The Case
A 55-year-old right-handed man presents with a left middle cerebral artery syndrome and National Institutes of Health Stroke Scale score of 20 five hours after symptom onset. He is known to have a recent transient ischemic attack and left carotid stenosis of 75%.
The Questions
Should the patient be transferred to a comprehensive stroke center or stay in a community hospital Stroke Unit? Why?
If yes, should he be transferred immediately or subacutely (first 48 hours)?
The Controversy
EARLY TRANSFER OF PATIENTS WITH STROKE TO COMPREHENSIVE CENTERS IS NECESSARY.
Since the publication of the National Institute of Neurological Disorders and Stroke tissue-type plasminogen activator (NINDS tPA) trial, the appropriate focus of patients with acute ischemic stroke has been to maximize the number of patients who can undergo safe and effective administration of intravenous tissue-type plasminogen activator. The exact timing and mode of various revascularization strategies, including endovascular treatment, is the subject of ongoing inquiries. Despite this area of clinical uncertainty, many patients with ischemic stroke are at high risk for serious complications in the initial hours after stroke, independent of exposure to reperfusion therapies. For the patient such …
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