Thrombolysis in ischaemic stroke in rural North East Thailand by neurologist and non-neurologists

Background & Objective: Acute ischemic stroke (AIS) has been shown to be effectively treated with thrombolytic therapy. Thailand and other developing countries have limited stroke specialists to prescribe this treatment. Data regarding stroke outcomes in AIS patients who received thrombolytic therapy prescribed by neurologists compared with non-neurologists are limited. Methods: This was a large, multicenter, retrospective study conducted in 9 hospitals across the northeastern part of Thailand. The inclusion criteria were AIS patients who were admitted and treated with thrombolytic therapy between January 2010 and December 2012. Patients were categorized into two groups by physician specialty; neurologist and non-neurologist. Clinical outcomes and in-hospital mortality were compared between the groups. Results: There were 915 AIS patients who participated in the study; 175 patients were treated by the non-neurologists (19.1%). The mean age of all patients was 64 years and 55.1% were men. The median onset to needle time in both groups were similar at 180 minutes. The National Institutes of Health Stroke Scale (NIHSS) at discharge were significantly higher in neurologist group than non-neurologist group (NIHSS 6 vs 3, p value 0.03). The in-hospital mortality was also higher in neurologist group (9.5% vs 4.0%; p value 0.02). Conclusions: Non-neurologists may be able to thrombolyze AIS patients safely and effectively. Neurology Asia 2016; 21(4) : 325 – 331 Address correspondence to: Narongrit Kasemsap, MD, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand. Tel: 66-43-363664, E-mail: [email protected] INTRODUCTION Stroke is a major health problem worldwide. Acute ischemic stroke (AIS) is the most common subtype of stroke. The estimated prevalence of stroke among adults older than 45 year is 1.88%. Thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) is the standard treatment for AIS. Intravenous rtPA within 4.5 hours after symptom onset is efficacy proven in AIS. The outcome was favorable by 28% if rtPA was given compared with placebo. Thrombolytic therapy has been used in Thailand for over 20 years but in 2010 the overall rtPA therapy in AIS patients in Thailand was still only 1.05%. Most of the patients received rtPA in tertiary and university hospitals. One reason for low rtPA use in Thailand is that the limited numbers of neurologists particularly in the rural area. The ratio of neurologist to population was 1: 1,429,512 people in the Northeastern, Thailand, while this ratio was 1:39,385 people in Bangkok, the capital city. To cope with the limited number of neurologists, the stroke network project was established in 2010. This project assists the non-neurologists in community and secondary hospitals in the treatment of AIS with rtPA. The neurologists at the main server hospitals such as university hospitals function as consultants by telephone and mobile application for communication for the client hospitals in their service area. The project also supports the client hospitals in terms of setting up comprehensive stroke units and referral systems. A previous study from Australia showed that the stroke outcomes were comparable between neurologists and nonneurologists prescribing thrombolytic therapy in Neurology Asia December 2016 326 49 AIS patients. In 2015 AHA/ASA has published update guideline on endovascular treatment of ischemic stroke, and strongly recommend patient with occlusion of internal carotid or proximal (M1) middle cerebral artery, which treatment to initiate within 6 hours of symptoms onset. However this neurointervention procedure can be performed only in one university hospital across the northeastern of Thailand since 2016. This study aimed to evaluate the clinical outcomes of thrombolytic therapy by neurologists and non-neurologists in multi-stroke centers across the Northeastern, Thailand and in a larger study population.