Considering Thrombolysis for Mild Stroke

The number of patients presenting to emergency departments with mild stroke (National Institutes of Health Stroke Scale [NIHSS] score 0-5) is substantial and seems to be increasing over time. Determining the acute reperfusion therapy approach in an individual patient has presented many challenges. These include the individualized nature of the functional impact of a particular mild deficit (eg, subtle nondominant hand weakness has more of an impact on function for a professional violinist than a retired person); cognitive effects, which are often underrecognized at emergent presentation; the risk of later neurological decline outside the eligible time window for lytic therapy; the potential for spontaneous recovery over time; and the small but real risk of symptomatic intracranial hemorrhage associated with lytic administration. Two pivotal trials, one by the National Institute of Neurological Disorders and Stroke (NINDS) and the European Cooperative Acute Stroke Study 3 (ECASS-3), both excluded patients with mild, nondisabling deficits (Table).