Acute Ischemic Stroke Management at Tertiary Hospital in Bangladesh: The Crucial Role of Alteplase in Thrombolysis

Acute Ischemic Stroke Management at Tertiary Hospital in Bangladesh: The Crucial Role of Alteplase in Thrombolysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Acute Ischemic Stroke Management at Tertiary Hospital in Bangladesh: The Crucial Role of Alteplase in Thrombolysis Himel Kumar Biswaas, Rama Biswas, Sheikh Nafis - ur Rahman1, Ashrafur Rahaman Mahadi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4430952/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract A 70-year-old hypertensive and past smoker gentleman presented an acute ischemic stroke with an NIHSS score of 12. Intravenous thrombolysis using Alteplase led to a remarkable recovery, reducing the NIHSS score to 2 within 48 hours. This highlights intravenous thrombolysis' efficacy in acute ischemic stroke management in low-resource settings in Bangladesh. Neurology Critical Care & Emergency Medicine Internal Medicine Thrombolysis Alteplase Stroke Neurology Bangladesh Figures Figure 1 Background Stroke is a serious and scary neurological condition that affects people all over the world due to its high mortality, morbidity, and financial burden [ 1 ]. Stroke is a serious problem on a global scale. Recent statistics show that 13.7 million new instances of stroke, 5 million fatalities, and 116.4 million DALYs (disability-adjusted life-years) were caused by stroke in 2016. There were more than 80 million stroke survivors in 2016, according to estimates [ 1 ]. Bangladesh has a 0.3% documented prevalence of strokes. In Bangladesh, stroke is the third leading cause of mortality [ 2 ] and a significant source of disability, despite being the second greatest cause of death globally [ 3 ]. It is predicted that as the population of seniors grows, so will the number of stroke cases [ 4 ]. Recanalization's significance was validated by a meta-analysis of 53 trials. Recanalization is highly connected with improved functional outcomes and lower mortality, according to the findings of the research [ 5 ]. In the first 6 to 8 hours after the commencement of the stroke, there was a 17% rate of spontaneous revascularisation, according to a systematic review of published articles [ 6 ]. More people experience an ischemic stroke than hemorrhagic stroke [ 7 ] and thrombolytic drugs have a crucial role in its management. In the treatment of acute ischemic stroke, the safety and effectiveness of intravenous recombinant tissue plasminogen activator (r-TPA) are well known [ 6 – 7 ]. The use of Alteplase in acute ischemic stroke has been authorized [ 7 – 8 ]. A low dose of Alteplase (0.6 mg/kg) has also been examined for effectiveness and safety in a few studies [ 9 – 11 ]. One of the most widely used thrombolytic drugs in the world, Alteplase has an average dose of 0.9 mg/kg [ 12 ]. According to one trial, the regular dose of Alteplase did not outperform the low dose in terms of mortality and morbidity at three months. A different study [ 10 ] compared the effects of Alteplase at low and regular doses on major disability reduction [ 11 ]. For the treatment of acute ischemic stroke, we have recently begun using Alteplase for thrombolysis at our hospital. Here, we presented a case of acute ischemic stroke due to occlusion in the middle cerebral artery with the use of thrombolytic therapy well within the window period with an excellent clinical outcome in low resource settings Bangladesh. Case Presentation The 70-year-old male patient, went to the emergency room complaining of rapid onset right-sided weakness, slurred speech, and trouble walking. His medical history included a history of hypertension, and he was a smoker. The patient's clinical examination revealed: pulse rate was 90 beats per minute, blood pressure was 170/90 mmHg, respiratory rate was 18 breaths per minute, oxygen saturation was 98% on room air and body temperature was normal. An evaluation of the patient's nervous system revealed the following: The National Institutes of Health Stroke Scale (NIHSS) score was 12; 2 points were assigned for dysarthria, 2 points were assigned for partial facial paralysis, and 8 points were assigned for right limb weakness, Muscle strength in right-sided upper and lower limbs: 0/5; left-sided upper and lower limbs: 5/5. The physical examination indicated clear awareness, dysarthria, a shallow right nasolabial groove, a left-angled mouth, grade 0 muscle strength in the right limb, low muscle tension, and a positive Babinski sign (+) on the right side. In line with the stroke protocol, the patient was immediately sent for an Magnetic resonance imaging (MRI), which indicated an infarct in the location (Fig-1 A,B) of the middle cerebral artery (MCA). After the beginning of symptoms, the patient was an excellent candidate for thrombolysis with Alteplase since he was taken to the emergency center within one hour, a stroke protocol MRI was performed within twenty minutes, and the medicine Alteplase was administered within two hours. After satisfying the RT-PA indications, intravenous Alteplase treatment at the worldwide standard dosage of 0.9 mg/Kg is administered. 