—Dr Garner makes three valid points that I will deal with in turn.
Sodium nitroprusside is not ideal, but should be the agent of choice because it is a powerful and predictably effective agent, without a direct effect on the central nervous system, and does not cause patchy ischemia.1 It is currently favored by most experts in the field.2-5 Its capacity to cause raised intracranial pressure is not clearly established.6,7 Diazoxide, used in small frequent boluses, and α-blockers, are also effective agents. However, newer agents such as captopril8 and the calcium channel blockers9 may prove more ideal.
The point that hydralazine hydrochloride caused neurologic deterioration as a result of raised intracranial pressure is well taken, however, the patient did not exhibit signs of raised
intracranial pressure; the computed tomographic scan showed no mass effect, and the neurologic deficit improved on raising the blood pressure. Trimethaphan camsylate, a good drug but
Lavin P. Sodium Nitroprusside Treatment in Patients With Acute Strokes-Reply. Arch Intern Med. 1986;146(7):1454. doi:10.1001/archinte.1986.00360190246046