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Clinical Pearl: No thrombolytics for non-disabling strokes : Emergency Medicine News


Emergency physicians know only too well the pressure of administering thrombolysis as quickly as possible to a patient with a recent acute ischemic stroke. What about a patient with a non-disabling AIS? Expert opinion now recommends not treating these patients with thrombolysis.

The 2021 European Stroke Organization guidelines stated that no intravenous thrombolysis should be given to patients who have had an acute non-disabling minor ischemic stroke lasting less than 4.5 hours. (Eur Stroke J. 2021;6[1]:I; The recommendation is based on PRISMS, a relatively small randomized controlled trial that was terminated early, and the NIHSS 0-5 cohort in the IST-3 trial. (JAMA. 2018;320[2]:156;; Lancet. 2012;379[9834]:2352; The quality of the evidence is therefore rated as moderate.

The PRISMS trial defined a disabling deficit as one that “if unchanged, would prevent the patient from performing the basic activities of daily living (i.e. bathing/dressing, moving around, going toilet, wash and eat) or return to work. Examples of non-disabling symptoms were isolated mild aphasia (patient still able to communicate meaningfully), isolated facial droop, mild cortical hand (mostly non-dominant), mild hemisensory loss, hemisensory loss, mild hemisensory motor loss and mild hemitaxy (patient still able to move).

Patients with large vessel occlusion have a higher risk of stroke progression and poor prognosis than other patients. (Eur Stroke J. 2021;6[1]:I; The guidelines found insufficient evidence to make a recommendation for patients with non-disabling acute minor ischemic stroke of less than 4.5 hours and with proven great vessel occlusion, but six of eight members of the group d consensus experts suggest intravenous thrombolysis.

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