Endovascular treatment decision-making in acute ischemic stroke patients with large vessel occlusion and low National Institutes of Health Stroke Scale: insights from UNMASK EVT, an international multidisciplinary survey

Neuroradiology. 2020 Jun;62(6):715-721. doi: 10.1007/s00234-020-02371-6. Epub 2020 Feb 15.


Purpose: Many stroke patients with large vessel occlusion present with a low National Institutes of Health Stroke Scale (NIHSS). There is currently no level 1A recommendation for endovascular treatment (EVT) for this patient subgroup. From a physician's standpoint, the deficits might only be slight, but they are often devastating from a patient perspective. Furthermore, early neurologic deterioration is common. The purpose of this study was to explore endovascular treatment attitudes of physicians in acute ischemic stroke patients presenting with low admission NIHSS.

Methods: In an international cross-sectional survey among stroke physicians, participants were presented the scenario of a 76-year-old stroke patient with an admission NIHSS of 2. Survey participants were then asked how they would treat the patient (A) given their current local resources, and (B) under assumed ideal conditions, i.e., without external (monetary or infrastructural) constraints. Overall, country-specific and specialty-specific decision rates were calculated and clustered multivariable logistic regression performed to provide adjusted measures of effect size.

Results: Two hundred seventy-five participants (150 neurologists, 84 interventional neuroradiologists, 30 neurosurgeons, 11 affiliated to other specialties) from 33 countries provided their treatment approach to this case scenario. Most physicians favored an endovascular treatment approach, either combined with intravenous alteplase (55.3% under assumed ideal and 52.0% under current working conditions) or as single treatment (11.3% under assumed ideal and 8.4% under current conditions).

Conclusion: Despite the limited evidence for endovascular therapy in acute stroke patients with low NIHSS, most physicians in this survey decided to proceed with endovascular therapy. A randomized controlled trial seems warranted.

Keywords: Acute ischemic stroke; Endovascular therapy; Guidelines; Minor stroke.

MeSH terms

  • Aged
  • Brain Ischemia / diagnostic imaging*
  • Brain Ischemia / therapy*
  • Cerebral Angiography
  • Computed Tomography Angiography
  • Cross-Sectional Studies
  • Decision Making*
  • Endovascular Procedures*
  • Female
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Internationality
  • Ischemic Stroke / diagnostic imaging*
  • Ischemic Stroke / therapy*
  • Male
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Surveys and Questionnaires
  • Tissue Plasminogen Activator / therapeutic use


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator