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reduced neuroregenerative capabilities in old patients, 1 Lohse KR, Hilderman CG, Cheung KL, Tatla S, Van der Loos HF. Virtual reality
therapy for adults post-stroke: a systematic review and meta-analysis
the optimum therapy duration might also vary with exploring virtual environments and commercial games in therapy.
patient age, which also requires further evidence. PloS ONE 2014; 9: e93318.
2 Lo AC, Guarino PD, Richards LG, et al. Robot-assisted therapy for long-term
EVREST is an important study because it shows that upper-limb impairment after stroke. N Engl J Med 2010; 362: 1772–83.
easily accessible, low-cost interventions are as useful 3 Duncan PW, Sullivan KJ, Behrman AL, et al. Body-weight-supported
treadmill rehabilitation after stroke. N Engl J Med 2011; 364: 2026–36.
as less accessible, higher cost ones. As the mountain 4 Dromerick AW, Lang CE, Birkenmeier RL, et al. Very early constraint-induced
movement during stroke rehabilitation (VECTORS): a single-center RCT.
of evidence grows regarding the types and doses of Neurology 2009; 73: 195–201.
treatments for rehabilitation after stroke, so too will the 5 Saposnik G, Cohen LG, Mamdani M, et al, for Stroke Outcomes Research
Canada. Efficacy and safety of non-immersive virtual reality exercising in
percentage of patients with improved outcomes. stroke rehabilitation (EVREST): a randomised, multicentre, single-blind,
controlled trial. Lancet Neurol 2016; published online June 27. http://dx.doi.
org/10.1016/S1474-4422(16)30121-1.
Brian Silver 6 Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced
Rhode Island Hospital, Providence, RI, USA movement therapy on upper extremity function 3 to 9 months after
stroke: the EXCITE randomized clinical trial. JAMA 2006; 296: 2095–104.
Brian_Silver@brown.edu
7 Bernhardt J, Langhorne P, Lindley RI, et al. Efficacy and safety of very early
I report personal fees for stroke outcomes adjudication in the Women’s Health mobilisation within 24 h of stroke onset (AVERT): a randomised controlled
Initiative and SOCRATES studies, personal fees from expert review for trial. Lancet 2015; 386: 46–55.
medicolegal cases related to stroke, salary as a Joint Commission stroke surveyor,
and personal fees for chapters written in Ebix, Medlink, and Medscape.
tissue.1–3 Occlusion of any part of the brain supplying In The Lancet Neurology, Eivind Berge and colleagues8 See Articles page 1028
arteries, including the large cerebral arteries and small report the effect of alteplase on stroke survival of up to
intracerebral arterioles, can be the cause of an ischaemic 3 years from the Third International Stroke Trial (IST-3).
stroke leading to various neurological deficits. Typically, This large, randomised, controlled, open-label trial
alteplase is administered within 4·5 h of symptom onset, included 3035 participants, and 1948 patients were
and the earlier it is given, the more effective it is.4 Young followed up with use of national death registries in the
age, low National Institutes of Health Stroke Scale score UK and Scandinavia. More patients given alteplase died
at onset, effective recanalisation, and early neurological within 7 days (99 [10%] of 967) than did those who
improvement are predictors of favourable outcome received standard care only (65 [7%] of 979) owing
at 3 months.5–7 However, alteplase can only be applied to intracranial haemorrhage and malignant brain
after an intracranial haemorrhage has been ruled out. infarction. Thereafter, fewer patients given alteplase
As alteplase might not recanalise the occluded cerebral and standard care died than did those given standard
artery, thrombectomy is used in many stroke centres. care alone (354 [41%] of 868 vs 429 [47%] of 914;
Otherwise, the patient is likely to develop a severe brain p=0·007), which was not due to patients’ age, stroke
infarction, which can become life threatening within the severity, or time lag until treatment. These data are
first few days after stroke. Also, the patient might have important and in line with a nationwide follow-up
an intracerebral haemorrhage after thrombolysis, which study in Denmark,9 providing a solid basis in favour of
is often fatal within the first few days after stroke.4 an effective treatment for a devastating neurological
After emergency treatment, the patient requires emergency. Although alteplase has the potential to
dedicated treatment, which is best provided in a stroke harm the individual patient, it has been shown to be
unit. This standard care aims to monitor and adjust vital cost-effective over the patient’s lifetime.10
variables, to initiate secondary prophylaxis according However, two important issues for this trial deserve
to the cerebrovascular, cardiac, or coagulatory cause of further consideration. First, similar to a previous
the individual patient’s stroke, and to rehabilitate the report from the IST-3 group,11 risk of death in patients