What Is a Minor Stroke?

Urs Fischer, MD, MSc; Adrian Baumgartner, MS; Marcel Arnold, MD; Krassen Nedeltchev, MD;
Jan Gralla, MD, MSc; Gian Marco De Marchis, MD; Liliane Kappeler, MD; Marie-Luise Mono, MD;
Caspar Brekenfeld, MD; Gerhard Schroth, MD; Heinrich P. Mattle, MD

Background and Purpose—The term “minor stroke” is often used; however a consensus definition is lacking. We explored
the relationship of 6 “minor stroke” definitions and outcome and tested their validity in subgroups of patients.
Methods—A total of 760 consecutive patients with acute ischemic strokes were classified according to the following
definitions: A, score ⱕ1 on every National Institutes of Health Stroke Scale (NIHSS) item and normal consciousness;
B, lacunar-like syndrome; C, motor deficits with or without sensory deficits; D, NIHSS ⱕ9 excluding those with aphasia,
neglect, or decreased consciousness; E, NIHSS ⱕ9; and F, NIHSS ⱕ3. Short-term outcome was considered favorable when
patients were discharged home, and favorable medium-term outcome was defined as a modified Rankin Scale score of ⱕ2
at 3 months. The following subgroup analyses were performed by definition: sex, age, anterior versus posterior and right
versus left hemispheric stroke, and early (0 to 6 hours) versus late admission (6 to 24 hours) to the hospital.
Results—Short-term and medium-term outcomes were most favorable in patients with definition A (74% and 90%,
respectively) and F (71% and 90%, respectively). Patients with definition C and anterior circulation strokes were more
likely to be discharged home than patients with posterior circulation strokes (P⫽0.021). The medium-term outcome of
older patients with definition E was less favorable compared with the outcome of younger ones (P⫽0.001), whereas
patients with definition A, D, and F did not show different outcomes in any subgroup.
Conclusions—Patients fulfilling definition A and F had best short-term and medium-term outcomes. They would be best
suited to the definition of “minor stroke.” (Stroke. 2010;41:661-666.)
Key Words: minor stroke 䡲 definitions 䡲 outcome 䡲 NIHSS
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T he term “minor stroke” is often used for stroke patients

with mild and nondisabling symptoms. However, a
consensus definition is lacking. We performed a structured
literature search of MEDLINE from 1950 to May 2009 with
the key word “minor stroke(s)” and found 670 articles with
the term in the abstract (568 articles) or the title (102 articles).
Most authors did not define their meaning of “minor stroke.”
In the journal, Stroke, the most relevant specialist journal on
cerebrovascular diseases, only 25 of 75 articles provided a
definition. All authors giving a definition tried to capture
stroke syndromes with mild and nondisabling symptoms, but
their definitions varied considerably (see supplemental Ap-
pendix, available online at http://stroke.ahajournals.org).
Patients are selected for trials and epidemiological studies
based on the syndrome of a “minor stroke.”1,2 Therefore, a
broadly acceptable concept and definition of “minor stroke” is
required. Ideally, a definition of a “minor stroke” should reflect
the following aspects: (1) it should capture patients with mild
and nondisabling symptoms in acute stage and favorable short-
term and medium-term outcomes; (2) it should be valid for
different subgroups of stroke patients; (3) it should imply both
qualitative and quantitative dimensions; (4) it should be simple
and useful in daily clinical practice; and (5) it should not overlap
with the definition of a transient ischemic attack (TIA).
The National Institute of Neurological Disorders and Stroke
(NINDS) rt-PA Stroke Study Investigators developed 5 working
definitions of “minor stroke” based on information limited to the
CT scan and clinical presentation, specifically, the baseline
NIHSS score, baseline NIHSS individual items, and baseline
stroke subtype.3 However, these 5 definitions have not been
tested in clinical practice, and none have been adopted in stroke
research.
We tested these definitions of “minor stroke” and the defini-
tion most often used according to our literature search (NIHSS
ⱕ3) in the Bernese Stroke cohort. We explored the relationship
of the 6 definitions with short-term and medium-term outcomes
and tested the validity in different subgroups of stroke patients.
Patients and Methods
The University Hospital of Bern (Inselspital) is a large teaching
hospital providing tertiary care for ⬎1 million people and primary
care for the urban area of Bern, with 300 000 inhabitants. This
indicates that we receive and admit both severe strokes from distant

