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Michael P. Alexander, MD
Beth Israel Hospital Boston, Mass

JAMA. 1997;278(13):1061.

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In Reply.

—Dr Palma's analysis of the acute phase of the illness of Mrs X is plausible. However, the clinical course of hemorrhagic transformation is common even in patients with ischemic infarction who do not receive rt-PA. There are 2 types of hemorrhage in ischemic brain, intraparenchymal hemorrhage and hemorrhagic transformation. There is recent evidence that rt-PA may not increase the risk of hemorrhagic transformation.¹ Mrs X had hemorrhagic transformation, but it is not certain that rt-PA was responsible, nor that the patchy hemorrhage worsened the outcome of the infarction.

Standard stroke scale assessments may have been applied in her case at the initial treating hospital. Information from that phase of her illness was not available to me. Standard assessment is essential in all patients with stroke, and particularly in those receiving rt-PA, thus, my emphasis on adherence to published guidelines that include such a requirement.²

The emerging science of . . . [Full Text PDF of this Article]

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