Intra Arterial Heparin Flushing (IAHF) and positive resuls of its usage for chronic stroke patients Essay

Intra Arterial Heparin Flushing (IAHF) modified Digital Substraction Angiography (DSA) in Gatot Soebroto Army Central Hospital showed a clinical improvement in chronic stroke patients empirically. In radiointervention procedure, heparin usually used as flushing solution for catheterization (Durran and Watts, 2012). Heparin have a role not only as an anticoagulant but also as a fibrinolytic. Heparin increases plasminogen conversion into plasmin by stimulating tissue plasminogen activator (Schellinger et al., 2001 Liang et al., 2000). Heparin also has potential in increasing thrombolysis by inhibit TAFI (thrombin activatable fibrinolysis inhibitor) formation (Colucci et al., 2002). Thus, heparin commonly used to treat both arterial and vein thrombosis because of its safety proven reason (Coull et al, 2002 Dvorak et al., 2010 Coutinho et al., 2011). Intravascular studies showed that heparin therapy can reduce the clot size, suggested its potency in brain reperfusion after ischemic (Lewis et al., 1964).
Material and method
Subjects
This study was approved by Hasanuddin University Ethical Committee with register number UH14110582 involved 75 chronic ischemic stroke patients in Cerebrovascular Center Gatot Soebroto Indonesian Army Central Hospital started from February 2015. The inclusion criterias including (1) patient diagnosed with chronic ischemic stroke (by radiology and neurology examination) (2) age 30  70 years old, and (3) agreed to follow the IAHF procedure and signed the informed consent form. The exclusion criterias including (1) any allergic to contrast and heparin, (2) blood clotting abnormality. (3) subjects with high risk or contraindication according to cardiology, pulmonology, internal medicine, and anesthesiology procedures. (4) not able to undergo MRI examination. (5) can not understand or not able to follow study instructions. (6) motoric dysfunction caused by another disease. (7) subjects diagnosed with brain stem stroke for more than 6 hours or less than 2 weeks (involution state).
Manual Muscle Test Measurement
The Manual Muscle Test Medical Research Council Scale (MMT-MRcs) method measurements used in this study with 6 scales, including 0 = stands for no movement detected 1 = only a weak contraction that can visualized or sensed at muscle 2 = the muscle can be moved horizontally but unable to move against gravity 3 = muscle strength declined and muscle contraction can moved the joints against gravity if there is no resistance added 4 = muscle strength declined but muscle contraction can move joints against resistance 5 = normal muscle contraction against full resistance. This measurement will be performed by a trained physicians and neurologist.
IAHF Procedure
Patients and instruments were readily prepared before, 5000 IU heparin diluted with 500 cc NS Otsu. Topical anesthesia EMLA was applied on femoral artery area, continued with povidone iodine 7,5% and alcohol 70%. Local anaesthesia lidocain was injected intracutaneous and subcutaneous. Femoral artery was punctured with abocath 18 G, and short guide wire was inserted. Fluoroscopy was performed to see the anatomical imaging. Diluted heparin was flushed intra arterial in both right and left carotid arteries and vertebral arteries. After completing the flushing process, fermoral artery bleeding was stopped using either conventional technique or angio seal.