Received November 12, 2009; final revision received December 15, 2009; accepted December 30, 2009.
From the Departments of Neurology (U.R., A.B., M.A., K.N., G.M.D.M., L.K., M.-L.M., H.P.M.) and Neuroradiology (J.G., C.B., G.S.), Inselspital,
University Hospital Bern and University of Bern, Switzerland.
Correspondence to Heinrich P. Mattle, MD, Department of Neurology, University of Bern, Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.
E-mail heinrich.mattle@insel.ch
© 2010 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.109.572883

661
 662 Stroke April 2010

areas and mild and severe strokes and TIA patients from the city Table 1. Baseline Characteristics of 760 Patients With an
area. Most patients with a TIA or stroke are usually admitted for Acute Ischemic Stroke
treatment and further investigation. From January 2000 to December
2005, 815 patients with acute ischemic strokes (time from symptom Characteristics
onset to presentation ⱕ24 hours) were admitted to the ward of the Age, years (SD) 62 (13)
Department of Neurology. Patients with retinal artery occlusions and
TIAs, defined as a focal cerebral ischemic event with symptoms Female sex, n (%) 275 (36)
lasting ⬍24 hours, were excluded. Some aspects of these patients Vascular risk factors, n (%)
have been reported previously.4,5
Hypertension 474 (62)
All patients were examined immediately after admission by a
neurologist, and the deficit was scored using the NIHSS.6 Demo- Diabetes mellitus 122 (16)
graphic data and time of symptom onset were recorded. After clinical Current smoking 197 (26)
evaluation, patients underwent a standard investigation protocol in
Hypercholesterolemia 386 (51)
the emergency department, including blood tests, ECG, cranial CT,
or MRI. Status of extracranial and intracranial vessels was assessed Coronary artery disease 313 (41)
by neurovascular ultrasound, CT angiography, magnetic resonance Previous TIA 108 (14)
angiography, or digital subtraction angiography. Based on the
ischemic lesions on the CT or MRI scan, infarctions were classified Previous stroke 76 (10)
into anterior and posterior circulation and right and left hemispheric Family history of stroke 159 (21)
strokes. The following stroke risk factors were assessed: sex, Family history of MI 120 (16)
hypertension, diabetes, current cigarette smoking, hypercholesterol-
emia, coronary heart disease, previous TIA or stroke, and a family Baseline NIHSS score, median (range) 8 (1–37)
history of TIA and stroke. Stroke etiology was classified using the Territory, n (%)
Trial of Org 10172 in Acute Stroke Treatment criteria after a
Anterior circulation 580 (76)
complete diagnostic work-up.7
Seventeen patients (2%) underwent intravenous therapy (⬍3 hours Posterior circulation 179 (24)
of onset), 146 (32%) intra-arterial thrombolysis (⬍6 hours of onset), Both 1
and 21 (3%) mechanical thromboaspiration, according to interna-
tional guidelines and our institutional protocol.8,9 Antithrombotic Hemisphere, n (%)
and secondary preventive therapy was given according to European Right 262 (35)
guidelines.10,11 All patients were admitted to the neurological ward. Left 333 (44)
Patients with disabling stroke symptoms including neuropsycholog-
ical deficits such as aphasia, visuospatial deficits, or neglect were Both 8 (1)
then transferred to the rehabilitation unit; those with nondisabling Brain stem 149 (20)
strokes were discharged home.
Stroke etiology, n (%)
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Definitions of “Minor Stroke” Large artery disease 129 (17)

