Endovascular Treatment for Acute Stroke Patients With a Pre-stroke Disability: An International Survey

Abstract

Background: It is unclear what factors clinicians consider when deciding about endovascular thrombectomy (EVT) in acute ischemic stroke patients with a pre-existing disability. We aimed to explore international practice patterns and preferences for EVT in patients with a pre-stroke disability, defined as a modified Rankin score (mRS) ≥ 2.Methods: Electronic survey link was sent to principal investigators of five major EVT trials and members of a professional interventional neurology society.Results: Of the 81 survey-responding clinicians, 57% were neuro-interventionalists and 33% were non-interventional stroke clinicians. Overall, 64.2% would never or almost never consider EVT for a patient with pre-stroke mRS of 4-5, and 49.3% would always or almost always offer EVT for a patient with pre-stroke mRS 2-3. Perceived benefit of EVT (89%) and severity of baseline disability (83.5%) were identified as the most important clinician-level and patient-level factors that influence EVT decisions in these patients.Conclusion: In this survey of 80 respondents, we found that EVT practice for patients with pre-stroke disability across the world is heterogenous and depends upon patient characteristics. Individual clinician opinions substantially alter EVT decisions in pre-stroke disabled patients.

Intravenous thrombolysis in acute ischemic stroke patients with pre‐stroke disability: A systematic review and meta‐analysis

“…A study involving sequential hospital admissions with acute stroke has demonstrated that every point increase in the pre‐stroke mRS score was associated with an increase in the rate of length‐of‐stay, discharge destination, mortality, and complications (Quinn et al., 2017). In general, IVT is not considered the first choice for AIS patients with PSD before stroke because of their possibly high mortality rate (Quinn et al., 2017; Salwi et al., 2021). Previous studies have demonstrated increased odds of mortality, whereas there was no significant difference between patients with and without PSD in return to their pre‐stroke level of function, sICH, or any ICH (Gensicke et al., 2016; Karlinski et al., 2014).…”

“…In general, IVT is not considered the first choice for AIS patients with PSD before stroke because of their possibly high mortality rate (Quinn et al, 2017;Salwi et al, 2021). Previous studies have demonstrated increased odds of mortality, whereas there was no significant difference between patients with and without PSD in return to their pre-stroke level of function, sICH, or any ICH (Gensicke et al, 2016;Karlinski et al, 2014).…”

Cost-Effectiveness of Endovascular Treatment in Large Vessel Occlusion Stroke With Mild Prestroke Disability: Results From the HERMES Collaboration

“…There is substantial uncertainty on whether EVT should be performed in patients with preexisting symptoms/disability, and treatment practices are highly variable. 35 The most commonly used argument against treating these patients with EVT is that functional outcomes are often poor, especially when compared to patients without preexisting symptoms/disability. 36,37 Indeed, a post hoc analysis of the HERMES collaboration showed that clinical outcome at 3 months is worse in patients with mild preexisting disability (mRS score 1–2), but this held true both for the control and EVT arms.…”

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

“…In general, clinicians do not always consider EVT for eligible ischemic stroke patients with prestroke disability due to the fact that they were more likely to die ( 6 , 28 ). Our findings were in line with previous studies ( 28 ) that showed every point increase in prestroke mRS was associated with a higher risk of mortality ( 28 ).…”

“…However, prestroke mRS ≥2 is relatively common among patients harboring acute ischemic stroke, with a reported frequency between 23.5 and 34.1% ( 4 , 5 ). Furthermore, an international survey has reported that the EVT practice for patients with prestroke mRS ≥2 is heterogenous, and the EVT decision largely depends on clinician opinions ( 6 ). Therefore, selecting optimal treatments is necessary for these patients to obtain timely and successful revascularizations and improved clinical outcomes.…”