Thrombolysis was associated with higher rates of brain haemorrhage and deterioration in patients with mild strokes.

The potential role of intravenous thrombolysis for patients with acute, mild ischaemic strokes is controversial. With recent positive trials of dual antiplatelet therapy for mild stroke, comparative data are welcome.

However, recent studies have excluded patients with mild but potentially disabling symptoms, such as aphasia or hemianopia (NEJM JW Neurol Jul 13 2023 and JAMA 2023; 329: 2135-2144).

These authors reviewed data from a prospective, nationwide registry in Austria to identify patients with mild stroke, defined as a NIH Stroke Scale (NIHSS) score of three or less. Patients with cardioembolic strokes or atrial fibrillation, those treated with antiplatelet monotherapy, and those missing three-month outcome data were excluded. The authors compared intravenous thrombolysis and dual antiplatelet therapy for a variety of endpoints, including symptomatic intracerebral haemorrhage (sICH), early neurological deterioration, increase in NIHSS score of four or more points, and functional outcome (modified Rankin Scale [mRS] score) at three months.

During the years 2018 through 2021, 1616 patients were identified (mean age, 69 years; 38% women). Patients who received intravenous thrombolysis were younger (mean, 68 vs 71 years), were significantly less likely to have hypertension (73% vs 84%) or diabetes (19% vs 29%), and had a higher NIHSS score (median, two vs one) than those given dual antiplatelet therapy. After propensity score adjustment, the rate of sICH was higher in the intravenous thrombolysis group (1.4% vs 0.1%). Early neurological deterioration was also higher in the intravenous thrombolysis group (3.9% vs 1.2%). The rate of mRS zero to one outcome at three months was similar in the two groups (74.2% vs 80.4%).

Comment: These data are mostly consistent with recent trials that have evaluated intravenous thrombolysis for patients with mild, nondisabling strokes. For patients with very low NIHSS scores, as in this study, dual antiplatelet therapy is preferred in most cases. For those with disabling deficits such as isolated hemianopia, intravenous thrombolysis could be offered with shared decision-making.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Seemant Chaturvedi, MD, Stewart J. Greenebaum Endowed Professor of Stroke Neurology and Stroke Program Director, University of Maryland Medical System, Baltimore; Vice-Chair for Strategic Operations, Department of Neurology, University of Maryland, Baltimore, USA.

Sykora M, et al. IV thrombolysis vs early dual antiplatelet therapy in patients with mild noncardioembolic ischemic stroke. Neurology 2023 Jul 5; e-pub (https://doi.org/10.1212/WNL.0000000000207538).

This summary is taken from the following Journal Watch title: Neurology.