50 mg of intravenous alteplase was provided at a lower dosage of 0.9 mg/kg, with 10% (5 mg) given as a bolus over 1 minute and the remaining 90% (45 mg) mixed to 400 mL of 0.9% normal saline (N/S) to run over 1 hour. The interdisciplinary team lead by Consultant neurologists and Consultant radiologist made the choice to deliver Alteplase at such in a critical situation within the specified time frame. During medication monitoring, the patient reported an improvement in dizziness symptoms, clearer speech, normal left limb function, and an NIHSS score of 2. A close watch was kept on the patient in the event that Alteplase had adverse consequences, such as bleeding or allergic reactions. Twenty-four hours following alteplase administration, a repeat MRI of the brain revealed successful recanalization of the M1 section of the middle cerebral artery and healthy vascular collaterals (Fig. 1 : C,D). In the first twenty-four hours following the injection of Alteplase, the patient's blood pressure was maintained below 180/90 mmHg and he did not require any anticoagulant medication. On the third day of admittance, he had made tremendous progress, with a power of 4/5 in his right upper and lower limbs and the ability to respond appropriately to inquiries with his voice. Reading, naming, and repeating were intact, and the individual was able to grasp directives. As his symptoms improved, he stepped down to cabin and afterwards discharged from the hospital on the fifth day on oral atorvastatin and low-dose aspirin and advised to continue outpatient physiotherapy and hospital follow-up at outpatient department (OPD). Discussion If a patient has an acute ischemic stroke and arrives at the hospital within the approved window of time, thrombolysis is the recommended course of treatment. The actual situation is different, though. Multiple obstacles have been identified for the use of thrombolysis in patients with acute ischemic stroke, according to a study from Egypt. Patient-related stated difficulties include not knowing about stroke, having a stroke while sleeping, having to travel a considerable distance to the hospital, having to stick to a budget, and being afraid of side effects. Obstacles facing hospitals and doctors include a lack of neurologists and/or hospital beds [ 12 ]. The majority of these obstacles are also a factor in Bangladesh, where thrombolysis rates are lower. In Bangladesh's capital city of Dhaka, thrombolysis was introduced by our hospital a few days back. Alteplase is now being used to treat acute ischemic strokes through thrombolysis. In this research, we discussed the outcomes of using Alteplase for thrombolysis in patients who had just suffered an ischemic stroke. Comorbidities are incredibly prevalent in stroke victims. According to a study [ 13 ], hypertension was the most prevalent comorbidity in these patients (80.7%). In a study from Bangladesh [ 4 ] that examined the characteristics of stroke patients receiving rehabilitation, 85% of the patients had a history of hypertension prior to the stroke. In our investigation, diabetes mellitus was significantly more prevalent in stroke patients than in another published study [ 13 ] (50% vs 16.9%), but less prevalent than in a study from Bangladesh (77% vs 50%) [ 4 ]. The significance of lifestyle modifications to lower the risk of stroke is highlighted by these comorbidities. Early management of chronic conditions may help to lessen the burden of stroke. One of the stated concerns regarding the use of TPA in ordinary clinical practice for the treatment of acute ischemic stroke is its safety [ 14 ]. Age is a risk factor for symptomatic hemorrhage following r-TPA treatment [ 15 ]. In our case study, the patient was 70-year-old and responded favorably to Alteplase without experiencing any hemorrhagic complications or allergic responses. Patients who are taking antiplatelet medications have a higher risk of symptomatic cerebral bleeding when using r-TPA activators. Data on the use of thrombolytic agents in middle- or low-income countries for the treatment of stroke are scarce [ 16 ]. This example will significantly increase our