Effectiveness and Safety of Endovascular Treatment in Large Vessel Occlusion Stroke with an NIHSS Score of ≤5 Exhibiting Predominant Cortical Signs

TL;DR

Endovascular treatment improves recovery and reduces bleeding risk in mild stroke patients with cortical signs, even with low NIHSS scores.

Contribution

Demonstrates that EVT benefits mild stroke patients with cortical signs, suggesting a need for individualized treatment decisions.

Findings

EVT group had a 65.3% rate of good functional recovery (mRS 0–1) compared to 39.3% in BMT group.

EVT reduced symptomatic hemorrhagic transformation risk (3.2% vs. 12.8%).

Patients with aphasia and spatial neglect had better outcomes with EVT.

Abstract

Background: Our study aimed to evaluate the impact of EVT on stroke outcomes in patients with LVO with a National Institute of Health Stroke Scale (NIHSS) score of ≤5, exhibiting primarily cortical signs. Methods: We conducted a multicenter registry-based analysis of patients with acute ischemic stroke with LVO who arrived within 12 h of onset. Among these, patients with low NIHSS scores and prominent cortical signs (Items 2, 3, 9, or 11) were included. Patients were divided into two groups: those who underwent EVT and those treated with the best medical therapy (BMT), which included intravenous thrombolysis where appropriate. The primary outcome measure was a modified Rankin scale (mRS) score of 0–1 at 3 months and symptomatic hemorrhagic transformation (SHT). We performed logistic regression analysis to evaluate the impact of EVT on the outcomes. Results: Of the 970 patients with LVO, 291 met the inclusion criteria, with 95 and 196 undergoing EVT and BMT, respectively. The EVT group demonstrated a significantly higher rate of 3-month mRS score of 0–1 (65.3% vs. 39.3%, p < 0.001) and a lower incidence of SHT than the BMT group (3.2% vs. 12.8%, p = 0.01). Multivariate analysis confirmed that EVT was associated with improved functional recovery (mRS score, 0–1; odds ratio [OR], 3.61; 95% confidence interval [CI], 1.82–7.06; p < 0.001) and reduced risk of SHT (OR, 0.19; 95% CI, 0.05–0.74; p = 0.02). Notably, patients with specific cortical signs, such as aphasia and spatial neglect, exhibited better outcomes with EVT. Conclusions: EVT may significantly improve the functional outcomes in patients with mild LVO stroke who present with cortical signs, despite low NIHSS scores. These findings suggest that cortical signs should be a key factor in EVT decision-making for mild stroke cases, thereby advocating for a more individualized approach in acute stroke management.

Figures