Patients with premorbid disability or dementia have generally been excluded from randomized controlled trials of reperfusion therapies such as thrombolysis and endovascular therapy for acute ischemic stroke. Consequently, stroke physicians face treatment dilemmas in caring for such patients. In this scientific statement, we review the literature on acute ischemic stroke in patients with premorbid disability or dementia and propose principles to guide clinicians, clinician-scientists, and policymakers on the use of acute stroke therapies in these populations. Recent clinical-epidemiological studies have demonstrated challenges in our concept and measurement of premorbid disability or dementia while highlighting the significant proportion of the general stroke population that falls under this umbrella, risking exclusion from therapies. Such studies have also helped clarify the adverse long-term clinical and health economic consequences with each increment of additional poststroke disability in these patients, underscoring the importance of finding strategies to mitigate such additional disability. Several observational studies, both case series and registry-based studies, have helped demonstrate the comparable safety of endovascular therapy in patients with premorbid disability or dementia and in those without, complementing similar data on thrombolysis. These data also suggest that such patients have a substantial potential to retain their prestroke level of disability when treated, despite their generally worse prognosis overall, although this remains to be validated in higher-quality registries and clinical trials. By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, we can work toward a more inclusive paradigm of patient-centered care for this often-neglected patient population.

Background: Despite the well-established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT has not been studied globally. We conducted a worldwide survey of countries on 6 continents to define MT access (MTA), the disparities in MTA, and its determinants on a global scale. Methods: Our survey was conducted in 75 countries through the Mission Thrombectomy 2020+ global network between November 22, 2020, and February 28, 2021. The primary end points were the current annual MTA, MT operator availability, and MT center availability. MTA was defined as the estimated proportion of patients with LVO receiving MT in a given region annually. The availability metrics were defined as ([current MT operators×50/current annual number of estimated thrombectomy-eligible LVOs]×100 = MT operator availability) and ([current MT centers×150/current annual number of estimated thrombectomy-eligible LVOs]×100= MT center availability). The metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150. Multivariable-adjusted generalized linear models were used to evaluate factors associated with MTA. Results: We received 887 responses from 67 countries. The median global MTA was 2.79% (interquartile range, 0.70–11.74). MTA was <1.0% for 18 (27%) countries and 0 for 7 (10%) countries. There was a 460-fold disparity between the highest and lowest nonzero MTA regions and low-income countries had 88% lower MTA compared with high-income countries. The global MT operator availability was 16.5% of optimal and the MT center availability was 20.8% of optimal. On multivariable regression, country income level (low or lower–middle versus high: odds ratio, 0.08 [95% CI, 0.04–0.12]), MT operator availability (odds ratio, 3.35 [95% CI, 2.07–5.42]), MT center availability (odds ratio, 2.86 [95% CI, 1.84–4.48]), and presence of prehospital acute stroke bypass protocol (odds ratio, 4.00 [95% CI, 1.70–9.42]) were significantly associated with increased odds of MTA. Conclusions: Access to MT on a global level is extremely low, with enormous disparities between countries by income level. The significant determinants of MT access are the country’s per capita gross national income, prehospital LVO triage policy, and MT operator and center availability.

Introduction: Alteplase is the only FDA approved thrombolytic agent for acute ischemic stroke, tenecteplase is rapidly emerging as an alternative. While both agents are readily available worldwide, low to middle income countries have limited access to acute treatment. To our knowledge, there is no validated tool available to objectively measure access to thrombolytic agents or barriers to routine clinical use. Methods: We develop the 17-item tPA Spot Check tool to assess utilization of acute stroke thrombolysis in multiple languages. This tool was used to evaluate the current state of clinical practices in the MT2020+ Caribbean Region. Data was analyzed via SPSS. Results: The survey was validated by three international experts with an Average Content Validity Index of 1 and a Universal Agreement index of 1 across three domains: local experience, financial constraints, and barriers to utilization.Survey response rate was 64% (73/114 responses) 46 in English, 14 in Spanish and 13 in French. Fifteen out of 44 MT2020+ Caribbean countries (34%) participated: Haiti, Dominican Republic, Jamaica, Puerto Rico, St. Lucia, Bermuda, Bahamas, Cayman Islands, Trinidad and Tobago, Barbados, Dominica, Venezuela, Nicaragua, Honduras, and Guadalupe. There was limited or no access to thrombolytic agents in 40% of countries surveyed, with 13% resorting to the use of streptokinase. Among cases treated with thrombolytics, 43% of patients had to pay out of pocket before treatment provided, 36% of treatment was paid by insurance plus patients and less than 10% were covered by insurance or governmental support respectively. Among 51% of countries survey, no acute thrombolytic treatment was provided for acute stroke in 2021 calendar year. Only 1 center treated more than 100 cases per year. Majority of respondents (88%) agreed there were barriers to acute stroke thrombolysis in the region. Absence of Stroke protocol (p<0.001), upfront cost of alteplase (p= 0.003) and access to CT scan (p=0.03) were independent predictors of fewer patients treated per year. Conclusion: This this survey brings light to an enormous disparity in care of stroke patients around the world, specifically in the MT2020+ Caribbean region. We create a valid tool can be used to assess local access to thrombolytic.