Large Vessel Occlusion in Patients With Minor Ischemic Stroke in a Population-Based Study. The Dijon Stroke Registry

Abstract

Introduction:Strategy for the acute management of minor ischemic stroke (IS) with large vessel occlusion (LVO) is under debate, especially the benefits of mechanical thrombectomy. The frequency of minor IS with LVO among overall patients is not well established. This study aimed to assess the proportion of minor IS and to depict characteristics of patients according to the presence of LVO in a comprehensive population-based setting.Methods:Patients with acute IS were prospectively identified among residents of Dijon, France, using a population-based registry (2013–2017). All arterial imaging exams were reviewed to assess arterial occlusion. Minor stroke was defined as that with a National Institutes of Health Stroke Scale (NIHSS) score of <6. Proportion of patients with LVO was estimated in the minor IS population. The clinical presentation of patients was compared according to the presence of an LVO.Results:Nine hundred seventy-one patients were registered, including 582 (59.9%) patients with a minor IS. Of these patients, 23 (4.0%) had a LVO. Patients with minor IS and LVO had more severe presentation [median 3 (IQR 2–5) vs. 2 (IQR 1–3), p = 0.001] with decreased consciousness (13.0 vs. 1.6%, p<0.001) and cortical signs (56.5 vs. 30.8%, p = 0.009), especially aphasia (34.8 vs. 15.4%, p = 0.013) and altered item level of consciousness (LOC) questions (26.1 vs. 11.6%, p = 0.037). In multivariable analyses, only NIHSS score (OR = 1.45 per point; 95% CI: 1.11–1.91, p = 0.007) was associated with proximal LVO in patients with minor IS.Conclusion:Large vessel occlusion (LVO) in minor stroke is non-exceptional, and our findings highlight the need for emergency arterial imaging in any patients suspected of acute stroke, including those with minor symptoms because of the absence of obvious predictors of proximal LVO.

What predicts large vessel occlusion in mild stroke patients?

“…In previous studies [20][21][22], the LOC, aphasia, gaze palsy, neglect and hemianopia were all considered as cortical symptoms which were highly associated with LVO in the stoke population. Recently, a retrospective study from France indicated that mild AIS patients with LVO were more prone to have higher score on consciousness and aphasia, although in the multivariable analysis these differences were not significant [18]. Therefore, most of prehospital prediction scales of LVO (e.g., 3I-SS [22], FAST-ED [21], RACE [23]) included at least two of these symptoms.…”

“…Consequently, mild AIS patients with LVO are more likely to be neglected and not expeditiously treated by recanalization therapies [ 17 ]. Recently, a small sample sized study in mild AIS patients in France compared the clinical symptoms between LVO and non-LVO patients but found no significant predictors for proximal LVO [ 18 ]. Thus, we aimed to explore the predictors for LVO in mild AIS patients in a nation-wide prospective registry.…”

Thrombectomy in Stroke With a Large Vessel Occlusion and Mild Symptoms: “Striving to Better, Oft We Mar What’s Well?”

“…sizeable fraction of acute ischemic strokes with a large vessel occlusion (LVO), likely owing to good leptomeningeal collaterals, presents with only mild neurological deficit, commonly defined as a National Institutes of Health Stroke Scale score below 6. 1 Approximately 85% of patients with this condition reach 3-month functional independence following best medical management alone-which includes intravenous thrombolysis unless contraindicated-this outcome is good but could be better. [2][3][4][5] Poor outcomes following best medical management in this population are mainly driven by the occurrence of early neurological deterioration (END), which is observed in 10% to 15% of cases.…”

Response to Letter by Hsia et al, Titled “Advanced Imaging for Mild Stroke Patients–Selection for Acute Interventions”

“…The focus of our research was to evaluate mild strokes presenting with large vessel occlusions that are potentially amenable to endovascular therapy. While the overall incidence of patients presenting with mild strokes is high (~50% of all strokes), 3 patients with mild strokes and large vessel occlusion (LVO) represent a much smaller population (~5% of all strokes) 4, 5 . This population differs from patients with mild stroke without LVO in their higher risk of neurological deterioration, resulting in poorer outcomes.…”

“…While the overall incidence of patients presenting with mild strokes is high (~50% of all strokes), 3 patients with mild strokes and large vessel occlusion (LVO) represent a much smaller population (~5% of all strokes). 4,5 This population differs from patients with mild stroke without LVO in their higher risk of neurological deterioration, resulting in poorer outcomes. The procedural risks are also higher, 2, 6-8 thus the heightened need for patient selection.…”