The edition · Neurology
Thrombectomy for mild large-vessel stroke with salvageable tissue
A Chinese trial found more excellent outcomes with endovascular therapy when NIHSS was under 6 but perfusion imaging showed tissue at risk. Also today: late-onset epilepsy as a vascular disease, minocycline in stroke, and the shift of TIA work-up into the emergency department.
The edition in brief
In MILD-MT, 300 Chinese patients with anterior-circulation large-vessel occlusion, NIHSS under 6 and a small core with large perfusion mismatch within 24 hours were randomised to endovascular therapy plus medical care or medical care alone; excellent 90-day outcome (mRS 0–1) was 69.4% versus 50.0% (OR 2.32), with equal symptomatic haemorrhage but serious procedural complications in 13.2%. A pooled analysis of six US cohorts (42,257 older adults) linked late-onset epilepsy to smoking, hypertension, diabetes, chronic kidney disease, prior stroke (HR 1.99) and APOE ε4. A meta-analysis of nine trials (2,186 patients) found minocycline associated with lower NIHSS (−2.43) and more functional independence after ischaemic stroke (RR 1.40), but at low certainty with inconclusive trial sequential analysis. US emergency departments discharged 66% of TIA patients in 2021 versus 45% in 2013, with CT angiography in discharged patients rising from 4% to 45%.
Late-onset epilepsy tracked vascular risk factors and prior stroke across six cohorts
Treat new epilepsy after 65 as a possible marker of cerebrovascular disease, and work up and manage vascular risk accordingly.
Minocycline after ischaemic stroke: a possible signal, not yet evidence
Do not use minocycline for acute stroke outside a trial; the signal is promising but low certainty.
TIA work-up has moved into the emergency department, with far more vessel imaging
Discharge after TIA is safe only if vessel imaging, rhythm assessment and early specialist follow-up are arranged.
The 'mild' stroke with a large-vessel occlusion is not mild
Image the vessels in every potential reperfusion candidate; a low NIHSS does not rule out a large-vessel occlusion.
Endovascular therapy improved outcomes in mild large-vessel stroke with perfusion mismatch
In mild anterior-circulation large-vessel stroke with a small core and large perfusion mismatch, consider endovascular therapy after discussing procedural risk.
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