understanding of stroke management in Bangladesh. This case is likely the most typical case describing the effective use of thrombolytic therapy in Bangladesh for the treatment of acute ischemic stroke. When treating acute ischemic stroke, especially when administering a thrombolytic drug, time is of the essence. Higher advantages are obtained when thrombolytic agents are administered earlier [ 17 ]. The hurdles for doctors include keeping blood pressure within the acceptable range, counseling patients to accept thrombolytic agents, and managing hypersensitivity reactions and bleeding when they do occur. Managing the usual door-to-needle time requires hospital staff to be more vigilant of stroke symptoms, report them to the hospital as soon as possible, and emphasize the value of using thrombolytic agents when they are needed. Our patient had an IV thrombolytic delivered shortly after the beginning of symptoms and had a better neurological prognosis. This highlights the importance of ongoing study, particularly among blacks, into the precise length of thrombolytic treatment in acute ischemic stroke, particularly in locations with limited access to thrombolytics and late admission to the hospital. Conclusions Thrombolysis with Alteplase saves acute ischemic stroke patients. Proper timing, selection, and monitoring of these patients carefully can reduce bleeding risk and improvement. In this example, Alteplase promptly resolved cerebral artery clots and improved the patient's neurological state. We suggest community-based stroke awareness initiatives, recognition of the Facial drooping, Arm weakness, Speech problems, and Time (FAST) symptoms of stroke, and more legislation and lobbying by policymakers to achieve a sustained worldwide decrease in stroke-related death and morbidity. Declarations Author Contributions: Dr Himel Kumar Biswas analyzed the patient’s data regarding the medical management of the case and wrote the manuscript. Dr Rama Biswas interpreted and analyzed the patient’s condition regarding the medical management of the case and helped to prepare the draft. Dr Sheikh Nafis - ur Rahman participated in patient’s enrolment and contributed in radiological interpretation. Dr. Ashrafur Rahaman Mahadi contributed in draft preparation and editing. The final manuscript was reviewed and approved by all the authors. Authors and Affiliations: *Dr Himel Kumar Biswas, Department of Neurology, Square Hospitals Ltd, Dhaka, Bangladesh. Email: [email protected] Dr Rama Biswas, Department of Neurology, Square Hospitals Ltd, Dhaka, Bangladesh. Email: [email protected] Dr Sheikh Nafis - ur Rahman, Department of Radiology & Imaging, Square Hospitals Ltd, Dhaka, Bangladesh. Email: [email protected] Dr. Ashrafur Rahaman Mahadi, Department of Medicine, Central Medical College, Comilla, Bangladesh. Email: [email protected] Acknowledgments: We want to thank the Emergency, Neurology team and all the clinical staffs in the hospital who participated in the treatment of the patient. Conflict of Interest statement: The authors have disclosed no conflicts of interest. Consent statement: Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy. Ethics statement: As per our institutional ethics committee guidelines, we do not require ethics approval for publishing case reports. Funding: This study received no financing from any governmental, corporate, or non-profit organization. Data availability: Data is readily available to the authors in the hospital electronic medical record. References GBD 2016 Stroke Collaborators Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol2019. 18:439 – 58 Islam MN, Moniruzzaman M, Khalil MI, Basri R, Alam MK, Loo KW (2013) Burden of stroke in Bangladesh. Int J Stroke 8:211–213 Mamin FA, Islam MS, Rumana FS, Faruqui F (2017) Profile of stroke patients treated at a rehabilitation center in Bangladesh. BMC Res Notes 10:520 Katan M, Luft A (2018) Global burden of stroke. Semin Neurol 38:208–211 Feigin VL, Florouzanfar MH, Krishnamurthi R et al (2014) The global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet 383:245–254 Rha JH, Saver JL (2007) The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 38:967–973 Dhillon S (2012) Alteplase: a review of its use in the management of acute ischaemic stroke. CNS Drugs 26:899–926 Syalaja PN, Dong W, Grotta JC et al (2007) Safety outcomes of Alteplase among acute ischemic stroke patients with special characteristics. Neurocrit Care 6:181–185 Anderson CS, Robinson T, Lindley RI et al (2016) Low-dose versus standard-dose intravenous Alteplase in acute ischemic stroke. N Engl J Med 374:2313–2323 Chao AC, Han K, Lin SF, Lin RT, Chen CH, Chan L et al (2019) Low-dose versus standard-dose intravenous Alteplase for octogenarian acute ischemic stroke:10.1016/j.jns.01.047 Yamaguchi T, Mori E, Minematsu K et al (2006) Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT). Stroke 37:1810–1815 Bahnasy WS, Ragab OAA, Elhassanien ME (2019) Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience. eNeurologicalSci. 