What is the management plan for a 66-year-old male with acute ischemic stroke due to right M2 occlusion and a confirmed NIHSS (National Institutes of Health Stroke Scale) score of 2?

Management Plan for Acute Ischemic Stroke with Right M2 Occlusion and NIHSS 2

The patient with a right M2 occlusion and confirmed NIHSS score of 2 should receive intravenous thrombolysis (alteplase) if within the appropriate time window, followed by careful monitoring for neurological deterioration, but does not require endovascular therapy given the mild deficit.

Initial Assessment and Discrepancy Resolution

The overnight nurse's NIHSS assessment of 4 versus the neurology resident's confirmed score of 2 highlights the importance of proper NIHSS certification. This discrepancy should be documented, with the neurologist's assessment taking precedence as they typically have more specialized training in neurological examination.

• NIHSS is a standardized, validated instrument that assesses stroke severity with high inter-rater reliability when performed by certified examiners 1
• The confirmed NIHSS score of 2 indicates a mild deficit with good prognosis (scores <6 forecast good recovery) 1

Treatment Algorithm Based on NIHSS and Occlusion Location

Step 1: Intravenous Thrombolysis

• Administer intravenous alteplase if patient is within 4.5 hours from symptom onset and has no contraindications 1
• Consider tenecteplase as an alternative thrombolytic agent, which has improved fibrin-specificity and can be administered as a single bolus 1

Step 2: Endovascular Therapy Decision

• For this patient with NIHSS 2 and M2 occlusion: Endovascular therapy is NOT recommended
  • Evidence suggests that endovascular therapy may pose an unfavorable risk-benefit profile over medical management for patients with mild symptoms (NIHSS ≤6) 2
  • Patients with mild symptoms who undergo endovascular therapy demonstrate increased overall rates of intracranial hemorrhage (35.3% vs. 10.0%) and longer hospital stays 2

Step 3: Monitoring and Supportive Care

• Implement close neurological monitoring for potential deterioration
• If deterioration occurs, reassess for potential rescue endovascular therapy 2
• Perform swallow screening before initiating oral intake to prevent aspiration 1
• Early mobilization to prevent complications 1

Secondary Prevention

• Initiate antiplatelet therapy (typically aspirin) before discharge 1
• Address modifiable risk factors:
  • Hypertension management
  • Lipid-lowering therapy
  • Diabetes management if applicable
  • Smoking cessation if applicable 1

Prognosis and Expected Outcomes

• Patients with NIHSS <6 have a high likelihood of good recovery 1
• M2 occlusions with low NIHSS scores (<9) have significantly better outcomes:
  • Good outcome rate of 78.4% (vs. 22.6% for NIHSS ≥9)
  • Mortality rate of only 2.7% (vs. 42% for NIHSS ≥9) 3

Pitfalls and Caveats

1. Beware of neurological deterioration: Despite initial mild symptoms, M2 occlusions can worsen. Implement frequent neurological checks.

2. NIHSS assessment accuracy: Ensure all staff are properly trained and certified in NIHSS assessment to avoid discrepancies 1.

3. Avoid overtreatment: Endovascular therapy in mild strokes may lead to higher complication rates without clear benefit 2.

4. Don't underestimate M2 occlusions: While this patient has mild symptoms, M2 occlusions constitute approximately 4% of all acute ischemic strokes and can cause significant morbidity in those with higher NIHSS scores 3.

5. Consider perfusion imaging: In borderline cases, perfusion imaging may help identify patients with target-mismatch profiles who might benefit from more aggressive treatment 2.