Would you give TNK or IVT to a patient with proximal occlusion and an NIHSS of 0-3 (non-disabling)?

For non-disabling stroke symptoms with an NIHSS 0-5, current AHA Guidelines recommend against IV thrombolysis. (Technically, TNK has not yet made it into the AHA Guidelines, but that's not the topic here). Of course, what is considered disabling is always a debate, but the PRISMS trial defined it as being unable to return to work or perform ADLs.

The benefit of thrombectomy for minor symptoms with LVO is an ongoing open question and the subject of ongoing RCTs (i.e., MOSTE, ENDOLOW). Although an LVO is more likely to produce severe symptoms, some patients have only minor symptoms due to good collateral flow. However, a significant portion, probably 20% or more (Mazya et al., PMID 31008335, others) of these patients will have collateral failu...

Yes, for sure. Disabling is relative and if there is occlusion, it will get worse later on if we don’t open it now with either TPA or TNK when we can’t give them.

It is always good to do CT perfusion in these cases, likely, the occlusion is chronic and there are good collaterals that had developed indicated by a low hypoperfusion index.

Thank you.

Yes, if the stroke is disabling at all, I would give TNK. Whether or not TNK is given, the patient should be monitored very closely and mechanical thrombectomy should be offered if the deficit worsens.

Indeed. I would start the meds. We always look for a reason "to give" and not withhold clot "busters".

I would give TNK if the patient has NIHSS 1-2 with sxs of Broca’s aphasia, mild rt. NLFD, left ICA occlusion, and CT perfusion scan is not available if the patient is still within the therapeutic window and meets all-inclusive criteria.