14:68–71 Ma AJ, Dong Z, Li G (2011) Prevalence rates and risk factors on stroke among 50–79 years-olds in. Beijing 33:645–648 Micieli G, Marcheselli S, Tosi PA: Safety and efficacy of Alteplase in the treatment of acute ischemic stroke. Vac Health Risk Manag; 5: 397-409, Owais M, Panwar A, Valupadas C, Veeramalla M (2009) Acute ischemic stroke thrombolysis with tenecteplase: an institutional experience from South India. Ann Afr Med. 2018, 17:90 – 3 Miller DJ, Simpson JR, Silver B (2011) Safety of thrombolysis in acute ischemic stroke: A review of complications, risk factors, and newer technologies. Neurohospitalist. :138–147 William AG, Pannu A, Kate MP et al (2017) Quality indicators of intravenous thrombolysis from North India. Ann Indian 20:393–398 Lees KR, Emberson J, Blackwell L et al (2016) Effects of Alteplase for acute stroke on the distribution of functional outcomes: a pooled analysis of nine trials. Stroke 47:2373–2379 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4430952","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":303235854,"identity":"71d7dd7f-750d-4553-90e1-a3c3b4552674","order_by":0,"name":"Himel Kumar Biswaas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYBACA2Yg8bBBAi4gByIOPCCkJRFJizFYSwI+LQxgLQgBCBufFnN27sQHiTss7A2OH3/AdDPHLn1+2OGHQFvs5HQbsGuxbObdbJB4RiJxw5kcA+bcbcm5G2+nGQC1JBubHcDhsMO82yQS2yQSzA7kMAC1HMjdODsBpOVA4jbcWrb/AGqxNzv//AFIS7rh7PQPhLRsYwBqYdx2IwHksAMJ8tI5BG3ZLAHyy/4bbwwOA/1iuEE6p+BAggEev5w/u/HDxx119pL96Q8f526zk5efnb75w4cKOzlcWlAAWI0BhCRCORzIN5CiehSMglEwCkYCAABAQWcQGvfX3QAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-5548-6165","institution":"Square Hospitals Ltd.","correspondingAuthor":true,"prefix":"","firstName":"Himel","middleName":"Kumar","lastName":"Biswaas","suffix":""},{"id":303235855,"identity":"f2741172-1925-4fc0-b7db-07e7f7cc393a","order_by":1,"name":"Rama Biswas","email":"","orcid":"https://orcid.org/0009-0003-2356-0852","institution":"Square Hospitals Ltd.","correspondingAuthor":false,"prefix":"","firstName":"Rama","middleName":"","lastName":"Biswas","suffix":""},{"id":303235856,"identity":"8aa22c59-68d1-4d52-adb4-612e2137122e","order_by":2,"name":"Sheikh Nafis - ur Rahman1","email":"","orcid":"","institution":"Square Hospitals Ltd.","correspondingAuthor":false,"prefix":"","firstName":"Sheikh","middleName":"Nafis - ur","lastName":"Rahman1","suffix":""},{"id":303235857,"identity":"c5fb313a-8ce3-44f7-9081-ebb7599b1a12","order_by":3,"name":"Ashrafur Rahaman Mahadi","email":"","orcid":"https://orcid.org/0000-0002-9670-6125","institution":"Central Medical College Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ashrafur","middleName":"Rahaman","lastName":"Mahadi","suffix":""}],"badges":[],"createdAt":"2024-05-16 12:03:20","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4430952/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4430952/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56973686,"identity":"ae7fe017-7142-4f8d-8ab8-579e0d54166a","added_by":"auto","created_at":"2024-05-23 01:43:53","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":552150,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e(A) Diffuse restriction is seen in left parietal region and posterior part of isular contex.(B) Acute infarct is again seen in left cerebral hemispheres. No significant increase of size. No hemorrhage. No perfusion defect is seen. (C,D) Evidence of cerebral small vessel disease again noted. Impression : Features indicates successful thrombolysis with restoration of blood supply to previously seen salvageable brain.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4430952/v1/8aef2dd3a4e2a35060d98174.jpeg"},{"id":56973687,"identity":"36209e8f-635b-44ad-9f79-e56d3dda21e3","added_by":"auto","created_at":"2024-05-23 01:43:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":820204,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4430952/v1/fa394f66-8c7c-4085-9dfb-98ceb58ca134.