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September 2009

Thrombolysis in Acute Ischemic Stroke With Vitreous Hemorrhage—Reply

Arch Neurol. 2009;66(9):1178-1179. doi:10.1001/archneurol.2009.185

In reply

We read with interest the comments by Sethi and Moudgil et al regarding our case report.1 We appreciate their confession that they missed the vitreous hemorrhage until it was pointed out in the manuscript. Even we detected it only on a second look at the brain computed tomographic scan.

We agree with Sethi et al that vitreous hemorrhage is not listed as a contraindication for systemic thrombolysis. However, we would like to draw their attention to the current guidelines,2 which mention that patients with “no evidence of active bleeding” can be considered for thrombolysis. We agree with Moudgil that knowing the duration of the vitreous hemorrhage could be important because a relatively older vitreous hemorrhage is less likely to rebleed. Our patient was aphasic and, in absence of any history of visual problems of recent onset, it was impossible to determine the age of the vitreous hemorrhage; we considered it active and to have new bleeding. Even the package insert for TPA lists “hemorrhagic ophthalmic conditions” as a relative contraindication. Furthermore, we wish to clarify that the decision against administering thrombolysis in this case should not be interpreted as a possibly reluctant act on our part. Our center runs a very active stroke unit and, in the year 2008, about 12% of acute ischemic strokes admitted to our hospital received intravenous thrombolysis within 3 hours of symptom onset.3

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