Endovascular thrombectomy in acute ischemic stroke patients with prestroke disability (mRS ≥2): A systematic review and meta-analysis

Abstract

ObjectiveThe effect of endovascular thrombectomy (EVT) in acute ischemic stroke patients with prestroke disability (modified Rankin Scale score, mRS) ≥2) has not been well-studied. This study aimed to assess the safety and benefit of EVT in patients with prestroke disability.MethodsAccording to PRISMA guidelines, literature searching was performed using PubMed, Embase, and Cochrane databases, for a series of acute ischemic stroke patients with prestroke mRS ≥2 treated by EVT. Random-effects meta-analysis was used to pool the rate of return to prestroke mRS and mortality at 3-month follow-up.ResultsIn total, 13 observational studies, with 2,625 patients, were analyzed. The rates of return to prestroke mRS in patients with prestroke mRS of 2–4 were 20% (120/588), 27% (218/827), and 31% (34/108), respectively. Patients with prestroke disability treated by EVT had a higher likelihood of return to prestroke mRS (relative risk, RR, 1.86; 95% CI 1.28–2.70) and a lower likelihood of mortality (RR 0.75; 95%CI 0.58–0.97) compared with patients with standard medical treatment. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b-3) after EVT gave a higher likelihood of return to prestroke mRS (RR 2.04; 95% CI 1.17–3.55) and lower mortality (RR 0.72; 95% CI 0.62–0.84) compared with unsuccessful reperfusion.ConclusionsAcute ischemic stroke patients with prestroke disability may benefit from EVT. Withholding EVT on the sole ground of prestroke disabilities may not be justified.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/.

Differential effects of premorbid functional dependency on mortality in patients with anterior and posterior circulation stroke

“…However, among ACS patients who underwent EVT, it elevated the risk of mortality at 1 year, but was not associated with mortality in PCS. According to a recent meta-analysis of EVT in patients with prestroke disability [7], premorbid disabled patients seem to benefit from EVT. Therefore, as EVT for patients with prestroke disability could be beneficial, cautious selection of EVT candidates is required to enhance stroke prognosis in patients with premorbid functional dependency.…”

“…Premorbid functional status has been utilized as a strong predictor of post-stroke prognosis, while the premorbid modified Rankin Scale (mRS) has been associated with mortality in acute ischemic stroke patients [4]. Furthermore, as landmark clinical trials that proved the efficacy of endovascular treatment (EVT) only included premorbid-independent patients [5,6], any evidence of the efficacy of EVT in premorbidly dependent patients is not yet supported by clinical trials and has been decided based on clinicians' own decisions [7].…”

Is thrombectomy indicated in all ischemic stroke with large vessel occlusion?

“…A separate analysis from the same registry [24], looking at 33 patients with high baseline disability (mRS 4–5), reported 84% rate of successful reperfusion and 36% patients returning to baseline functional status. A meta-analysis [25 ▪▪ ] incorporating 13 observational studies and 2625 patients also demonstrated higher likelihood of returning to prestroke functional status (pooled relative risk (RR): 1.86, 95% CI 1.28–2.70) and lower mortality (pooled RR: 0.75, 95% CI 0.58–0.97) when treated with EVT as compared to medical care only. Selection bias remains a concern across these analyses.…”