Acute ischemic stroke when presents within the time window period of 3 to 4.5 hours, can be treated with intravenous tissue plasminogen activator (i.v. tPA) with best outcome. Stroke is in the decreasing trend in high income countries, e.g. recently, stroke is the third leading cause of death in United States. Robust economy, better health care policy, wide coverage of health insurance, public health education are some important factors that have helped to curb on the disease progression. On the other hand, incidence of stroke is in increasing trend in low income countries like Nepal. Given the limited resources available in these countries, the ‘access to standard health care to all’ is nearly impossible. Nepal is a landlocked country surrounded by some highest mountains of the world. According to the World Health Organization (WHO), more than 70% of health expenditure comes out-of pocket contribution from individuals. Administration of i.v. tPA has been licensed in Nepal for thrombolysis in selected patients with acute ischemic stroke only recently. The use of tPA is still low but in increasing trends across Nepal. We carried an observational study on institutional basis in regards to i.v. tPA usage in acute ischemic stroke. This institutional experience statement provides a review of the evidence for, and implementation of, tPA in acute ischaemic stroke with specific reference to Nepalese health-care system.
Material and Methods: Institutional audit was carried out from last two years (2015-2017) and the cases with ‘acute stroke/hyperacute stroke’ were collected from database in our institute. Administration of tPA was based on international inclusion and exclusion criteria of iv tPA administration, international dosing protocol (0.9mg/kg body wt with 10% of bolus).Clinical information e.g. Age, Sex, NIHSS, Risk factors, time duration of using tPA and presentation of ischemic stroke to ER data were collected. Observational (correlational) analysis was carried out. Stroke severity was determined with using different scales like National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (MRS).
Results: From all stroke patients, we had more than 300 ischemic stroke patients, among which 30% appeared within 24 hours of stroke onset (but more than 4.5 hours). Only little over to 5% (15) of patients was eligible for intravenous tPA (including time window of 4.5 hours). About 15% of patients in our total stroke population did not know if they had stroke. This shows the importance of making strategies for public education for stroke. 20% of stroke victims had transient ischemic attack (TIA) or rapidly improving stroke like symptom (RISS) anytime in their life. This means, our majority of stroke patients were asymptomatic previously. NIHSS score of our total stroke patients ranged from 22 to 1. Among tPA eligible candidate, the NIHSS ranged from 18 to 6 with mean of 11.86. Notably, many patients had important neurological deficit like aphasia, dysarthria (more than 10 patients) even though, their total score of NIHSS was low. NIHSS was scored 24 hours after iv tPA was administered. Post tPA, there was a significant improvement seen clinically. There was significant difference in NIHSS (mean NIHSS of 4.5). (figure 1). A greater improvement was seen in patients affected with speech. Hence, using tPA even in low NIHSS score carried a very useful meaning. The door to needle time was impressive in our study (1.5 hours on average)
Conclusion: This institutional audit provides a review of the evidence for, and implementation of, tPA in acute ischaemic stroke with specific reference to Nepalese health-care system. In this statement, we have also tried to present and project the current scenario of acute stroke which plagues economically poor countries. This statement is also a call for our neurologist society to work for the betterment of neurological condition of poorer nations.