Systematic review| Volume 101, ISSUE 7, P1243-1259, July 2020

Inconsistent Classification of Mild Stroke and Implications on Health Services Delivery

Published:January 27, 2020DOI:



      To conduct a scoping review on classifications of mild stroke based on stroke severity assessments and/or clinical signs and symptoms reported in the literature.

      Data Sources

      Electronic searches of PubMed, PsycINFO (Ovid), and Cumulative Index to Nursing and Allied Health (CINAHL–EBSCO) databases included keyword combinations of mild stroke, minor stroke, mini stroke, mild cerebrovascular, minor cerebrovascular, transient ischemic attack, or TIA.

      Study Selection

      Inclusion criteria were limited to articles published between January 2003 and February 2018. Inclusion criteria included studies (1) with a definition of either mild or minor stroke, (2) written in English, and (3) with participants aged 18 years and older. Animal studies, reviews, dissertations, blogs, editorials, commentaries, case reports, newsletters, drug trials, and presentation abstracts were excluded.

      Data Extraction

      Five reviewers independently screened titles and abstracts for inclusion and exclusion criteria. Two reviewers independently screened each full-text article for eligibility. The 5 reviewers checked the quality of the included full-text articles for accuracy. Data were extracted by 2 reviewers and verified by a third reviewer.

      Data Synthesis

      Sixty-two studies were included in the final review. Ten unique definitions of mild stroke using stroke severity assessments were discovered, and 10 different cutoff points were used. The National Institutes of Health Stroke Scale was the most widely used measure to classify stroke severity. Synthesis also revealed variations in classification of mild stroke across publication years, time since stroke, settings, and medical factors including imaging, medical indicators, and clinical signs and symptoms.


      Inconsistencies in the classification of mild stroke are evident with varying use of stroke severity assessments, measurement cutoff scores, imaging tools, and clinical or functional outcomes. Continued work is necessary to develop a consensus definition of mild stroke, which directly affects treatment receipt, referral for services, and health service delivery.


      List of abbreviations:

