Acute Treatment of Disabling and Nondisabling Minor Ischemic Stroke: Expert Guidance for Clinicians

Minor ischemic strokes, usually defined as acute ischemic strokes with National Institutes of Health Stroke Scale score ≤5, account for over half of all cases and are often underestimated due to initially mild symptoms. Yet up to 30% of patients develop disability within 90 days, challenging the notion of a benign course. This guidance offers a pragmatic, scenario-based framework for acute minor ischemic stroke management, considering symptom severity (disabling versus nondisabling), eligibility for reperfusion, and presence of large vessel occlusion. Drawing from randomized trials, real-world evidence, and international guidelines, we examine therapeutic strategies, including dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor, anticoagulation, intravenous thrombolysis, and endovascular treatment. Intravenous thrombolysis is preferred for disabling symptoms within 4.5 hours of symptom onset, whereas dual antiplatelet therapy remains standard for noncardioembolic, nondisabling events. For cardioembolic minor ischemic stroke ineligible for reperfusion, early anticoagulation within 48 hours appears safe and beneficial. Evidence for routine endovascular treatment in minor ischemic stroke with large vessel occlusion remains limited and controversial. We also address management of rapidly improving yet disabling symptoms and postreperfusion antithrombotic strategies, emphasizing individualized care and the need for further research.