Decision-Making for Endovascular Thrombectomy in Patients With Large Vessel Occlusions and Mild Neurological Deficit: A Consensus Statement

Abstract

Acute ischemic stroke patients with mild deficits (National Institutes of Health Stroke Scale [NIHSS] of 0–5) but confirmed large vessel occlusions (LVO) present a clinical challenge for endovascular thrombectomy (EVT) decisions due to limited evidence and the absence of clear guidelines. A Delphi consensus was conducted at the 2024 5T (Teamwork, Training, Technology, Technique, Transport) Think Tank conference with 40 international stroke experts. Following a systematic literature review, three iterative Delphi rounds were employed to explore EVT decisionmaking in strokes due to LVO with low NIHSS. Data were collected through surveys and in-person discussions, focusing on disability evaluation, imaging markers, procedural risk, and outcome scales. Consensus was achieved on key factors influencing EVT decisions. Experts emphasized the importance of symptom-specific disability (e.g., aphasia, vision loss) over NIHSS scores alone. Early neurological deterioration (END) was perceived as main concern in this patient population. Imaging markers such as proximal occlusion, poor collaterals, and large penumbra were expected to be predictors of END. The anticipated technical difficulty and patient-specific factors, such as independence and quality of life, also guided decisions. The Potential of rtPA for Ischemic Strokes With Mild Symptoms (PRISMS) trial definition of disabling deficits and the 9-level modified Rankin Scale were favored as outcome measures for future studies. EVT decisions for acute ischemic strokes with mild deficit but proven LVO require nuanced, individualized approaches beyond NIHSS thresholds. Disability assessment, imaging-based risk evaluation, and patient-centered discussions are critical for optimizing outcomes, emphasizing the need for further research and standardized guidelines.