      BI (Barthel Index), CINAHL (Cumulative Index to Nursing and Allied Health), CNS (Canadian Neurological Scale), CT (computed tomography), FMA (Fugl-Meyer Assessment), GCS (Glasgow Coma Scale), ICF (International Classification of Functioning, Disability, and Health), MMSE (Mini–Mental State Examination), MRI (magnetic resonance imaging), mRS (modified Rankin scale), NIHSS (National Institutes of Health Stroke Scale), PET (positron-emission tomography), SSS (Scandinavian Stroke Scale), TIA (transient ischemic attack)
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        • Carlsson G.E.
        • Moller A.
        • Blomstrand C.
        Managing an everyday life of uncertainty--a qualitative study of coping in persons with mild stroke.
        Disabil Rehabil. 2009; 31: 773-782
        • Edwards J.D.
        • Kapral M.K.
        • Fang J.
        • Swartz R.H.
        Long-term morbidity and mortality in patients without early complications after stroke or transient ischemic attack.
        CMAJ. 2017; 189: 954-961
        • Jovin T.G.
        • Chamorro A.
        • Cobo E.
        • et al.
        Thrombectomy within 8 hours after symptom onset in ischemic stroke.
        N Engl J Med. 2015; 372: 2296-2306
        • Messe S.R.
        • Khatri P.
        • Reeves M.J.
        • et al.
        Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry.
        Neurology. 2016; 87: 1565-1574
        • Hao Z.
        • Liu M.
        • Wang D.
        • Wu B.
        • Tao W.
        • Chang X.
        Etiologic subtype predicts outcome in mild stroke: prospective data from a hospital stroke registry.
        BMC Neurol. 2013; 13: 154
        • Smith E.E.
        • Fonarow G.C.
        • Reeves M.J.
        • et al.
        Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator: findings from Get With The Guidelines-Stroke.
        Stroke. 2011; 42: 3110-3115
        • Schumacher H.C.
        • Bateman B.T.
        • Boden-Albala B.
        • et al.
        Use of thrombolysis in acute ischemic stroke: analysis of the Nationwide Inpatient Sample 1999 to 2004.
        Ann Emerg Med. 2007; 50: 99-107
        • Smith E.E.
        • Abdullah A.R.
        • Petkovska I.
        • Rosenthal E.
        • Koroshetz W.J.
        • Schwamm L.H.
        Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke.
        Stroke. 2005; 36: 2497-2499
        • Chen T.
        • Zhang B.
        • Deng Y.
        • Fan J.C.
        • Zhang L.
        • Song F.
        Long-term unmet needs after stroke: systematic review of evidence from survey studies.
        BMJ Open. 2019; 9028137
        • Winstein C.J.
        • Stein J.
        • Arena R.
        • et al.
        Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2016; 47: 98-169
        • Miller E.L.
        • Murray L.
        • Richards L.
        • et al.
        Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association.
        Stroke. 2010; 41: 2402-2448
        • Cormier D.J.
        • Frantz M.A.
        • Rand E.
        • Stein J.
        Physiatrist referral preferences for postacute stroke rehabilitation.
        Medicine (Baltimore). 2016; 95: 4356
        • Faux S.G.
        • Arora P.
        • Shiner C.T.
        • Thompson-Butel A.G.
        • Klein L.A.
        Rehabilitation and education are underutilized for mild stroke and TIA sufferers.
        Disabil Rehabil. 2018; 40: 1480-1484
        • Adamit T.
        • Maeir A.
        • Ben Assayag E.
        • Bornstein N.M.
        • Korczyn A.D.
        • Katz N.
        Impact of first-ever mild stroke on participation at 3 and 6 month post-event: the TABASCO study.
        Disabil Rehabil. 2015; 37: 667-673
        • Brott T.
        • Adams Jr., H.P.
        • Olinger C.P.
        • et al.
        Measurements of acute cerebral infarction: a clinical examination scale.
        Stroke. 1989; 20: 864-870
        • Chappell F.M.
        • Del Carmen Valdes Hernandez M.
        • Makin S.D.
        • et al.
        Sample size considerations for trials using cerebral white matter hyperintensity progression as an intermediate outcome at 1 year after mild stroke: results of a prospective cohort study.
        Trials. 2017; 18: 78
        • van Swieten J.C.
        • Koudstaal P.J.
        • Visser M.C.
        • Schouten H.J.
        • van Gijn J.