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eAcute Ischemic Stroke Management at Tertiary Hospital in Bangladesh: The Crucial Role of Alteplase in Thrombolysis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eStroke is a serious and scary neurological condition that affects people all over the world due to its high mortality, morbidity, and financial burden [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Stroke is a serious problem on a global scale. Recent statistics show that 13.7\u0026nbsp;million new instances of stroke, 5\u0026nbsp;million fatalities, and 116.4\u0026nbsp;million DALYs (disability-adjusted life-years) were caused by stroke in 2016. There were more than 80\u0026nbsp;million stroke survivors in 2016, according to estimates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Bangladesh has a 0.3% documented prevalence of strokes. In Bangladesh, stroke is the third leading cause of mortality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and a significant source of disability, despite being the second greatest cause of death globally [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is predicted that as the population of seniors grows, so will the number of stroke cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Recanalization's significance was validated by a meta-analysis of 53 trials. Recanalization is highly connected with improved functional outcomes and lower mortality, according to the findings of the research [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the first 6 to 8 hours after the commencement of the stroke, there was a 17% rate of spontaneous revascularisation, according to a systematic review of published articles [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. More people experience an ischemic stroke than hemorrhagic stroke [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and thrombolytic drugs have a crucial role in its management. In the treatment of acute ischemic stroke, the safety and effectiveness of intravenous recombinant tissue plasminogen activator (r-TPA) are well known [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The use of Alteplase in acute ischemic stroke has been authorized [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A low dose of Alteplase (0.6 mg/kg) has also been examined for effectiveness and safety in a few studies [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. One of the most widely used thrombolytic drugs in the world, Alteplase has an average dose of 0.9 mg/kg [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. According to one trial, the regular dose of Alteplase did not outperform the low dose in terms of mortality and morbidity at three months. A different study [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] compared the effects of Alteplase at low and regular doses on major disability reduction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For the treatment of acute ischemic stroke, we have recently begun using Alteplase for thrombolysis at our hospital. Here, we presented a case of acute ischemic stroke due to occlusion in the middle cerebral artery with the use of thrombolytic therapy well within the window period with an excellent clinical outcome in low resource settings Bangladesh.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eThe 70-year-old male patient, went to the emergency room complaining of rapid onset right-sided weakness, slurred speech, and trouble walking. His medical history included a history of hypertension, and he was a smoker. The patient's clinical examination revealed: pulse rate was 90 beats per minute, blood pressure was 170/90 mmHg, respiratory rate was 18 breaths per minute, oxygen saturation was 98% on room air and body temperature was normal. An evaluation of the patient's nervous system revealed the following: The National Institutes of Health Stroke Scale (NIHSS) score was 12; 2 points were assigned for dysarthria, 2 points were assigned for partial facial paralysis, and 8 points were assigned for right limb weakness, Muscle strength in right-sided upper and lower limbs: 0/5; left-sided upper and lower limbs: 5/5. The physical examination indicated clear awareness, dysarthria, a shallow right nasolabial groove, a left-angled mouth, grade 0 muscle strength in the right limb, low muscle tension, and a positive Babinski sign (+) on the right side.\u003c/p\u003e \u003cp\u003eIn line with the stroke protocol, the patient was immediately sent for an Magnetic resonance imaging (MRI), which indicated an infarct in the location (Fig-1 A,B) of the middle cerebral artery (MCA). After the beginning of symptoms, the patient was an excellent candidate for thrombolysis with Alteplase since he was taken to the emergency center within one hour, a stroke protocol MRI was performed within twenty minutes, and the medicine Alteplase was administered within two hours. After satisfying the RT-PA indications, intravenous Alteplase treatment at the worldwide standard dosage of 0.9 mg/Kg is administered. 