Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores

Abstract

Background and Purpose— The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion. Methods— Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0–2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy. Results— We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30–4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59–5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32–6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22–4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71–3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%; P <0.05). Conclusions— Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02419794.

More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores

“…We identified 10 manuscripts comparing EVT with BMM in patients with LVO-AIS and a low NIHSS score (table 2), six (60%) of which had low NIHSS defined as NIHSS score ≤5. [3][4][5][6][7][8][9][10][11][12] Additionally, four meta-analyses were identified (two, NIHSS score ≤5; two, NIHSS score ≤8). 3 12 18 19 To compare EVT with BMM in mild strokes, the functional benefits of recanalization must be weighed against the added risk of the EVT procedure.…”

“…8 Additional EVT versus BMM articles failed to detect clinical benefit for EVT. [9][10][11] Recently, Goyal et al performed a meta-analysis of patients with AIS and NIHSS score ≤5 with an additional 251 patients from 16 centers. 3 From their original data, patients receiving BMM and EVT had similar rates of 90-day functional outcomes (mRS score ≤2, 76.7% vs 85.2%, p=0.12; mRS score ≤1, 63.1% vs 70.4%, p=0.26).…”

“…Our review of the EVT versus BMM literature yielded EVT bridging rates ranging from 9% to 61%, with only one study performing IVT subgroup analyses (table 2). 9 This wide IVT treatment range probably increases interstudy outcome variability. It is essential to compare IVT with EVT±IVT in patients with a low NIHSS score to elucidate the role of EVT bridging therapy in IVTeligible patients.…”

“…2 3 The efficacy of EVT in patients with AIS-LVO and a low NIHSS score continues to be widely debated, with the literature comprising retrospective investigations that demonstrate conflicting results. [3][4][5][6][7][8][9][10][11][12] Variability in outcomes in patients with AIS and a low NIHSS score highlights the limitations of the NIHSS as a screening tool for treatment eligibility. 13 While the NIHSS is predictive of overall AIS outcome, not all low NIHSS scores are equivalent with regard to clinical outcome.…”

How Long Are Reperfusion Therapies Beneficial for Patients after Stroke Onset? Lessons from Lethal Ischemia Following Early Reperfusion in a Mouse Model of Stroke

“…Moreover, accumulating evidence from animal studies shows that cellular responses, including degenerative and reparative events following ischemic stroke, differ according to one’s age [ 108 , 109 , 110 , 111 , 112 ]. Thus, it may be challenging to acquire evidence for the efficacy of reperfusion therapies after lethal ischemia in patients with stroke, as human samples can be influenced by factors such as age, sex, the presence of complicating diseases (e.g., hyperlipidemia and hyperglycemia), ischemic area, the size of the ischemic area, and time to reperfusion after stroke onset [ 34 , 113 , 114 ]. Therefore, compared with a mouse model of stroke, in the case of patients with stroke, it is more difficult to determine, with precision, the time window for induction of lethal ischemia with mature neural cell death.…”