Based on clinical presentation, baseline NIHSS score, and baseline
NIHSS items, we classified all patients for this study into “yes” or
“no” for each definition A through F. The definitions are summa-
rized below. Thirty-eight patients (4.7%) could not be classified
because clinical records were inadequate to classify them into all of
the 6 definitions.
The 6 definitions of minor stroke used in this study:
A. all patients with a score 0 or 1 on every baseline NIHSS score
item, except level of consciousness items (items 1a to 1c),
which must be 0;
B. all patients with a lacunar-like syndrome (presumed small-
vessel occlusive disease) such as pure sensory syndrome, pure
motor hemiparesis, sensorimotor syndrome, ataxic hemipare-
sis, and dysarthria-clumsy hand syndrome;
C. all patients with only motor deficits (can include dysarthria or
ataxia) with or without sensory deficits. These patients can
have only a combination of motor, coordination, and sensory
deficits without any deficits in the spheres of language, level
of consciousness, extinction or neglect, horizontal eye move-
ments, or visual fields, deficits generally ascribed to larger
territories of focal ischemia;
D. all patients with baseline NIHSS in the lowest (least severe)
quartile of severity (NIHSS ⱕ9), excluding all patients with
aphasia, extinction, or neglect, or any points on the level-of-
consciousness questions;
E. all patients with baseline NIHSS in the lowest (least severe)
quartile of severity (NIHSS ⱕ9); and
F. all patients with baseline NIHSS ⱕ3.
Follow-Up Assessment
Short-term outcome was considered favorable when patients were
discharged home from our hospital and unfavorable when they died
or were referred to a rehabilitation unit or another hospital. Medium-
Cardioembolic 268 (35)
Small artery disease 75 (10)
Other determined etiology 82 (11)
Unknown etiology 200 (26)
More than one cause 5 (1)
MI indicates Myocardial infarction.
term outcome was assessed 3 months after stroke using the modified
Rankin scale.12 A total of 41.4% of patients were examined clini-
cally, and 58.6% were interviewed by phone. A good outcome was
defined as a modified Rankin Scale score of 0 to 2. Telephone
interviews were performed by physicians and study nurses experi-
enced in the use of the modified Rankin Scale. Recurrent vascular
events after hospital discharge such as TIA, recurrent stroke, or
myocardial infarction were recorded. Seventeen (2.1%) of 815
patients were lost for follow-up.
Statistical Analysis
Quantitative data are expressed as mean values⫾1SD. The NIHSS
score on admission is given as median value. Data are reported in
frequency tables. Effect of different variables on clinical outcome
among patients with each of the 6 definitions was assessed using
Fisher exact test for comparison of proportions. The following
variables were assessed: sex, age (⬎65 years versus ⱕ65 years),
anterior versus posterior circulation strokes, right versus left hemi-
spheric stroke (those with bilateral, cerebellar, or brain stem ische-
mia were excluded for this subanalysis), and early (0 to 6 hours)
versus late presentation (6 to 24 hours). P⬍0.05 was considered
significant.
 Fischer et al What Is a Minor Stroke? 663

Table 2. Characteristics of Patients With “Minor Stroke” Classified According to Different Definitions
Def A Def B Def C Def D Def E Def F
n⫽144 n⫽183 n⫽191 n⫽251 n⫽417 n⫽160
Baseline variables
Age, mean (SD) 62 (13) 62 (13) 62 (13) 62 (13) 62 (13) 62 (14)
Sex, women 38 (26) 68 (37) 67 (35) 86 (34) 137 (33) 46 (29)
NIHSS, median (range) 2 (1–6) 3 (1–11) 4 (1–13) 3 (1–9) 5 (1–9) 2 (1–3)
Stroke etiology, n (%)
Large artery disease 32 (22) 28 (15) 29 (15) 42 (17) 78 (19) 34 (21)
Cardioembolic 40 (28) 48 (26) 56 (29) 75 (30) 131 (31) 45 (28)
Small vessel disease 38 (27) 52 (29) 51 (27) 59 (23) 73 (18) 40 (25)
Other cause 9 (6) 11 (6) 9 (5) 19 (7) 35 (8) 12 (8)
Unknown etiology 22 (15) 40 (22) 42 (22) 52 (21) 96 (23) 28 (17)
More than one cause 3 (2) 4 (2) 4 (2) 4 (2) 4 (1) 1 (1)
Thrombolysis, n (%) 3 (2) 11 (6) 15 (8) 15 (6) 64 (15) 4 (3)
Territory, n (%)
Anterior 98 (68) 133 (73) 140 (73) 151 (60) 282 (68) 99 (62)
Posterior 46 (32) 50 (27) 51 (27) 100 (40) 134 (32) 61 (38)
Hemisphere, n (%)
Right 44 (44) 69 (52) 77 (54) 92 (56) 134 (45) 41 (39)
Left 55 (56) 64 (48) 65 (46) 72 (44) 164 (55) 64 (61)
Def indicates definition.

