Aphasia Predicts Unfavorable Outcome in Mild Ischemic Stroke Patients and Prompts Thrombolytic Treatment Mascia Nesi, MD,* Giuseppe Lucente, MD,† Patrizia Nencini, MD,* Laura Fancellu, MD,‡ and Domenico Inzitari, MD* Background: Patients with an acute ischemic stroke rated as mild, and for this reason not submitted to thrombolysis, have an unfavorable outcome in a non-negligible proportion. Whether selective presentation features help identify those at risk of bad outcome, and whether it could be recommended to treat only patients with such features, is poorly elucidated. We report our experience based on retrospective evaluation of a consecutive series of patients scoring 6 or less on baseline National Institutes of Health Stroke Scale (NIHSS), some of whom received thrombolysis. Methods: From the prospective Careggi Hospital Stroke Registry, Florence, Italy, we selected a series of patients who fulfilled the following criteria: (1) screening for treatment within 3 hours of symptom onset; (2) mild symptoms, defined as a score of 6 or less on NIHSS, with or without rapid improvement; (3) no other reason for exclusion from thrombolysis; (4) no previous disability; and (5) admission to the stroke unit. We choose a modified Rankin scale score of less than 2 to define a good 3-month functional outcome. We studied as potential outcome predictors: age, base- line NIHSS score, isolated aphasia, motor impairment with or without aphasia, thrombolysis, previous stroke or transient ischemic attack, and interactions between each of these factors and thrombolysis. Results: Between February 2004 and June 2011, 128 patients fulfilled the selection criteria: 47 (36.7%) received tissue plasmin- ogen activator, 81 (63.3%) did not. At 3 months, of the 81 patients not receiving tissue plasminogen activator, 14 (17.3%) had an unfavorable outcome, compared with 6 (12.8%) among the 47 treated. Hemorrhagic complications or death occurred in nei- ther group. Adjusting for major confounders and for thrombolysis, the presence of aphasia on early assessment proved the only independent predictor of worse out- come. NIHSS score variation showed no effect. Conclusions: Aphasia is an early marker of unfavorable outcome in mild ischemic stroke patients. In these patients thrombolysis should be considered beyond the NIHSS scoring. Key Words: Aphasia—ischemic stroke—thrombolysis—mild symptoms. Ó 2013 by National Stroke Association From the *Stroke Unit, Careggi University Hospital, Florence, Italy; †Department of Neurological and Psychiatric Sciences, University of Florence, Italy; and ‡Neurological Department, University of Sassari, Italy. Received July 13, 2012; revision received November 14, 2012; accepted November 19, 2012. Supported by the Italian Ministry of Health as part of the strategic project ‘‘Nuove conoscenze e problematiche assistenziali nell’ictus,’’ grant 2006. Dr Inzitari served on a scientific advisory board for Servier; serves on the editorial board of Stroke and Cerebrovascular Disease and is asso- ciate editor of Neurological Sciences; received speaker honoraria from Bayer Schering Pharma, Novartis, Pfizer Inc, Sanofi-aventis, and Boehringer Ingelheim; and received research grants from Bayer Italia, Lilly Italia, and Pfizer. Address correspondence to Mascia Nesi, MD, Stroke Unit, Careggi University Hospital, Viale Morgagni, 85, 50134 Florence, Italy. E-mail: nesims@aou-careggi.toscana.it. 1052-3057/$ - see front matter Ó 2013 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2012.11.018 Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2013: pp 1-5 1