Acute Stroke Management in Türkiye: Intravenous Tissue Plasminogen Activator and Thrombectomy NöroTek: Türkiye Neurology Single Day Study

Mehmet Akif Topçuoğlu1, Atilla Özcan Özdemir2, Ethem Murat Arsava1, Aygül Güneş3, Özlem Aykaç2, Elif Sarıönder Gencer4, Murat Çabalar5, Vildan Yayla5, Hacı Ali Erdoğan5, Mücahid Erdoğan6, Zeynep Özdemir Acar6, Semih Giray7, Yüksel Kablan8, Zeynep Tanrıverdi9, Ülgen Yalaz Tekan9, Talip Asil10, Çetin Kürşad Akpınar11, Vedat Ali Yürekli12, Bilgehan Acar13, Hadiye Şirin14, Ayşe Güler14, Recep Baydemir15, Merve Akçakoyunlu15, Levent Öcek16, Mustafa Çetiner17, Bijen Nazliel18, Hale Batur Çağlayan18, Nedim Ongun19, Alper Eren20, Zülfikar Arlıer21, Utku Cenikli22, Mustafa Gökçe23, Songül Bavli23, Erdem Yaka24, Ayça Özkul25, Bahar Değirmenci26, Ufuk Aluçlu26, Canan Togay Işıkay27, Eda Aslanbaba27, Mine Sorgun27, Emrah Aytaç28, Halil Ay29, Refik Kunt30, Songül Şenadım31, Yaprak Özüm Ünsal32, Neslihan Eşkut32, Zekeriya Alioğlu33, Arda Yılmaz34, Hamit Genç34, Ayşe Yılmaz35, Aysel Milanoğlu36, Erdem Gürkaş37, Eylem Değirmenci38, Hesna Bektaş39, İrem İlgezdi40, Adnan Burak Bilgiç40, Şenol Akyol40, İ. Levent Güngör41, Nilüfer Kale42, Eda Çoban42, Nilüfer Yeşilot43, Esme Ekizoğlu43, Özgü Kizek43, Oğuzhan Kurşun39, Özlem Kayım Yıldız44, Aslı Bolayır44, Ayşın Kısabay45, Birgül Baştan46, Zeynep Acar46, Buket Niflioğlu47, Bülent Güven48, Dilaver Kaya49, Nazire Afşar49, Duran Yazıcı50, Eren Toplutaş51, Esra Özkan52, Faik İlik53, Fatma Birsen İnce54, Gülseren Büyükşerbetçi55, Halil Önder56, Hasan Hüseyin Karadeli57, Hasan Hüseyin Kozak58, Hayri Demirbaş59, İpek Midi60, İsa Aydın61, M. Tuncay Epçeliden62, Murat Mert Atmaca63, Mustafa Bakar64, Mustafa Şen65, Nilda Turgut66, Ahmet Onur Keskin67, Özlem Akdoğan68, Ufuk Emre68, Özlem Bilgili69, Pınar Bekdik Şirinocak70, Recep Yevgi71, Sinem Yazıcı Akkaş72, Tahir Yoldaş73, Taşkın Duman74, Tuğba Özel75, Ali Ünal75, Babür Dora75, H. Tuğrul Atasoy76, Bilge Piri Çınar76, Tülin Demir77, Turgay Demir78, Ufuk Can79, Yıldız Aslan80, Demet Funda Baş80, Ufuk Şener80, Zahide Yılmaz81, Zehra Bozdoğan82, Gökhan Özdemir83, Yakup Krespi84, Şerefnur Öztürk83