Results Discussion
Baseline characteristics, clinical information and stroke eti- In this study, we assessed the outcome of 760 stroke patients
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ology of all 760 patients included in this analysis are classified as “minor stroke” according to 6 different definitions.
presented in Table 1. Table 2 summarizes the number of Definition A (score 0 or 1 on every baseline NIHSS score item
patients fulfilling “minor stroke” definitions A through F and
their characteristics. Median NIHSS on admission was lowest
mRS 0-2 Discharge Home
in patients with definitions A and F and highest in those with
definition E. Short-term and medium-term outcome was best 100
in patients with definitions A and F and worst in those with
definitions C and E (Figure 1). The number of recurrent 95
vascular events at 3 months among patients with different 90 90 90
88
definitions was comparable and low (range, 0.6 to 2.5%). 85 85 85
Outcome in nonthrombolyzed patients compared with all 83
patients in the corresponding definition group was similar 80
Percentage

(Table 3). Supplemental Table I (available online at http:// 75 74

stroke.ahajournals.org) shows subgroup analyses of short- 71
70
term and medium-term outcomes. Patients with definitions B
and E presenting after 6 hours were more likely to be 65
discharged home than patients presenting within the first 6 60
57 58
hours (P⫽0.048 and P⫽0.019, respectively). Patients with 55 54
definition C experiencing an anterior circulation stroke were
more likely to be discharged home (P⫽0.021) than those with 50
48
posterior circulation strokes, and older patients with defini- 45
tion E were more likely to be handicapped at 3 months than 40
younger patients (P⫽0.001). Patients with definition A, D,
Def A Def B Def C Def D Def E Def F
and F did not show different outcomes in any subgroup.
n=144 n=183 n=191 n=251 n=417 n=160
However, older patients with definition A tended to be
handicapped after 3 months more frequently than younger Definition
patients (P⫽0.054). Figure 2 shows short-term and medium-
Figure 1. Short-term (Œ) and medium-term (f) outcomes in
term outcomes in relation to stroke severity, measured with patients with different definitions (Def) of “minor stroke” (95% CI
the NIHSS score at admission. indicated by whiskers). mRS indicates modified Rankin Scale.
 664 Stroke April 2010

Table 3. Short-Term and Medium-Term Outcomes and Recurrence Events in Patients With Different
Definitions of “Minor Stroke”
Short-Term Follow-Up Follow-Up at 3 Months

Minor Stroke, n (%) n Discharge Home Death mRS ⱕ1 mRS ⱕ2 Death

Definition A
No thrombolysis n⫽141 105 (74.5) 0 98 (69.5) 127 (90.1) 2 (1.4)
All patients n⫽144 106 (73.6) 0 99 (68.8) 129 (89.6) 2 (1.4)
Definition B
No thrombolysis n⫽172 100 (58.1) 1 (0.6) 108 (62.8) 145 (84.3) 1 (0.6)
All patients n⫽183 104 (56.8) 1 (0.5) 116 (63.4) 155 (84.7) 1 (0.5)
Definition C
No thrombolysis n⫽176 99 (56.3) 2 (0.6) 108 (61.4) 146 (82.9) 2 (0.6)
All patients n⫽191 103 (53.9) 2 (1.0) 117 (61.3) 159 (83.2) 3 (1.6)
Definition D
No thrombolysis n⫽236 142 (60.2) 0 154 (65.3) 206 (87.3) 2 (0.8)
All patients n⫽251 146 (58.2) 0 164 (65.3) 221 (88.0) 2 (0.8)
Definition E
No thrombolysis n⫽353 188 (53.3) 2 (0.6) 217 (61.5) 300 (84.9) 7 (1.9)
All patients n⫽417 201 (48.2) 5 (1.2) 252 (60.4) 356 (85.4) 11 (2.6)
Definition F
No thrombolysis n⫽156 113 (72.4) 0 108 (69.2) 141 (90.4) 3 (1.9)
All patients n⫽160 114 (71.3) 0 110 (68.8) 144 (90) 3 (0.9)
mRS indicates modified Rankin Scale.

