Stroke is the second highest cause of death globally and a leading cause of not only physical disability but also cognitive. Approximately two-thirds of Ischemic Stroke patients, who represent the most common type of stroke are found to have mild deficits. Minor stroke, sometimes also referred to as “mild stroke”, is often defined in research studies as a National Institute of Health Stroke Scale (NIHSS) score of 5 or less, although, the cut point for NIHSS score or standardized criterion to define minor stroke has not been established. In the past, many studies have been focusing on the definition of the minor stroke to better stabilize the acute treatment guidelines, to predict the functional outcome, and also for early risk factors stratification. Different studies use different criteria or different cut-points of NIHSS scores to define minor stroke. Aside from indecision of acute management of minor stroke, many other questions have been raised regarding minor strokes, for example, the interaction of large vessel occlusion with minor stroke, the prevalence rate of depression, anxiety, cognitive dysfunction, chronic head after minor stroke, and so on. Finding a universal definition for minor stroke is the key to establish the guideline for management for this group of patients. However, the guidance of treatment of minor stroke is not the focus of this review. The review will focus on the deep comprehension of minor stroke characteristics, summarizing the new findings related to minor stroke, and highlight the essential points to consider for characterizing mild stroke symptoms for a new direction guide for future studies.
Crespi, V., Braga, M., Beretta, S., Carolei, A., Bignamini, A. and Sacco, S. (2013) A Practical Definition of Minor Stroke. Neurological Sciences, 34, 1083-1086. https://doi.org/10.1007/s10072-012-1205-8
Barber, P.A., Zhang, J., Demchuk, A.M., Hill, M.D. and Buchan, A.M. (2001) Why Are Stroke Patients Excluded from TPA Therapy?: An Analysis of Patient Eligibility. Neurology, 56, 1015-1020. https://doi.org/10.1212/WNL.56.8.1015
Fischer, U., Baumgartner, A., Arnold, M., Nedeltchev, K., Gralla, J., et al. (2010) What Is a Minor Stroke? Stroke, 41, 661-666. https://doi.org/10.1161/STROKEAHA.109.572883
The National Institute of Neurological Disorders Stroke rt-PA Stroke Study Group (2005) Recombinant Tissue Plasminogen Activator for Minor Strokes: The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Experience. Annals of Emergency Medicine, 46, 243-252. https://doi.org/10.1016/j.annemergmed.2005.02.013
Kleindorfer, D., Kissela, B., Schneider, A., Woo, D., Khoury, J., Miller, R., Alwell, K., et al. (2004) Eligibility for Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke: A Population-Based Study. Stroke, 35, e27-e29. https://doi.org/10.1161/01.STR.0000109767.11426.17
Smith, E.E., Fonarow, G.C., Reeves, M.J., Cox, M., et al. (2011) Outcomes in Mild or Rapidly Improving Stroke Not Treated with Intravenous Recombinant Tissue-Type Plasminogen Activator. Stroke, 42, 3110-3115. https://doi.org/10.1161/STROKEAHA.111.613208
Strambo, D., Zambon, A.A., Roveri, L., Giacalone, G., Di Maggio, G., et al. (2015) Defining Minor Symptoms in Acute Ischemic Stroke. Cerebrovascular Diseases, 39, 209-215. https://doi.org/10.1159/000375151
Kernan, W.N., Horwitz, R.I., Brass, L.M., Viscoli, C.M. and Taylor, K.J.W. (1991) A Prognostic System for Transient Ischemia or Minor Stroke. Annals of Internal Medicine, 114, 552-557. https://doi.org/10.7326/0003-4819-114-7-552
Carlsson, G., Möller, A. and Blomstrand, C. (2004) A Qualitative Study of the Consequences of ‘Hidden Dysfunctions’ One Year after a Mild Stroke in Persons 75 Years. Disability and Rehabilitation, 26, 1373-1380. https://doi.org/10.1080/09638280400000211
Johansson, A., Mishina, E., Ivanov, A. and Björklund, A. (2007) Activities of Daily Living among St Petersburg Women after Mild Stroke. Occupational Therapy International, 14, 170-182. https://doi.org/10.1002/oti.232
Muren, M.A., Hütler, M. and Hooper, J. (2008) Functional Capacity and Health-Related Quality of Life in Individuals Post Stroke. Topics in Stroke Rehabilitation, 15, 51-58. https://doi.org/10.1310/tsr1501-51
Jones, M.R., Horner, R.D., Edwards, L.J., et al. (2000) Racial Variation in Initial Stroke Severity. Stroke, 31, 563-567. https://doi.org/10.1161/01.STR.31.3.563
