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Outcome of patients with large vessel occlusion in the anterior circulation and low NIHSS score



Optimal management of patients with large vessel occlusion (LVO) and low NIHSS score is unknown, which was the aim to investigate in this study.


This is a retrospective analysis of a prospective single tertiary care centre 14-year cohort of patients with LVO in the anterior circulation and NIHSS score ≤ 5 on admission. Outcome was analysed according to primary intended therapy.


Among 185 patients (median age 67.4 years), 52.4% received primary conservative therapy (including 26.8% secondary reperfusion in case of secondary neurological deterioration), 12.4% IV thrombolysis (IVT) only and 35.1% primary endovascular therapy (EVT). 95 (51.4%) patients experienced neurological deterioration until 3 months. Primary-IVT-only and primary-EVT compared to conservative-therapy patients had better 3 months’ outcome (54.5% vs. 30.8%: adjustedOR 6.02; adjustedp = 0.004 for mRS 0–1 and 54.7% vs. 30.8%: adjustedOR 5.09; adjustedp = 0.002, respectively). Also mRS shift analysis favored primary-IVT-only and primary-EVT patients (adjustedOR 6.25; adjustedp = 0.001 and adjustedOR 3.14; adjustedp = 0.003). Outcome in primary-IVT-only vs. primary-EVT patients did not differ significantly. Patients who received secondary EVT because of neurological deterioration after primary-conservative-therapy had worse 3 months’ outcome than primary-EVT patients (20.8% vs. 30.8%: adjustedOR 0.24; adjustedp = 0.047 for mRS 0–1 and adjustedOR 0.31; adjustedp = 0.019 in mRS shift analysis). Survival and symptomatic intracranial haemorrhage did not differ amongst groups.


Our data indicate that primary IVT and/or EVT may be better than primary conservative therapy in patients with LVO in the anterior circulation and low NIHSS score. Furthermore, primary EVT was better than secondary EVT in case of neurological deterioration. There is an unmet need for RCTs to find the optimal therapy for this patient group.

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We thank the Bernese Stroke team for data acquisition.


Bangerter Foundation.

Author information

Study concept, design and supervision: MRH and SJ. Acquisition of data: Bernese Stroke Team, all co-authors. Extraction of data and statistical analysis: MRH. Analysis and interpretation: MRH and SJ. Drafting of the manuscript: MRH and SJ. Critical revision of the manuscript for important intellectual content and final approval of the version to be published: All co-authors.

Correspondence to Mirjam R. Heldner.

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Conflicts of interest

The authors declare that they have conflicts of interest all outside the submitted work: MRH: Personal fees from Bayer. Scientific advisory board honoraria from Amgen. Grant from Bangerter Foundation. BV: Personal fees from Pfizer Bristol-Myers Squibb SA/Bayer. Institutional (Inselspital) grant. JK: Grants by Swiss Medical Academy of Medical Sciences/Bangerter Foundation/Swiss Stroke Society. JG: Global PI of STAR/SWIFT DIRECT (Medtronic). CEC-member of the Promise Study (Penumbra). Swiss National Foundation grant (MRI in stroke). MA: Personal fees from Bayer/Medtronic/Covidien. Scientific advisory board honoraria from Amgen/Bayer/Boehringer Ingelheim/BMS/Pfizer/Covidien/Daiichi Sankyo and Nestlé Health Science. UF: Consultant for Medtronic/Stryker/CSL Behring, Co-PI of SWIFT DIRECT (Medtronic). PI of SWITCH/ELAN. Research support of the Swiss National Foundation/Swiss Heart Foundation and Medtronic. SJ: Scientific advisory board honoraria from Bayer/Boehringer Ingelheim/Pfizer. The other authors declare that they have no conflict of interest.

Ethical standard

Patients or their relatives have signed written informed consent for treatment and study participation. The study was approved by the local ethics committee of the canton of Bern (231/14) and has, therefore, been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Data analyses followed EQUATOR reporting guidelines.

Data sharing statement

Raw data of all patients included in this study can be made available upon request to the corresponding author and after clearance by the local ethics committee.

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Heldner, M.R., Chaloulos-Iakovidis, P., Panos, L. et al. Outcome of patients with large vessel occlusion in the anterior circulation and low NIHSS score. J Neurol (2020).

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  • Low NIHSS score
  • Large vessel occlusion
  • Different therapy modalities
  • NIHSS score subitems
  • Outcome