and normal level of consciousness) and definition F (NIHSS item. The limitation of this definition according to our results
ⱕ3) would be best suitable to the concept of “minor stroke”: is that it might not be entirely robust for all subtypes of stroke
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patients with definition A or F were most likely to be discharged patients.

home and to be independent at 3 months.
Definition F was valid for all subgroups of stroke patients.
In addition, definition F is easily applicable in clinical
practice and relies on NIHSS total score. Several eminent
groups in stroke research have adopted this definition.13,14
However, using a specific cut point of the NIHSS for defining
a minor stroke might provoke criticism and raise the question
why a stroke with an NIHSS score of 3 should be minor but
with an NIHSS score of 4 not? Figure 2 relates NIHSS scores
and short-term and medium-term outcome: two thirds of
patients with an NIHSS score of ⱕ3 were discharged home.
The difference for patients with an NIHSS score of 4 is not
impressive, whereas a significant number of patients with
NIHSS scores of ⱖ5 have a less favorable short-term out-
come compared with patients with scores of ⱕ4. This
illustrates how arbitrary a cut point is. There is no real
scientific reason to choose a cut point of 3 or 4. Therefore, it
would be desirable to define a cut point for “minor stroke” by
consensus of several stroke researchers.
A minor stroke patient, according to definition F, could
have a severe deficit in one NIHSS item or a mild deficit in
more than one item. Some stroke physicians would consider
the first situation (eg, hemianopia⫽2 points) more severe
than a mild facial weakness combined with dysarthria (ie, 1
plus 1⫽2 points). Definition A circumvents this problem.
According to this definition, “minor stroke” includes only
patients who are conscious and score ⱕ1 on each NIHSS
item. This means that definition A includes only patients who
show mild but no severe functional deficits in any NIHSS
Patients classified with definition D had worse short-term
outcomes than patients with definitions A and F. Neverthe-
less, definition D merits some discussion; it includes all
patients with an NIHSS score of ⱕ9 but excludes patients
with decreased consciousness or neuropsychological deficits
such as aphasia, extinction phenomena, or neglect. Medium-
term outcome of patients with minor stroke definition D was
favorable in quasi as many patients as with definition A or F,
although the cutoff of the NIHSS score was considerably
high. Furthermore, this definition turned out to be robust in
many subgroups of stroke patients.
Less than 60% of patients with definitions B, C, and E were
independent enough to be discharged home. Furthermore,
these definitions were not robust for all subgroups of stroke
patients. In addition, more patients with definitions B, C, and
E compared with definitions A, D, and F had significant
disabilities at 3 months. Therefore, these definitions are less
suitable to define a “minor stroke.”
Thrombolysis might have influenced short-term and medium-
term outcomes in patients with different definitions of a minor
stroke. Therefore, patients without thrombolysis were analyzed
separately (Table 2). Outcome in nonthrombolyzed patients
compared with all patients in the corresponding definition group
was similar. However, only a minority of patients with different
definitions of “minor stroke” underwent thrombolysis, ranging
from 2% to 15%. Whether thrombolysis is beneficial in patients
with different definitions of a “minor stroke” cannot be derived
from this study. However, in a previous analysis, we assessed
outcome in patients with mild and rapidly improving symptoms;

