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

Abstract

BackgroundPersons with pre-existing disabilities represent over one-third of acute stroke presentations, but account for a far smaller proportion of those receiving endovascular thrombectomy (EVT) and thrombolysis. This is despite existing ethical, economic, legal, and social directives to maximize equity for this vulnerable population. We sought to determine associations between baseline modified Rankin Scale (mRS) and outcomes after EVT.MethodsIndividuals who underwent EVT were identified from a prospectively maintained database. Demographics, medical history, presentations, treatments, and outcomes were recorded. Baseline disability was defined as baseline mRS≥2. Accumulated disability was defined as the delta between baseline mRS and absolute 90-day mRS.ResultsOf 381 individuals, 49 had baseline disability (five with mRS=4, 23 mRS=3, 21 mRS=2). Those with baseline disability were older (81 vs 68 years, P<0.0001), more likely female (65% vs 49%, P=0.032), had more coronary disease (39% vs 20%, P=0.006), stroke/TIA history (35% vs 15%, P=0.002), and higher NIH Stroke Scale (19 vs 16, P=0.001). Baseline mRS was associated with absolute 90-day mRS ≤2 (OR=0.509, 95%CI=0.370–0.700). However, baseline mRS bore no association with accumulated disability by delta mRS ≤0 (ie, return to baseline, OR=1.247, 95%CI=0.943–1.648), delta mRS ≤1 (OR=1.149, 95%CI=0.906–1.458), delta mRS ≤2 (OR 1.097, 95% CI 0.869–1.386), TICI 2b–3 reperfusion (OR=0.914, 95%CI=0.712–1.173), final infarct size (P=0.853, β=−0.014), or intracerebral hemorrhage (OR=0.521, 95%CI=0.244–1.112).ConclusionsWhile baseline mRS was associated with absolute 90-day disability, there was no association with accumulated disability or other outcomes. Patients with baseline disability should not be routinely excluded from EVT based on baseline mRS alone.

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

“…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.…”

Symmetric CTA Collaterals Identify Patients with Slow-progressing Stroke Likely to Benefit from Late Thrombectomy

“…Age and sex were recorded at the time of enrollment (12). The presentation National Institutes of Health Stroke Scale (NIHSS) was determined at clinical examination by certified neurologists to measure clinical stroke severity (13). The time from last seen well and stroke onset was documented.…”

Mechanical thrombectomy is efficacious in patients with pre‐stroke moderate disability

“…[5][6][7] Consequently, the recently updated guidelines from the American Stroke Association/American Heart Association have suggested that only patients with pre-stroke mRS 0-2 should undergo MT. 8 Nevertheless, recent studies have reported no increase in mRS status in 20.7% of patients with premorbid mRS 3 9 , 26.7% of patients with mRS 2-3 10 and 24% of patients with mRS 2-4 11 The aim of this study was to examine whether the functional outcome of patients with pre-stroke mRS 3 undergoing MT at our stroke centre compared favourably to those previously reported. We also sought to analyse the financial implications of performing MT as measured by change in accommodation costs.…”