50 mg of intravenous alteplase was provided at a lower dosage of 0.9 mg/kg, with 10% (5 mg) given as a bolus over 1 minute and the remaining 90% (45 mg) mixed to 400 mL of 0.9% normal saline (N/S) to run over 1 hour. The interdisciplinary team lead by Consultant neurologists and Consultant radiologist made the choice to deliver Alteplase at such in a critical situation within the specified time frame.\u003c/p\u003e\u003cp\u003eDuring medication monitoring, the patient reported an improvement in dizziness symptoms, clearer speech, normal left limb function, and an NIHSS score of 2.\u003c/p\u003e \u003cp\u003eA close watch was kept on the patient in the event that Alteplase had adverse consequences, such as bleeding or allergic reactions. Twenty-four hours following alteplase administration, a repeat MRI of the brain revealed successful recanalization of the M1 section of the middle cerebral artery and healthy vascular collaterals (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: C,D). In the first twenty-four hours following the injection of Alteplase, the patient's blood pressure was maintained below 180/90 mmHg and he did not require any anticoagulant medication. On the third day of admittance, he had made tremendous progress, with a power of 4/5 in his right upper and lower limbs and the ability to respond appropriately to inquiries with his voice. Reading, naming, and repeating were intact, and the individual was able to grasp directives. As his symptoms improved, he stepped down to cabin and afterwards discharged from the hospital on the fifth day on oral atorvastatin and low-dose aspirin and advised to continue outpatient physiotherapy and hospital follow-up at outpatient department (OPD).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIf a patient has an acute ischemic stroke and arrives at the hospital within the approved window of time, thrombolysis is the recommended course of treatment. The actual situation is different, though. Multiple obstacles have been identified for the use of thrombolysis in patients with acute ischemic stroke, according to a study from Egypt. Patient-related stated difficulties include not knowing about stroke, having a stroke while sleeping, having to travel a considerable distance to the hospital, having to stick to a budget, and being afraid of side effects. Obstacles facing hospitals and doctors include a lack of neurologists and/or hospital beds [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The majority of these obstacles are also a factor in Bangladesh, where thrombolysis rates are lower. In Bangladesh's capital city of Dhaka, thrombolysis was introduced by our hospital a few days back. Alteplase is now being used to treat acute ischemic strokes through thrombolysis. In this research, we discussed the outcomes of using Alteplase for thrombolysis in patients who had just suffered an ischemic stroke. Comorbidities are incredibly prevalent in stroke victims. According to a study [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], hypertension was the most prevalent comorbidity in these patients (80.7%). In a study from Bangladesh [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] that examined the characteristics of stroke patients receiving rehabilitation, 85% of the patients had a history of hypertension prior to the stroke. In our investigation, diabetes mellitus was significantly more prevalent in stroke patients than in another published study [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] (50% vs 16.9%), but less prevalent than in a study from Bangladesh (77% vs 50%) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe significance of lifestyle modifications to lower the risk of stroke is highlighted by these comorbidities. Early management of chronic conditions may help to lessen the burden of stroke. One of the stated concerns regarding the use of TPA in ordinary clinical practice for the treatment of acute ischemic stroke is its safety [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Age is a risk factor for symptomatic hemorrhage following r-TPA treatment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our case study, the patient was 70-year-old and responded favorably to Alteplase without experiencing any hemorrhagic complications or allergic responses. Patients who are taking antiplatelet medications have a higher risk of symptomatic cerebral bleeding when using r-TPA activators. Data on the use of thrombolytic agents in middle- or low-income countries for the treatment of stroke are scarce [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This example will significantly increase our understanding of stroke management