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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 55, Num. 1, 2007, pp. 9-10

Neurology India, Vol. 55, No. 1, January-March, 2007, pp. 9-10

Invited Commentaries

Thrombolysis for acute ischemic stroke in India: Overcoming the challenges

Division of Neurology, Department of Medicine, University of Alberta
Correspondence Address:Division of Neurology, Department of Medicine, University of Alberta,

Code Number: ni07006

Good stroke care programs and making thrombolysis accessible and attainable for patients is of critical importance, particularly in the Indian subcontinent where stroke rates are amongst the highest in the world. Acute stroke care has improved greatly in the last decade, particularly after the National Institute of Neurological Disorders and Stroke (NINDS) study group showed that recombinant tissue plasminogen activator (rtPA) administered within three hours after the onset of ischemic stroke symptoms improved patient outcomes.[1] However, delivery of this hyperacute therapy can be quite difficult, especially in developing nations where issues of stroke infrastructure and costs may obstruct efforts to set up efficient stroke care programs. In this issue of Neurology India, Padma et al[2] report their experience of 54 patients treated with rtPA over a four-year period in a tertiary care hospital in India. Their experience mirrors the experience of many centers in North America, but also highlights some of the unique challenges to establishing acute stroke care in developing nations.

Although rtPA is the established and approved treatment for acute stroke within three hours of symptom onset, many centers in North America have low rates of thrombolysis. Overall in the United States, it has been estimated that only 2-3% of stroke patients receive this therapy,[3] particularly due to patients being out of the limited therapeutic window.[4] However, it has also been shown that with dedicated stroke programs and stroke teams, the rate of thrombolysis can be increased, with some centers, including our own, reporting rates as high as 20%.[5] In order to establish stroke programs and achieve good rates of thrombolysis, neurologists must advocate for this therapy and work hard with local officials, radiology departments, and emergency room physicians and personnel to make this service available.

In many ways, the challenges faced to establish stroke care are more difficult in India. For example, as noted by the authors, the lack of rapid processing for bloodwork would make most patients ineligible for treatment, as the results would not be available within the three-hour window. By carefully selecting their patients, they were able to administer rtPA with impressive door-to-needle times and had no reported symptomatic intracerebral hemorrhage, despite giving therapy without coagulation profiles or platelet counts. One should be cautious, as it should be noted that the most feared complication of thrombolytic therapy, symptomatic intracerebral hemorrhage, is higher when deviations for the NINDS tPA protocol occur.[6] However, due to the different circumstances faced by the treating physicians in India, such innovative approaches may be necessary and, as long as the safety of such approaches can be established, they should be encouraged. In addition, continued campaigns to increase public awareness of stroke, improving the emergency medical systems to allow patients to arrive in time for therapy and producing cheaper, generic alternatives to commercially available rtPA are crucial to improve patients′ outcomes in the Indian subcontinent. We applaud the efforts of the authors and we are optimistic that with continued efforts such as this, India can be a leader in the practical application of acute stroke care in the developing world.


1.Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995;333:1581-7.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Padma MV, Singh MB, Bhatia R, Srivastava A, Tripathi M, Shukla G, et al . Hyperacute thrombolysis with IV rtPA of acute ischemic stroke: Efficacy and safety profile of 54 patients at a tertiary referral center in a developing country. Neurol India 2007;55:46-9.  Back to cited text no. 2    
3.Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, et al . Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA 2000;283:3102-9.  Back to cited text no. 3    
4.Katzan IL, Furlan AJ, Lloyd LE, Frank JI, Harper DL, Hinchey JA, et al . Use of tissue-type plasminogen activator for acute ischemic stroke: The Cleveland area experience. JAMA 2000;283:1151-8.  Back to cited text no. 4    
5.Katzan IL, Hammer MD, Furlan AJ, Hixson ED, Nadzam DM; Cleveland Clinic Health System Stroke Quality Improvement Team. Quality improvement and tissue-type plasminogen activator for acute ischemic stroke: A Cleveland update. Stroke 2003;34:799-800.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Hill MD, Buchan AM; Canadian Alteplase for Stroke Effectiveness Study (CASES) Investigators. Thrombolysis for acute ischemic stroke: Results of the Canadian Alteplase for Stroke Effectiveness Study. CMAJ 2005;172:1307-12.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]

Copyright 2007 - Neurology India

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