1Hacettepe University Faculty of Medicine, Department of Neurology, Ankara, Türkiye
2Eskisehir Osmangazi University Faculty of Medicine, Department of Neurology, Eskisehir, Türkiye
3University of Health Sciences Türkiye, Bursa Yuksek Ihtisas Training and Research Hospital, Stroke Unit, Bursa, Türkiye
4University of Health Sciences Türkiye, Antalya Training and Research Hospital, Clinic of Neurology, Antalya, Türkiye
5University of Health Sciences Türkiye, Istanbul Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Clinic of Neurology, Istanbul, Türkiye
6University of Health Sciences Türkiye, Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurological Diseases Training and Research Hospital, Neurology Intensive Care Unit, Istanbul, Türkiye
7Gaziantep University Faculty of Medicine, Department of Neurology, Gaziantep, Türkiye
8Inonu University Faculty of Medicine, Department of Neurology, Malatya, Türkiye
9University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Clinic of Neurology, Istanbul, Türkiye
10Memorial Hizmet Hospital, Clinic of Neurology, Istanbul, Türkiye
11University of Health Sciences Türkiye, Samsun Training and Research Hospital, Clinic of Neurology, Samsun, Türkiye
12Suleyman Demirel University Faculty of Medicine, Department of Neurology, Afyon, Türkiye
13Sakarya University Faculty of Medicine, Department of Neurology, Sakarya, Türkiye
14Ege University Faculty of Medicine, Department of Neurology, Izmir, Türkiye
15Erciyes University Faculty of Medicine, Department of Neurology, Kayseri, Türkiye
16Usak State Hospital, Clinic of Neurology, Usak, Türkiye
17Dumlupinar University Faculty of Medicine, Department of Neurology, Kutahya, Türkiye
18Gazi University Faculty of Medicine, Department of Neurology, Ankara, Türkiye
19Burdur State Hospital, Clinic of Neurology, Burdur, Türkiye
20Ataturk University Research Hospital, Clinic of Neurology, Erzurum, Türkiye
21Baskent University, Adana Application and Research Center, Department of Neurology, Adana, Türkiye
22Mugla Sitki Kocman University Faculty of Medicine, Department of Neurology, Mugla, Türkiye
23Kahramanmaras Sutcu Imam University Faculty of Medicine, Department of Neurology, Kahramanmaras, Türkiye
24Dokuz Eylül University Faculty of Medicine, Department of Neurology, Izmir, Türkiye
25Aydin Adnan Menderes University Faculty of Medicine, Department of Neurology, Aydin, Türkiye
26Dicle University Faculty of Medicine, Department of Neurology, Diyarbakir, Türkiye
27Ankara University Faculty of Medicine, Department of Neurology, Ankara, Türkiye
28Firat University Faculty of Medicine, Department of Neurology, Elazıg, Türkiye
29Harran University Faculty of Medicine, Department of Neurology, Sanliurfa, Türkiye
30Aydin State Hospital, Clinic of Neurology, Aydin, Türkiye
31Bakirkoy Psychiatric and Nervous Diseases Hospital, Clinic of 1st Neurology, Istanbul, Türkiye
32University of Health Sciences Türkiye, Izmir Bozyaka Training and Research Hospital, Clinic of Neurology, Izmir, Türkiye
33Karadeniz Technical University Faculty of Medicine, Department of Neurology, Trabzon, Türkiye
34Mersin University Faculty of Medicine, Department of Neurology, Mersin, Türkiye
35Bakirkoy Psychiatric and Nervous Diseases Hospital, Clinic of 2nd Neurology, Istanbul, Türkiye
36Van Yuzuncu Yil University Faculty of Medicine, Department of Neurology, Van, Türkiye
37University of Health Sciences Türkiye, Gulhane Training and Research Hospital, Clinic of Neurology, Ankara, Türkiye
38Pamukkale University Faculty of Medicine, Department of Neurology, Denizli, Türkiye
39Ankara Bilkent City Hospital, Clinic of Neurology, Ankara, Türkiye
40Giresun University Faculty of Medicine, Department of Neurology, Giresun, Türkiye
41Ondokuz Mayis University Faculty of Medicine, Department of Neurology, Samsun, Türkiye
42University of Health Sciences Türkiye, Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurological Diseases Training and Research Hospital, Clinic of Neurology, Istanbul, Türkiye
43Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Istanbul, Türkiye
44Sivas Cumhuriyet University Faculty of Medicine, Department of Neurology, Sivas, Türkiye
45Manisa Celal Bayar University Faculty of Medicine, Department of Neurology, Manisa, Türkiye
46University of Health Sciences Türkiye, Istanbul Haseki Training and Research Hospital, Clinic of Neurology, Istanbul, Türkiye
47Mus State Hospital, Clinic of Neurology, Mus, Türkiye
48University of Health Sciences Türkiye, Diskapi Yildirim Beyazit Training and Research Hospital, Clinic of Neurology, Ankara, Türkiye
49Acibadem University Faculty of Medicine; Altunizade Hospital, Department of Neurology, Istanbul, Türkiye
50Ordu State Hospital, Clinic of Neurology, Ordu, Türkiye
51Istanbul Medipol University Faculty of Medicine, Department of Neurology, Istanbul, Türkiye
52Tokat State Hospital, Clinic of Neurology, Tokat, Türkiye
53Konya Medicana Hospital, Clinic of Neurology, Konya, Türkiye
54Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Neurology, Istanbul, Türkiye
55Balikesir University Faculty of Medicine, Department of Neurology, Balikesir, Türkiye
56Yozgat City Hospital, Clinic of Neurology, Yozgat, Türkiye
57Istanbul Medeniyet University Faculty of Medicine, Department of Neurology, Istanbul, Türkiye
58Necmettin Erbakan University Meram Faculty of Medicine, Department of Neurology, Konya, Türkiye
59Afyon Kocatepe University Faculty of Medicine, Department of Neurology, Afyon, Türkiye
60Marmara University Faculty of Medicine, Department of Neurology, Istanbul, Türkiye
61Balikligol State Hospital, Clinic of Neurology, Sanliurfa, Türkiye
62Kemer State Hospital, Clinic of Neurology, Antalya, Türkiye
63University of Health Sciences Türkiye, Sultan 2nd Abdulhamid Han Training and Research Hospital, Clinic of Neurology, Istanbul, Türkiye
64Bursa Uludag University Faculty of Medicine, Department of Neurology, Bursa, Türkiye
65Yalova State Hospital, Clinic of Neurology, Yalova, Türkiye
66Tekirdag Namik Kemal University Faculty of Medicine, Department of Neurology, Tekirdag, Türkiye
67Eskisehir Yunus Emre State Hospital, Clinic of Neurology, Eskisehir, Türkiye
68University of Health Sciences Türkiye, Istanbul Training and Research Hospital, Clinic of Neurology, Istanbul, Türkiye
69Edirne State Hospital, Clinic of Neurology, Edirne, Türkiye
70University of Health Sciences Türkiye, Kocaeli Derince Training and Research Hospital, Clinic of Neurology, Kocaeli, Türkiye
71University of Health Sciences Türkiye, Erzurum Regional Training and Research Hospital, Clinic of Neurology, Erzurum, Türkiye
72University of Health Sciences Türkiye, Istanbul Bagcilar Training and Research Hospital, Clinic of Neurology, Istanbul, Türkiye
73University of Health Sciences Türkiye, Ankara Training and Research Hospital, Clinic of Neurology, Ankara, Türkiye
74Mustafa Kemal University Faculty of Medicine, Department of Neurology, Hatay, Türkiye
75Akdeniz University Faculty of Medicine, Department of Neurology, Antalya, Türkiye
76Zonguldak Bulent Ecevit University Faculty of Medicine, Department of Neurology, Zonguldak, Türkiye
77Sanliurfa Training and Research Hospital, Clinic of Neurology, Sanliurfa, Türkiye
78Cukurova University Faculty of Medicine, Department of Neurology, Adana, Türkiye
79Baskent University Faculty of Medicine, Department of Neurology, Ankara, Türkiye
80University of Health Sciences Türkiye, Izmir Tepecik Training and Research Hospital, Clinic of Neurology, İzmir, Türkiye
81University of Health Sciences Türkiye, Kocaeli Derince Training and Research Hospital, Clinic of 1st Neurology, Kocaeli, Türkiye
82Kars Harakani State Hospital, Clinic of Neurology, Kars, Türkiye
83Selcuk University Faculty of Medicine, Department of Neurology, Konya, Türkiye
84Istanbul Aydin University Faculty of Medicine; VM Florya Medical Park Hospital; Comprehensive Stroke Center; Istanbul and Istinye University; Bahcesehir Liv Hospital; Pendik Medical Park Hospital; Department of Neurology, Istanbul, Türkiye

