Intravenous thrombolysis for acute ischemic stroke in the 3- to 4·5-hour window--the Malabar experience

Background: Intravenous thrombolysis for acute ischemic stroke with recombinant tissue plasminogen activator has been shown to be beneficial up to 4.5-hours of symptom onset.

Aims: The study aims to review our experience with thrombolysis with recombinant tissue plasminogen activator in the 3- to 4.5-hours window in acute ischemic stroke.

Settings and design: Prospective observational study of patients with acute ischemic stroke thombolysed between 3- and 4.5-hours after onset from July 2009 to October 2012 at a tertiary-care center in the Malabar region of South India.

Materials and methods: The dose of recombinant tissue plasminogen activator used was 50 mg in all patients. Inclusion and exclusion criteria were similar to European Co-operative Acute Stroke Study-3 criteria, with the exceptions that we did not use an age cutoff of 80 years and did not restrict thrombolysis for previous stroke with diabetes or elevated blood glucose levels.

Statistical analysis used: Good outcome was defined as a three-month modified Rankin Score of 2 or less. The chi-square test was used to compare the outcome among various sub-types of ischemic stroke. The age, blood glucose, National Institute of Health Stroke Scale Score, and time to thrombolysis were compared between groups with the nonparametric Mann-Whitney U-test.

Results: Thirty-one patients (median age 65 years, range 44-85, and median National Institute of Health Stroke Scale Score 10, range 5-22) were thrombolysed in the 3- to 4.5-hours window after stroke onset during the study period. In the first 24 h, 16 patients (52%) improved in National Institute of Health Stroke Scale Score by 4 or more points while three worsened by 4 or more points. At the three-month follow up, 15 patients (48%) were functionally independent (modified Rankin Score ≤ 2). None had symptomatic intracerebral hemorrhage. There was no significant difference in outcome between the various ischemic stroke sub-types. The baseline age, National Institute of Health Stroke Scale Score, blood glucose, and onset to treatment time did not differ significantly between the groups with good and poor outcome.

Conclusion: Our initial experience confirms that thrombolysis for ischemic stroke in the extended window is safe and beneficial.