Minor Updates For Minor Stroke

Minor stroke is all in the eye of the beholder.

If the general stroke thrombolysis debate remains a valid point of contention, then, even more absurd becomes the idea of thrombolysis in minor stroke. Yet, despite a gross paucity of evidence, here we are.

This clinical review breaks down the evidence and distills it down into recommendations encapsulated in this information graphic:

As you can see, the needle shows up quite frequently – and these authors yet again do the (lack of) evidence a disservice. Every RCT specifically enrolling patients with minor stroke has come up with harms resulting from IVT: PRISMS, ARAMIS, PUMICE, and TEMPO-2. The “out” neurologists have in these situations is that these primarily enrolled patients with “non-disabling stroke” – and recommendations for IVT involve “disabling” stroke. Instead, they point to the Emberson individual-patient meta-analysis and the 666 patients with NIHSS 0-4 included – and an aOR of [1.07 - 2.06] for better outcome with IVT in this cohort.

However, studies parroting the Emberson aOR persistently decline to note 400 patients out of this 666 cohort came from IST-3, and the NIHSS 0-5 results actually favored the control group in that trial [0.52 - 1.38]. Likewise, in the 58 NIHSS ≤ 5 patients in the NINDS trials, there was no difference in outcome between IVT and control [0.20 - 3.63]. Any apparent favoring of IVT must therefore come from skewed, small cohorts in the remaining included trials. There’s no reasonable basis for drawing a strong conclusion IVT is appropriate even in minor, disabling stroke.

Finally, the definition of “disabling” stroke completely hamstrung by its lack of definition – a subjective, individualized assessment of the degree of functional impairment suffered by a patient with minor stroke. Stroke is heterogeneous enough with anatomy, occlusion type, and collateral circulation, without tossing in a further subjective component to treatment decisions. Then, given the medicolegal environment in the U.S., there is virtually no incentive not to treat given the lack of certainty over patient-centered values or potential for downstream liability. In a word: chaos.

These authors do a disservice by failing to mention equipoise absolutely remains for minor stroke with disabling symptoms – other than to note a structured definition of “disability” would greatly help clarify treatment decisions.

<END RANT>