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Neurology India, Vol. 55, No. 2, April-June, 2007, pp. 174-175 Letter To Editor Authors' reply Padma MV, Singh MB, Bhatia R, Srivastava A, Tripathi M, Shukla G, Goyal V, Singh S, Prasad K, Behari M Department of Neurology, All India Institute of Medical Sciences, New Delhi - 110029 Date of Acceptance: 09-Feb-2007 Code Number: ni07064 Sir, I agree that it helps to strictly adhere to a dedicated protocol when we start any management strategy. However, practical constraints are real and cannot be wished away! In developing countries where stroke burden is felt more acutely (second commonest cause of death and disability), I strongly feel that the protocol can be modified to be more suitable to our practical concerns. Even with our best efforts we do not thrombolyze more than 2-6% of our stroke patients. With additional tests cutting into our limited resources, peculiar to the developing world and the terribly narrow therapeutic time window of opportunity, we will be able to ultimately treat even less! No doubt there are and will be more strategies to extend the therapeutic time window; better select patients for reperfusion strategies etc. I also agree on the clinical dictum of primum non nocere (primarily do no harm), either by actively committing an act or withholding a proven therapy through inaction! In the present clinical scenario, we at AIIMS tried to clinically identify patients who may not require additional tests for coagulation studies thereby limiting the resources and time required. Our results certainly have not been worse off for the deviations in the protocol. None of our patients who showed the hemorrhagic transformation or the small frontal bleed had any clinical deterioration. We still believe that protocols can be modified, albeit judiciously where the clinical problem is immense and resources are limited. Copyright 2007 - Neurology India |
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