To evaluate the results and factors affecting intravenous thrombolysis in the treatment of acute ischemic stroke in Thainguyen Central Hospital. Subjects and methods: 50 patients with acute ischemic stroke were done intravenous thrombolysis at Thainguyen Central Hospital from December 2016 to June 2018, meeting inclusive and exclusive criteria as directed by American Stroke Association (AHA/ASA), according to cross-sectional descriptive study. Treatment outcomes were assessed at hospital discharge and 1 month by NIHSS and modified Rankin Scale (mRS).
Journal of military pharmaco-medicine n02-2019 RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR FOR THE TREATMENT OF ACUTE ISCHEMIC STROKE AT THAINGUYEN CENTRAL HOSPITAL Bui Thi Huyen1; Tran Van Tuan2; Nguyen Truong Giang1 Hoang Quoc Hai1; Le Xuan Tung1; Nguyen Thi Thu Thai2 Nguyen Thi Khanh1; Hoang Thuy Trang1; Pham Thi Kim Dung2 SUMMARY Objectives: To evaluate the results and factors affecting intravenous thrombolysis in the treatment of acute ischemic stroke in Thainguyen Central Hospital Subjects and methods: 50 patients with acute ischemic stroke were done intravenous thrombolysis at Thainguyen Central Hospital from December 2016 to June 2018, meeting inclusive and exclusive criteria as directed by American Stroke Association (AHA/ASA), according to cross-sectional descriptive study Treatment outcomes were assessed at hospital discharge and month by NIHSS and modified Rankin Scale (mRS) Results: The treatment of acute ischemic stroke with intravenous thrombolysis showed a good recovery with a significant decrease in mean NIHSS (from 10.12 ± 3.57 to 3.7 ± 4.93); door-to-drug time was 49.88 ± 30.984; onset-to-drug time less than hours showed better recovery (76.9%), after hours the rate of good recovery was only 50%; patients with atrial fibrillation were more likely to have a worse outcome than those who did not have atrial fibrillation (a good recovery in atrial fibrillation: 85.7%, no atrial fibrillation 97.7%) Conclusion: Intravenous thrombolysis is an effective method for emergency and treatment of acute ischemic stroke * Keywords: Ischemic stroke; Intravenous thrombolysis; Plasminogen activator INTRODUCTION Stroke is the third leading cause of death after cardiovascular disease and cancer, and is the most common cause of disability in developed countries Its burden of disease on the families and society is great In 1996, after the research results of National Institute of Neurological Disorders and Stroke/NINDS (National Institute of Neurological Disorders) was published, the US Food and Drug Administration (FDA) has approved the use of recombinant tissue plasminogen activator (rtPA) in the treatment of acute ischemic stroke NINDS study results showed that with intravenous plasminogen activator, 13% of patients achieved complete or near complete rehabilitation after three months (corresponding to revised Rankin score - 1) Thainguyen Central Hospital Thainguyen University of Medicine and Pharmacy Corresponding author: Tran Van Tuan (tranvantuanyktn@gmail.com) Date received: 20/12/2018 Date accepted: 17/01/2019 164 Journal of military pharmaco-medicine n02-2019 Countries in Europe and America use a dose of 0.9 mg/kg, which is considered "standard doses", whereas Asian countries tend to use low doses of 0.6 mg/kg, which pioneer country is Japan Many studies have been published with relatively large number of treated patients using low dose of alteplase 0.6 mg/kg for good functional rehabilitation after three months similar to 0.9 mg/kg in studies in Europe and America In recent years, some studies have also shown that thrombolytic treatment may be effective and safe with treatment windows that extend to 270 minutes (4.5 hours) if physicians have periods The treatment of thrombolytic drug therapy requires a careful selection of patients In the past few years, at 115 People‟s Hospital in Hochiminh City and Bachmai Hospital in Hanoi researches on treatment of low-dose venous thrombocytopenia 0.6 mg/kg showed higher recovery results than the standard dose, while the complication rate was lower This is also the basis for us to study aiming at two objectives: - To evaluate the results of treatment of thrombolytic agent recombinant tissue plasminogen activator in patients with acute ischemic stroke in the first 4.5 hours - To analyze a number of factors affecting the results of treatment in patients with acute ischemic stroke treated for intravenous thrombolytic SUBJECTS AND METHODS Subjects 50 patients were diagnosed with acute ischemic stroke within the first 4.5 hours after onset * Selected criteria: - Diagnosed with acute ischemic stroke - Age > 18 years - The time from onset to 4.5 hours - NIHSS score from - 22 points - CT-scanner or