Mechanical thrombectomy (Mt) in patients with a disabling low NIHSS, Southampton experience and outcomes

Cerejo, E., Weir, N., Crawford, P., Evans, S., Battersby Wood, E., Mavrokordatos, C., Siddegowda, S. and Marigold, R. (2024) Mechanical thrombectomy (Mt) in patients with a disabling low NIHSS, Southampton experience and outcomes. International Journal of Stroke, 19 (3 Suppl.). (doi:10.1177/17474930241300284).

Abstract

Introduction: current international guidelines recommend treatment MT for an LVO in the anterior circulation for an NIHSS >6. 20% of patients with a low NIHSS (<6) are likely to deteriorate without intervention and 1:4 patients with an LVO and low NIHSS fail to gain functional independence with best medical treatment.
Method: We present 2 cases of patients with low NIHSS and LVO using CT perfusion (CTP) to identify ischaemic core and at risk penumbra who had MT.

Results: a 79 year old man was transferred to UHS for MT with an NIHSS 2, (CT head ASPECTS 9) due to severe dysphasia. His symptoms persisted despite intravenous thrombolysis. CTA|CTP left M2 branch occlusion, CTP Tmax >6s: 85mls, CBF <30%: 0ml. MT was performed with TICI 3 recanalisation, NIHSS 1 at 24hrs due to a superior quadrantanopia. A 31 year old man with a previous history of ablations for SVT and smoking presented to Bournemouth with a wake up stroke mild word finding difficulty and right sided weakness. NIHSS 4. CT|CTA|CTP showed ASPECTS 9, left M1 MCA occlusion, T-max >6.0 sec of 131 mL and CBF<30ml of 0ml. MT 21hrs after last seen well, TICI 3 recanalisaion, NIHSS 1 at 24hrs.

Conclusions: despite concerns about lack of symptomatic benefit and increased risk of intracranial bleeding, we have shown a clear clinical benefit treating patients with MT using CTP in 2 patients with a low NIHSS score. The current ENDOLOW and MOSTE studies will provide RCT data in this challenging area.

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