|Year : 2022 | Volume
| Issue : 3 | Page : 125-129
Clinicoetiological profile of acute ischemic stroke patients in the therapeutic window in a tertiary care hospital in Northern India
Amit Chandra, Maqbool Wani, Adnan Firdous Raina, Hilal Ahmad Ganie, Waseem Dar, Arjimand Yaqoob, Ravouf Asimi
Department of Neurology, SKIMS, Srinagar, Jammu and Kashmir, India
|Date of Submission||06-Feb-2022|
|Date of Decision||30-Mar-2022|
|Date of Acceptance||03-Apr-2022|
|Date of Web Publication||01-Aug-2022|
Dr. Adnan Firdous Raina
Department of Neurology, SKIMS, Soura, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: A stroke is defined by the rapid emergence of clinical symptoms and focuses on evidence (applicable to individuals in a deep coma and those with subarachnoid hemorrhage) or widespread brain damage. The study aimed to evaluate the clinical characteristics of patients with acute ischemic stroke in a tertiary care hospital in North India. Methods: By analyzing case files and conducting patient interviews, information on the patients was gathered and evaluated. The study's inclusion and exclusion criteria were based on the 2018 American Heart Association and American Stroke Association (AHA/ASA) thrombolysis guidelines for acute ischemic stroke. Recent major trauma or major surgery within 14 days not involving the head, seizure at the onset of stroke, systemic malignancy, and pregnancy were excluded. Results: The study enlisted the participation of 76 patients who were divided into two groups. Patients in the one group were given tenecteplase, whereas the other group were given alteplase. Patients in the tenecteplase and alteplase groups were of different ages and had various other risk factors for hypertension, atrial fibrillation, diabetes, smoking, and previous stroke or transient ischemic attack. The risk factor distribution in both the groups was statistically significant for variables such as hypertension and diastolic blood pressure (P < 0.05). Stroke in internal carotid artery territory was present in 3 out of 42 in the tenecteplase group and 2 out of 32 in the alteplase group. Most patients in both the groups had a stroke of undetermined cause. Small vessel and large vessel strokes were found in 9.5% and 14.7%, respectively. Conclusion: In the development of stroke, there is a definite relationship between age and gender. A sedentary lifestyle, food, and obesity are risk factors for stroke. According to an AHA/ASA drug utilization analysis, most medicines were appropriate for stroke patients.
Keywords: Coronary syndrome, hypertension, risk factors, stroke, thrombosis
|How to cite this article:|
Chandra A, Wani M, Raina AF, Ganie HA, Dar W, Yaqoob A, Asimi R. Clinicoetiological profile of acute ischemic stroke patients in the therapeutic window in a tertiary care hospital in Northern India. Curr Med Issues 2022;20:125-9
|How to cite this URL:|
Chandra A, Wani M, Raina AF, Ganie HA, Dar W, Yaqoob A, Asimi R. Clinicoetiological profile of acute ischemic stroke patients in the therapeutic window in a tertiary care hospital in Northern India. Curr Med Issues [serial online] 2022 [cited 2022 Oct 6];20:125-9. Available from: https://www.cmijournal.org/text.asp?2022/20/3/125/352969
| Introduction|| |
The World Health Organization (WHO) defines a stroke as a clinical syndrome characterized by the rapid onset of clinical symptoms and signs of focal (applicable to patients in a deep coma and those with subarachnoid hemorrhage) or global dysfunction involved in the brain, loss of cerebral function, with symptoms lasting more than 24 h or leading to death, and no apparent cause other than a vascular origin. People over the age of 60 years are more likely to die from a stroke. Stroke deaths are more common in people aged 15–59 years. Death rates in places such as the Middle East, Sub-Saharan Africa, and Latin America are expected to rise and quadruple over the next two decades., According to the WHO projections, poor- and middle-income nations such as China and India would account for about 80% of all stroke incidents by 2050. According to trustworthy mortality and morbidity estimates, stroke incidence in India is low due to incorrect death classifications, ambiguity in defining the reason for sudden death, numerous comorbid diseases, and short death certificates.
