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September 2009

Would You Save This Patient’s Eye or His Brain?

Arch Neurol. 2009;66(9):1178. doi:10.1001/archneurol.2009.183

We read with interest the article by Ahmad et al.1 We have to admit that we did not appreciate the vitreous hemorrhage in the right eye until it was pointed out by the authors. The authors mention that the presence of the vitreous hemorrhage made them decide not to initiate thrombolysis, listing it as an absolute contraindication for system thrombolysis. While history of a stroke or major head trauma within the past 3 months, major surgery within the past 14 days, gastrointestinal or urinary tract hemorrhage within the last 21 days, and arterial puncture at a noncompressible site within the last 7 days are listed among the absolute contraindications to thrombolysis, vitreous hemorrhage is not. Moreover, here we have a patient presenting with a major left middle cerebral artery stroke with global aphasia, left gaze deviation, and significant right-sided hemiplegia, though the authors do not tell us the Medical Research Council grade. The patient had a National Institutes of Health Stroke Scale score of 13, a further indication of his significant level of impairment. Should intravenous thrombolysis have still been given to this patient? Would he have lost vision in his right eye but gained back his faculties of speech and language and use of his limbs if thrombolysis had been initiated? Would this have been acceptable to us as doctors and, more importantly, to the patient and his family? Was this an acceptable risk to take? All of these questions arose in our mind, for which we know there are no clear answers. Intra-arterial thrombolysis was surely an option the authors could have pursued. After reading Ahmad and colleagues' case report, our question was not whether we would perform thrombolysis in this patient with acute ischemic stroke but whether we would save his eye or his brain.

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