        Interobserver agreement for the assessment of handicap in stroke patients.
        Stroke. 1988; 19: 604-607
        • Hand B.
        • Page S.J.
        • White S.
        Stroke survivors scoring zero on the NIH Stroke Scale Score still exhibit significant motor impairment and functional limitation.
        Stroke Res Treat. 2014; 2014: 462681
        • Colquhoun H.L.
        • Levac D.
        • O'Brien K.K.
        • et al.
        Scoping reviews: time for clarity in definition, methods, and reporting.
        J Clin Epidemiol. 2014; 67: 1291-1294
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        Ann Intern Med. 2009; 151: 65-94
        • Gorelick P.B.
        Primary and comprehensive stroke centers: history, value and certification criteria.
        J Stroke. 2013; 15: 78-89
        • Fedder W.
        National and international quality initiatives to improve stroke care.
        Neurol Clin. 2008; 26: 1191-1207
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Alt Murphy M.
        • Willen C.
        • Sunnerhagen K.S.
        Kinematic variables quantifying upper-extremity performance after stroke during reaching and drinking from a glass.
        Neurorehabil Neural Repair. 2011; 25: 71-80
        • Atanassova P.A.
        • Semerdjieva M.A.
        • Naydenov V.I.
        • Dzhurkova A.G.
        • Traykova N.I.
        • Chalakova N.T.
        Transient ischaemic attacks and minor strokes (analyses and clinically significant comparisons).
        Folia Med (Plovdiv). 2006; 48: 30-36
        • Bejot Y.
        • Mehta Z.
        • Giroud M.
        • Rothwell P.M.
        Impact of completeness of ascertainment of minor stroke on stroke incidence: implications for ideal study methods.
        Stroke. 2013; 44: 1796-1802
        • Bejot Y.
        • Guilloteau A.
        • Joux J.
        • et al.
        Social deprivation and stroke severity on admission: a French cohort study in Burgundy and the West Indies - Guyana region.
        Eur J Neurol. 2017; 24: 694-702
        • Bhattacharjee M.
        • Vairale J.
        • Gawali K.
        • Dalal P.M.
        Factors affecting burden on caregivers of stroke survivors: population-based study in Mumbai (India).
        Ann Indian Acad Neurol. 2012; 15: 113-119
        • Boulos M.I.
        • Murray B.J.
        • Muir R.T.
        • et al.
        Periodic limb movements and white matter hyperintensities in first-ever minor stroke or high-risk transient ischemic attack.
        Sleep. 2017; 40
        • Bustren E.L.
        • Sunnerhagen K.S.
        • Alt Murphy M.
        Movement kinematics of the ipsilesional upper extremity in persons with moderate or mild stroke.
        Neurorehabil Neural Repair. 2017; 31: 376-386
        • Carlsson G.E.
        • Moller A.
        • Blomstrand C.
        Consequences of mild stroke in persons <75 years -- a 1-year follow-up.
        Cerebrovasc Dis. 2003; 16: 383-388
        • Carlsson G.E.
        • Moller A.
        • Blomstrand C.
        A qualitative study of the consequences of 'hidden dysfunctions' one year after a mild stroke in persons <75 years.
        Disabil Rehabil. 2004; 26: 1373-1380
        • Chang W.H.
        • Sohn M.K.
        • Lee J.
        • et al.
        Long-term functional outcomes of patients with very mild stroke: does a NIHSS score of 0 mean no disability? An interim analysis of the KOSCO study.
        Disabil Rehabil. 2017; 39: 904-910
        • Dabrowska-Bender M.
        • Milewska M.
        • Golabek A.
        • Duda-Zalewska A.
        • Staniszewska A.
        The impact of ischemic cerebral stroke on the quality of life of patients based on clinical, social, and psychoemotional factors.
        J Stroke Cerebrovasc Dis. 2017; 26: 101-107
        • Daniels S.K.
        • Pathak S.
        • Mukhi S.V.
        • Stach C.B.
        • Morgan R.O.
        • Anderson J.A.
        The relationship between lesion localization and dysphagia in acute stroke.
        Dysphagia. 2017; 32: 777-784
        • Divya K.P.
        • Menon R.N.
        • Varma R.P.
        • et al.
        Post-stroke cognitive impairment - a cross-sectional comparison study between mild cognitive impairment of vascular and non-vascular etiology.
        J Neurol Sci. 2017; 372: 356-362
        • Edwards D.F.
        • Hahn M.
        • Baum C.
        • Dromerick A.W.
