What is the next step in management for a patient with a National Institutes of Health (NIH) stroke score of 2?

Management of a Patient with NIH Stroke Score of 2

For a patient with a National Institutes of Health (NIH) stroke score of 2, the next step should be administration of IV recombinant tissue plasminogen activator (r-tPA) if the patient is within 3 hours of symptom onset and has no contraindications.

Understanding the NIHSS Score of 2

An NIHSS score of 2 represents a mild stroke severity. The NIHSS is an 11-item scale that measures neurological deficits, with scores ranging from 0 to 42 1. A score of less than 5 indicates a small stroke 1.

Despite the low score, it's important to recognize that:

• Even patients with mild strokes can have significant disability
• Low NIHSS scores in posterior circulation strokes may underestimate stroke severity 2
• 15% of patients with "minor" posterior circulation strokes (NIHSS ≤4) still have poor outcomes at 3 months 2

Management Algorithm

Step 1: Immediate Assessment and Treatment Decision

• Confirm time of symptom onset
• If within 3 hours of symptom onset:
  • Administer IV r-tPA (Grade 1A recommendation) 1
  • Dose: 0.9 mg/kg (maximum 90 mg), with 10% given as bolus and 90% as continuous infusion over 60 minutes 1
• If between 3-4.5 hours of symptom onset:
  • Consider IV r-tPA (Grade 2C recommendation) 1
• If beyond 4.5 hours:
  • IV r-tPA is not recommended (Grade 1B recommendation) 1

Step 2: Post-thrombolysis Management (if r-tPA given)

• Monitor blood pressure:
  • Every 15 minutes for 2 hours
  • Every 30 minutes for the next 6 hours
  • Every hour until 24 hours after treatment 1
• Monitor for hemorrhagic complications:
  • Perform neurological assessments every 15 minutes during infusion, then hourly 1
  • Watch for headache, nausea, vomiting, deterioration in neurological status 1

Step 3: If r-tPA Cannot Be Given or After Initial Management

• Administer aspirin 160-325 mg within 48 hours (Grade 1A recommendation) 1
• Avoid therapeutic anticoagulation (Grade 1A recommendation) 1

Step 4: Early Secondary Prevention and Supportive Care

• Implement DVT prophylaxis:
  • Early mobilization when appropriate (after 24 hours) 1
  • Consider prophylactic-dose LMWH over UFH for immobile patients (Grade 2B) 1
• Monitor temperature every 4 hours for first 48 hours 1
• Treat fever >37.5°C aggressively 1
• Avoid indwelling urinary catheters if possible 1

Important Considerations

Prognosis

Patients with low NIHSS scores generally have better outcomes:

• Approximately 45% of patients with initial NIHSS ≤7 return to normal neurological function within 48 hours 3
• Age and NIHSS score within 6 hours of onset are strong predictors of functional outcome 4

Cautions and Pitfalls

1. Don't underestimate mild strokes: Even with NIHSS of 2, patients can have significant disability if not treated appropriately.

2. Posterior circulation strokes: These often present with lower NIHSS scores but may have worse outcomes than suggested by the score 2. The optimal NIHSS cutoff for outcome prediction is 4 for posterior circulation versus 8 for anterior circulation strokes 2.

3. Early progression risk: Patients with initial NIHSS ≤7 have a 14.8% risk of neurological worsening in the first 48 hours 3, making early treatment crucial.

4. Avoid withholding treatment based solely on low NIHSS: Thrombolytic treatment should not be withheld based only on a low NIHSS score, especially in posterior circulation strokes 2.

5. Serial assessments: Continue to monitor the patient as early improvement or deterioration can occur, which may necessitate changes in management 5.