Egyptian experience in increasing utilization of reperfusion therapies in acute ischemic stroke

Abstract

Background The rate of alteplase (tPA) thrombolysis utilization in acute stroke in Egypt is <1%. We report on the causes of this low rate of reperfusion therapies and take corrective action to improve it. Methods Two prospective observational studies were conducted at Ain Shams University hospitals. The first included 269 acute stroke patients admitted to the hospital over a six-month period. Obstacles to reperfusion therapy were identified, and based on the results, a corrective action plan was implemented including making alteplase(tPA) available, training, and establishing a standardized local protocol for reperfusion therapy. A second study was then conducted that included 284 acute ischemic stroke patients over another six-month period. Results In the first study, 53/269 patients (19.7%) arrived at hospital within 4.5 h and were eligible for reperfusion therapy. Of those, seven (13.2%) received alteplase(tPA), representing 2.6% of the total ischemic stroke patients admitted. The main causes for not giving thrombolytic therapy was unavailability of alteplase(tPA) (56.5%), wrong treatment decision (17.4%), missed window while performing brain imaging (15%), and unavailability of intermediate care bed (10.9%). The second study showed that out of 284 cases admitted with acute ischemic stroke, 37 were eligible for thrombolysis and 35 received alteplase(tPA) (94.3%), representing 12.3% of the total ischemic stroke admissions. Conclusion A comprehensive action plan that centers around making the drug available and training resulted in a significant improvement of reperfusion therapy utilization in Egypt.

Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience

“…Great advancements had occurred in AIS management in Egypt during the last years, but the usage of IV thrombolysis (<1%) is still very far away from the proposed rate [2]. The drug is one of the few evidence-based managements of AIS with the earlier initiation of therapy, the better the clinical response and the lower degree of disabilities [10].…”

“…Cerebrovascular stroke (CVS) is the second most common cause of deaths (after ischemic heart disease) and the third most common cause of disability adjusted life years (after ischemic heart disease and cancer) [1]. The overall crude prevalence rate of stroke in Egypt is 963/100,000 inhabitants [2]. In 1996, the Food and Drug Administration (FDA) had approved IV r-tPA as the only therapy for early acute ischemic stroke (AIS) management and since this date, many efforts have been spent to reduce the stroke onset/needle time owing to the narrow therapeutic window of the drug [3].…”

Stroke in the Time of Coronavirus Disease 2019: Experience of Two University Stroke Centers in Egypt

“…Three years ago, since the implementation of the acute stroke protocol in our stroke centers, the rate of revascularization therapy has increased up to about 5 folds. 4 Thus, since the emergence of COVID-19 in Egypt, our main concern was to keep the acute stroke service running with the same efficiency.…”

Factors related to time of stroke onset versus time of hospital arrival: A SITS registry-based study in an Egyptian stroke center

“…Over the last 4 years (2016-2020), stroke care in Egypt became in the center of attention of medical health providers. Intravenous recombinant tissue plasminogen activator (r TPA) was endorsed by ministry of health after a study that was conducted to assess the obstacles regarding its availability, and this resulted in 5 times increase in thrombolysis in Ain Shams University stroke centers [3].…”

“…In 2018, Zakaria et al conducted a study in Egypt, to assess the causes of pre-hospital delay that would interfere with early arrival and administration of rTPA, and found that lack of patient or relative awareness about symptoms of stroke and waiting for symptoms to resolve spontaneously, in addition to lacking knowledge about the availability of acute intervention for stroke were the most common causes of prolonged onset to door [ 3 ]. Pre-hospital delay was estimated to range from 3–6 hours, and others reported that only 20% to 25% arrived to emergency within 3 hours of onset [ 4 , 5 ].…”