“Minor” stroke: not a minor, still open question

Minor stroke treatment remains a challenge for neurologists. Indeed, clear evidence as to the best treatment is still weak, mainly when the stroke symptoms are not disabling. More than 50% of ischemic stroke patients have a mild neurological deficit, with an NIHSS score of < 5 at onset. Unfortunately, about 30% of them worsen in the following few hours, with an unfavourable 3-month outcome [1]. Minor strokes have been poorly represented in most major alteplase trials and only a few series have reported outcomes after treatment with intravenous (i.v.) recombinant tissue plasminogen activator (r-tPA). A meta-analysis [2] of individual patient data from nine randomized trials assessed the role of stroke severity, along with treatment delay and age, on the effects of intravenous thrombolysis with alteplase for acute ischemic stroke. It was observed that the overall odds of a good stroke outcome improved significantly when r-tPA was administered within 4.5 h of stroke onset, whatever the stroke severity score and despite an increased risk of fatal intracranial haemorrhage [2]. A Cochrane review [3] on 27 randomized trials, involving 10,187 participants with mild stroke, testing r-tPA (70% of the cases), urokinase, streptokinase, recombinant pro-urokinase or desmoteplase, reported that thrombolytic therapy significantly reduced the proportion of participants who were dead or dependent at 3–6 months after stroke [odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78–0.93], but increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11–4.51), early death (OR 1.69, 95% CI 1.44–1.98) and death at three to six post-stroke months (OR 1.18, 95% CI 1.06–1.30) [3]. Although these data seem to be in favour of thrombolytic treatment, compared to the risk, few randomized studies have addressed the question of the benefit and safety of intravenous thrombolysis in minor stroke.