Authors: Cerebral Angiography Image

Francesco Diana, Interventional Neuroradiology, Vall d’Hebron University Hospital, Barcelona, Spain

Miriam Caterino, Neurology and Stroke Unit, Medical Sciences Department, AOU San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Italy

Acute ischemic stroke (AIS) can manifest with mild neurological deficits, even in cases of large vessel occlusion (LVO), accounting for up to 4% of minor strokes. Among patients with mild deficits, those with LVO, more frequently present with disabling subitems of the NIHSS like aphasia, altered consciousness and motor deficit1,2. Current AHA/ASA and ESO guidelines recommend IVT for these patients, while the controversy arises for those with non-disabling strokes and LVO. In general, AHA/ASA and ESO guidelines discourage IVT for patients with minor non-disabling stroke. However, for those with minor non-disabling stroke and LVO, the expert consensus statement in the ESO guidelines3, despite lacking evidence, suggests IVT. This is supported by new evidence confirming its efficacy in both minor disabling and non-disabling strokes with LVO4.

Similar discussion surrounds recommendations of EVT for patients with minor stroke. AHA/ASA suggests no treatment for patients with NIHSS≤5, ESO guidelines advocate randomization in ongoing clinical trials. In cases where randomization is not possible, ESO experts recommend considering EVT for minor disabling symptoms or worsening despite IVT. There is a lack of evidence on EVT efficacy and safety for LVO with non-disabling minor strokes, as these patients were excluded from clinical trials of EVT. However, approximately 12% of patients treated with IVT were found to be at risk of early neurological deterioration (END), suggesting a potential benefit of EVT in these patients.

Predictive factors for END in LVO patients with mild symptoms include occlusion site and thrombus length. Proximal occlusion and longer thrombus increase END risk. A 4-point score based on these variables shows good discriminative power for END6. Although retrospective studies comparing EVT and best medical therapy (BMT) in LVO patients with NIHSS ≤5 show no clinical benefit of EVT and an increased risk of intracranial hemorrhage, none of these studies used the END score to select high-risk patients7.

In conclusion, treatment decisions for these patients should consider age, hypoperfusion volume, operator experience, technical difficulty of EVT, and presumed treatment benefits. Ongoing trials, e.g., ENDOLOW (NCT04167527) and MOSTE (NCT03796468), will provide further insights. Until then, individual decisions should be made on a case-by-case basis, trying to identify patients at high risk of END. For these patients, a watchful waiting approach does not seem appropriate, as clinical deterioration is unpredictable and treatment may then come too late.


1 Duloquin G, Crespy V, Jakubina P, Giroud M, Vergely C, Béjot Y. Large Vessel Occlusion in Patients With Minor Ischemic Stroke in a Population-Based Study. The Dijon Stroke Registry. Front Neurol. 2022 Jan 14;12:796046. doi: 10.3389/fneur.2021.796046. PMID: 35095739; PMCID: PMC8795366.

2 Khatri P,Kleindorfer DO,Devlin T, et al.; PRISMS Investigators. Effect of alteplase vs aspirin on functional outcome for patients with acute ischemic stroke and minor non disabling neurologic deficits: the PRISMS randomized clinical trial. JAMA 2018;320:156–166.

3 Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J. 2021 Mar;6(1):I-LXII. doi: 10.1177/2396987321989865. Epub 2021 Feb 19. PMID: 33817340; PMCID: PMC7995316.

4 Duan C, Xiong Y, Gu H, Wang S, Yang KX, Hao M, Feng X, Zhao X, Meng X, Wang Y. Intravenous thrombolysis versus antiplatelet therapy in minor stroke patients with large vessel occlusion. CNS Neurosci Ther. 2023 Jun;29(6):1615-1623. doi: 10.1111/cns.14124. Epub 2023 Mar 7. PMID: 36880290; PMCID: PMC10173711.

5 Mazya MV, Cooray C, Lees KR, Toni D, Ford GA, Bar M, Frol S, Moreira T, Sekaran L, Švigelj V, Wahlgren N, Ahmed N. Minor stroke due to large artery occlusion. When is intravenous thrombolysis not enough? Results from the SITS International Stroke Thrombolysis Register. Eur Stroke J. 2018 Mar;3(1):29-38. doi: 10.1177/2396987317746003. Epub 2017 Nov 29. PMID: 31008335; PMCID: PMC6453245.

6 Seners P, Ben Hassen W, Lapergue B, et al. Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone. JAMA Neurol. 2021;78(3):321–328. doi:10.1001/jamaneurol.2020.4557

7 Safouris A, Palaiodimou L, Nardai S, Kargiotis O, Magoufis G, Psychogios K, Matusevicius M, Feil K, Ahmed N, Kellert L, Spiliopoulos S, Brountzos E, Szikora I, Sarraj A, Goyal N, Aguiar de Sousa D, Strbian D, Caso V, Alexandrov AV, Tsivgoulis G. Medical Management Versus Endovascular Treatment for Large-Vessel Occlusion Anterior Circulation Stroke With Low NIHSS. Stroke. 2023 Sep;54(9):2265-2275. doi: 10.1161/STROKEAHA.123.043937. Epub 2023 Aug 1. PMID: 37526011.

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