Response to Letter by Gonzalez-Hernandez et al
To the Editor:
We thank Gonzalez-Hernandez et al for their interest in our article.1 Firstly, we acknowledge that treatments similar to FASTER2/EXPRESS were initiated quickly in this population, which may have contributed to the low incidence of recurrence in the first few days. Given that these strategies are frequently implemented acutely this study highlights the growing importance of persistent vessel occlusion with ongoing infarction of penumbral tissue3 as the critical “untreated” cause for stroke progression. We agree that if all proven secondary prevention treatments are used4 then the mechanism behind worsening in many cases is from progression of the presenting event, rather than a distinct recurrent event. We also agree that the classic definition of TIA (made at 24 hours) has little use in centers that can assess patients very early into their symptoms. Our work highlights the unstable nature of these patients very early in their disease process. We also found that the presence of minor neurological deficits may further identify patients who are unstable. Further studies are required in larger populations to confirm our findings. Mechanistic information that can be urgently acquired using MRI or CT/CTA is needed in future trials in these patients. This way we can assess which subset of patients benefit from individual treatments and eventually will be able to tailor treatments on an individual patient basis.
Coutts BS, Hill MD, Campos CR, Choi YB, Subramaniam S, Kosior JC, Demchuk AM; for the VISION study group. Recurrent events in transient ischemic attack and minor stroke. What events arehappening and to which patients? Stroke. 2008; 39: 2461–2466.
Torres-Mozqueda F, He J, Yeh IB, Schwamm LH, Lev MH, Schaefer PW, Gonzalez RG. An acute ischemic stroke classification instrument that includes CT or MR angiography: the Boston Acute Stroke Imaging Scale. AJNR Am J Neuroradiol. 2008; 29: 1111–1117.
Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O, Redgrave JN, Lovelock CE, Binney LE, Bull LM, Cuthbertson FC, Welch SJ, Bosch S, Alexander FC, Silver LE, Gutnikov SA, Mehta Z; Early use of Existing Preventive Strategies for Stroke (EXPRESS) study. Effect of urgent treatment of transient ischaemic attack and minor strokeon early recurrent stroke (EXPRESS study): a prospective population-basedsequential comparison. Lancet. 2007; 370: 1432–1442.