{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T18:16:48Z","timestamp":1791915408638,"version":"4.3.4"},"reference-count":65,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,11,10]],"date-time":"2025-11-10T00:00:00Z","timestamp":1762732800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:p>Acute ischemic stroke caused by large vessel occlusion (LVO) with low National Institutes of Health Stroke Scale (NIHSS) scores (\u22645) presents a critical clinical dilemma regarding optimal management. While endovascular thrombectomy (EVT) is established for moderate-to-severe strokes, its role in milder cases remains controversial, balancing potential benefits against risks of intracranial hemorrhage and procedural complications. This review synthesizes evidence from observational studies, registry data, and meta-analyses comparing EVT with best medical therapy (including intravenous thrombolysis and antiplatelet treatment) in this population. Key findings indicate no significant difference in 90-day functional outcomes between EVT and medical management; across observational cohorts, EVT has been associated with higher symptomatic intracranial hemorrhage (sICH) and a possible increase in 90-day mortality, but these estimates derive from non-randomized data and may reflect selection bias and residual confounding. Subgroup analyses highlight the influence of occlusion location (proximal vs. distal), risk of early neurological deterioration (END), time window, and bridging therapy on treatment decisions: proximal occlusions (e.g., internal carotid artery, middle cerebral artery M1 segment) and high END risk may favor more aggressive intervention, while distal occlusions (e.g., M2 segment) often respond adequately to medical therapy with close monitoring. Clinical recommendations emphasize an individualized approach: prioritizing medical management for most patients, with EVT reserved for high-risk cases or those with neurological deterioration during observation. Future randomized controlled trials are needed to refine patient selection criteria and validate risk stratification tools for this challenging population.<\/jats:p>","DOI":"10.3389\/fneur.2025.1681311","type":"journal-article","created":{"date-parts":[[2025,11,10]],"date-time":"2025-11-10T13:31:46Z","timestamp":1762781506000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":4,"title":["Low NIHSS score in large vessel occlusion stroke: optimal treatment and clinical controversies"],"prefix":"10.3389","volume":"16","author":[{"given":"Tonghe","family":"Chen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wenhong","family":"Zhi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ning","family":"Hao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zaili","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xu","family":"Cao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qiuchi","family":"Chen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Li","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhiguang","family":"Liu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,11,10]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"1723","DOI":"10.1161\/STROKEAHA.123.043937","article-title":"Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials","volume":"387","author":"Goyal","year":"2016","journal-title":"Lancet"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"3211","DOI":"10.1161\/STROKEAHA.113.002881","article-title":"Distribution of National Institutes of Health stroke scale in the Cincinnati\/northern Kentucky stroke study","volume":"44","author":"Reeves","year":"2013","journal-title":"Stroke"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"796046","DOI":"10.3389\/fneur.2021.796046","article-title":"Large vessel occlusion in patients with minor ischemic stroke in a population-based study. The Dijon stroke registry","volume":"12","author":"Duloquin","year":"2021","journal-title":"Front Neurol"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1186\/s12883-022-03020-6","article-title":"What predicts large vessel occlusion in mild stroke patients?","volume":"23","author":"Lu","year":"2023","journal-title":"BMC Neurol"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"1428","DOI":"10.1161\/STROKEAHA.119.027011","article-title":"Acute neurological deterioration in large vessel occlusions and mild symptoms managed medically","volume":"51","author":"Saleem","year":"2020","journal-title":"Stroke"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"1619","DOI":"10.1111\/ene.15272","article-title":"Minor stroke in large vessel occlusion: a matched analysis of patients from the German stroke registry-endovascular treatment (GSR-ET) and patients from the safe implementation of treatments in stroke-international stroke thrombolysis register (SITS-ISTR)","volume":"29","author":"Feil","year":"2022","journal-title":"Eur J Neurol"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"107721","DOI":"10.1016\/j.jstrokecerebrovasdis.2024.107721","article-title":"A comparison of endovascular therapy and medical management in patients with large vessel occlusion mild stroke treated between 2015 and 2023: a systematic review and meta-analysis","volume":"33","author":"Xu","year":"2024","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"I","DOI":"10.1177\/2396987321989865","article-title":"European stroke organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke","volume":"6","author":"Berge","year":"2021","journal-title":"Eur Stroke J"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"905","DOI":"10.54029\/2024rkh","article-title":"Medical management versus intravenous thrombolysis for patients with minor non-disabling acute ischemic stroke: a systematic review and meta-analysis","volume":"29","author":"An","year":"2024","journal-title":"Neurol Asia"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"214","DOI":"10.3390\/brainsci13020214","article-title":"Assessing the efficacy of mechanical thrombectomy in patients with an NIHSS < 6 presenting with proximal middle cerebral artery vessel occlusion as compared to best medical management","volume":"13","author":"Yedavalli","year":"2023","journal-title":"Brain Sci"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"163","DOI":"10.1159\/000442303","article-title":"Thrombolysis in stroke patients with isolated aphasia","volume":"41","author":"Denier","year":"2016","journal-title":"Cerebrovasc Dis"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"321","DOI":"10.1001\/jamaneurol.2020.4557","article-title":"Prediction of early neurological deterioration in individuals with minor stroke and large vessel occlusion intended for intravenous thrombolysis alone","volume":"78","author":"Seners","year":"2021","journal-title":"JAMA Neurol"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"3331","DOI":"10.1161\/STROKEAHA.119.027708","article-title":"Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke","volume":"50","author":"Warner","year":"2019","journal-title":"Stroke"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"2500","DOI":"10.1161\/STROKEAHA.113.000878","article-title":"Review, historical context, and clarifications of the NINDS rt-PA stroke trials exclusion criteria: part 1: rapidly improving stroke symptoms","volume":"44","author":"Levine","year":"2013","journal-title":"Stroke"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"955725","DOI":"10.3389\/fneur.2022.955725","article-title":"Effectiveness and safety of EVT in patients with acute LVO and low NIHSS","volume":"13","author":"Kim","year":"2022","journal-title":"Front Neurol"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"123623","DOI":"10.1016\/j.wneu.2024.123623","article-title":"Early neurological deterioration in acute ischemic minor stroke patients with large vessel occlusion following intravenous thrombolysis","volume":"194","author":"Hu","year":"2025","journal-title":"World Neurosurg"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"1426084","DOI":"10.3389\/fstro.2024.1426084","article-title":"Outcome in acute ischemic stroke patients with large-vessel occlusion and initial mild deficits","volume":"3","author":"Kazmi","year":"2024","journal-title":"Front Stroke"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"682827","DOI":"10.3389\/fneur.2021.682827","article-title":"Pitfalls in the diagnosis of posterior circulation stroke in the emergency setting","volume":"12","author":"Hoyer","year":"2021","journal-title":"Front Neurol"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"1361","DOI":"10.1056\/NEJMoa2206317","article-title":"Trial of endovascular treatment of acute basilar-artery occlusion","volume":"387","author":"Tao","year":"2022","journal-title":"N Engl J Med"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"81","DOI":"10.5853\/jos.2022.03755","article-title":"Endovascular versus medical management of acute basilar artery occlusion: a systematic review and meta-analysis of the randomized controlled trials","volume":"25","author":"Abdalkader","year":"2023","journal-title":"J Stroke"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"290","DOI":"10.5853\/jos.2024.00458","article-title":"Endovascular thrombectomy versus intravenous thrombolysis of posterior cerebral artery occlusion stroke","volume":"26","author":"R\u00e4ty","year":"2024","journal-title":"J Stroke"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"434","DOI":"10.1001\/jamaneurol.2021.0001","article-title":"Thrombectomy for primary distal posterior cerebral artery occlusion stroke: the TOPMOST study","volume":"78","author":"Meyer","year":"2021","journal-title":"JAMA Neurol"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"591","DOI":"10.1161\/STROKEAHA.122.041254","article-title":"Acute and interventional treatments","volume":"54","author":"Campbell","year":"2023","journal-title":"Stroke"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"156","DOI":"10.1001\/jama.2018.8496","article-title":"Effect of alteplase vs aspirin on functional outcome for patients with acute ischemic stroke and minor nondisabling neurologic deficits: the PRISMS randomized clinical trial","volume":"320","author":"Khatri","year":"2018","journal-title":"JAMA"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"1615","DOI":"10.1111\/cns.14124","article-title":"Intravenous thrombolysis versus antiplatelet therapy in minor stroke patients with large vessel occlusion","volume":"29","author":"Duan","year":"2023","journal-title":"CNS Neurosci Ther"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"502","DOI":"10.3389\/fneur.2019.00502","article-title":"A simple imaging guide for endovascular thrombectomy in acute ischemic stroke: from time window to perfusion mismatch and beyond","volume":"10","author":"Yu","year":"2019","journal-title":"Front