CASE SERIES: EFFICACY OF THROMBOLYSIS USING INTRAVENOUS ALTEPLASE IN ACUTE ISCHEMIC STROKE WITH ONSET LESS THAN 6 HOURS (CODE STROKE)
DOI:
https://doi.org/10.21776/ub.mnj.2024.010.02.22Keywords:
code stroke, acute ischemic stroke, thrombolysis, alteplase, standard doseAbstract
Background: The gold standard therapy for acute ischemic stroke is timely reperfusion of ischemic brain tissue. Intravenous thrombolysis with tPA is the only proven medical therapy for acute ischemic stroke within 4.5 hours of symptom onset using intravenous alteplase at a dose of 0.9 mg per kilogram of body weight. Hemorrhagic transformation is one of the complications of thrombolytic therapy and East Asian population having a higher prevalence of cerebral hemorrhage. This study will examine several cases of ischemic stroke that were treated with thrombolysis using a standard dose (0.9 mg/kg) of intravenous alteplase in acute ischemic stroke with an onset of less than 6 hours in the Special Region of Yogyakarta, especially at the UGM Academic Hospital.
Objective: To determine the efficacy of standard dose thrombolysis using intravenous alteplase (rTPA-recombinant tissue plasminogen activator) in acute ischemic stroke with an onset of less than 6 hours through activation of the Code Stroke.
Methods: Descriptive research design using a case series, the hyperacute stroke patients with an onset of less than 6 hours who received intravenous alteplase which were then assessed by the National Institutes of Health Stroke Scale (NIHSS) score at initial admission, 24 hours post-alteplase and 30 days post -alteplase. The study took place and was conducted from May to October 2022 by administering intravenous alteplase at a dose of 0.9 mg/kg body weight in acute ischemic stroke patients at UGM RSA who are eligible for thrombolysis therapy with a maximum administration time of 6 hours after stroke onset with the maximum dose of alteplase is 50 mg.
Results: The study sample was 8 patients with acute ischemic stroke who were treated between May to October 2022. There were 2 patients who died before completing the 3-month follow-up. One of the patients died within the second week of treatment from sepsis which may have occurred from a pre-existing pneumonia. Another patient died from ileus that occurred 1 month after tissue plasminogen activator (tPA). However, the patient with this ileus showed clinical improvement at the 24-hour post-tPA follow-up, i.e. the initial NIHSS score of 12 improved to an NIHSS score of 6.
Conclusion: The modified Alteplase dose, which is 0.9 mg/kg body weight with a maximum dose of 50 mg, at the onset of stroke less than 6 hours can be an option to maximize thrombolytic therapy while still considering the efficiency of treatment costs.
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Setyopranoto I, Bayuangga HF, Panggabean AS, Alifaningdyah S, Lazuardi L, Dewi FST, Malueka RG. Prevalence of stroke and associated risk factors in Sleman District of Yogyakarta Special Region, Indonesia. Stroke Res Treat; 2019. 2019:1-8. DOI:10.1155/2019/2642458
Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart disease and stroke statistics—2020 Update: A report from the American Heart Association. Circulation; 2020. 141(9).
DOI: 10.1161/CIR.0000000000000757
Akbarzadeh MA, Sanaie S, Kuchaki Rafsanjani M, Hosseini MS. Role of imaging in early diagnosis of acute ischemic stroke: A literature review. Egypt J Neurol Psychiatry Neurosurg; 2021. 57(1):175.
DOI: 10.1186/s41983-021-00432-y
Bhaskar S, Stanwell P, Cordato D, Attia J, Levi C. Reperfusion therapy in acute ischemic stroke: Dawn of a new era? BMC Neurol; 2018. 18(1):8.
DOI: 10.1186/s12883-017-1007-y
Seah HM, Burney M, Phan M, Shell D, Wu J, Zhou K, Brooks O, Coulton B, Maingard J, Tang J, Yazdabadi G, Tahayori B, Barras C, Kok HK, Chandra R, Thijs V, Brooks DM, Asadi H. Code stroke alert—Concept and development of a novel open-source platform to streamline acute stroke management. Front Neurol; 2019. 10. DOI: 10.3389/fneur.2019.00725
Situmeang RFV, Pangestu A, Stevano R, Tannu Y, Herlambang J, Putri C. Reasons withholding intravenous thrombolysis for acute ischemic stroke in an Indonesian Tertiary Center. Egypt J Neurol Psychiatry Neurosurg; 2023. 59(1):11.
DOI: 10.1186/s41983-023-00613-x
Lyden PD. Thrombolytic therapy for acute ischemic stroke. Stroke; 2019. 50(9):2597-2603.
