title: Treatment of patients with mild acute ischemic stroke and associated large vessel occlusion.
abstract: Several recent studies have shown that patients presenting with mild acute ischemic stroke (mAIS) symptoms may have an unfavorable natural history. The presence of associated large vessel occlusion (LVO) may lead to even worse outcomes, but most mAIS patients are still excluded from acute stroke treatment (AST). A retrospective review of patients with acute ischemic stroke presenting to our institution between 2010 and 2014 was carried out. Inclusion criteria were mAIS (initial National Institutes of Health Stroke Scale [NIHSS] ⩽7) due to LVO, presenting within 6hours from onset. Demographics, treatments and short-term outcomes were analyzed. Favorable 30day outcome was defined as modified Rankin Scale (mRS) ⩽2. Out of 2636 patients, 62 patients (median age 63years, 33 (53.2%) males) met inclusion criteria. The anterior circulation was involved in 74.1%. Median admission NIHSS and pre-admission mRS were 4 and 0, respectively. Twenty-three patients (71.8%) received AST (intravenous tissue plasminogen activator: 14, intra-arterial therapy: 4, both: 5). Favorable outcomes were 4.5 times higher in treated (78.3%) versus untreated (53.8%) patients (odds ratio 4.5, 95% confidence interval 1.26-19.2; p=0.028). None of the treated patients had symptomatic intracranial hemorrhage. We demonstrate that a significant proportion of untreated mAIS patients with LVO have an unfavorable natural history. Our results suggest better outcomes in patients who receive early therapy rather than conservative management. The detection of LVO, even with mild clinical symptoms, may prompt rapid treatment considerations.
authors.affiliation: Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Avenue, S80, Cleveland, OH 44195, USA.
authors.forename: Russell
authors.initials: R
authors.lastname: Cerejo
authors.affiliation: Department of Neurology, Miami Valley Hospital, Dayton, OH, USA.
authors.forename: Esteban
authors.initials: E
authors.lastname: Cheng-Ching
authors.affiliation: Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Avenue, S80, Cleveland, OH 44195, USA.
authors.forename: Ferdinand
authors.initials: F
authors.lastname: Hui
authors.affiliation: Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Avenue, S80, Cleveland, OH 44195, USA.
authors.forename: M Shazam
authors.initials: MS
authors.lastname: Hussain
authors.affiliation: Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Avenue, S80, Cleveland, OH 44195, USA.
authors.forename: Ken
authors.initials: K
authors.lastname: Uchino
authors.affiliation: Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bullen
authors.affiliation: Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Avenue, S80, Cleveland, OH 44195, USA. Electronic address: tothg@ccf.org.
authors.forename: Gabor
authors.initials: G
authors.lastname: Toth
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy* / Q000473:pathology*; D015912:Thrombolytic Therapy / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Acute stroke therapy; Large vessel occlusion; Mild ischemic stroke