Neurol"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"2135","DOI":"10.1001\/jama.2023.7827","article-title":"Dual antiplatelet therapy vs alteplase for patients with minor nondisabling acute ischemic stroke: the ARAMIS randomized clinical trial","volume":"329","author":"Chen","year":"2023","journal-title":"JAMA"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"e213863","DOI":"10.1212\/WNL.0000000000213863","article-title":"Meta-analysis of randomized controlled trials on IV thrombolysis in patients with minor acute ischemic stroke","volume":"105","author":"Doheim","year":"2025","journal-title":"Neurology"},{"key":"ref29","author":"Diana","year":"2024"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"3442","DOI":"10.1038\/s41598-020-60399-3","article-title":"Subtypes of anterior circulation large artery occlusions with acute brain ischemic stroke","volume":"10","author":"Zhang","year":"2020","journal-title":"Sci Rep"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"802","DOI":"10.1161\/STROKEAHA.120.031672","article-title":"Treatment and outcome in stroke patients with acute M2 occlusion and minor neurological deficits","volume":"52","author":"Dobrocky","year":"2021","journal-title":"Stroke"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"160","DOI":"10.1002\/ana.25756","article-title":"Bridging therapy or IV thrombolysis in minor stroke with large vessel occlusion","volume":"88","author":"Seners","year":"2020","journal-title":"Ann Neurol"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"e198","DOI":"10.1136\/jnis-2022-019557","article-title":"Mechanical thrombectomy in minor stroke due to isolated M2 occlusion: a multicenter retrospective matched analysis","volume":"15","author":"Alexandre","year":"2023","journal-title":"J Neurointerv Surg"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"419","DOI":"10.1161\/STROKEAHA.118.023117","article-title":"Endovascular treatment: the role of dominant Caliber M2 segment occlusion in ischemic stroke","volume":"50","author":"Compagne","year":"2019","journal-title":"Stroke"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"350","DOI":"10.1136\/neurintsurg-2022-018662","article-title":"Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis","volume":"15","author":"Lin","year":"2023","journal-title":"J Neurointerv Surg"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"796","DOI":"10.1136\/jnis-2024-021930","article-title":"Thrombectomy patients with minor stroke: factors of early neurological deterioration","volume":"17","author":"Heitkamp","year":"2025","journal-title":"J Neurointerv Surg"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"421","DOI":"10.1186\/s12883-021-02455-7","article-title":"The length of susceptibility vessel sign predicts early neurological deterioration in minor acute ischemic stroke with large vessel occlusion","volume":"21","author":"He","year":"2021","journal-title":"BMC Neurol"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"1165484","DOI":"10.3389\/fneur.2023.1165484","article-title":"Case report: flow changes in routes of collateral circulation in patients with LVO and low NIHSS: a point favor to treat","volume":"14","author":"Dos Santos Neto","year":"2023","journal-title":"Front Neurol"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1002\/ana.26418","article-title":"Thrombectomy versus medical management in mild strokes due to large vessel occlusion: exploratory analysis from the EXTEND-IA trials and a pooled international cohort","volume":"92","author":"Sarraj","year":"2022","journal-title":"Ann Neurol"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"397","DOI":"10.3340\/jkns.2023.0181","article-title":"Endovascular thrombectomy for acute ischemic stroke: current concept in management","volume":"67","author":"Bae","year":"2024","journal-title":"J Korean Neurosurg Soc"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"2265","DOI":"10.1161\/STROKEAHA.123.043937","article-title":"Medical management versus endovascular treatment for large-vessel occlusion anterior circulation stroke with low NIHSS","volume":"54","author":"Safouris","year":"2023","journal-title":"Stroke"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"19","DOI":"10.33696\/Neurol.5.084","article-title":"Mechanical thrombectomy for all LVO \u2013 is it feasible? \u2013 recent evidence to expand the current stroke guidelines","volume":"5","author":"Xu","year":"2024","journal-title":"J Exp Neurol"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1056\/NEJMoa1706442","article-title":"Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct","volume":"378","author":"Nogueira","year":"2018","journal-title":"N Engl J Med"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"e213442","DOI":"10.1212\/WNL.0000000000213442","article-title":"Endovascular therapy for patients with low NIHSS scores and large vessel occlusion in the 6- to 24-hour window: analysis of the CLEAR study","volume":"104","author":"Marto","year":"2025","journal-title":"Neurology"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"1083","DOI":"10.3174\/ajnr.A5644","article-title":"Clinical outcomes of endovascular treatment within 24 hours in patients with mild ischemic stroke and perfusion imaging selection","volume":"39","author":"Shang","year":"2018","journal-title":"AJNR Am J Neuroradiol"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"354","DOI":"10.7461\/jcen.2021.E2021.01.003","article-title":"Extending