Mechanical Thrombectomy in Patients with Minor Strokes and Large Vessel Occlusion: The “Too Good to Intervene” Dilemma
Victor J. Del Brutto, MD
Nagel S, Bouslama M, Krause LU, Küpper C, Messer M, Petersen M, et al. Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions: A Multicenter Matched Analysis. Stroke. 2018
Over half of acute ischemic strokes in the U.S. present with mild deficits as defined by an initial NIHSS score of 5 or less. Despite having deficits perceived as “minor”, around 30% of these patients will not achieve a good functional outcome at follow-up. Large vessel occlusion (LVO) is found in 10 to 20% of patients with minor strokes. Presence of LVO has been associated with early neurological deterioration, as well as decreased likelihood of good recovery. Minor symptoms in the setting of a major occluded vessel pictures good collateral flow maintaining tissue perfusion. On the other hand, frequent early clinical deterioration and worse functional outcomes expose the potential failure of aforementioned collaterals and infarct expansion.
Mechanical thrombectomy (MT) is the current standard of care for selected patients with LVO and initial NIHSS score ≥6; however, the benefit of MT in patients with milder symptoms remains uncertain. Recanalization is an appealing solution to prevent clinical deterioration and improve long-term functional outcome in these patients. Nonetheless, the treatment effect might not provide a significant benefit and could add potential risk for complications related to the procedure, such as hemorrhagic conversion, emboli to new vascular territories, failure of collaterals due to transient hypotension related to anesthesia, etc.