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Clinical Crossroads: A 36-Year-Old Woman Recuperating From Stroke

Lombardo Palma, MD, MSPH
JAMA. 1997;278(13):1060-1061. doi:10.1001/jama.1997.03550130034022.
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To the Editor.  —A recent Clinical Crossroads1 began with the case of Mrs X's recovery from a severe ischemic stroke, probably due to thromboembolic phenomena generated by severe mitral stenosis. Although Dr Alexander, the discussant, presented the case differently, after detailed reading I am recounting the case as follows. The patient was treated with recombinant tissue-type plasminogen activator (rt-PA) within the Food and Drug Administration's (FDA's) approved time window. I assume her coagulation test results were normal before administration of thrombolytic therapy, although those findings were not given.The patient's condition deteriorated over the next 2 days; she became drowsy and lethargic. Despite this clinical observation, I am surprised that no standardized stroke scales were used to document this change objectively. A time plot of the values of a neurologic deficit stroke scale would have made this neurologic decline evident. Additionally, this would have suggested the need to repeat the


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