HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Correspondence to:

BRIEF COMMUNICATIONS: D. Georgiadis, O. Lanczik, S. Schwab, S. Engelter, R. Sztajzel, M. Arnold, M. Siebler, S. Schwarz, P. Lyrer, and R. W. Baumgartner IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection Neurology 2005; 64: 1612-1614 [Abstract] [Full text] [PDF]

Correspondence: Submit a response to this article

Correspondence published:

Reply to Topakian et al

Dimitrios Georgiadis, Lanczik O, Schwab S, Engelter S, Sztajzel R, Arnold M, Siebler M, Schwarz S, Lyrer P, Baumgartner RW   (14 September 2005)

IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection

Raffi Topakian, Hans-Peter Haring, MD, Franz T. Aichner, MD (Linz, Austria)   (14 September 2005)

Reply to Topakian et al 14 September 2005
Dimitrios Georgiadis, Department of Neurology, University of Zuerich Frauenklinikstr. 26, 8091 Zuerich, Switzerland, Lanczik O, Schwab S, Engelter S, Sztajzel R, Arnold M, Siebler M, Schwarz S, Lyrer P, Baumgartner RW Send Correspondence to journal: Re: Reply to Topakian et al dg_de{at}yahoo.com Dimitrios Georgiadis, et al.	We would like to thank Topakian et al for their letter concerning our article and the two presented cases. [1] The reason for deterioration in the first patient is unclear, and is thus not neccessarily associated with the carotid dissection. Embolism from a dislocated thrombus from the dissection site was the most probable underlying cause in the second described case. We postulated this complication in our article, but only encountered it in 1/33 (3%) patients. As Topakian et al point out, the number of patients described up to date is too small to allow any meaningful conclusions concerning safety and efficicacy of intravenous thrombolysis (IVT) caused by carotid dissection. Considering the low incidence of carotid dissection, the narrow therapeutic window for IVT, and the fact that-- even within the 3-hour window-- earlier treatment is associated with better outcome, conducting a prospective study does not appear feasible because screening for carotid dissection would have to be performed in all patients with acute ischemic stroke. This would delay application of IVT or even making this impossible in certain patients. A registry retrospectively evaluating prospectively collected data could provide more information on this intriguing issue. The authors report no conflict of interest.
IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection 14 September 2005
Raffi Topakian, Wagner-Jauregg Hospital Linz Wagner-Jauregg-Weg 15, 4020 Linz, Austria, Hans-Peter Haring, MD, Franz T. Aichner, MD (Linz, Austria) Send Correspondence to journal: Re: IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection raffi.topakian{at}aon.at Raffi Topakian, et al.	We read the article by Georgiadis et al with great interest. [1] In their study, only one out of 33 patients with spontaneous carotid dissection markedly deteriorated during IV thrombolysis (IVT). This is in contrast to our experience. Since 2003, two patients with acute stroke due to extracranial carotid artery dissection have been treated with IVT at our institution. Both patients deteriorated significantly after the start of IVT and remained dependent on others after 3 months. In patient 1, a 41-year-old woman, IVT was started without pre-treatment vascular imaging 3.5 hours after stroke onset. Baseline brain computed tomography (CT) was unremarkable for early ischemic changes. IVT was stopped after 30 minutes because of a significant deterioration in the National Institute of Health Stroke Scale (NIHSS) Score from 7 to 12. Emergency brain CT did not show any bleeding but demarkation of the infarction, and we decided to continue IVT. Patient 2, a 35-year-old man, deteriorated significantly at the end of IVT which had been started 1 hour after stroke onset. His NIHSS Score increased from 9 to 18. Baseline magnetic resonance imaging (MRI) had shown multiple emboliform signal alterations in diffusion weighted imaging in the territory of the left anterior and middle cerebral artery and there was considerable diffusion/perfusion mismatch. Pre-treatment magnetic resonance angiography revealed a reduced caliber of the left internal carotid artery (ICA). Post-IVT brain CT and MRI showed multiple small parenchymal hemorrhages within infarcted brain areas and an occlusion of the left ICA, respectively. In both patients carotid dissection was diagnosed by non-invasive vascular imaging. The cause of their neurological deterioration during IVT remains unclear. However, the progression from ICA stenosis toward occlusion in patient two supports the pathogenetic concept that IVT might confer the risk of local hematoma expansion in dissected vessels including additional cerebral embolism. [1] Current data do not suggest withholding IVT from these patients in general, it seems obvious that the issue of individual risk/benefit balancing has not yet been settled. References 1. Georgiadis D, Lanczik O, Schwab S et al. IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection. Neurology 2005;64:1612-1614. The authors report no conflicts of interest.