In reply: In response to Macdonald’s letter, we agree there are many effective interventions for stroke that should be routinely available, including stroke units and early coordinated care for minor strokes and transient ischaemic attacks (early care is particularly neglected in Australia). However, thrombolysis is one of the interventions that should be more widely available. Australian and international guidelines (the National Health and Medical Research Council [NHMRC]-approved clinical guidelines for stroke management, the United Kingdom Royal College of Physicians stroke guidelines and the American Heart Association/American Stroke Association guidelines) recommend thrombolysis with alteplase for acute ischaemic stroke.1-3 While there is a risk of early death from intracranial haemorrhage, long-term outcomes are significantly improved with thrombolysis. Although the primary outcome of the third international stroke trial (IST-3) was not significant, there was a significant improvement in 6-month disability (a prespecified secondary outcome) in the alteplase group, and no difference in number of deaths by 6 months (as the alteplase group had a lower death rate from 7 days to 6 months).4 It is on the basis of all of this evidence, confirming that treatment is beneficial, that guidelines consistently recommend thrombolysis as the standard of care for those who are eligible.
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