Diagnosis and management of transient ischaemic attack and ischaemic stroke in the acute phase

We read with keen interest the very informative and practice changing
clinical review of the diagnosis and management of TIA and ischaemic
stroke by K S McArthur et al [1].

This review highlighted the benefits of thrombolysis in the form of
rt-PA, in reducing longer term disability as opposed to improving survival
or immediate neurological impairment in suitable patients.

Although the authors did state that the landscape of contra-
indications to thrombolysis was evolving, they nevertheless advised,
'referral of all hyperacute suspected strokes to a specialist team unless
there is substantial premorbid disability'. Should we really be aiming to
exclude the 'already functionally impaired' in spite of the stated benefit
of reducing disability?

Disability, also known as Activity limitation, is any restriction or
lack of activity, resulting from an impairment to perform an activity in
the manner or range considered normal for people of the same age, sex and
culture (International Classification of Functioning, Disability and
Health (ICF) by the World Health Organisation (WHO).

We submit that if thrombolysis has a beneficial effect on activity
limitation (disability), it is likely to have a desirable clinical and
functional outcome even in those 'already functionally impaired'.

We take consolation in the evolving nature of the landscape and the
highlighted Questions For Future Research - How safe and effective is
thrombolysis in elderly patients or those with a previous stroke?

References

1. K S McArthur, T J Quinn, J Dawson, M R Walters. Diagnosis and
management of transient ischaemic attack and ischaemic stroke in the acute
phase. BMJ 2011; 342:d1938