) presented after 12 hours of ictus (X(2) = 4.027 d=1, P =0.045). Age (X(2)=0.008, P =0.931) and gender (X(2)1.742, d=1,P =0.187) had no statistically significant relationship with the time of presentation for CT imaging.

CONCLUSION

None of our patients met the time criteria for thrombolytic therapy. Ischemic stroke patients presented for imaging later than patients with intracerebral haemorrhage. There is a need to increase the awareness regarding early recognition, presentation and diagnosis of stroke for timely intervention in Nigeria.

ROLE OF TRANSCRANIAL COLOUR-CODED DUPLEX SONOGRAPHY IN STROKE MANAGEMENT - REVIEW ARTICLE

The development of transcranial colour-coded duplex sonography (TCCS) has resurrected the hope of safe, real time bedside brain imaging beyond childhood. This review article provides an overview of the role of TCCS in the management of patients with stroke. The objective is to stimulate interest in the field of neurosonology as a potential means of improving neurological outcome for stroke patients and a area for stroke research endeavors in Africa. Literature search was done on MEDLINE, Cochrane library, and Google Scholar databases with the following keywords: transcranial colour Doppler, Transcranial duplex sonography, transcranial colour-coded Doppler sonography, stroke, infarct and haemorrhage. We also identified relevant articles from the references section of studies produced by our literature search. We discussed the roles of TCCS to discriminate ischaemic from haemorrhagic forms; unravel the mechanism of stroke; monitor temporal evolution of stroke and predictors of stroke outcome; and promote better understanding of the epidemiology of stroke. Its emerging role as a potent point-of-care imaging modality for definitive treatment in ischaemic stroke within and outside the hospital setting is also highlighted. Comparison of TCCS with alternative modalities for neuroimaging in stroke is also discussed. A root cause analysis of the untenable high cost of neuroimaging for stroke patients in Africa is presented vis-à-vis the potential economic relief which widespread adoption of TCCS may provide. We advocate capacity building for TCCS and suggest some action plans required to achieve safe, cheap, affordable and reliable ultrasound based neuroimaging for stroke patients in resource limited areas of Africa.

In vitro characterization of a multifunctional staphylokinase variant with reduced reocclusion, produced from salt inducible E. coli GJ1158

The thrombolytic therapy with clinically approved drugs often ensues with recurrent thrombosis caused by thrombin-induced platelet aggregation from the clot debris. In order to minimize these problems, a staphylokinase (SAK)-based bacterial friendly multifunctional recombinant protein SRH (staphylokinase (SAK) linked with tripeptide RGD and dodecapeptide Hirulog (SRH)) was constructed to have Hirulog as an antithrombin agent and RGD (Arg-Gly-Asp) as an antiplatelet agent in the present study. This multifunctional fusion protein SRH was expressed in osmotically inducible E. coli GJ1158 as soluble form and purified with a yield of 0.27 g/L and functionally characterized in vitro. SRH retained the fibrinolytic activity and plasminogen activation rate comparable to the parental counterpart SAK. The antithrombin activity of SRH was significantly higher than SAK. The platelet rich clot lysis assay indicated that SRH had enhanced platelet binding activity and T_50% and C₅₀ of SRH were significantly lower than that of SAK. Furthermore, SRH inhibited the ADP-induced platelet aggregation in dose-dependent manner while SAK had no significant effect on platelet aggregation. Thus, the current study suggests that the SAK variant produced from osmotically inducible GJ1158 is more potent thrombolytic agent with antithrombin and antiplatelet aggregation activities for reduction of reocclusion in thrombolytic therapy.

Evaluation of a multifunctional staphylokinase variant with thrombin inhibition and antiplatelet aggregation activities produced from salt-inducible E. coli GJ1158

Reocclusion is one of the major root causes for secondary complications that arise during thrombolytic therapy. A multifunctional staphylokinase variant SRH (staphylokinase (SAK) linked with tripeptide RGD and didecapeptide Hirulog) with antiplatelet and antithrombin activities in addition to clot specific thrombolytic function, was developed to address the reocclusion problem. We preferred to use Escherichia coli GJ1158 as the host in this study for economic production of SRH by osmotic (0.3 mol/L sodium chloride) induction, to overcome the problems associated with the yeast expression system. The therapeutic potential of SRH was evaluated in the murine model of vascular thrombosis. The SAK protein (1 mg/kg body mass) and SRH protein (1 mg/kg and 2 mg/kg) were administered intravenously to the different treatment groups. The results have shown a dose-dependent antithrombotic effect in carrageenan-induced mouse tail thrombosis. The thrombin time, activated partial thromboplastin time, and prothrombin time were significantly prolonged (p < 0.05) in the SRH-infused groups. Moreover, SRH inhibited platelet aggregation in a dose-dependent manner (p < 0.05), while the bleeding time was significantly (p < 0.05) prolonged. All of these results inferred that the osmotically produced multifunctional fusion protein SRH (SAK-RGD-Hirulog) is a promising thrombolytic agent, and one which sustained its multifunctionality in the animal models.

Design of a standard Iranian protocol of Intravenous thrombolysis with tissue plasminogen activator: A national project

Standard protocols should be established for treating eligible stroke patients with tissue plasminogen activator (TPA) (recommendation class I, level of evidence B). The Iranian standard protocol of Intravenous Thrombolysis with recombinant Tissue Plasminogen Activator (IVTTPA) is the best possible and easy to use method for performing intravenous thrombolysis in Iran. This protocol overcomes problems and limitations of IVTTPA in Iran. The protocol achieves the best selection criteria and assessment method of IVTTPA for our residents and neurologists. This protocol was provided in Persian language and could be easily downloaded from Google site by writing Thrombolysis and Iran in Persian.