To the Editor: The article on ‘thrombolytic treatment after acute ischemic stroke’ was very timely, and the observation that those who were ambulating independently prior to admission seemed to have ‘poor discharge outcomes’ was astute, to say the least. However, I would have liked to hear from the authors of this article, something, that would give us direction on reducing such poor outcomes. Could these patients who were described as ‘rapid resolution of symptoms or mild stroke’ actually suffer from ‘crescendo TIAs’ or other forms of TIAs while hospitalized or in rehabilitation? This second question is that if the patient initially improves perhaps not to baseline but with minimal deficits, and then suffers neurological worsening on day 2, should onset time be reset to the worsening of deficits and considered for thrombolytic treatment?
We think that these patients who are initially “too good” for thrombolytic treatment but later have poor outcomes are a heterogeneous group comprised of i) TIAs that subsequently progress to strokes; ii) Mild strokes which worsen during hospitalization; and, iii) Seemingly mild strokes with low NIHSS score on admission but who do have gait ataxia which is not captured by the NIHSS score and also not identified on initial examination since stroke patient are usually not ambulated in the emergency department. Dr. Edwards-Conrad raises a very valid question and one that we have struggled with in our practice. Currently, we are doing the following: i) For patients with clear TIAs with resolution of all symptoms, we re-start the clock if there are recurrent symptoms unless, there are imaging correlates that suggest tissue damage - e.g. changes on diffusion weighted imaging. We order neurochecks on these patients every 30–60 minutes at least for the first 12 hours post-admission to capture a new episode as soon as possible. ii) For the second group of patients we do not re-start the clock since they have never resolved to baseline and our reasoning is that there is likely some tissue damage (which would increase the chances of intracranial hemorrhage after thrombolysis) if the symptoms do not resolve within a few hours. iii) The third group of patients are the most difficult to identify in a timely fashion due to the issues mentioned above. It is currently unclear what can be done since they might not have a high NIHSS despite gait difficulties. Ideally, a clinical trial should examine the utility of thrombolytic treatment in patients with mild deficits to help optimize their management since these patients were excluded in the original trials.