Acute Ischemic Stroke With Mild Symptoms–To Thrombolyse or Not to Thrombolyse?

Abstract

Management of stroke with minor symptoms may represent a therapeutical dilemma as the hemorrhage risk of acute thrombolytic therapy may eventually outweigh the stroke severity. However, around 30% of patients presenting with minor stroke symptoms are ultimately left with disability. The objective of this review is to evaluate the current literature and evidence regarding the management of minor stroke, with a particular emphasis on the role of IV thrombolysis. Definition of minor stroke, pre-hospital recognition of minor stroke and stroke of unknown onset are discussed together with neuroimaging aspects and existing evidence for IV thrombolysis in minor strokes. Though current guidelines advise against the use of thrombolysis in those without clearly disabling symptoms due to a paucity of evidence, advanced imaging techniques may be able to identify those likely to benefit. Further research on this topic is ongoing.

The Optimal Management for People with Acute Stroke and Minor Deficits: Intravenous Thrombolysis or Medical Management?

“…7,9 Of course, judging if, and to what extent, a deficit may be disabling in the future is challenging in the hyperacute setting. 7 Using a dichotomous NIHSS cut-off to determine stroke syndromes that are likely to be disabling and which should be treated with intravenous thrombolysis has important limitations. The NIHSS is strongly weighted towards dominant hemisphere anterior circulation deficits and underestimates clinical severity in people with non-dominant or posterior circulation strokes.…”

“…6 In the acute stage, how best to manage those who present acutely with minor ischaemic strokes has posed a therapeutic dilemma for stroke clinicians. 7 On the one hand, we wish to restore any…”

“…The majority of randomised controlled trials that provide the evidence base for intravenous thrombolysis in acute stroke did not include people without disabling symptoms. 7 The Potential of r-tPA for Ischemic Strokes With Mild Symptoms (PRISMS) trial assessed the safety and efficacy of thrombolysis with alteplase in people presenting acutely with minor ischaemic stroke and NIHSS 0-5. 9 The trial only recruited 313 participants, which is one-third of the planned sample size, and was terminated early.…”

“…6 In the acute stage, how best to manage those who present acutely with minor ischemic strokes has posed a therapeutic dilemma for stroke clinicians. 7 We wish to restore, on the one hand, any impairment in cerebral blood flow, prevent subsequent ischemia, and improve functional recovery, while on the other hand, avoiding neurological deterioration or symptomatic intracranial hemorrhage (sICH), which is one of the most feared complications in the early period after stroke. The efficacy of intravenous thrombolysis is generally well established in the context of acute ischemic stroke.…”

“…8 However, the relative efficacy and safety of intravenous thrombolysis in people who present with minor symptoms is less clear and often presents a challenge when faced with someone presenting with acute minor focal neurological symptoms in the emergency department. 7 More than half of people with acute ischemic stroke have minor symptoms only, 9,10 yet up to a third of these people have functional disability at 90 days after stroke. 10,11 The optimal management of people presenting with acute minor stroke is therefore of exceptional clinical importance.…”