mRS 0-2 at 3 months Discharge home
100
90
80
70
60
Percentage
50
40
30
20
10
0 Circulation and the Gottfried und Julia Bangerter Foundation.
1 2 3 4 5 6 7 8 9 10 11
n=48 n=60 n=52 n=47 n=53 n=47 n=51 n=26 n=33 n=24 n=22 n=29
NIHSS score
Figure 2. Short-term (Œ) and medium-term (f) outcomes in rela-
tion to stroke severity measured with NIHSS scores. mRS indi-
cates modified Rankin Scale.
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overall, 75% of these patients had a favorable outcome (modi-
fied Rankin Scale score 0 to 1).4 Baseline NIHSS score ⱖ10
points increased the odds of unfavorable outcome or death
17-fold, and proximal vessel occlusion increased the odds
7-fold. Therefore, selected patients, especially those with prox-
imal vessel occlusions and baseline NIHSS scores ⱖ10 points,
are likely to derive a benefit from thrombolysis. In a post hoc
subgroup analysis of the NINDS study, no difference in the
beneficial effects of tissue plasminogen activator in patients with
minor stroke syndromes compared with the overall treatment
effects in the entire cohort could be detected.3 Our current policy
is to work up all TIA and minor stroke patients rapidly and base
our treatment decisions (IV thrombolysis, endovascular treat-
ment, or no treatment) on the clinical evolution and the results of
the ancillary investigations.
The present definitions of a “minor stroke” are based on
clinical deficits and exclude information obtained from im-
aging. CT scans of patients with mild deficits are often
normal in the acute stage of a stroke. However, nearly all
patients with neurological signs lasting ⬎24 hours show
abnormalities on diffusion-weighted imaging. A combination
of clinical signs and information from diffusion-weighted
imaging might define a “minor stroke” more accurately than
a definition based on clinical information only. However,
such a study has yet to be performed.
An important issue is the validity and interrater reproduc-
ibility of our minor stroke definitions. However, we cannot
address this issue with the data of this study. All patients were
categorized based on clinical presentation, baseline NIHSS
Fischer et al What Is a Minor Stroke? 665
score, and baseline NIHSS items by the first author. On the
other hand, both the NIHSS, which relies on 4 of the 6 minor
stroke definitions, and the modified Rankin Scale, on which
we assessed outcome, have been used extensively in many
trials.15–18 Their reproducibility and validity have been ana-
lyzed in many studies and are considered as being fair.
In conclusion, to date, there is no consensus on the
definition of a “minor stroke.” Our study indicates that
patients fulfilling definition A (conscious patients scoring ⱕ1
on every NIHSS item) and definition F (patients with NIHSS
ⱕ3) had the best short-term and medium-term outcomes.
They would be suitable best to define “minor stroke” for
clinical and research purposes. Future consensus panels from
international stroke organizations should consider a uniform
definition of minor stroke to enhance clinical research.
Acknowledgments
We thank Neal Thurley for the support with the systematic literature
search and Pietro Ballinari for statistical advice.
Sources of Funding
Urs Fischer was supported by the KK Foundation for Cardiology and
12
Disclosures
None.
References
1. Rothwell PM, Giles MF, Chandratheva A, Marquardt L, Geraghty O,
Redgrave JN, Lovelock CE, Binney LE, Bull LM, Cuthbertson FC,
Welch SJ, Bosch S, Alexander FC, Silver LE, Gutnikov SA, Mehta Z;
Early Use of Existing Preventive Strategies for Stroke (EXPRESS) Study.
Effect of urgent treatment of transient ischaemic attack and minor stroke
on early recurrent stroke (EXPRESS study): a prospective
population-based sequential comparison. Lancet. 2007;370:1432–1442.
2. Kennedy J, Hill MD, Ryckborst KJ, Eliasziw M, Demchuk AM, Buchan
