Minor Stroke, Major Uncertainty

Four randomized trials found no benefit to intravenous thrombolytics (IVT) in minor stroke patients. However, most patients considered to have disabling deficits were excluded from these trials. Some argue that this means minor strokes should still be considered for IVT if the provider considers the deficit disabling.

To conduct a structured narrative review of the IVT literature and argue that, if subgroups of patients with minor stroke benefit from IVT, they must first be identified in randomized trials.

Compared to other analogous therapies like IVT for acute coronary syndrome, or mechanical thrombectomy for stroke, the literature for IVT in ischemic stroke patients is inconsistent-there are beneficial, negative, and harmful results. In the positive trials, there is movement in the modified Rankin Scale; in minor stroke trials, it is not clear there will be movement in this outcome as we suspect most minor stroke patients will have low scores. Considering the inconsistent results of IVT for stroke in all patients, the theoretical difficulty in showing a benefit in minor stroke patients, and the negative trials-broadly accepting that IVT benefits certain minor stroke patients risks exposing patients to a potentially harmful treatment while consuming resources for an uncertain benefit.

Randomized trials for IVT in minor stroke patients should explore which deficits experience benefit. Intravenous thrombolytics should not be routinely offered to patients with minor stroke in the absence of clearly demonstrable, measurable disability.