June 04, 2015

Two small retrospective studies have suggested that revascularization therapy may be beneficial for patients with mild acute ischemic stroke.

Both studies were presented at the recent 24th European Stroke Conference (ESC).

The presenters explained that in clinical practice, it is very common not to treat patients who have had very mild stroke with tissue plasminogen activator (tPA) because of the fear of hemorrhagic conversion.

But in the current studies, patients with mild strokes treated with thrombolysis or intra-arterial therapy had better outcomes than those treated conservatively.

The first study focused on patients with large-vessel occlusions presenting with mild symptoms. Investigator Gabor Toth, MD, Cleveland Clinic, Ohio, noted that these patients often do not receive acute revascularization therapies because symptoms are mild but they still have quite a high risk for mortality and morbidity. "This is not a benign condition," he said.

For his study, Dr Toth and colleagues compared outcomes in patients with mild stroke who had revascularization treatment with tPA or intra-arterial therapy with those who had received conservative treatment.

Patients were included if they had had a mild stroke (National Institutes of Health Stroke Scale [NIHSS] score of 1 to 7) within 24 hours and had imaging evidence of a major vessel occlusion. Of 2636 patients screened, 126 met the entry criterion of having a large-vessel inclusion. They had a mean age of 63 years, an initial mean NIHSS score of 4 and a mean time from symptom onset of 6 hours.

Of these, 25 patients received revascularization treatment (14 tPA, 6 intra-arterial therapy, and 5 both).

Outcome data at 30 days were available for 89 patients and was imputed for the remaining 37 patients.

Results showed that after adjustment for baseline modified Rankin Scale score, baseline NIHSS score, and time from onset, 76% of patients who received revascularization treatment had a good outcome (mRS score, 0 to 2 at 30 days) compared with 60% of those given conservative care (odds ratio, 2.7; P = .076).

When just considering the 62 patients presenting within 6 hours (23 of whom received revascularization), then good outcomes occurred in 78% of the revascularization patients vs 54% of those given conservative treatment (odds ratio, 4.5; P = .028).

Dr Toth concluded that the study had many limitations, including a retrospective design, small sample size, and some imputed data, but results suggested that early treatment with revascularization resulted in improved clinical outcomes.

He proposed that rapid evaluation of vessel status and finding large-vessel occlusions in patients with mild symptoms may prompt more aggressive treatment with tPA in the future.

For the second study, Ivan Matoz Diaz, MD, Mount Sinai Beth Israel Hospital, New York, reported a retrospective chart review of stroke patients presenting to an academic stroke center within 4.5 hours of onset who had an NIHSS score of 5 or less or rapidly improving deficit and who received tPA (n = 22) or conservative treatment (n = 68).

Results showed that patients who received tPA had a greater chance of NIHSS score improvement at discharge.

Specifically, 20 of the 22 patients (90.9%) given tPA had a decrease in NIHSS score of 2 points or more at time of discharge compared with 25 of 68 patients (36.7%) treated conservatively.

24th European Stroke Conference (ESC). Presented May 14, 2015.


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