MRI without images of cerebral bleeding or cerebral edema > 1/3 of the area that dominates the middle brain artery - Get the agreement of patients and families - The symptoms are fixed and have not recovered * Exclusive criteria: - Onset over 4.5 hours or uncertain about time - Stroke or serious head trauma in the last months - Severe trauma, major surgery in the previous 14 days - Gastrointestinal or urinary tract hemorrhage in the last 21 days - Myocardial infarction within months - History of brain bleeding, varicose veins, venous hypertension, brain tumors - Prickling of the spinal cord or artery in a position where it cannot be pressed for the previous days - Patients had congenital diseases or acquired bleeding - Seizures at onset stroke - There are severe medical conditions (heart failure, liver failure, severe renal failure) 165 Journal of military pharmaco-medicine n02-2019 - Sustained systolic blood pressure > 185 mm Hg, diastolic blood pressure > 110 mm Hg, or aggressive treatment necessary to lower blood pressure - Recovery level according to mRs scale - Suggested signs of subarachnoid bleeding * Data processing: According to medical statistics method - Evidence of active bleeding or acute trauma (fracture) on examination - Evaluate the status of admission and hospital discharge at the NIHSS scale * Ethical issues in research: - Patients who are pregnant or breast feeding The study aims to improve the quality of treatment for patients and does not affect the results of treatment - Serum glucose < 2.8 mmol/L or > 22.2 mmol/L RESULTS - Platelet count < 100,000 µL - Hematocrit < 25% - Heparin administration for 48 hours with APTT lasts longer than 40 seconds - Oral anticoagulants with prothrombine time over 15 seconds or INR above 1.7 * Time and place of study: The study was conducted from December 2016 to June 2018 at Thainguyen Central Hospital Methods * Classification of diseases by age (n = 50): 39 - 55 years old: patients (8.0%); 55 - 75 years old: 34 patients (68.0%); > 75 years old: 12 patients (24.0%) The most common acute ischemic stroke in the age group from 55 to 75 accounted for 68.0% (34 patients), the lowest was 39 years, the highest was 85 years Table 1: The level of recovery on the NIHSS scale Average - Design: Cross-sectional study - Method: Descriptive study - Sample size: Convenient sample selection, according to selected criteria and excluded criteria - Steps to be taken: The patients were collected data according to a unified form * Research targets: - Age, time to hospital admission 166 NIHSS score ± SD Lowest Highest Time Admission 10.12 ± 3.57 19 Discharge 3.7 ± 4.93 23 Acute ischemic stroke patients treated with venous thrombolysis brought a good recovery, of which average NIHSS scores decreased from 10.12 ± 3.57 to 3.7 ± 4.93 Journal of military pharmaco-medicine n02-2019 Table 2: Results of treatment according to age Rankin score Good Medium Severe or fatal Age n % n % n % 39 - 55 (n = 6) 83.3 16.7 0 56 - 70 (n = 23) 15 65.2 30.4 4.3 > 70 (n = 21) 12 57.1 38.1 4.8 p > 0.05 There was no difference in treatment results between age groups Table 3: Treatment results from onset to treatment of thrombolysis Rankin score Good Medium Severe or fatal n % n % n % ≤ 180 (n = 26) 20 76.9 19.2 3.8 > 180 (n = 24) 12 50.0 11 45.8 4.2 Time (minute) p < 0.05 Patients treated during the first hours had a higher recovery rate * The average time from hospital admission to CT-scan and treatment for thrombolysis: The time when patients went to hospital until they received CT-scanner was 17.46 ± 11.25 minutes; from admission to thrombolysis was 49.88 ± 30.984 mins Table 4: Treatment results in patients with atrial fibrillation NIHSS score Improve (%) Worse (%) Total Yes 85.7 14.3 No 97.7 2.3 43 Atrial fibrillation p > 0.05 Patients with no atrial fibrillation rate were better than those with accompanied atrial fibrillation, but this data was not statistically significant Table 5: Evaluation of the recovery level after month on the mRS scale mRs Good recovery Medium recovery Severe or fatal n 35 % 70.0 18.0 4.0 Patients with ischemic stroke treated with venous thrombolysis had good recovery after month (70%) There were patients who did not return to the examination or were unable to contact, or had just left the hospital for less than month 167 Journal of military pharmaco-medicine n02-2019 DISCUSSION - In Thainguyen Central Hospital, a stroke patient was treated the same regime as the one at 108 Military Central Hospital Stroke patients go to the emergency department, being recognized by emergency doctors during the intervention period and are informed on Zalo and then the patients are measured blood pressure, test glucosemia, intravenous line, CT and CTA and doctors in stroke center