Liu-Ambrose, T., Pang, M. Y. C. and Eng, J. J. (2007) Executive Function Is Independently Associated with Performances of Balance and Mobility in Community-Dwelling Older Adults after Mild Stroke: Implications for Falls Prevention. Cerebrovascular Diseases, 23, 203-210. https://doi.org/10.1159/000097642
Dubuc, V., Choi, P., Hill, M.D. and Coutts, S.B. (2015) Can 90-Day NIHSS Be Used for Outcome Assessment in TIA and Minor Stroke Studies? Cerebrovascular Diseases, 40, 97-98. https://doi.org/10.1159/000431187
Yaghi, S., Willey, J.Z., Andrews, H., Boehme, A.K., Marshall, R.S. and Boden-Albala, B. (2016) The Itemized NIHSS Scores Are Associated with Discharge Disposition in Patients With Minor Stroke. The Neurohospitalist, 6, 102-106. https://doi.org/10.1177/1941874416641466
Park, T.H., Hong, K.S., Choi, J.C., et al. (2013) Validation of Minor Stroke Definitions for Thrombolysis Decision Making. Journal of Stroke and Cerebrovascular Diseases, 22, 482-490. https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.03.006
Yaghi, S., Herber, C., Boehme, A.K., Andrews, H., Willey, J.Z., et al. (2017) The Association between Diffusion MRI-Defined Infarct Volume and NIHSS Score in Patients with Minor Acute Stroke. Journal of Neuroimaging, 27, 388-391. https://doi.org/10.1111/jon.12423
Woo, D., Broderick, J.P., Kothari, R.U., et al. (1999) Does the National Institutes of Health Stroke Scale Favor Left Hemisphere Strokes? Stroke, 30, 2355-2359. https://doi.org/10.1161/01.STR.30.11.2355
Leira, E.C., Adams, H.P., Rosenthal, G.E. and Torner, J.C. (2008) Baseline NIH Stroke Scale Responses Estimate the Probability of Each Particular Stroke Subtype. Cerebrovascular Diseases, 26, 573-577. https://doi.org/10.1159/000165109
Martin-Schild, S., Albright, K.C., Tanksley, J., et al. (2011) Zero on the NIHSS Does Not Equal the Absence of Stroke. Annals of Emergency Medicine, 57, 42-45. https://doi.org/10.1016/j.annemergmed.2010.06.564
Adams, H.P., Davis, P.H., Leira, E.C., Bendixen, B.H., et al. (1999) Baseline NIH Stroke Scale Score Strongly Predicts Outcome after Stroke: A Report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology, 53, 126. https://doi.org/10.1212/WNL.53.1.126
Fink, J.N., Selim, M.H., Kumar, S., Silver, B., Linfante, I., Caplan, L.R., and Schlaug, G. (2002) Is the Association of National Institutes of Health Stroke Scale Scores and Acute Magnetic Resonance Imaging Stroke Volume Equal for Patients with Right- and Left-Hemisphere Ischemic Stroke? Stroke, 33, 954-958. https://doi.org/10.1161/01.STR.0000013069.24300.1D
Wendt, M., Tütüncü, S., Fiebach, J.B., Scheitz, J.F., Audebert, H.J. and Nolte, C.H. (2013) Preclusion of Ischemic Stroke Patients from Intravenous Tissue Plasminogen Activator Treatment for Mild Symptoms Should Not Be Based on Low National Institutes of Health Stroke Scale Scores. Journal of Stroke and Cerebrovascular Diseases, 22, 550-553. https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.01.021
Sato, S., Uehara, T., Ohara, T., Suzuki, R., Toyoda, K. and Minematsu, K. (2014) Factors Associated with Unfavorable Outcome in Minor Ischemic Stroke. Neurology, 83, 174-181. https://doi.org/10.1212/WNL.0000000000000572
Coutts, S.B., O'Reilly, C., Hill, M.D., Steffenhagen, N., Poppe, A.Y., Boyko, M.J., et al. (2009) Computed Tomography and Computed Tomography Angiography Findings Predict Functional Impairment in Patients with Minor Stroke and Transient Ischaemic Attack. International Journal of Stroke, 4, 448-453. https://doi.org/10.1111/j.1747-4949.2009.00346.x
Rajajee, V., Kidwell, C., Starkman, S., Ovbiagele, B., Alger, J.R., Villablanca, P., Vinuela, F., et al. (2006) Early MRI and Outcomes of Untreated Patients with Mild or Improving Ischemic Stroke. Neurology, 67, 980-984. https://doi.org/10.1212/01.wnl.0000237520.88777.71
Nedeltchev K., Schwegler, B., Haefeli, T., Brekenfeld, C., Gralla, J., Fischer, U., et al. (2007) Outcome of Stroke with Mild or Rapidly Improving Symptoms. Stroke, 38, 2531-2535. https://doi.org/10.1161/STROKEAHA.107.482554
Nagel S., Bouslama, M., Krause, L.U., Küpper, C., Messer, M., Petersen, M., Lowens, S., Herzberg, M., et al. (2018) Mechanical Thrombectomy in Patients with Milder Strokes and Large Vessel Occlusions. Stroke, 49, 2391-2397. https://doi.org/10.1161/STROKEAHA.118.021106