in Bangladesh. This case is likely the most typical case describing the effective use of thrombolytic therapy in Bangladesh for the treatment of acute ischemic stroke. When treating acute ischemic stroke, especially when administering a thrombolytic drug, time is of the essence. Higher advantages are obtained when thrombolytic agents are administered earlier [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The hurdles for doctors include keeping blood pressure within the acceptable range, counseling patients to accept thrombolytic agents, and managing hypersensitivity reactions and bleeding when they do occur. Managing the usual door-to-needle time requires hospital staff to be more vigilant of stroke symptoms, report them to the hospital as soon as possible, and emphasize the value of using thrombolytic agents when they are needed. Our patient had an IV thrombolytic delivered shortly after the beginning of symptoms and had a better neurological prognosis. This highlights the importance of ongoing study, particularly among blacks, into the precise length of thrombolytic treatment in acute ischemic stroke, particularly in locations with limited access to thrombolytics and late admission to the hospital.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThrombolysis with Alteplase saves acute ischemic stroke patients. Proper timing, selection, and monitoring of these patients carefully can reduce bleeding risk and improvement. In this example, Alteplase promptly resolved cerebral artery clots and improved the patient's neurological state. We suggest community-based stroke awareness initiatives, recognition of the Facial drooping, Arm weakness, Speech problems, and Time (FAST) symptoms of stroke, and more legislation and lobbying by policymakers to achieve a sustained worldwide decrease in stroke-related death and morbidity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDr Himel Kumar Biswas\u0026nbsp;\u003c/strong\u003eanalyzed the patient\u0026rsquo;s data regarding the medical management of the case and wrote the manuscript. \u003cstrong\u003eDr Rama Biswas\u003c/strong\u003e interpreted and analyzed the patient\u0026rsquo;s condition regarding the medical management of the case and helped to prepare the draft. \u003cstrong\u003eDr\u0026nbsp;Sheikh Nafis - ur Rahman\u003c/strong\u003e participated in patient\u0026rsquo;s enrolment and contributed in radiological interpretation. \u003cstrong\u003eDr. Ashrafur Rahaman Mahadi\u003c/strong\u003e contributed in draft preparation and editing. The final manuscript was reviewed and approved by all the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations:\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e*Dr Himel Kumar Biswas, Department of Neurology, Square Hospitals Ltd, Dhaka, Bangladesh. Email: [email protected]\u003c/li\u003e\n \u003cli\u003eDr Rama Biswas, Department of Neurology, Square Hospitals Ltd, Dhaka, Bangladesh. Email: [email protected]\u003c/li\u003e\n \u003cli\u003eDr Sheikh Nafis - ur Rahman, Department of Radiology \u0026amp; Imaging, Square Hospitals Ltd, Dhaka, Bangladesh. Email: [email protected]\u003c/li\u003e\n \u003cli\u003eDr. Ashrafur Rahaman Mahadi, Department of Medicine, Central Medical College, Comilla, Bangladesh. Email: [email protected]\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank the Emergency, Neurology team and all the clinical staffs in the hospital who participated in the treatment of the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have disclosed no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient to publish this report in accordance with the journal\u0026apos;s patient consent policy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs per our institutional ethics committee guidelines, we do not require ethics approval for publishing case reports.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no financing from any governmental, corporate, or non-profit organization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is readily available to the authors in the hospital electronic medical record.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGBD 2016 Stroke Collaborators Global, regional, and national burden of stroke, 1990\u0026ndash;2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol2019. 