Ischemic and hemorrhagic strokes account for around 87% and 13% of all strokes, respectively. During an ischemic stroke, a blood artery in the brain gets clogged, allowing blood to flow into nearby brain areas. A blood artery weakens during a hemorrhagic stroke, causing it to burst and bleed into the surrounding brain areas. This blood would pool and crush the tissue surrounding it.,
Nonmodifiable risk factors (age, gender, race, family history, and low birth weight) are among the risk factors, as are modifiable risk factors (smoking or tobacco use, obesity, residential area, and diet) and possibly modifiable risk factors (excessive alcohol, hypercoagulability, drugs, oral contraceptive use, and acute infection)., A neurological examination utilizing the National Institute of Health Stroke Scale is suggested by the American Heart Association/American Stroke Association (AHA/ASA) recommendations (NIHSS). As per recommendations from AHA/ASA, “TPA, antiplatelet like (aspirin and clopidogrel), anticoagulants (heparin and warfarin), antihypertensive, and lipid-lowering agents are required for treatment of ischemic stroke, while osmotherapy, neuromuscular relaxants, neuroprotection and neurorestorative therapy, reperfusion therapy, and calcium channel blockers are required for hemorrhagic stroke treatment.,, It has become clear that population expansion and aging can increase the total number of persons at risk of stroke. Improved stroke survival also predicts a more considerable prevalence of chronic stroke. As a result, determining the breadth of the problem and the etiology, clinical profile of patients, and therapeutic options utilized to treat acute ischemic stroke is necessary. This study aimed to evaluate the clinical features of patients with acute ischemic stroke in a tertiary care hospital in North India.
| Methods|| |
This was a prospective study.
Study setting and period
The study was conducted from September 2018 to March 2021 at the Department of Neurology, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar.
By analyzing case files and conducting patient interviews, information on the patients was gathered and evaluated. The study's inclusion and exclusion criteria were based on the 2018 AHA/ASA thrombolysis guidelines for acute ischemic stroke. The study covered patients with ischemic and hemorrhagic stroke, with or without concomitant condition, who were above the age of 18 years and both genders had onset of disease symptoms 4.5 h before starting treatment and had a diagnosis of ischemic stroke with measurable neurological damage. Recent major trauma or major surgery within 14 days not involving the head, seizure at the onset of stroke, systemic malignancy, and pregnancy were all excluded. Patient interviews were used to determine demographic data such as age, gender, risk factors (lifestyle, diet, body mass index, educational and socioeconomic status, residential areas, previous and family history, and comorbid disease), the onset of stroke and neurological severity using NIHSS, contraindication of thrombolytic therapy, and prescribing trends.
Statistical analysis was done using the IBM Corp. Released 2019. IBM SPSS (Statistical package for the social sciences) Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Data were expressed as mean and standard deviation or as median with interquartile range or percentage, whichever was appropriate for the subject's characteristic description variable. Group differences were compared using the Pearson's Chi-square test or Fisher's exact test to test the significance of groups for categorical variables and the Student's t-test or the Mann–Whitney U test to test the effectiveness of continuous variables. For testing individual subgroups of the two groups, the z test was used. P < 0.05 was considered statistically significant.
The study was conducted after getting proper ethics committee approval from our institutional ethics committee (IEC-SKIMS/34/2021/SSB).
| Results|| |
The study had a total of 76 participants divided into two groups. One group containing 42 patients were given Tenecteplase between September 2018 and March 2021 while another group had 34 patients who had undergone thrombolysis with alteplase from July 2015 to July 2017. During the patient selection process 2018 AHA/ASA thrombolysis guidelines were followed. These data were compared and statistically analyzed, yielding the following results.
