Author reply

Abstract

We thank the authors for their remarks and their call for brain imaging in thrombolysis. We agree that brain imaging as inclusion and exclusion criteria is widely used and standard worldwide in stroke trials. It is well accepted to exclude intracerebral hemorrhages and to gain knowledge of the location and size of ischemic tissue in acute stroke.1Adams H.P. del Zoppo G. Alberts M.J. et al.Guidelines for the early management of adults with ischemic stroke Stroke Council of the American Stroke Association.Stroke. 2007; 38: 1655-1711Crossref PubMed Scopus (1990) Google Scholar, 2International Stroke Trial Collaborative GroupThe International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19.435 patients with acute ischaemic stroke.Lancet. 1997; 349: 1564-1565Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study GroupTissue plasminogen activator for acute ischemic stroke.N Engl J Med. 1995; 333: 1581-1587Crossref PubMed Scopus (9943) Google Scholar, 4Rha J.H. Saver J.L. The impact of recanalization on ischemic stroke outcome: a meta-analysis.Stroke. 2007; 38: 967-973Crossref PubMed Scopus (1189) Google Scholar, 5Hacke W. Kaste M. Bluhmki E. et al.Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke.N Engl J Med. 2008; 359: 1317-1329Crossref PubMed Scopus (4836) Google Scholar Patients are included in such studies particularly because of acute neurological deficits, whereas the only symptoms in the EAGLE study were those of acute central retinal artery occlusion within the last 20 hours. The concept for thrombolytic treatment is more comparable to treatment studies after cardiac and other noncerebral ischemic events and less comparable to stroke, even though the objection is correct that similar to cerebral embolic strokes, retinal emboli often arise from arteriosclerotic carotid arteries.6Hayreh S.S. Podhajsky P.A. Zimmerman M.B. Retinal artery occlusion: associated systemic and ophthalmic abnormalities.Ophthalmology. 2009; 116: 1928-1936Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar This was the reason that we carefully investigated the carotid arteries by conventional catheter angiography in all cases treated by thrombolysis. The main reason for the premature termination of the study and our recommendation not to treat patients with central retinal artery occlusion any longer by thrombolysis was first the apparent similar visual efficacy in both treatment groups. The higher rate of adverse reactions was a secondary end point. The 2 serious adverse reactions did not arise due to a previously overlooked cerebral infarction. The first complication happened after thromboembolic vessel occlusion during the catheter maneuver. It was treated immediately by local intra-arterial fibrinolysis of the occluded cerebral artery branch and recovered completely. The second serious event with cerebellar hemorrhage was due to a drop of platelets down to 80 000. After this experience, the additional exclusion criteria of thrombocytopenia <100 000/ml was required. Except these cases, which are well understood based on the etiology described above, there was no hemorrhagic transformation in the thrombolysis group. The other patient in the conservative standard treatment group who developed right hemiparesis 1 day after recruitment was examined intensively by neurologists before the event occurred. It is correct as mentioned by the authors that thrombolysis should not be performed later than 6 hours after onset of symptoms in cerebral infarction5Hacke W. Kaste M. Bluhmki E. et al.Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke.N Engl J Med. 2008; 359: 1317-1329Crossref PubMed Scopus (4836) Google Scholar, 7Paciaroni M. Agnelli G. Corea F. et al.Early hemorrhagic transformation of brain infarction: rate, predictive factors, and influence on clinical outcome: results of a prospective multicenter study.Stroke. 2008; 39: 2249-2256Crossref PubMed Scopus (336) Google Scholar but we have to keep in mind that EAGLE is not a stroke study. For the retina itself hemorrhagic risk is low. Although we support the author's recommendation that brain imaging might be safer in stroke patients we cannot conclude that the complications could have been avoided using brain imaging. Thrombolysis for Artery OcclusionOphthalmologyVol. 118Issue 3PreviewWe read with interest the article by Schumacher et al1 entitled, “Central Retinal Artery Occlusion: Local Intra-arterial Fibrinolysis versus Conservative Treatment, a Multicenter Randomized Trial.” This study was discontinued mainly because the first interim analysis showed a higher rate of adverse events (symptomatic intracerebral hemorrhage) in the local intra-arterial fibrinolysis (LIF) group. Full-Text PDF