American Academy of Neurology replies to Jeanne Lenzer

The recent BMJ article on viewing clinical guidelines with scepticism focused mainly on the recent American Academy of Neurology (AAN) and American College of Emergency Physicians (ACEP) guideline advocating use of tissue plasminogen activator (tPA; alteplase) in select patients within 4.5 hours of onset of ischaemic stroke.1

The author published a similar article in the BMJ in 2002 focusing on conflicts of interests among the investigators and potential methodological flaws in the original National Institutes of Neurologic Diseases and Stroke (NINDS) stroke study.2 This premise was subsequently debunked when an independent author panel reviewed the data and arrived at the same conclusions.3 Ensuing randomised trials have also supported the original findings. Since then, professional organizations including the American Heart Association/American Stroke Association, the American Academy of Emergency Medicine, and the Society for Academic Emergency Medicine have published guidelines supporting alteplase in stroke. The Joint Commission for Accreditation of Hospital Organizations has made alteplase use a quality metric and has developed primary and comprehensive stroke center certification to encourage its use. These endeavours have probably contributed to the improving outcomes for stroke patients in the US. …