The basic clinical characteristics of patients of the two groups are shown in [Table 1]. Most patients were in the 70–79 years of age group in the tenecteplase group, while in the alteplase group, most patients were in the 60–69 years of age group. The mean age in the tenecteplase group was 65.57 ± 13.01 years, whereas in the alteplase group, it was 62.44 ± 13.62 years. The total number of males and females in the tenecteplase group was 20 (47.6%) and 22 (52.4%) out of 42 patients, respectively, whereas in the alteplase group, 24 (74.6%) were male and 10 (29.4%) were female out of 34 patients.
|Table 1: Clinicodemographic characteristics of study participants between groups|
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In the tenecteplase group, 6% of 42 patients belonged to the urban area, whereas 88% of the total 34 patients in the alteplase group belonged to the urban area. In the tenecteplase group, out of 42 patients, 36 had hypertension, 18 were diabetics, 15 had atrial fibrillation, 11 had dyslipidemia, 8 sustained a previous stroke or transient ischemic attack (TIA), and 5 were smokers. In the alteplase group, 24 patients had hypertension, 18 were smokers, 8 had dyslipidemia, 7 had atrial fibrillation, and 6 were diabetics. The risk factors distributed in both the groups were statistically significant in hypertension, atrial fibrillation, diabetes, smoking, and previous stroke or TIA (P < 0.05). The mean systolic blood pressure (BP) in the tenecteplase and alteplase groups was 144 and 143.5 mmHg, whereas the mean diastolic BP was 80 and 89 mmHg, respectively. The association of diastolic BP was significant in both the groups (P < 0.05). The mean blood sugar in the tenecteplase and alteplase groups was 137.4 ± 45.7 mg/dl and 125.4 ± 47.1 mg/dl, respectively.
Vascular territory involvement of stroke in the two groups is shown in [Table 2]. Most patients had a stroke in MCA territories in both the groups. Stroke in internal carotid artery territory was present in 3 patients out of 42 in the tenecteplase group and two patients out of 32 in the alteplase group. Two patients in the alteplase group had a pseudostroke. In contrast, none in the tenecteplase group had a pseudostroke.
The type of stroke in the two groups is shown in [Table 3]. Most patients in both the groups had strokes of undetermined cause. The cardioembolic cause was found in 31% and 18% of patients in the tenecteplase and alteplase groups, respectively, which was statistically significant (P < 0.05). Large vessel stroke was found in 19% and 14.7% of patients in the tenecteplase and alteplase groups, respectively; small vessel stroke was found in 9.5% of patients in the tenecteplase group and 17.6% of patients in the alteplase group.
|Table 3: Incidence and classification of stroke type among the study groups|
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| Discussion|| |
In the NORTEST study, patients aged < 60 years, 60–80 years, and more than 80 years in the tenecteplase group were 20%, 65%, and 15% of the total 549 patients, respectively. In contrast, this distribution was 19%, 64%, and 17% of the total 551 patients in the alteplase group, respectively. The mean age in our study in the tenecteplase and alteplase groups was 65.6 ± 13 years and 62.4 ± 13.6 years, respectively. In a study done by Haley et al., the mean age was 69 ± 15 years in tenecteplase (0.25 mg/kg group), whereas in alteplase, it was 72 ± 16 years. In a study done by Parsons et al., the mean age in the tenecteplase and alteplase groups was 68 ± 9.4 years and 70 ± 8.4 years, respectively. In a study done by Campbell et al., the mean age in the tenecteplase and alteplase groups was 70.4 ± 15.1 years and 71.9 ± 13.7 years, respectively. Thus, in our study, patients were from the younger age group. This discrepancy might be because stroke incidence and prevalence in India are increasing in the young population because of exposure to genetic and other risk factors. Our study's mean age distribution was consistent with the TENVALT study, conducted in South India in 2019. The mean age in the tenecteplase and alteplase groups was 66.6 ± 8.7 and 62.5 ± 9.2 years, respectively.
In the current study, males predominated in both the groups (tenecteplase and alteplase) although the proportion of males in the alteplase group (74.6%) was much higher than the tenecteplase group (47.6%). In the study by Haley et al., males in the tenecteplase group were 52%, while in the alteplase group, males were 51%. In a study done by Parsons et al., males in the tenecteplase and alteplase groups were 52% and 48%, respectively. In the NORTEST trial, 58% and 62% were male in tenecteplase and alteplase groups, respectively.