AM; FASTER Investigators. Fast assessment of stroke and transient
ischaemic attack to prevent early recurrence (FASTER): a randomised
controlled pilot trial. Lancet Neurol. 2007;6:961–969.
3. National Institute of Neurological Disorders and Stroke rt-PA Stroke
Study Group. Recombinant tissue plasminogen activator for minor
strokes: the National Institute of Neurological Disorders and Stroke rt-PA
Stroke Study Experience. Ann Emerg Med. 2005;46:243–252.
4. Nedeltchev K, Schwegler B, Haefeli T, Brekenfeld C, Gralla J, Fischer U,
Arnold M, Remonda L, Schroth G, Mattle HP. Outcome of stroke with
mild or rapidly improving symptoms. Stroke. 2007;38:2531–2535.
5. Arnold M, Halpern M, Meier B, Fischer U, Haefeli T, Kappeler L, Brek-
enfeld C, MD, Mattle HP, Nedeltchev K. Age-dependent differences in
demographics, risk factors, comorbidity, aetiology, management, and clinical
outcome of acute ischemic stroke. J Neurol. 2008;255:1503–1507.
6. Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J,
Spilker J, Holleran R, Eberle R, Hertzberg V, Roorick M, Moomaw CJ,
Walker M. Measurements of acute cerebral infarction: a clinical exami-
nation scale. Stroke. 1989;20:846 – 870.
7. Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL,
Marsh EE III. Classification of subtype of acute ischemic stroke. Defi-
nitions for use in a multicenter clinical trial TOAST Trial of Org 10172
in Acute Stroke Treatment. Stroke. 1993;24:35– 41.
8. Adams H, Adams R, Del Zoppo G, Goldstein LB; Stroke Council of the
American Heart Association; American Stroke Association. Guidelines for
the early management of patients with ischemic stroke: 2005 guidelines
update a scientific statement from the Stroke Council of the American Heart
Association/American Stroke Association. Stroke. 2005;36:916–923.
9. Arnold M, Schroth G, Nedeltchev K, Loher T, Remonda L, Stepper F,
Sturzenegger M, Mattle HP. Intra-arterial thrombolysis in 100 patients
with acute stroke due to middle cerebral artery occlusion. Stroke. 2002;
33:1828 –1833.
10. The European Stroke Initiative Recommendations for Stroke Man-
agement. European Stroke Council, European Neurological Society and
 666 Stroke April 2010
European Federation of Neurological Societies. Cerebrovasc Dis. 2000;
10:335–351.
11. The European Stroke Initiative Recommendations for Stroke Man-
agement – Update 2003. Cerebrovasc Dis. 2003;16:311–337.
12. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Inter-
observer agreement for the assessment of handicap in stroke patients.
Stroke. 1988;19:604 – 607.
13. Luengo-Fernandez R, Gray AM, Rothwell PM. Effect of urgent treatment
for transient ischaemic attack and minor stroke on disability and hospital
costs (EXPRESS study): a prospective population-based sequential com-
parison. Lancet Neurol. 2009;8:218 –219.
14. Coutts SB, Hill MD, Campos CR, Choi YB, Subramaniam S, Kosior JC,
Demchuk AM. Recurrent events in transient ischemic attack and minor
stroke. Stroke. 2008;39:2461–2466.
Downloaded from http://ahajournals.org by on April 24, 2022
15. Dewey HM, Donnan GA, Freeman EJ, Sharples CM, Macdonell RA,
McNeill JJ, Thrift AG. Interrater reliability of the National Institutes of
Health Stroke Scale: rating by neurologists and nurses in a community-based
stroke incidence study. Cerebrovasc Dis. 1999;9:323–327.
16. Kasner SE, Chalela JA, Lucaino JM, Cucchiara BL, Raps EC, McGarvey
ML, Conroy MB, Localio AR. Reliability and validity of estimating the
NIH stroke scale from medical records. Stroke. 1999;30:1534 –1537.
17. Williams LS, Yilmaz EY, Lopez-Yunez AM. Retrospective assessment of
initial stroke severity with the NIH Stroke Scale. Stroke. 2000;31:
858 – 862.
18. Bushnell CD, Johnston DC, Goldstein LB. Retrospective assessment of
initial stroke severity: comparison of the NIH Stroke Scale and the
Canadian Neurological Scale. Stroke. 2001;32:656 – 660.