Do patients with large vessel occlusion ischemic stroke harboring prestroke disability benefit from thrombectomy?

Abstract

Objectives Evidence of endovascular treatment (EVT) for acute large vessel occlusion (LVO) ischemic stroke in patients harboring substantial prestroke disability is lacking due to their exclusion from randomized trials. Here, we used routine care observational data to compare outcomes in patients with and without prestroke disability receiving EVT for LVO ischemic stroke. Methods Consecutive patients undergoing EVT for acute LVO ischemic stroke at the Sahlgrenska University Hospital from January 1st, 2015 to March 31st, 2018 were registered in the Sahlgrenska Stroke Recanalization Registry. Pre-and poststroke functional levels were assessed by the modified Rankin Scale (mRS). Outcomes were recanalization rate (mTICI = 2b/3), symptomatic intracranial hemorrhage [sICH], complications during hospital stay, and return to prestroke functional level and mortality at 3 months. Results Among 591 patients, 90 had prestroke disability (mRS ≥ 3). The latter group were older, more often female, had more comorbidities and higher NIHSS scores before intervention compared to patients without prestroke disability. Recanalization rates (80.0% vs 85.0%, p = 0.211), sICH (2.2% vs 6.3% p = 0.086) and the proportion of patients returning to prestroke functional level (22.7% vs 14.8% p = 0.062) did not significantly differ between those with and without prestroke disability. Patients with prestroke disability had higher complication rates during hospital stay (55.2% vs 40.1% p < 0.01) and mortality at 3 months (48.9% vs 24.3% p < 0.001). Conclusion One of five with prestroke disability treated with thrombectomy for a LVO ischemic stroke returned to their prestroke functional level. However, compared to patients without prestroke disability, mortality at 3 months was higher.

Endovascular Therapy vs. Thrombolysis in Pre-stroke Dependent Patients With Large Vessel Occlusions Within the Anterior Circulation

“…Furthermore, 11% of the patients within the MR CLEAN registry were likewise pre-stroke dependent ( 9 ). Comparable rates were also found in single-center studies from Israel or from Sweden ( 11 , 18 ). Studies focusing on patients treated with thrombolysis alone and with unknown vessel status reported proportions of patients with pre-stroke disability ranging from 10 to 30% ( 19 , 20 ).…”

“…Recently, several single-center studies and registries have reported the beneficial effects of ET in pre-stroke dependent patients ( 8 , 9 , 11 , 18 ). In fact, all of these studies were able to show that pre-stroke disability does not significantly reduce the likelihood to return to the pre-stroke functional level after ET.…”

“…Since pre-stroke disability will continue to rise in the coming years (7), the potential impact of ET on outcome in patients with prior disabilities has received increased attention. In fact, several recent case series as well as an analysis of the MR Clean Registry have revealed favorable functional and procedural outcome rates after ET in patients with prior disabilities compared to those without pre-stroke disability (8)(9)(10)(11)), yet all of these studies lacked a control group, such that the true treatment effect of ET in pre-stroke disabled patients is unknown.…”

Toward a more inclusive paradigm: thrombectomy for stroke patients with pre-existing disabilities

“…16 22 Recent observational data have added to the evidence base suggesting that baseline disability status does not significantly impact the likelihood of a return to prestroke functional level after EVT. 23 While baseline disability was associated with increased rate of post-stroke mortality, 23 24 we hypothesize that this association is more likely to arise from the unequal neurologic impact of stroke itself on vulnerable patients with baseline disability rather than from EVT. This association between stroke and mortality is likely further magnified in the counterfactual scenario where EVT is categorically withheld from patients with baseline disability.…”

Updating estimates of the number of UK stroke patients eligible for endovascular thrombectomy: incorporating recent evidence to facilitate service planning

“…Larsson and colleagues observed that 20% of patients with prestroke disability receiving EVT returned to their pre-stroke functional level. 31 SELECT 2, estimated to report at very earliest in early 2022, includes patients with an ASPECTS score of 3 or above within 24 h of 'last known well' and therefore has a similar potential to impact our estimates as TESLA (nodes G, H and M). LASTE, reporting at very earliest February 2022, includes early presenters with an ASPECTS score of 0-5 or 4-5 if aged 80 or over.…”