        The impact of mild stroke on meaningful activity and life satisfaction.
        J Stroke Cerebrovasc Dis. 2006; 15: 151-157
        • Eriksson G.
        • Carolyn Baum M.
        • Wolf T.J.
        • Connor L.T.
        Perceived participation after stroke: the influence of activity retention, reintegration, and perceived recovery.
        Am J Occup Ther. 2013; 67: 131-138
        • Fang J.
        • Saposnik G.
        • Silver F.L.
        • Kapral M.K.
        Association between weekend hospital presentation and stroke fatality.
        Neurology. 2010; 75: 1589-1596
        • Faulkner J.
        • McGonigal G.
        • Woolley B.
        • Stoner L.
        • Wong L.
        • Lambrick D.
        A randomized controlled trial to assess the psychosocial effects of early exercise engagement in patients diagnosed with transient ischaemic attack and mild, non-disabling stroke.
        Clin Rehabil. 2015; 29: 783-794
        • Faulkner J.
        • Stoner L.
        • Lanford J.
        • Jolliffe E.
        • Mitchelmore A.
        • Lambrick D.
        Long-term effect of participation in an early exercise and education program on clinical outcomes and cost implications, in patients with TIA and minor, non-disabling stroke.
        Transl Stroke Res. 2017; 8: 220-227
        • Fride Y.
        • Adamit T.
        • Maeir A.
        • et al.
        What are the correlates of cognition and participation to return to work after first ever mild stroke?.
        Top Stroke Rehabil. 2015; 22: 317-325
        • Gadodia G.
        • Rizk N.
        • Camp D.
        • et al.
        Presenting symptoms and dysphagia screen predict outcome in mild and rapidly improving acute ischemic stroke patients.
        J Stroke Cerebrovasc Dis. 2016; 25: 2876-2881
        • Ghahremanfard F.
        • Asghari N.
        • Ghorbani R.
        • Samaei A.
        • Ghomi H.
        • Tamadon M.
        The relationship between mean platelet volume and severity of acute ischemic brain stroke.
        Neurosciences (Riyadh). 2013; 18: 147-151
        • Hsieh C.Y.
        • Lin H.J.
        • Hu Y.H.
        • Sung S.F.
        Stroke severity may predict causes of readmission within one year in patients with first ischemic stroke event.
        J Neurol Sci. 2017; 372: 21-27
        • Joa K.L.
        • Kim W.H.
        • Choi H.Y.
        • et al.
        The effect of sleep disturbances on the functional recovery of rehabilitation inpatients following mild and moderate stroke.
        Am J Phys Med Rehabil. 2017; 96: 734-740
        • Jung J.M.
        • Choi J.
        • Eun M.Y.
        • et al.
        Prestroke antiplatelet agents in first-ever ischemic stroke: clinical effects.
        Neurology. 2015; 84: 1080-1089
        • Kim J.
        • Kim Y.
        • Yang K.I.
        • Kim D.E.
        • Kim S.A.
        The relationship between sleep disturbance and functional status in mild stroke patients.
        Ann Rehabil Med. 2015; 39: 545-552
        • Lin H.J.
        • Yeh P.S.
        • Tsai T.C.
        • et al.
        Differential risks of subsequent vascular events for transient ischaemic attack and minor ischaemic stroke.
        J Clin Neurosci. 2007; 14: 17-21
        • Liu D.
        • Sun W.
        • Scalzo F.
        • et al.
        Early magnetic resonance imaging predicts early neurological deterioration in acute middle cerebral artery minor stroke.
        J Stroke Cerebrovasc Dis. 2016; 25: 469-474
        • Luengo-Fernandez R.
        • Gray A.M.
        • Rothwell P.M.
        Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison.
        Lancet Neurol. 2009; 8: 235-243
        • Moustafa R.R.
        • Izquierdo-Garcia D.
        • Fryer T.D.
        • et al.
        Carotid plaque inflammation is associated with cerebral microembolism in patients with recent transient ischemic attack or stroke: a pilot study.
        Circ Cardiovasc Imaging. 2010; 3: 536-541
        • Muren M.A.
        • Hutler M.
        • Hooper J.
        Functional capacity and health-related quality of life in individuals post stroke.
        Top Stroke Rehabil. 2008; 15: 51-58
        • Muus I.
        • Petzold M.
        • Ringsberg K.C.
        Health-related quality of life among Danish patients 3 and 12 months after TIA or mild stroke.
        Scand J Caring Sci. 2010; 24: 211-218