will coordinate with doctors in radiology department in order to examine and evaluate patients, if there are indications for thrombolysis, it should be done immediately at radiology department The rational combination between departments has shortened time for curing stroke patients - Use of thrombolytic agents (rTPA) is considered to be the key to success in the treatment of acute ischemic stroke - In terms of neurological recovery, patients in our study had an average NIHSS admission score of 10.12 ± 3.57, after treatment of venous thombolysis Average NIHSS decreased to 3.7 ± 4.93, equivalent to Ngo Van Dung‟s study [1] - As recommended by AHA/ASA (American Heart Association and American Stroke Association) in 2013, treatment of venous thrombolytic agents with acute ischemic stroke patients is a top priority even in case arterial intervention therapies can (1) However, the number of acute ischemic stroke patients treated for venous thrombolysis was very low at Thainguyen Central Hospital, the rate was 4.06% (figure 1); lower than developed countries, for example in the USA was 10.3% in 2003 [3] 168 - Treatment window is a very important factor, patients will benefit from treatment of thrombolysis within 90 minutes to hours after the onset of symptoms [3] Good recovery rate at discharge (mRS = - 2) accounted for 76.9% for patients treated within the first hours after onset, after hours, this rate decreased to 50% Thus, it can be said that time is an independent prognostic factor with good recovery of patients Therefore, we always try our best to treat patients with intravenous thrombolysis in the shortest time when coming to the hospital with a harmonious combination of departments: Emergency, Neurology and Diagnostic Image In Thainguyen Central Hospital, the average time from hospital admission to thrombolytic treatment was 49.88 ± 30.984 minutes; fibrinolytic drugs at Thainguyen Central Hospital are still not covered by health isurance, so we spent a lot of time explaining and waiting for the patient‟s family to decide to be treated CONCLUSION Through the study on 50 patients with acute ischemic stroke who received intravenous thrombolytic treatment at Stroke Center, Thainguyen Central Hospital, we obtained the following results: - The most common acute ischemic stroke is between the ages of 55 and 75 - Acute ischemic stroke patients receiving intravenous thrombolysis had good recovery, of which average NIHSS scores decreased from 10.12 to 3.7 ± 4.93 Journal of military pharmaco-medicine n02-2019 - Patients with accompanied atrial fibrillation had poorer recovery compared to those without atrial fibrillation (p = 0.134, not statistically significant) facilities that are eligible to use rTPA for emergency and treatment as soon as possible REFERENCES - The patients treated in the first hours had a better recovery Ngo Van Dung Intravenous blood fibrinolysis for patients with acute cerebral infarction in Vietiep Hospital Journal of Clinical Medicine and Pharmacy 2017, 108 - Patients with acute ischemic treated with intravenous thrombolysis had good recovery after month RECOMMENDATIONS Communication in the community should be promoted on how to detect and manage stroke, so that patients with stroke will be taken to the hospital as soon as the earliest stroke happens The window of thrombolysis treatment is limited, only within the first 4.5 hours Therefore, after detecting the symptoms of stroke suspicion: mouth distortion, trouble speaking and paralysis, patients must be taken immediately to the health Le Van Thanh, Nguyen Thi Kim Lien, Phan Cong Tan, Nguyen Van Tuan Treatment of venous thrombolysis in 121 patients with acute cerebral infarction in the first hours in Hochiminh City Report at Vietnam Stroke Conference 2010, October Dick A.P, Straka J IV rTPA for acute ischemic stroke Results of the first 101 patients in a community practise The Neurologist 2005, 11, pp.305-308 Jauch, Edward C et al Guidelines for early management of patients with acute ischemic stroke A guideline for healthcare professionals from American Heart Association/ American Association Stroke 2013, 44, pp.870-974 169 ... recombinant tissue plasminogen activator in patients with acute ischemic stroke in the first 4.5 hours - To analyze a number of factors affecting the results of treatment in patients with acute ischemic. .. treatment at Stroke Center, Thainguyen Central Hospital, we obtained the following results: - The most common acute ischemic stroke is between the ages of 55 and 75 - Acute ischemic stroke patients... number of acute ischemic stroke patients treated for venous thrombolysis was very low at Thainguyen Central Hospital, the rate was 4.06% (figure 1); lower than developed countries, for example in the