Keywords: Acute stroke, thrombolytic therapy, thrombectomy, prognosis, treatment window, metric

Abstract

Objective: To reveal the profile and practice in patients with acute stroke who received intravenous tissue plasminogen activator (IV tPA) and/or neuro-interventional therapy in Türkiye.

Materials and Methods: On World Stroke Awareness Day, May 10, 2018, 1,790 patients hospitalized in 87 neurology units spread over 30 health regions were evaluated retrospectively and prospectively.

Results: Intravenous tPA was administered to 12% of 859 cases of acute ischemic stroke in 45 units participating in the study. In the same period, 8.3% of the cases received neurointerventional treatment. The rate of good prognosis [modified Rankin score (mRS) 0–2] at discharge was 46% in 83 patients who received only IV tPA [age: 67 ± 12 years; National Institutes of Health Stroke Scale (NIHSS): 12 ± 6; hospital stay, 24 ± 29 days]; 35% in 51 patients who underwent thrombectomy (MT) alone (age: 64 ± 13 years; NIHSS: 14.1 ± 6.5; length of hospital stay, 33 ± 31 days), 19% in those who received combined treatment (age: 66 ± 14 years; NIHSS: 15.6 ± 5.4; length of hospital stay, 26 ± 35 days), and 56% of 695 patients who did not receive treatment for revascularization (age: 70 ± 13 years; NIHSS: 7.6 ± 7.2; length of hospital stay, 21 ± 28 days). The symptom-to-door time was 87 ± 53 minutes in the IV treatment group and 200 ± 26 minutes in the neurointerventional group. The average door-to-needle time was 66 ± 49 minutes in the IV tPA group. In the neurothrombectomy group, the door-to-groin time was 103 ± 90 minutes, and the TICI 2b-3 rate was 70.3%. In 103 patients who received IV tPA, the discharge mRS 0–2 was 41%, while the rate of mRS 0–1 was 28%. In 71 patients who underwent neurothrombectomy, the mRS 0–2 was 31% and mRS 0–1 was 18%. The door-to-groin time was approximately 30 minutes longer if IV tPA was received (125 ± 107 and 95 ± 83 minutes, respectively). Symptomatic bleeding rates were 4.8% in IV recipients, 17.6% among those who received only MT, and 15% in combined therapy. Globally, the hemorrhage rate was 6.8% in patients receiving IV tPA and 16.9% in MT.

Conclusion: IV thrombolytic and neurointerventional treatment applications in acute ischemic stroke in Türkiye can provide the anticipated results. Heterogeneity has begun to be reduced in our country with the dissemination of the system indicated by the “Directive on Health Services to be Provided to Patients with Acute Stroke.”

Ethics Committee Approval

Non-invasive Ethics Committee of the Hacettepe University Faculty of Medicine (27.03.2018; number, 18/331).

Peer Review

Externally peer-reviewed.

Author Contributions

Surgical and Medical Practices: All authors, Concept: M.A.T., E.M.A., A.Ö.Ö., Design: M.A.T., E.M.A., A.Ö.Ö., Data Collection or Processing: All authors, Analysis or Interpretation: M.A.T., E.M.A., A.Ö.Ö., Literature Search: M.A.T., Writing: M.A.T.

Conflict of Interest

No conflict of interest was declared by the authors.

Financial Disclosure

The authors declared that this study received no financial support.