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

Abstract

Background: In the past few years, several randomized trials have clearly shown that endovascular treatment (ET) in addition to intravenous thrombolysis (IVT) is superior to IVT alone in patients with proximal cerebral arterial occlusions. However, the effectiveness of ET in pre-stroke dependent patients (modified Rankin Scale ≥3) is uncertain.Methods: Using our prospectively obtained stroke database, we analyzed the impact of pre-stroke dependence on the rates of poor outcome (discharge mRS 5–6), in-hospital death, infarct sizes, and symptomatic intracranial hemorrhage (SICH) in patients with distal intracranial carotid artery M1 and M2 occlusions during two time periods.Results: From 1/2008 to 10/2012, a total of 544 patients (455 without and 89 with dependence) were treated with IVT, and from 11/2012 to 12/2019 a total of 1,061 patients (919 without and 142 with dependence) received ET (with or without IVT). Irrespective of the treatment modality, the dependent patients had significantly higher rates of poor outcome (55 vs. 32%, p < 0.001), death (24 vs. 11%; p < 0.001), or SICH (8.2 vs. 3.6%, p < 0.01) than independent patients. In dependent patients, ET significantly reduced the rates of poor outcome (49 vs. 64%, p < 0.01) and led to smaller infarcts, whereas the rates of in-hospital death (25 vs. 22%; p = 0.6) or SICH (8.5 vs. 7.9%, p = 0.9) were comparable between both treatment modalities.Conclusions: Compared with IVT, ET avoids poor outcome and leads to smaller infarcts in dependent patients. However, the overall high rates of poor outcome in this patient population stress the importance to perform decisions based on a case-by-case basis.

Endovascular treatment of acute ischemic stroke in patients with pre-morbid disability: a meta-analysis

“…Indeed, we also found that patients with pre-morbid disability were older, more frequently women, and had higher baseline NIHSS scores compared with non-disabled patients, corroborating previous reports 32 36. The trend towards lower mortality seen in patients with pre-morbid disability who received EVT, compared with those who only received MM in the two studies that included this control group,25 26 also suggests that EVT is unlikely to be driving the higher mortality of these patients in the other observational studies. Of note, among the included studies, only two reported the cause of death in patients with pre-morbid disability, with ICH and ischemic stroke progression being the most frequent causes 14 15…”

“…Ten studies compared outcomes between patients with versus without pre-morbid stroke disability treated with EVT 14–24. We found two studies comparing patients with pre-morbid disability treated with EVT to pre-morbidly disabled patients receiving medical management alone 25 26. One study included only patients with disability and did not have a control group,27 and one study included only patients older than 80 years 20.…”

Influence of pre-stroke dependency on safety and efficacy of endovascular therapy: A systematic review and meta-analysis

“…Six conference abstracts were excluded ( 9 – 14 ). Two articles focusing on the comparison of PSD patients undergoing EVT vs. standard medical treatment (SMT) were excluded ( 3 , 4 ). Two articles that failed to compare PSD and PSI groups were also excluded ( 15 , 16 ).…”

“…However, most randomized controlled trials (RCTs) and real-world research limited investigation of patients with a pre-stroke modified Rankin scale (mRS) score of 0–1, and those with a score of ≥2 were largely excluded ( 2 ). There are studies showing that even with a higher mRS score, pre-stroke dependent (PSD) patients may also benefit from EVT when compared with best medical therapy ( 3 , 4 ). It is less clear whether these patients achieve similar safety and efficacy as pre-stroke independent patients (PSI) after EVT.…”

Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

“…Some studies have investigated the impact of EVT or bridging therapy compared to IVT alone in patients with PSD. For example, Kastrup et al ( 29 ) reported that EVT improved clinical outcome at the time of discharge, avoided poor outcome, and caused smaller infarcts compared to IVT in PSD patients. However, more randomized trials and comparative studies that adopt this study design are needed to shed light on whether this group of PSD patients should be recommended for EVT.…”