        • Muus I.
        • Christensen D.
        • Petzold M.
        • et al.
        Responsiveness and sensitivity of the Stroke Specific Quality of Life Scale Danish version.
        Disabil Rehabil. 2011; 33: 2425-2433
        • Novak V.
        • Yang A.C.
        • Lepicovsky L.
        • Goldberger A.L.
        • Lipsitz L.A.
        • Peng C.K.
        Multimodal pressure-flow method to assess dynamics of cerebral autoregulation in stroke and hypertension.
        Biomed Eng Online. 2004; 3: 39
        • O'Brien A.N.
        • Wolf T.J.
        Determining work outcomes in mild to moderate stroke survivors.
        Work. 2010; 36: 441-447
        • Ois A.
        • Cuadrado-Godia E.
        • Rodriguez-Campello A.
        • Jimenez-Conde J.
        • Roquer J.
        High risk of early neurological recurrence in symptomatic carotid stenosis.
        Stroke. 2009; 40: 2727-2731
        • Pfaff J.
        • Herweh C.
        • Pham M.
        • et al.
        Mechanical thrombectomy in patients with acute ischemic stroke and lower NIHSS scores: recanalization rates, periprocedural complications, and clinical outcome.
        AJNR Am J Neuroradiol. 2016; 37: 2066-2071
        • Rist P.M.
        • Buring J.E.
        • Kase C.S.
        • Ridker P.M.
        • Kurth T.
        Biomarkers and functional outcomes from ischaemic cerebral events in women: a prospective cohort study.
        Eur J Neurol. 2013; 20: 375-381
        • Rochette A.
        • Desrosiers J.
        • Bravo G.
        • St-Cyr-Tribble D.
        • Bourget A.
        Changes in participation after a mild stroke: quantitative and qualitative perspectives.
        Top Stroke Rehabil. 2007; 14: 59-68
        • Rozon J.
        • Rochette A.
        Changes in life habits affected by mild stroke and their association with depressive symptoms.
        J Rehabil Med. 2015; 47: 495-501
        • Ruuskanen E.I.
        • Laihosalo M.
        • Kettunen J.
        • et al.
        Predictors of discharge to home after thrombolytic treatment in right hemisphere infarct patients.
        J Cent Nerv Syst Dis. 2010; 2: 73-79
        • Sarker S.J.
        • Heuschmann P.U.
        • Burger I.
        • et al.
        Predictors of survival after haemorrhagic stroke in a multi-ethnic population: the South London Stroke Register (SLSR).
        J Neurol Neurosurg Psychiatry. 2008; 79: 260-265
        • Seymour L.M.
        • Wolf T.J.
        Participation changes in sexual functioning after mild stroke.
        OTJR (Thorofare N J). 2014; 34: 72-80
        • Shi Y.
        • Xiang Y.
        • Yang Y.
        • et al.
        Depression after minor stroke: prevalence and predictors.
        J Psychosom Res. 2015; 79: 143-147
        • Shi Y.Z.
        • Xiang Y.T.
        • Yang Y.
        • et al.
        Depression after minor stroke: the association with disability and quality of life--a 1-year follow-up study.
        Int J Geriatr Psychiatry. 2016; 31: 421-427
        • Song B.
        • Wang Y.
        • Zhao X.
        • et al.
        Association between statin use and short-term outcome based on severity of ischemic stroke: a cohort study.
        PLoS One. 2014; 9: 84389
        • Tellier M.
        • Rochette A.
        • Lefebvre H.
        Impact of mild stroke on the quality of life of spouses.
        Int J Rehabil Res. 2011; 34: 209-214
        • Torres-Mozqueda F.
        • He J.
        • Yeh I.B.
        • et al.
        An acute ischemic stroke classification instrument that includes CT or MR angiography: the Boston Acute Stroke Imaging Scale.
        AJNR Am J Neuroradiol. 2008; 29: 1111-1117
        • Tseng M.C.
        • Chang K.C.
        Stroke severity and early recovery after first-ever ischemic stroke: results of a hospital-based study in Taiwan.
        Health Policy. 2006; 79: 73-78
        • Valdes Hernandez Mdel C.
        • Armitage P.A.
        • Thrippleton M.J.
        • et al.
        Rationale, design and methodology of the image analysis protocol for studies of patients with cerebral small vessel disease and mild stroke.
        Brain Behav. 2015; 5e00415
        • Villain M.
        • Sibon I.
        • Renou P.
        • Poli M.
        • Swendsen J.
        Very early social support following mild stroke is associated with emotional and behavioral outcomes three months later.