18:439\u0026thinsp;\u0026ndash;\u0026thinsp;58\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIslam MN, Moniruzzaman M, Khalil MI, Basri R, Alam MK, Loo KW (2013) Burden of stroke in Bangladesh. Int J Stroke 8:211\u0026ndash;213\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMamin FA, Islam MS, Rumana FS, Faruqui F (2017) Profile of stroke patients treated at a rehabilitation center in Bangladesh. BMC Res Notes 10:520\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatan M, Luft A (2018) Global burden of stroke. Semin Neurol 38:208\u0026ndash;211\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeigin VL, Florouzanfar MH, Krishnamurthi R et al (2014) The global and regional burden of stroke during 1990\u0026ndash;2010: findings from the Global Burden of Disease Study 2010. Lancet 383:245\u0026ndash;254\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRha JH, Saver JL (2007) The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 38:967\u0026ndash;973\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhillon S (2012) Alteplase: a review of its use in the management of acute ischaemic stroke. CNS Drugs 26:899\u0026ndash;926\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSyalaja PN, Dong W, Grotta JC et al (2007) Safety outcomes of Alteplase among acute ischemic stroke patients with special characteristics. Neurocrit Care 6:181\u0026ndash;185\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson CS, Robinson T, Lindley RI et al (2016) Low-dose versus standard-dose intravenous Alteplase in acute ischemic stroke. N Engl J Med 374:2313\u0026ndash;2323\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChao AC, Han K, Lin SF, Lin RT, Chen CH, Chan L et al (2019) Low-dose versus standard-dose intravenous Alteplase for octogenarian acute ischemic stroke:10.1016/j.jns.01.047\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamaguchi T, Mori E, Minematsu K et al (2006) Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT). Stroke 37:1810\u0026ndash;1815\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahnasy WS, Ragab OAA, Elhassanien ME (2019) Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience. eNeurologicalSci. 14:68\u0026ndash;71\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa AJ, Dong Z, Li G (2011) Prevalence rates and risk factors on stroke among 50\u0026ndash;79 years-olds in. Beijing 33:645\u0026ndash;648\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMicieli G, Marcheselli S, Tosi PA: Safety and efficacy of Alteplase in the treatment of acute ischemic stroke. Vac Health Risk Manag; 5: 397-409, Owais M, Panwar A, Valupadas C, Veeramalla M (2009) Acute ischemic stroke thrombolysis with tenecteplase: an institutional experience from South India. Ann Afr Med. 2018, 17:90\u0026thinsp;\u0026ndash;\u0026thinsp;3\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller DJ, Simpson JR, Silver B (2011) Safety of thrombolysis in acute ischemic stroke: A review of complications, risk factors, and newer technologies. Neurohospitalist. :138\u0026ndash;147\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliam AG, Pannu A, Kate MP et al (2017) Quality indicators of intravenous thrombolysis from North India. Ann Indian 20:393\u0026ndash;398\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLees KR, Emberson J, Blackwell L et al (2016) Effects of Alteplase for acute stroke on the distribution of functional outcomes: a pooled analysis of nine trials. Stroke 47:2373\u0026ndash;2379\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Square Hospitals","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Thrombolysis, Alteplase, Stroke, Neurology, Bangladesh","lastPublishedDoi":"10.21203/rs.3.rs-4430952/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4430952/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA 70-year-old hypertensive and past smoker gentleman presented an acute ischemic stroke with an NIHSS score of 12. Intravenous thrombolysis using Alteplase led to a remarkable recovery, reducing the NIHSS score to 2 within 48 hours. This highlights intravenous thrombolysis' efficacy in acute ischemic stroke management in low-resource settings in Bangladesh.\u003c/p\u003e","manuscriptTitle":"Acute Ischemic Stroke Management at Tertiary Hospital in Bangladesh: The Crucial Role of Alteplase in Thrombolysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-23 01:43:48","doi":"10.21203/rs.3.rs-4430952/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"15ad7a9f-b136-4a13-ba7c-a01ad0cf4d7c","owner":[],"postedDate":"May 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":32004888,"name":"Neurology"},{"id":32004889,"name":"Critical Care \u0026 Emergency Medicine"},{"id":32004890,"name":"Internal Medicine"}],"tags":[],"updatedAt":"2024-05-23T01:43:48+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-23 01:43:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4430952","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4430952","identity":"rs-4430952","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}