[Downloaded free from http://www.neurologyindia.com on Sunday, July 26, 2009] Letters to Editor
However, it would still be out of reach for most. Some of the patients also had medical insurance. We agree that the two main barriers in effective utilization of thrombolysis are the cost of the drug and the delayed presentation. However, besides these two, the selection criteria of the patients are also extremely stringent to make it safe. We cannot thrombolyze every patient with ischemic stroke even if they present in time and can afford the drug. We also need “safer” and more “effective’’ reperfusion strategies. We fully agree with the concept that primary and secondary prevention strategies remain the cornerstone for effectively reducing the stroke burden.
of symptomatic, asymptomatic and fatal ICH, without improving the recovery rate.[4] Therefore, I think it is dangerous to perform thrombolysis for AIS with protocol violations (such as without obtaining coagulation profile or after the 3h window period) and every effort should be made to strictly adhere to the NINDS protocol.
Sudhir Kumar Apollo Hospitals, Jubilee Hills, Hyderabad - 500 033, Andhra Pradesh, India. E-mail:
[email protected]
m o fr M. V. Padma, M. B. Singh, R. Bhatia, d ns A. Srivastava, M. Tripathi, G. Shukla, V. Goyal, a S. Singh, K. Prasad, M. Behari o tio l n a w c i o l d ub e rf e w P m). r o o Thrombolysis with tissue fo n .c k plasminogen activator: le d ow b e n Protocol violation is notilaan M k a by ed v option
a d .m is te w Sir,
s Padmawet al Authors' Reply I read with interest a recentFarticle by o regarding thrombolysis with tissue plasminogen hHowever,(wactivator PD(AIS). (tPA) in acute ischemic stroke I would Sir, si site like to make certain observations. I agree that it helps to strictly adhere to a dedicated h Patients were thrombolyzed without obtaining the protocol when we start any management strategy. However, Tin this study. a Out of 54, six patients practical constraints are real and cannot be wished away! coagulation profile References
1.
Department of Neurology, All India Institute of Medical Sciences, New Delhi - 110029, India. E-mail:
[email protected]
2.
3.
Accepted on 08-03-2007
4.
Padma MV, Singh MB, Bhatia R, Srivastava A, Tripathi M, Shukla G, et al. Hyperacute thrombolysis with IV rtPA of acute ischemic stroke: Efficacy and safety profile of 54 patients at a tertiary referral center in a developing country. Neurol India 2007;55:46-9. Dzialowski I, Pexman JH, Barber PA, Demchuk AM, Buchan AM, Hill MD, et al. Asymptomatic hemorrhage after thrombolysis may not be benign: Prognosis by hemorrhage type in the Canadian alteplase for stroke effectiveness study registry. Stroke 2007;38:75-9. Lopez-Yunez AM, Bruno A, Williams LS, Yilmaz E, Zurru C, Biller J. Protocol violations in community-based rTPA stroke treatment are associated with symptomatic intracerebral hemorrhage. Stroke 2001;32:12-6. Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: A randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA 1999;282:2019-26.
Accepted on 09-02-2007
[1]
(11.1%) had hemorrhagic complications- five patients developed hemorrhagic infarction (HI) and one developed intracranial hemorrhage (ICH). Though these were asymptomatic and nonfatal, these could result in poor prognosis. In a recent study, the proportion of patients with good outcome after thrombolysis was 41% in those without any hemorrhagic transformation, whereas the proportion dropped to 17-30% in patients with HI and even lower in those with parenchymal hematoma.[2] Another study reported a higher incidence of symptomatic and asymptomatic ICH with protocol violations (prolonged prothrombin time and activated partial thromboplastin time).[3] The time to reach emergency ranged up to 3.4h in this study. However, it should be noted that intravenous thrombolysis is approved only within 3h of stroke onset. Intravenous thrombolysis beyond 3h increases the rate 174 174 CMYK
In developing countries where stroke burden is felt more acutely (second commonest cause of death and disability), I strongly feel that the protocol can be modified to be more suitable to our practical concerns. Even with our best efforts we do not thrombolyze more than 2-6% of our stroke patients. With additional tests cutting into our limited resources, peculiar to the developing world and the terribly narrow therapeutic time window of opportunity, we will be able to ultimately treat even less! No doubt there are and will be more strategies to extend the therapeutic time window; better select patients for reperfusion strategies etc. I also agree on the clinical dictum of primum non nocere (primarily do no harm), either by actively committing an act or withholding a proven therapy through inaction! In the present clinical scenario, we at AIIMS tried to clinically identify patients who may not require additional Neurology India | April-June 2007 | Vol 55 | Issue 2