        Clin Rehabil. 2017; 31: 135-141
        • Volonghi I.
        • Pendlebury S.T.
        • Welch S.J.
        • Mehta Z.
        • Rothwell P.M.
        Cognitive outcomes after acute coronary syndrome: a population based comparison with transient ischaemic attack and minor stroke.
        Heart. 2013; 99: 1509-1514
        • Ward K.
        • Rao P.
        • Reilly C.C.
        • et al.
        Poor cough flow in acute stroke patients is associated with reduced functional residual capacity and low cough inspired volume.
        BMJ Open Respir Res. 2017; 4000230
        • Wolf T.J.
        • Barbee A.R.
        • White D.
        Executive dysfunction immediately after mild stroke.
        OTJR (Thorofare N J). 2011; 31: 23-29
        • Wolf T.J.
        • Rognstad M.C.
        Changes in cognition following mild stroke.
        Neuropsychol Rehabil. 2013; 23: 256-266
        • Wolf T.J.
        • Dahl A.
        • Auen C.
        • Doherty M.
        The reliability and validity of the Complex Task Performance Assessment: a performance-based assessment of executive function.
        Neuropsychol Rehabil. 2017; 27: 707-721
        • Xue W.Y.
        • Xu Y.C.
        • Wu Y.W.
        • Yang M.
        Observation of elevated fasting blood glucose and functional outcome after ischemic stroke in patients with and without diabetes.
        Oncotarget. 2017; 8: 67980-67989
        • Zhang W.
        • Cadilhac D.A.
        • Churilov L.
        • Donnan G.A.
        • O'Callaghan C.
        • Dewey H.M.
        Does abnormal circadian blood pressure pattern really matter in patients with transient ischemic attack or minor stroke?.
        Stroke. 2014; 45: 865-867
        • Zhang Z.
        • Ren W.
        • Shao B.
        • et al.
        Leukoaraiosis is associated with worse short-term functional and cognitive recovery after minor stroke.
        Neurol Med Chir (Tokyo). 2017; 57: 136-143
        • Zhang X.
        • Xie Y.
        • Ding C.
        • et al.
        Subclinical hypothyroidism and risk of cerebral small vessel disease: a hospital-based observational study.
        Clin Endocrinol (Oxf). 2017; 87: 581-586
        • Zhou X.
        • Yu F.
        • Feng X.
        • et al.
        Immunity and inflammation predictors for short-term outcome of stroke in young adults.
        Int J Neurosci. 2018; 128: 634-639
        • Schwartz J.K.
        • Capo-Lugo C.E.
        • Akinwuntan A.E.
        • et al.
        Classification of mild stroke: a mapping review.
        PM R. 2019; 11: 996-1003
        • de Kleijn-de Vrankrijker M.W.
        The long way from the International Classification of Impairments, Disabilities and Handicaps (ICIDH) to the International Classification of Functioning, Disability and Health (ICF).
        Disabil Rehabil. 2003; 25: 561-564
        • Krishnan S.
        • Pappadis M.R.
        • Weller S.C.
        • et al.
        Needs of stroke survivors as perceived by their caregivers: a scoping review.
        Am J Phys Med Rehabil. 2017; 96: 487-505
        • Lyden P.
        • Lu M.
        • Jackson C.
        • et al.
        Underlying structure of the National Institutes of Health Stroke Scale: results of a factor analysis. NINDS tPA Stroke Trial Investigators.
        Stroke. 1999; 30: 2347-2354
        • Rankin J.
        Cerebral vascular accidents in patients over the age of 60. II. Prognosis.
        Scott Med J. 1957; 2: 200-215
        • Howard G.
        • Schwamm L.H.
        • Donnelly J.P.
        • et al.
        Participation in Get With The Guidelines-Stroke and Its Association With Quality of Care for Stroke.
        JAMA Neurol. 2018; 75: 1331-1337
        • Easton J.D.
        • Saver J.L.
        • Albers G.W.
        • et al.
        Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists.
        Stroke. 2009; 40: 2276-2293
        • Kwei K.T.
        • Liang J.
        • Wilson N.
        • Tuhrim S.
        • Dhamoon M.
        Stroke severity affects timing: time from stroke code activation to initial imaging is longer in patients with milder strokes.
        Neurologist. 2018; 23: 79-82
        • Meretoja A.
        • Strbian D.
        • Mustanoja S.
        • Tatlisumak T.
        • Lindsberg P.J.
        • Kaste M.
        Reducing in-hospital delay to 20 minutes in stroke thrombolysis.
        Neurology. 2012; 79: 306-313