DOI: 10.1161/STROKEAHA.119.025699
Yu W. Ongoing improvement in acute ischemic stroke therapy per concurrent guidelines and easily implementable quality improvement protocol. Neurosci Neurol Surg; 2021. 8(6):01-09.
DOI: 10.31579/2578-8868/184
Bhardwaj A, Sharma G, Raina SK, Sharma A, Angra M. Advanced age and higher national institutes of health stroke scale score as predictors of poor outcome in ischemic stroke patients treated with alteplase: A study from a tertiary care centre in rural North-west India. J Neurosci Rural Pract; 2017. 8(2):236-240. DOI: 10.4103/jnrp.jnrp_431_16
Rasyid A, Harris S, Kurniawan M, Mesiano T, Hidayat R, Herqutanto, Rahmadhani MA. Efficacy of low-dose thrombolysis with intravenous alteplase within 6 h of acute ischemic stroke onset: Evidence from single referral center in Indonesia. Int J Pharm Pharm Sci; 2019. 11(8):64-68.
DOI: 10.22159/ijpps.2019v11i8.34029
Anderson CS, Robinson T, Lindley RI, Arima H, Lavados PM, Lee TH, Broderick JP, Chen X, Chen G, Sharma VK, Kim JS, Thang NH, Cao Y, Parsons MW, Levi C, Huang Y, Olavarría VV, Demchuk AM, Bath PM, Donnan GA, Martins S, Pontes-Neto OM, Silva F, Ricci S, Roffe C, Pandian J, Billot L, Woodward M, Li Q, Wang X, Wang J, Chalmers J. Low-dose versus standard-dose intravenous alteplase in acute ischemic stroke. N Engl J Med; 2016. 374(24):2313-2323.
DOI: 10.1056/NEJMoa1515510
Yaghi S, Willey JZ, Cucchiara B, Goldstein JN, Gonzales NR, Khatri P, Kim LJ, Mayer SA, Sheth KN, Schwamm LH. Treatment and outcome of hemorrhagic transformation after intravenous alteplase in acute ischemic stroke: A Scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke; 2017. 48(12). DOI: 10.1161/STR.0000000000000152
Kim BJ, Han MK, Park TH, Park SS, Lee KB, Lee BC, Yu KH, Oh MS, Cha JK, Kim DH, Lee J, Lee SJ, Ko Y, Park JM, Kang K, Cho YJ, Hong KS, Kim JT, Choi JC, Kim DE, Shin DI, Kim WJ, Lee J, Lee JS, Yoon BW, Gorelick PB, Bae HJ. Low-versus standard-dose alteplase for ischemic strokes within 4.5 hours. Stroke; 2015. 46(9):2541-2548.
DOI: 10.1161/STROKEAHA.115.010180
Keigher KM. Large vessel occlusion in the acute stroke patient. Crit Care Nurs Clin North Am; 2020. 32(1):21-36. DOI: 10.1016/j.cnc.2019.11.007
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN,
Southerland AM, Summers DV, Tirschwell DL. Guidelines for the early management of patients with acute ischemic stroke: 2019 Update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke. Stroke; 2019. 50(12).
DOI: 10.1161/STR.0000000000000211
Zhou Z, Delcourt C, Xia C, Yoshimura S, Carcel C, Torii-Yoshimura T, You S, Malavera A, Chen X, Hackett ML, Woodward M, Chalmers J, Xu J, Robinson TG, Parsons MW, Demchuk AM, Lindley RI, Mair G, Wardlaw JM, Anderson CS. Low-dose vs standard-dose alteplase in acute lacunar ischemic stroke. Neurology; 2021. 96(11).
DOI: 10.1212/WNL.0000000000011598
Huang Y, Sharma VK, Robinson T, Lindley RI, Chen X, Kim JS, Lavados P, Olavarría V, Arima H, Fuentes S, Nguyen HT, Lee TH, Parsons MW, Levi C, Demchuk AM, Bath PMW, Broderick JP, Donnan GA, Martins S, Pontes-Neto OM, Silva F, Pandian J, Ricci S, Stapf C, Woodward M, Wang J, Chalmers J, Anderson CS. Rationale, design, and progress of the enhanced control of hypertension and thrombolysis stroke study (enchanted) trial: An international multicenter 2 × 2 quasi-factorial randomized controlled trial of low- vs. standard-dose rt-pa and early intensive vs. Int J Stroke; 2015. 10(5):778-788.
DOI: 10.1111/ijs.12486
Kementerian Kesehatan Republik Indonesia. Pedoman Nasional Pelayanan Kedokteran Tatalaksana Stroke; 2019. HK.01.07/MENKES/394/2019.
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