the stroke treatment window beyond DAWN in patients with very slow progressor type collaterals: how far can we go?","volume":"23","author":"Pagiola","year":"2021","journal-title":"J Cerebrovasc Endovasc Neurosurg"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"722","DOI":"10.1161\/STROKEAHA.122.039793","article-title":"Mechanical thrombectomy versus best medical treatment in the late time window in non-DEFUSE-non-DAWN patients: a Multicenter cohort study","volume":"54","author":"Dittrich","year":"2023","journal-title":"Stroke"},{"key":"ref48","doi-asserted-by":"publisher","first-page":"708","DOI":"10.1056\/NEJMoa1713973","article-title":"Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging","volume":"378","author":"Albers","year":"2018","journal-title":"N Engl J Med"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"282","DOI":"10.5853\/jos.2023.00017","article-title":"Tissue clock beyond time clock: endovascular thrombectomy for patients with large vessel occlusion stroke beyond 24 hours","volume":"25","author":"Mohamed","year":"2023","journal-title":"J Stroke"},{"key":"ref50","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1186\/s13049-015-0101-7","article-title":"Are the current MRI criteria using the DWI-FLAIR mismatch concept for selection of patients with wake-up stroke to thrombolysis excluding too many patients?","volume":"23","author":"Odland","year":"2015","journal-title":"Scand J Trauma Resusc Emerg Med"},{"key":"ref51","doi-asserted-by":"publisher","first-page":"e364","DOI":"10.1161\/STR.0000000000000375","article-title":"2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the american heart association\/american stroke association","volume":"52","author":"Kleindorfer","year":"2021","journal-title":"Stroke"},{"key":"ref52","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1056\/NEJMoa1215340","article-title":"Clopidogrel with aspirin in acute minor stroke or transient ischemic attack","volume":"369","author":"Wang","year":"2013","journal-title":"N Engl J Med"},{"key":"ref53","doi-asserted-by":"publisher","first-page":"1312","DOI":"10.1111\/ene.15722","article-title":"Intravenous thrombolysis + endovascular thrombectomy versus thrombolysis alone in large vessel occlusion mild stroke: a propensity score matched analysis","volume":"30","author":"Schwarz","year":"2023","journal-title":"Eur J Neurol"},{"key":"ref54","doi-asserted-by":"publisher","first-page":"660","DOI":"10.1161\/STROKEAHA.117.020315","article-title":"First pass effect: a new measure for stroke thrombectomy devices","volume":"49","author":"Zaidat","year":"2018","journal-title":"Stroke"},{"key":"ref55","doi-asserted-by":"publisher","first-page":"150","DOI":"10.1016\/j.thromres.2022.09.020","article-title":"Endovascular thrombectomy or bridging therapy in minor ischemic stroke with large vessel occlusion","volume":"219","author":"Tu","year":"2022","journal-title":"Thromb Res"},{"key":"ref56","doi-asserted-by":"publisher","first-page":"475","DOI":"10.1186\/s12883-021-02499-9","article-title":"Critical issue on the extinction and inattention subtest of NIHSS scale: an analysis on post-acute stroke patients attending inpatient rehabilitation","volume":"21","author":"Basagni","year":"2021","journal-title":"BMC Neurol"},{"key":"ref57","doi-asserted-by":"publisher","first-page":"1549","DOI":"10.1161\/STROKEAHA.117.018912","article-title":"Patient-reported outcome measures (PROMs) for acute stroke: rationale, methods and future directions","volume":"49","author":"Reeves","year":"2018","journal-title":"Stroke"},{"key":"ref58","doi-asserted-by":"publisher","first-page":"363","DOI":"10.1177\/19418744251341922","article-title":"Early neurological deterioration in ischemic stroke: prevalence, predictors, causes and 90-day outcome in a retrospective tunisian cohort","volume":"14","author":"Gouta","year":"2025","journal-title":"Neurohospitalist"},{"key":"ref59","doi-asserted-by":"publisher","first-page":"3127","DOI":"10.1161\/STROKEAHA.125.052121","article-title":"Endovascular thrombectomy versus best medical therapy for large vessel occlusion stroke beyond 24 hours: a systematic review and meta-analysis","volume":"56","author":"Rodriguez-Calienes","year":"2025","journal-title":"Stroke"},{"key":"ref60","year":"2018"},{"key":"ref61","year":"2024"},{"key":"ref62","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1177\/2396987319832140","article-title":"European stroke organisation (ESO) - european society for minimally invasive neurological therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischaemic StrokeEndorsed by stroke alliance for Europe (SAFE)","volume":"4","author":"Turc","year":"2019","journal-title":"Eur Stroke J"},{"key":"ref63","author":"Nogueira","year":"2025"},{"key":"ref64","year":"2023"},{"key":"ref65","year":""}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2025.1681311\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,10]],"date-time":"2025-11-10T13:31:47Z","timestamp":1762781507000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2025.1681311\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,10]]},"references-count":65,"alternative-id":["10.3389\/fneur.2025.1681311"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2025.1681311","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,10]]},"article-number":"1681311"}}