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To the Editor:

Recently, Smith et al. [1] reported results from the American Heart Association Get with the Guidelines. This study shows that, among 93 517 patients with acute stroke within two-hours, 29 200 (31, 2%) were excluded from therapy with intravenous (IV) recombinant human tissue plasminogen activator (rtPA) because they presented with mild or rapidly improving stroke symptoms (RISSs) according to initial National Institutes of Health Stroke Scale (NIHSS) score. However, outcome of these patients was not invariably benign, and many of them were dependent upon discharge. Furthermore, their outcome was worse than of patients diagnosed with transient ischemic attack. As Smith et al. suggest [1], these are key data to argue for a more effective approach to patients with minor stroke or RISS.

One reason for this worse outcome could be that patients with low NIHSS scores are functionally worse than expected [2]. This might occur, for example, in patients with aphemia. This is a rare disorder of speech. The clinical manifestation of aphemia is classically a mute individual with intact comprehension, writing skills, and buccofacial function. Aphemia is usually caused by an ischemic lesion seated in the opercular division of the precentral gyrus and can be a presenting symptom of acute stroke. As NIHSS scores in most cases of aphemia are likely to be low; the question whether to treat or not to treat these patients with IV rtPA may be a dilemma for physicians. We have recently treated two patients with aphemia because of an acute stroke successfully resolved with IV rtPA. The first patient was a 78-year-old man with history of hypertension and atrial fibrillation, and the second one was a 77-year-old man with history of dilated myocardiopathy. Both were attended in the emergency department after sudden development of speech difficulty. On examination, they made sounds but could not produce words. They kept intact written language expression and had also full comprehension. Oro-bucco-facial apraxia was not present. They were able to move tongue on command. All other neurological examinations were normal. Both cases scored 3 in NIHSS. After brain computed tomography (CT) scan, both patients received intravenously 0·9 mg/kg rtPA 110 and 130 min after symptoms onset, respectively. Two-hours later, both of them were fully recovered. CT brain at 24 h was normal in both cases. They were discharged after four-days with oral warfarin sodium prescription.

As in ours patients, the NIHSS score in aphemia's cases are likely to be lower than four but in this setting such a low score represents a devastating scenario for patient's lifestyle because of severe inability to communicate. The question arises whether it is justified to exclude patients with low NIHSS from IV thrombolysis. Up to this date, there is no a controlled trial of reperfusion therapy to formally guide appropriate management of patients with minor stroke or RISS. Current guidelines advise against treatment with IV rtPA in this patient group owing to the fact that pivotal trials of reperfusion therapy have excluded such patients, and the safety and efficacy of this treatment in patients with minor stroke or RISS have therefore not been evaluated. However, some authors recommend that the decision regarding acute thrombolysis be guided by likelihood of disability rather than simply the NIHSS score itself [3]. So, we suggest treating patients suffering from acute aphemia with IV rtPA as well as any stroke causing difficulty in oral communication. Hopefully, further prospective studies will help clarify optimal treatment for this patient group with low NIHSS scores.

References

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  2. References
  • 1
    Smith EE, Fonarow GC, Reeves MJet al. Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator. Findings from Get With The Guidelines-Stroke. Stroke 2011; 42:31103115.
  • 2
    Nedeltchev K, Schwegler B, Haefeli Tet al. Outcome stroke with mild or rapidly improving symptoms. Stroke 2007; 38:25312535.
  • 3
    Willey JZ, Stillman J, Rivolta JAet al. Too good to treat? Outcomes in patients not receiving thrombolysis du to mild deficits or rapidly improving symptoms. Int J Stroke 2012; 7:202206.