doi:10.1093/brain/awu066
Brain 2014: 137; 1
| e282
BRAIN A JOURNAL OF NEUROLOGY
LETTER TO THE EDITOR Reply: Thrombolysis in acute ischaemic stroke Joyce S. Balami,1 Gina Hadley,2 Brad A. Sutherland,2 Hasneen Karbalai3 and Alastair M. Buchan2,3,4 1 2 3 4
Acute Stroke Programme, Department of Medicine and Clinical Geratology, Oxford University Hospitals NHS Trust, Oxford, UK Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, Oxford, UK Medical Sciences Division, University of Oxford, Oxford, UK Acute Vascular Imaging Centre, University of Oxford, Oxford University Hospitals, Oxford, UK
Sir, We thank Vidale and Agostoni (2014) for their very thoughtful suggestions as to how one might select patients that derive benefit from thrombolysis, especially in the grey areas. In the absence of randomized evidence based on metrics, patient selection does still rely very much on the art and not the science of clinical medicine. ‘Practice and thought might gradually forge many an art.’ Virgil (70–19 BC). At best, what has been suggested is empirically strong but experimentally weak and above all, not evidence-based. We agree that it is not an exhaustive catalogue of potential indications and contraindications to thrombolysis. As further results from trials and case reports accumulate, the inclusion and exclusion criteria can be further honed to optimize selection of the patients most likely to benefit. Isolated deficits suggestive of posterior circulation insults may be relative contraindications to intravenous thrombolysis, but if they are indicative of serious circulatory compromise, as determined by imaging, targeted intra-arterial interventions may be more appropriate.
We acknowledged in the paper that radiological recanalization does not necessarily correlate with clinical recovery, although it can be useful as an outcome measure in clinical trials. The evidence regarding the prognostic value of statin use as an indication or contraindication for thrombolysis is still conflicting (Meseguer et al., 2012; Rocco et al., 2012). The lipid profile is not directly addressed under the current guidelines, but these guidelines may be revised once sufficient evidence resolves this conflict.
References Meseguer E, Mazighi M, Lapergue B, Labreuche J, Sirimarco G, Gonzalez-Valcarcel J, et al. Outcomes after thrombolysis in AIS according to prior statin use: a registry and review. Neurology 2012; 79: 1817–23. Rocco A, Sykora M, Ringleb P, Diedler J. Impact of statin use and lipid profile on symptomatic intracerebral haemorrhage, outcome and mortality after intravenous thrombolysis in acute stroke. Cerebrovasc Dis 2012; 33: 362–8. Vidale S, Agostoni E. Thrombolysis in acute ischaemic stroke. Brain 2014, doi:10.1093/brain/awu065.
Advance Access publication April 10, 2014 ß The Author (2014). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://brain.oxfordjournals.org/ by guest on June 5, 2016
Correspondence to: Professor Alastair M. Buchan, Dean of the Medical School, Head of the Medical Sciences Division, Professor in Stroke Medicine, Acute Vascular Imaging Centre, Biomedical Research Centre, University of Oxford, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK E-mail: [email protected]
Brain 2014: 137; 1
| e282
BRAIN A JOURNAL OF NEUROLOGY
LETTER TO THE EDITOR Reply: Thrombolysis in acute ischaemic stroke Joyce S. Balami,1 Gina Hadley,2 Brad A. Sutherland,2 Hasneen Karbalai3 and Alastair M. Buchan2,3,4 1 2 3 4
Acute Stroke Programme, Department of Medicine and Clinical Geratology, Oxford University Hospitals NHS Trust, Oxford, UK Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, Oxford, UK Medical Sciences Division, University of Oxford, Oxford, UK Acute Vascular Imaging Centre, University of Oxford, Oxford University Hospitals, Oxford, UK
Sir, We thank Vidale and Agostoni (2014) for their very thoughtful suggestions as to how one might select patients that derive benefit from thrombolysis, especially in the grey areas. In the absence of randomized evidence based on metrics, patient selection does still rely very much on the art and not the science of clinical medicine. ‘Practice and thought might gradually forge many an art.’ Virgil (70–19 BC). At best, what has been suggested is empirically strong but experimentally weak and above all, not evidence-based. We agree that it is not an exhaustive catalogue of potential indications and contraindications to thrombolysis. As further results from trials and case reports accumulate, the inclusion and exclusion criteria can be further honed to optimize selection of the patients most likely to benefit. Isolated deficits suggestive of posterior circulation insults may be relative contraindications to intravenous thrombolysis, but if they are indicative of serious circulatory compromise, as determined by imaging, targeted intra-arterial interventions may be more appropriate.
We acknowledged in the paper that radiological recanalization does not necessarily correlate with clinical recovery, although it can be useful as an outcome measure in clinical trials. The evidence regarding the prognostic value of statin use as an indication or contraindication for thrombolysis is still conflicting (Meseguer et al., 2012; Rocco et al., 2012). The lipid profile is not directly addressed under the current guidelines, but these guidelines may be revised once sufficient evidence resolves this conflict.
References Meseguer E, Mazighi M, Lapergue B, Labreuche J, Sirimarco G, Gonzalez-Valcarcel J, et al. Outcomes after thrombolysis in AIS according to prior statin use: a registry and review. Neurology 2012; 79: 1817–23. Rocco A, Sykora M, Ringleb P, Diedler J. Impact of statin use and lipid profile on symptomatic intracerebral haemorrhage, outcome and mortality after intravenous thrombolysis in acute stroke. Cerebrovasc Dis 2012; 33: 362–8. Vidale S, Agostoni E. Thrombolysis in acute ischaemic stroke. Brain 2014, doi:10.1093/brain/awu065.
Advance Access publication April 10, 2014 ß The Author (2014). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://brain.oxfordjournals.org/ by guest on June 5, 2016
Correspondence to: Professor Alastair M. Buchan, Dean of the Medical School, Head of the Medical Sciences Division, Professor in Stroke Medicine, Acute Vascular Imaging Centre, Biomedical Research Centre, University of Oxford, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK E-mail: [email protected]