In this study, in the tenecteplase group, hypertension was the most common risk factor of stroke, followed by diabetes, AF, and dyslipidemia. In the TENVALT study, hypertension was also the most common risk factor, accounting for 67%, diabetes in 43.6%, and dyslipidemia in 14.5% of patients in the tenecteplase group. In a study conducted by Ramakrishnan in 2018 in India, hypertension, diabetes, and smoking were 80%, 33.3%, and 30% of the total patients in the tenecteplase (0.2 mg/kg dose) group, respectively. In our study, in the alteplase group, the proportion of hypertension, atrial fibrillation, diabetes, dyslipidemia, and smoking was 70.5%, 20.5%, 17.6%, 23%, and 53% in patients as risk factors for the stroke, respectively. In the study done by Haley et al., hypertension and diabetes were in 71% and 13% of patients in the alteplase group, respectively. In the NORTEST study, diabetes and smoking were in 13% and 54% of patients in the alteplase group, respectively. In the ATTEST study, AF in the tenecteplase and alteplase groups was in 40% and 31% of patients, whereas dyslipidemia in the tenecteplase and alteplase groups was in 9% and 14% of patients, respectively. In the TENVALT study, the proportion of hypertension and dyslipidemia in the alteplase group was 76% and 21.5% of patients as risk factors for stroke, respectively. Thus, the balance of various risk factors of stroke in the present study population was consistent with the previous studies.
In our study, the mean systolic BP in the tenecteplase and alteplase groups was 144.02 ± 18.21 and 143.5 ± 19.21 mmHg, whereas the mean diastolic BP in both the groups was 80.14 ± 9.39 and 88.73 ± 10.56 mmHg, respectively. In an analysis by Kvistad, the mean systolic BP in the tenecteplase and alteplase groups was 153.7 ± 20.9 and 146.2 ± 20.7 mmHg, respectively. In Haley et al.'s study, diastolic BP in the tenecteplase and alteplase groups was 84 ± 14 and 81 ± 13 mmHg, respectively. Thus, the mean BP values in our study were in concordance with prior studies.
In the present study, the blood sugar in the tenecteplase and alteplase groups was 137.4 ± 45.7 and 125.4 ± 47.1 mg/dl, respectively. In a meta-analysis by Huang et al., the blood sugar was 124.2 ± 30.6 and 124.2 ± 36 mg/dl in tenecteplase and alteplase groups, respectively. In the ATTEST trial, the blood sugar in the tenecteplase and alteplase groups was 126 ± 18 and 126 ± 36 mg/dl, respectively. The relatively higher mean blood sugar in tenecteplase group was related to a more significant proportion of diabetics in our study.
In the present study, in the tenecteplase group, 19% and 10% of the strokes belonged to a large vessel and small vessel categories, respectively. In contrast, in the alteplase group, these etiologies of stroke were found in 14% and 17% of patients, respectively. The cardioembolic cause was seen in 31% and 17% of patients and undetermined cause of the stroke in 40% and 44% in the tenecteplase and alteplase groups, respectively; pseudostroke was seen in none of the patients in the tenecteplase group but in 6% of patients in the alteplase group. In NORTEST study, extensive vessel disease as etiology of stroke in the tenecteplase and alteplase groups was in 20% of the population each, small vessel disease in 15% and 12% of patients, the cardioembolic cause in 21% and 27% of patients, and undetermined cause of the stroke in 39% and 36% of patients, respectively. In Haley et al.'s study, small vessel disease was found in 13% and 23% and pseudostroke in 0% and 7% of patients in tenecteplase and alteplase groups, respectively. The proportion of various etiologies of stroke seen in our study was thus similar to previous studies.
| Conclusion|| |
The study was helpful in establishing the risk factors, clinical manifestations, onset patterns, and prescribing trends among stroke patients admitted to a tertiary care hospital. According to the findings, there is a clear link between age and gender in stroke development. Stroke risk may be influenced by a sedentary lifestyle, diet, obesity, residential location, previous and family history of stroke, hypertension, and diabetes. The AHA/ASA drug utilization review indicated that most of the prescriptions were reasonable. The study establishes a paradigm for ongoing examination of stroke patients' prescription patterns.
Ethics approval and consent
Ethics approval and consent to participate in the study were obtained.
