title: 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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  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.
  
  
  METHODS
  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 contraindication to IVT. In this study, we found that patients with documented large vessel disease with no evidence of cross flow through Willisian collaterals benefit from endovascular treatment. We recommend that all patients of acute ischemic stroke, be subjected to a baseline angiogram either computed tomography (CT) or magnetic resonance imaging (MRI) to document vessel status. This will help in identifying patients who may benefit from early endovascular treatment, if they fail to improve with IVT. Further, large trials using stent retrievers are needed, to prove that endovascular treatment is superior to IVT, in presence of documented large vessel disease.
authors.affiliation: Department of Neurology, Narayana Hrudayalaya Institute of Neurosciences, Bangalore, Karnataka, India.
authors.forename: Vikram
authors.initials: V
authors.lastname: Huded
authors.affiliation: Department of Neurology, Narayana Hrudayalaya Institute of Neurosciences, Bangalore, Karnataka, India.
authors.forename: Romnesh
authors.initials: R
authors.lastname: De Souza
authors.affiliation: Department of Neurology, Narayana Hrudayalaya Institute of Neurosciences, Bangalore, Karnataka, India.
authors.forename: Rajesh Karalumangala
authors.initials: RK
authors.lastname: Nagarajaiah
authors.affiliation: Department of Neurology, Narayana Hrudayalaya Institute of Neurosciences, Bangalore, Karnataka, India.
authors.forename: Syed Moeed
authors.initials: SM
authors.lastname: Zafer
authors.affiliation: Department of Neurology, Narayana Hrudayalaya Institute of Neurosciences, Bangalore, Karnataka, India.
authors.forename: Rithesh
authors.initials: R
authors.lastname: Nair
authors.affiliation: Department of Neurology, Narayana Hrudayalaya Institute of Neurosciences, Bangalore, Karnataka, India.
authors.forename: Hariram
authors.initials: H
authors.lastname: Acharya
keywords: Endovascular thrombolysis; IV thrombolysis; intravenous thrombolysis; stent retriever; stroke
references.citation: Stroke. 2008 Apr;39(4):1205-12
references.pmid: 18309168
references.citation: N Engl J Med. 2013 Mar 7;368(10):914-23
references.pmid: 23394476
references.citation: N Engl J Med. 2013 Mar 7;368(10):904-13
references.pmid: 23387822
references.citation: Stroke. 2005 Jul;36(7):1432-8
references.pmid: 15961709
references.citation: Stroke. 1998 Jan;29(1):4-11
references.pmid: 9445320
references.citation: N Engl J Med. 1995 Dec 14;333(24):1581-7
references.pmid: 7477192
references.citation: Int J Stroke. 2014 Jul;9(5):658-68
references.pmid: 23130938
references.citation: N Engl J Med. 2008 Sep 25;359(13):1317-29
references.pmid: 18815396
references.citation: N Engl J Med. 2013 Mar 7;368(10):893-903
references.pmid: 23390923
references.citation: Stroke. 2009 Aug;40(8):2761-8
references.pmid: 19590057