This Article Full Text All Versions of this Article: 34/3/821    most recent 01.STR.0000059431.80687.D8v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lyden, P. Search for Related Content PubMed PubMed Citation Articles by Lyden, P.

(Stroke. 2003;34:821.)
© 2003 American Heart Association, Inc.

Controversies in Stroke

Early Major Ischemic Changes on Computed Tomography Should Not Preclude Use of Tissue Plasminogen Activator

From the University of California at San Diego School of Medicine.

Correspondence to Dr Patrick Lyden, UCSD School of Medicine, OPC Third Floor, Suite 3, 200 West Arbor Dr, San Diego, CA 92103-8466. E-mail plyden@ucsd.edu

Key Words: brain ischemia • computed tomography • tissue plasminogen activator

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Early major ischemic changes on CT should not preclude use of tPA. In 1997, Prof von Kummer and his colleagues in ECASS greatly advanced stroke neurology by showing us the importance of early ischemic changes (EIC) on computed tomography.¹ They devised the so-called one third rule and taught us to estimate whether EIC subsumed more or less than one third of the territory of the middle cerebral artery (MCA). In the NINDS study, we missed this important finding. In our trial, we focused on treating half our patients within 90 minutes, and the remainder within 3 hours; there was only time to review the scans for hemorrhage, perform a history and physical, and obtain informed consent prior to mixing up the drug.² Following the regulatory approval of intravenous (IV) thrombolysis in the United States, physicians have tried to implement CT reading and to learn to read EIC and use the one third rule.¹ Although FDA approval was based primarily on NINDS, the approval language and package insert incorporated the ECASS warning about EIC and the one third rule. Listening to neurologists and emergency medicine physicians debate the importance of EIC, I would guess that no single aspect of hyperacute stroke therapy has produced more physician angst, and excluded more patients from IV thrombolysis, unless it might be the time window. Yet this angst is ultimately needless, and these patients could be treated, for 3 very simple reasons.

First, von Kummer and I agree on some simple definitions of terms that . . . [Full Text of this Article]

This article has been cited by other articles:

				L Derex and N Nighoghossian Intracerebral haemorrhage after thrombolysis for acute ischaemic stroke: an update J. Neurol. Neurosurg. Psychiatry, October 1, 2008; 79(10): 1093 - 1099. [Abstract] [Full Text] [PDF]

				G. W. Albers, P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 630S - 669S. [Abstract] [Full Text] [PDF]

				K. W. Muir, J. Baird-Gunning, L. Walker, T. Baird, M. McCormick, and S. B. Coutts Can the Ischemic Penumbra Be Identified on Noncontrast CT of Acute Stroke? Stroke, September 1, 2007; 38(9): 2485 - 2490. [Abstract] [Full Text] [PDF]

				I. Dzialowski, M. D. Hill, S. B. Coutts, A. M. Demchuk, D. M. Kent, O. Wunderlich, and R. von Kummer Extent of Early Ischemic Changes on Computed Tomography (CT) Before Thrombolysis: Prognostic Value of the Alberta Stroke Program Early CT Score in ECASS II Stroke, April 1, 2006; 37(4): 973 - 978. [Abstract] [Full Text] [PDF]

				T. Hirano, T. Yonehara, Y. Inatomi, Y. Hashimoto, and M. Uchino Presence of Early Ischemic Changes on Computed Tomography Depends on Severity and the Duration of Hypoperfusion: A Single Photon Emission-Computed Tomographic Study Stroke, December 1, 2005; 36(12): 2601 - 2608. [Abstract] [Full Text] [PDF]

				G. W. Albers, P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 483S - 512S. [Abstract] [Full Text] [PDF]

				J. Grotta, R. von Kummer, S. Davis, and G. Donnan NIHSS/EIC Mismatch Explains the >1/3 MCA Conundrum * Response * Response Stroke, September 1, 2003; 34 (9): e148 - e149. [Full Text] [PDF]