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To the Editor:
The report of Barber et al.1 of the exclusion of stroke patients from treatment with tissue plasminogen activator (tPA) raises some important issues for stroke physicians. The authors’ finding that a third of the patients excluded from tPA treatment based on clinical assessment of “mild” stroke severity or “improvement” ultimately had a poor outcome is of particular concern. We recently experienced an illustrative case.
An 82-year-old woman presented to an affiliated hospital 20 minutes after the sudden onset of left hemiplegia and neglect. The emergency physician contacted the stroke fellow at our hospital after his examination for advice. A CT scan was performed and was reported negative. The treating physician was reluctant to proceed with tPA treatment after the CT scan because the patient had improved from complete paralysis to mild weakness on the left side. The patient was immediately transferred to our hospital for expert assessment. On arrival, she was conversant. Motor deficits were mild. However, she had gaze deviation, neglect, and hemisensory loss, with an NIH Stroke Scale (NIHSS) score of 12. MRI was contraindicated owing to pacemaker. Perfusion CT revealed an abnormality in the right temporal region and CT angiography (CTA) revealed occlusion of the inferior division of the right middle cerebral artery (MCA). IV tPA was administered. The next day, repeat CTA showed recanalization of the right MCA; her NIHSS score was 1.
It has …
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