Letter to the Editor Stroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.
Response to Letter Regarding Article, “Safety of Intravenous Thrombolysis in Stroke Mimics: Prospective 5-Year Study and Comprehensive Meta-Analysis”
We thank Drs Yang and Bai for reading our article entitled Safety of Intravenous Thrombolysis in Stroke Mimics: Prospective 5-Year Study and Comprehensive Meta-Analysis and for their comments on the topic.1 Drs Yang and Bai argue that intravenous thrombolysis (IVT) with recombinant tissue-type plasminogen activator is an unnecessary, inefficient, expensive, and potentially harmful treatment. We interpret this as disbelief in tissue-type plasminogen activator for ischemic stroke in general, let alone stroke mimics (SM). Tissue-type plasminogen activator remains the only effective medical therapy to reverse ischemic stroke and the best option to treat most patients presenting early into the course of symptoms. Following the disbelief, Drs Yang and Bai further indicate that IVT should not be offered inadvertently and diagnostic alternatives should be sought to discriminate SM reliably from patients with acute ischemic stroke (AIS). We respectfully disagree with Drs Yang and Bai in view of the beneficial effects of IVT both in the outcome of AIS and SM in terms of favorable functional outcome at 3 months.1 More specifically, the rate of favorable functional outcome in our prospective cohort and in the comprehensive meta-analysis of 9 case series studies was 88% and 85% respectively.1 Another argument contradicting the statements of Drs Yang and Bai is related to the fact that although medical history (eg, mental illness or epilepsy), demographic features (age or sex), and clinical tests (such as Hoover sign) may be indicative of a diagnosis alternative of AIS, they can also be misleading and prompt an unjustified delay in both the diagnosis and the treatment of a patient with AIS.2,3 Hoover sign, for example, has moderate sensitivity (63%) with many limitations and may yield either false-positive or false-negative results.2 Finally, it should be kept in mind that a minority (especially with lacunar infarctions in the brain stem) of patients with AIS may have a negative diffusion weight imaging study, whereas some other conditions mimicking AIS may manifest with diffusion restriction on magnetic resonance imaging (eg, seizures, herpes encephalitis, and Wernicke encephalopathy).4,5 We agree that the future development of rapid imaging protocols that do not further delay the diagnosis and treatment of AIS in an emergency setting could prevent the inadvertent administration of IVT in SMs. Until these protocols become widely available, current stroke guidelines recommend only the use of noncontrast computed tomography before the initiation of IVT.
Although we think that patients presenting with an acute neurological deficit in the emergency department should undergo to the point and quick examination by an experienced stroke neurologist before the administration of IVT, we disagree with the notion of losing valuable time to perform additional neuroimaging for exclusion of SM. Our personal experience coupled with the findings of our comprehensive meta-analysis provide further reassurance to stroke physicians that eligible patients with AIS should not be excluded per se of IVT treatment because of the fear of a final SM diagnosis and in anticipation of further diagnostic workup. As vascular neurologists, we stand side by side with our emergency physicians and offer them immediate help and advice to provide the only effective systemic stroke therapy. The key to better outcomes after IVT is faster time to treatment. Shorter times are only be achieved by physicians finding reasons to treat instead of spending time-seeking reasons not to treat.
Disclosures None.
Georgios Tsivgoulis, MD Aristeidis H. Katsanos, MD Second Department of Neurology “Attikon Hospital” University of Athens, School of Medicine Athens, Greece Andrei V. Alexandrov, MD Department of Neurology University of Tennessee Health Sciences Center Memphis 1. Tsivgoulis G, Zand R, Katsanos AH, Goyal N, Uchino K, Chang J, et al. Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke. 2015;46:1281–1287. doi: 10.1161/STROKEAHA.115.009012. 2. Mehndiratta MM, Kumar M, Nayak R, Garg H, Pandey S. Hoover’s sign: clinical relevance in Neurology. J Postgrad Med. 2014;60:297–299. doi: 10.4103/0022-3859.138769. 3. Saver JL, Barsan WG. Swift or sure?: the acceptable rate of neurovascular mimics among IV tPA-treated patients. Neurology. 2010;74:1336– 1337. doi: 10.1212/WNL.0b013e3181dbe0ad. 4. Lövblad KO, Laubach HJ, Baird AE, Curtin F, Schlaug G, Edelman RR, et al. Clinical experience with diffusion-weighted MR in patients with acute stroke. AJNR Am J Neuroradiol. 1998;19:1061–1066. 5. Ay H, Buonanno FS, Rordorf G, Schaefer PW, Schwamm LH, Wu O, et al. Normal diffusion-weighted MRI during stroke-like deficits. Neurology. 1999;52:1784–1792.