Powers, W.J., Rabinstein, A.A., Ackerson, T., et al. (2018) 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke, 49, e46-e99. https://doi.org/10.1161/STR.0000000000000158
Griessenauer, C.J., Medin, C., Maingard, J., et al. (2018) Endovascular Mechanical Thrombectomy in Large-Vessel Occlusion Ischemic Stroke Presenting with Low National Institutes of Health Stroke Scale: Systematic Review and Meta-Analysis. World Neurosurgery, 110, 263-269. https://doi.org/10.1016/j.wneu.2017.11.076
Rocha, M. and Jovin, T.G. (2017) Fast versus Slow Progressors of Infarct Growth in Large Vessel Occlusion Stroke. Stroke, 48, 2621-2627. https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.117.017673
Manno, C., Disanto, G., Bianco, G., et al. (2019) Outcome of Endovascular Therapy in Stroke with Large Vessel Occlusion and Mild Symptoms. Neurology, 93, e1618-e1626. https://doi.org/10.1212/WNL.0000000000008362
Urra, X., San Román, L., Gil, F., et al. (2014) Medical and Endovascular Treatment of Patients with Large Vessel Occlusion Presenting with Mild Symptoms: An Observational Multicenter Study. Cerebrovascular Diseases, 38, 418-424. https://doi.org/10.1159/000369121
Sarraj, A., Hassan, A., Savitz, S.I., Grotta, J.C., et al. (2018) Endovascular Thrombectomy for Mild Strokes: How Low Should We Go? Stroke, 49, 2398-2405. https://doi.org/10.1161/STROKEAHA.118.022114
Towfighi, A., Ovbiagele, B., Husseini, N.E., et al. (2017) Poststroke Depression: A Scientific Statement for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke, 48, e30-e43. https://doi.org/10.1161/STR.0000000000000113
Hackett, M.L. and Anderson, C.S. (2005) Predictors of Depression after Stroke: A Systematic Review of Observational Studies. Stroke, 36, 2296-2301. https://doi.org/10.1161/01.STR.0000183622.75135.a4
Ayerbe, L., Ayis, S., Wolfe, C.D.A. and Rudd, A.G. (2013) Natural History, Predictors and Outcomes of Depression after Stroke: Systematic Review and Meta-Analysis. The British Journal of Psychiatry: The British Journal of Psychiatry, 202, 14-21. https://doi.org/10.1192/bjp.bp.111.107664
Altieri, M., Maestrini, I., Mercurio, A., Troisi, P., Sgarlata, E., Rea, V., Di Piero, V. and Lenzi, G.L. (2012) Depression after Minor Stroke: Prevalence and Predictors. European Journal of Neurology, 19, 517-521. https://doi.org/10.1111/j.1468-1331.2011.03583.x
Shi, Y.Z., Xiang, Y.T., Yang, Y., Zhang, N., et al. (2015) Depression after Minor Stroke: Prevalence and predictors. Journal of Psychosomatic Research, 79, 143-147. https://doi.org/10.1016/j.jpsychores.2015.03.012
Carnes-Vendrell, A., Deus, J., Molina-Seguin, J., Pifarré, J. and Purroy, F. (2019) Depression and Apathy after Transient Ischemic Attack or Minor Stroke: Prevalence, Evolution and Predictors. Scientific Reports, 9, Article No. 16248. https://doi.org/10.1038/s41598-019-52721-5
Morsund, Å.H., Ellekjær, H., Gramstad, A., et al. (2019) The Development of Cognitive and Emotional Impairment after a Minor Stroke: A Longitudinal Study. Acta Neurologica Scandinavica, 140, 281-289. https://doi.org/10.1111/ane.13143
Radman, N., Staub, F., Aboulafia-Brakha, T., Berney, A., Bogousslavsky, J. and Annoni, J.-M. (2012) Poststroke Fatigue Following Minor Infarcts: A Prospective Study. Neurology, 79, 1422-1427. https://doi.org/10.1212/WNL.0b013e31826d5f3a
Charlotte, W., Catherine, S., Ziyah, M. and Rothwell, P.M. (2009) A Population-Based Study of the Prevalence of Fatigue after Transient Ischemic Attack and Minor Stroke. Stroke, 40, 757-761. https://doi.org/10.1161/STROKEAHA.108.527101
Harriott, A.M., Karakaya, F. and Ayata, C. (2020) Headache after Ischemic Stroke: A Systematic Review and Meta-Analysis. Neurology, 94, e75-e86. https://doi.org/10.1212/WNL.0000000000008591
Rothwell, P.M., et al. (2007) Effect of Urgent Treatment of Transient Ischaemic Attack and Minor Stroke on Early Recurrent Stroke (EXPRESS Study): A Prospective Population-Based Sequential Comparison. The Lancet, 370, 1432-1442. https://doi.org/10.1016/S0140-6736(07)61448-2
Wang, Y.L., Pan, Y.S., Zhao, X.Q., et al. (2015) Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) Trial. Circulation, 132, 40-46. https://doi.org/10.1161/CIRCULATIONAHA.114.014791
Finch, E., Foster, M., Fleming, J., et al. (2020) Exploring Changing Needs Following Minor Stroke. Health & Social Care in the Community, 28, 347-356. https://doi.org/10.1111/hsc.12866