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BRAINA JOURNAL OF NEUROLOGY
LETTER TO THE EDITOR
Thrombolysis in acute ischaemic stroke
Simone Vidale1 and Elio Agostoni2
1 Department of Neurology and Stroke Unit, Sant’Anna Hospital, Como, Italy
2 Department of Neurology and Stroke Unit, Niguarda Ca’ Granda Hospital, Milan, Italy
Correspondence to: Simone Vidale, M.D.,
Department of Neurology and Stroke Unit,
Sant’Anna Hospital,
Via Napoleona, 60,
22100 Como, Italy
E-mail: [email protected]
Sir,
We read with interest the recent paper by Balami et al. (2013)
concerning thrombolysis in stroke patients. In medicine, every pro-
cedure requires a careful evaluation of benefit-to-risk ratio, and
thrombolysis is no exception. As reported by the authors, the selec-
tion of patients is crucial to obtain the best benefit with the lowest
risk. Time to treatment is critical in this selection and the reduction of
the avoidable delay represents the key factor in improving the
number of potentially treatable patients. Optimal management of
the acute phase could contribute to obtaining this result, with a pre-
notification of single specialists involved in stroke care (from pre-
hospital to in-hospital setting) (Fassbender et al., 2013). This facili-
tation might contribute to achieving the timing that is recom-
mended for referral to clinical examination and multimodal stroke
imaging. This instrumental evaluation has received, in recent years,
a significant evolution in technology and a concomitant wide distri-
bution. The use of CT or MRI angiography for extra- and intracranial
arteries contributes to a better definition of the site of the arterial
occlusion and the size of the clot. Therefore, the introduction of
these investigations in selected patients during routine management
could contribute in the facilitation of adequate and effective treat-
ment (Costalat et al., 2011). Balami et al. (2013) report that the
presence of isolated ataxia or hemianopia could represent a relative
contraindication to intravenous thrombolysis. However, these
symptoms are referred to the posterior circulation and for this
reason related to a potentially high life-threatening risk. In these
cases it might be useful to obtain an angiographic study of arteries
by CT scan to evaluate the posterior circulation if arterial subocclu-
sion/occlusion is suspected. Other emerging factors are the lipid
profile or a concomitant use of statins. To date, some data have
shown an increased risk of haemorrhagic transformation in patients
using statins or with low levels of high-density lipoprotein choles-
terol (Nardi et al., 2012). If these observations are confirmed, lipid
profile may be another relative contraindication to thrombolytic
treatment. Finally, concerning the efficiency of thrombolytic ther-
apy, we must distinguish between a clinical and a radiological out-
come. Despite a recanalization of the vessel in approximately half of
patients, a clinical improvement does not occur in all patients. This
condition can be summarized by the concept of the revasculariza-
tion-outcome paradox (Cohen et al., 2013). Good clinical outcomes
have not always been achieved with high rates of recanalization and
may be due to futile recanalization, when the tissue is no longer
viable. Another critical point is also represented by the reocclusion
after an initial and successful recanalization. Therefore, two factors
appear to be mandatory for a selection of patients: the time from
symptom onset and the status of collaterals that supply the penum-
bra area. Taken together, we could reverse the title of the review
and the aim of the future studies should be the science of patient
selection in the art of stroke thrombolysis.
ReferencesBalami JS, Hadley G, Sutherland BA, Karbalai H, Buchan AM. The exact
science of stroke thrombolysis and the quiet art of patient selection.
Brain 2013; 136: 3528–53.Cohen JE, Leker RR. Revascularization-outcome paradox: not
only time and collaterals status, but also complete
doi:10.1093/brain/awu065 Brain 2014: 137; 1–2 | e281
Advance Access publication March 31, 2014
� The Author (2014). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.
For Permissions, please email: [email protected]
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recanalizcontribute to good neurological outcome. Int J Stroke 2013;8: 542–4.
Costalat V, Machi P, Lobotesis K, Maldonado I, Vendrell JF, Riquelme C,
et al. Rescue, combined, and stand-alone thrombectomy in the
management of large vessel occlusion stroke using the solitaire de-vice: a prospective 50-patient single-center study. Stroke 2011; 42:
1929–35.
Fassbender K, Balucani C, Walter S, Levine SR, Haass A, Grotta J.
Streamlining of prehospital stroke management: the golden hour.
Lancet Neurol 2013; 12: 585–96.
Nardi K, Engelter S, Strbian D, Sarikaya H, Arnold M, Casoni F, et al.
Lipid profile and outcome in patients treated by intravenous
thrombolysis for cerebral ischemia. Neurology 2012; 79: 1101–8.
e281 | Brain 2014: 137; 1–2 Letter to the Editor
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