(Stroke. 2015;46:00-00. DOI: 10.1161/STROKEAHA.115.009665.) © 2015 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.115.009665
Downloaded from http://stroke.ahajournals.org/ at New York 1 University/ Medical Center--New York on May 9, 2015
Response to Letter Regarding Article, ''Safety of Intravenous Thrombolysis in Stroke Mimics: Prospective 5-Year Study and Comprehensive Meta-Analysis'' Georgios Tsivgoulis, Aristeidis H. Katsanos and Andrei V. Alexandrov Stroke. published online April 30, 2015; Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2015 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://stroke.ahajournals.org/content/early/2015/04/30/STROKEAHA.115.009665.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Stroke is online at: http://stroke.ahajournals.org//subscriptions/
Downloaded from http://stroke.ahajournals.org/ at New York University/ Medical Center--New York on May 9, 2015
Response to Letter Regarding Article, “Safety of Intravenous Thrombolysis in Stroke Mimics: Prospective 5-Year Study and Comprehensive Meta-Analysis”
We thank Drs Yang and Bai for reading our article entitled Safety of Intravenous Thrombolysis in Stroke Mimics: Prospective 5-Year Study and Comprehensive Meta-Analysis and for their comments on the topic.1 Drs Yang and Bai argue that intravenous thrombolysis (IVT) with recombinant tissue-type plasminogen activator is an unnecessary, inefficient, expensive, and potentially harmful treatment. We interpret this as disbelief in tissue-type plasminogen activator for ischemic stroke in general, let alone stroke mimics (SM). Tissue-type plasminogen activator remains the only effective medical therapy to reverse ischemic stroke and the best option to treat most patients presenting early into the course of symptoms. Following the disbelief, Drs Yang and Bai further indicate that IVT should not be offered inadvertently and diagnostic alternatives should be sought to discriminate SM reliably from patients with acute ischemic stroke (AIS). We respectfully disagree with Drs Yang and Bai in view of the beneficial effects of IVT both in the outcome of AIS and SM in terms of favorable functional outcome at 3 months.1 More specifically, the rate of favorable functional outcome in our prospective cohort and in the comprehensive meta-analysis of 9 case series studies was 88% and 85% respectively.1 Another argument contradicting the statements of Drs Yang and Bai is related to the fact that although medical history (eg, mental illness or epilepsy), demographic features (age or sex), and clinical tests (such as Hoover sign) may be indicative of a diagnosis alternative of AIS, they can also be misleading and prompt an unjustified delay in both the diagnosis and the treatment of a patient with AIS.2,3 Hoover sign, for example, has moderate sensitivity (63%) with many limitations and may yield either false-positive or false-negative results.2 Finally, it should be kept in mind that a minority (especially with lacunar infarctions in the brain stem) of patients with AIS may have a negative diffusion weight imaging study, whereas some other conditions mimicking AIS may manifest with diffusion restriction on magnetic resonance imaging (eg, seizures, herpes encephalitis, and Wernicke encephalopathy).4,5 We agree that the future development of rapid imaging protocols that do not further delay the diagnosis and treatment of AIS in an emergency setting could prevent the inadvertent administration of IVT in SMs. Until these protocols become widely available, current stroke guidelines recommend only the use of noncontrast computed tomography before the initiation of IVT.
Although we think that patients presenting with an acute neurological deficit in the emergency department should undergo to the point and quick examination by an experienced stroke neurologist before the administration of IVT, we disagree with the notion of losing valuable time to perform additional neuroimaging for exclusion of SM. Our personal experience coupled with the findings of our comprehensive meta-analysis provide further reassurance to stroke physicians that eligible patients with AIS should not be excluded per se of IVT treatment because of the fear of a final SM diagnosis and in anticipation of further diagnostic workup. As vascular neurologists, we stand side by side with our emergency physicians and offer them immediate help and advice to provide the only effective systemic stroke therapy. The key to better outcomes after IVT is faster time to treatment. Shorter times are only be achieved by physicians finding reasons to treat instead of spending time-seeking reasons not to treat.
Disclosures None.
Georgios Tsivgoulis, MD Aristeidis H. Katsanos, MD Second Department of Neurology “Attikon Hospital” University of Athens, School of Medicine Athens, Greece Andrei V. Alexandrov, MD Department of Neurology University of Tennessee Health Sciences Center Memphis 1. Tsivgoulis G, Zand R, Katsanos AH, Goyal N, Uchino K, Chang J, et al. Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke. 2015;46:1281–1287. doi: 10.1161/STROKEAHA.115.009012. 2. Mehndiratta MM, Kumar M, Nayak R, Garg H, Pandey S. Hoover’s sign: clinical relevance in Neurology. J Postgrad Med. 2014;60:297–299. doi: 10.4103/0022-3859.138769. 3. Saver JL, Barsan WG. Swift or sure?: the acceptable rate of neurovascular mimics among IV tPA-treated patients. Neurology. 2010;74:1336– 1337. doi: 10.1212/WNL.0b013e3181dbe0ad. 4. Lövblad KO, Laubach HJ, Baird AE, Curtin F, Schlaug G, Edelman RR, et al. Clinical experience with diffusion-weighted MR in patients with acute stroke. AJNR Am J Neuroradiol. 1998;19:1061–1066. 5. Ay H, Buonanno FS, Rordorf G, Schaefer PW, Schwamm LH, Wu O, et al. Normal diffusion-weighted MRI during stroke-like deficits. Neurology. 1999;52:1784–1792.
(Stroke. 2015;46:00-00. DOI: 10.1161/STROKEAHA.115.009665.) © 2015 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.115.009665
Downloaded from http://stroke.ahajournals.org/ at New York 1 University/ Medical Center--New York on May 9, 2015
Response to Letter Regarding Article, ''Safety of Intravenous Thrombolysis in Stroke Mimics: Prospective 5-Year Study and Comprehensive Meta-Analysis'' Georgios Tsivgoulis, Aristeidis H. Katsanos and Andrei V. Alexandrov Stroke. published online April 30, 2015; Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2015 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://stroke.ahajournals.org/content/early/2015/04/30/STROKEAHA.115.009665.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Stroke is online at: http://stroke.ahajournals.org//subscriptions/
Downloaded from http://stroke.ahajournals.org/ at New York University/ Medical Center--New York on May 9, 2015