Research quality and ethics statement
All authors of this manuscript declare that this scientific study is in compliance with standard reporting guidelines set forth by the EQUATOR Network. The authors ratify that this study required institutional review board/ethics committee review, and hence, prior approval was obtained IRB Min. No. IEC-SKIMS/34/2021/SSB dated 27/07/2018). We also declare that we did not plagiarize the contents of this manuscript and have performed a plagiarism check.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thrift AG, Thayabaranathan T, Howard G, Howard VJ, Rothwell PM, Feigin VL, et al.
Global stroke statistics. Int J Stroke 2017;12:13-32.
Pandian JD, Sudhan P. Stroke epidemiology and stroke care services in India. J Stroke 2013;15:128-34.
Anthony S, Kasper L, Dan L, Braunwald E. Harrison's Principles of Internal Medicine. 17th
ed. United States of America, NY: McGrawHill; 2012.
Gary D, Stephen J. Pathophysiology of Disease an Introduction to Clinical Medicine. 7th
ed. New York, NY: McGraw-Hill; 2014.
Jickling GC, Liu D, Stamova B, Ander BP, Zhan X, Lu A, et al.
Hemorrhagic transformation after ischemic stroke in animals and humans. J Cereb Blood Flow Metab 2014;34:185-99.
Jauch EC, Saver JL, Adams HP Jr., Bruno A, Connors JJ, Demaerschalk BM, et al.
Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947.
Marinigh R, Lip GY, Fiotti N, Giansante C, Lane DA. Age as a risk factor for stroke in atrial fibrillation patients: Implications for thromboprophylaxis. J Am Coll Cardiol 2010;56:827-37.
Lisabeth L, Bushnell C. Stroke risk in women: The role of menopause and hormone therapy. Lancet Neurol 2012;11:82-91.
James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005;106:509-16.
Eriksson JG, Forsén T, Tuomilehto J, Osmond C, Barker DJ. Early growth, adult income, and risk of stroke. Stroke 2000;31:869-74.
Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000;355:1670-4.
Logallo N, Novotny V, Assmus J, Kvistad CE, Alteheld L, Rønning OM, et al.
Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): A phase 3, randomised, open-label, blinded endpoint trial. Lancet Neurol 2017;16:781-8.
Haley EC Jr., Thompson JL, Grotta JC, Lyden PD, Hemmen TG, Brown DL, et al.
Phase IIB/III trial of tenecteplase in acute ischemic stroke: Results of a prematurely terminated randomized clinical trial. Stroke 2010;41:707-11.
Parsons M, Spratt N, Bivard A, Campbell B, Chung K, Miteff F, et al.
A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med 2012;366:1099-107.
Campbell BC, Mitchell PJ, Churilov L, Yassi N, Kleinig TJ, Dowling RJ, et al.
Effect of intravenous tenecteplase dose on cerebral reperfusion before thrombectomy in patients with large vessel occlusion ischemic stroke: The EXTEND-IA TNK part 2 randomized clinical trial. JAMA 2020;323:1257-65.
Sundar K, Bhirud L, Panwar A, Cherian JJ, Paul EM, Kuruttukulam GV. Tenecteplase versus alteplase (TENVALT): A study comparing two thrombolytic agents in acute ischemic stroke. Neurol Asia 2019;24:203-8.
Ramakrishnan TC, Kumaravelu S, Narayan SK, Buddha SS, Murali C, Majeed PH, et al.
Efficacy and safety of intravenous tenecteplase bolus in acute ischemic stroke: Results of two open-label, multicenter trials. Am J Cardiovasc Drugs 2018;18:387-95.
Huang X, Cheripelli BK, Lloyd SM, Kalladka D, Moreton FC, Siddiqui A, et al.
Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): A phase 2, randomised, open-label, blinded endpoint study. Lancet Neurol 2015;14:368-76.
Kvistad CE, Novotny V, Kurz MW, Rønning OM, Thommessen B, Carlsson M, et al.
Safety and outcomes of tenecteplase in moderate and severe ischemic stroke. Stroke 2019;50:1279-81.
Huang X, MacIsaac R, Thompson JL, Levin B, Buchsbaum R, Haley EC Jr., et al.
Tenecteplase versus alteplase in stroke thrombolysis: An individual patient data meta-analysis of randomized controlled trials. Int J Stroke 2016;11:534-43.
[Table 1], [Table 2], [Table 3]