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To the Editor: We noted a surprising result in Table 3 in the article by Dr Sherman and colleagues¹ discussing ancrod for management of acute ischemic stroke. Patients in the placebo group who presented before 3 hours had elapsed from the onset of stroke symptoms fared better than patients presenting later, whether the latter were given placebo or ancrod.

One possible interpretation is that the time lag between symptom onset and presentation to the hospital is actually an indirect marker for stroke severity. There is a known correlation between initial stroke severity and prognosis.² One might imagine that patients with severe impairment from a large stroke would present later, on average, either because they are more likely to be anosognosic or because they find it more difficult to summon help. However, there are no empirical data addressing this question. The National Institute of Neurological Disorders and Stroke (NINDS) trial³ did . . . [Full Text of this Article]

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