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Predictors of Lack of Improvement After Thrombolytic Stroke Therapy
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To the Editor: In their study, Dr Saposnik and colleagues1 note that they followed the National Institute of Neurological Disorders and Stroke inclusion and exclusion criteria for the administration of a recombinant tissue plasminogen activator (alteplase) for acute stroke. However, 40 patients (18% of the study population) received alteplase after the accepted 3-hour window. The authors do not report the outcomes for this group of patients separately, but from the figure, approximately 50% of the cumulative total proportion of patients who failed to improve were treated after 3 hours. It would be important to know the ratio of risk to benefit for the administration of alteplase in this subgroup; as Dr Caplan described in his Editorial,2 there have been suggestions to extend the window for alteplase administration to as long as 4.5 hours.
Andrew Pastewski, MD;
Yizhak Kupfer, MD;
Sidney Tessler, MD
stessler@maimonidesmed.org
Maimonides Medical Center
Brooklyn, NY
1. Saposnik G, Young B, Silver B, et al. Lack of improvement in patients with acute stroke after treatment with thrombolytic therapy: predictors and association with outcome. JAMA. 2004;292:1839-1844.
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2. Caplan LR. Treatment of acute stroke: still struggling. JAMA. 2004;292:1883-1885.
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JAMA. 2005;293:421.
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