Clinical outcome of patients with mild pre-stroke morbidity following endovascular treatment: a HERMES substudy

McDonough, Rosalie; Ospel, Johanna M.; Majoie, Charles B. L. M.; Saver, Jeffrey L.; White, Philip; Dippel, Diederik W.J.; Brown, Scott; Demchuk, Andrew M.; Jovin, Tudor G; Mitchell, Peter; Bracard, Serge; Campbell, Bruce; Muir, Keith W.; Hill, Michael D.; Guillemin, Françis; Goyal, Mayank

doi:10.1136/neurintsurg-2021-018428

Cited by 11 publications

(13 citation statements)

References 26 publications

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“…Third, we could not draw valid conclusions about patients with a prestroke mRS of 5 because EVT was very uncommon in this population. Four, one ( 25 ) of the three studies that compared the outcomes between EVT and SMT involved some patients with mRS 1, also limiting the validity of our findings.…”

Section: Discussionmentioning

confidence: 71%

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

et al. 2022

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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/.

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Section: Discussionmentioning

confidence: 71%

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

et al. 2022

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“…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. 16 Furthermore, there was no evidence of treatment effect modification of EVT by prestroke mRS, suggesting that the effect of EVT is similar in patients with and without mild preexisting symptoms/disability. Although the former may be at a slightly higher risk of death compared with the latter, they are not more likely to accumulate additional disability over and beyond their preexisting deficits compared to those patients without preexisting symptoms/disability.…”

Section: Discussionmentioning

confidence: 90%

“…HERMES included 199 patients with prestroke mRS score 1 or 2; 98 in the EVT arm and 101 in the best medical management arm. 16…”

Section: Methodsmentioning

confidence: 99%

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

Ospel

Kunz

McDonough

et al. 2023

Stroke

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Background: The clinical and economic benefit of endovascular treatment (EVT) in addition to best medical management in patients with stroke with mild preexisting symptoms/disability is not well studied. We aimed to investigate cost-effectiveness of EVT in patients with large vessel occlusion and mild prestroke symptoms/disability, defined as a modified Rankin Scale score of 1 or 2. Methods: Data are from the HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials), which pooled patient-level data from 7 large, randomized EVT trials. We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes from a health care and a societal perspective. Incremental cost-effectiveness ratio and net monetary benefits were calculated, and a probabilistic sensitivity analysis was performed. Results: EVT in addition to best medical management resulted in lifetime cost savings of $2821 (health care perspective) or $5378 (societal perspective) and an increment of 1.27 quality-adjusted life years compared with best medical management alone, indicating dominance of additional EVT as a treatment strategy. The net monetary benefits were higher for EVT in addition to best medical management compared with best medical management alone both at the higher (100 000$/quality-adjusted life years) and lower (50 000$/quality-adjusted life years) willingness to pay thresholds. Probabilistic sensitivity analysis showed decreased costs and an increase in quality-adjusted life years for additional EVT compared with best medical management only. Conclusions: From a health-economic standpoint, EVT in addition to best medical management should be the preferred strategy in patients with acute ischemic stroke with large vessel occlusion and mild prestroke symptoms/disability.

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“…While the mRS is a validated measure to assess poststroke neurological and functional outcomes, 14 whether it is an appropriate tool to quantify non-neurological disability prior to stroke onset is unclear. Past studies have demonstrated that prestroke mRS is a negative prognostic factor for post-EVT outcomes, [15][16][17] however, no study to date has investigated whether these associations apply to both neurological and non-neurological causes of higher prestroke mRS. There is currently little guidance on how to assess non-neurological disability during acute triage, and using prestroke mRS to quantify disability from osteoarthritis and other musculoskeletal diseases has not been validated.…”

Section: Discussionmentioning

confidence: 99%

Associations of Osteoarthritis With Thrombectomy Utilization and Outcomes for Large Vessel Acute Ischemic Stroke

Chen

Khunte

Colasurdo

et al. 2023

Stroke

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BACKGROUND: Osteoarthritis and other musculoskeletal disorders are the leading causes of disability in the United States. While osteoarthritis is not a direct risk factor for stroke, osteoarthritis may impact patient selection for endovascular thrombectomy (EVT) due to prestroke disability. This study investigates associations of osteoarthritis with EVT utilization and outcomes. METHODS: This was a large-scale cross-sectional study of the 2016 to 2019 National Inpatient Sample database. Adult patients with anterior large vessel ischemic strokes were identified. Patient demographics, stroke risk factors, stroke etiology, presence of osteoarthritis, medical comorbidities, EVT, intravenous thrombolysis treatments, and discharge destinations were recorded. Primary outcome was the rate of EVT treatment. Secondary outcomes include rates of discharge to home and in-hospital mortality. Propensity score matching and multivariable logistic regression models were used to account for possible confounders. RESULTS: Two hundred fifty-two thousand five hundred five patients were identified, of whom 8.5% (21 500 patients) had osteoarthritis. After propensity score matching for 32 clinical variables, osteoarthritis patients were found to be 17.3% less likely to receive EVT than non-osteoarthritis patients (14.4% versus 17.3%, respectively; P <0.001). In multivariable logistic regression analysis, osteoarthritis was associated with 22.6% lower odds of receiving EVT (OR, 0.77 [95% CI, 0.70–0.86]; P <0.001), an effect size larger than any medical comorbidity captured in this study other than dementia and nonstroke neurological disease. Among those treated with EVT, multivariable logistic regression models showed that osteoarthritis was not associated with different odds of being discharged home (OR, 0.99 [95% CI, 0.81–1.21]; P =0.93); however, osteoarthritis was marginally associated with lower odds of in-hospital mortality (OR, 0.74 [95% CI, 0.54–1.01]; P =0.054). CONCLUSIONS: Large vessel ischemic stroke patients with osteoarthritis were significantly less likely to receive EVT therapy despite similar post-EVT outcomes. These results warrant further investigation and prompt a critical review of current patient selection practices for stroke EVT therapy, specifically for patients with baseline disability due to musculoskeletal conditions such as osteoarthritis.

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Clinical outcome of patients with mild pre-stroke morbidity following endovascular treatment: a HERMES substudy

Cited by 11 publications

References 26 publications

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

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

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

Associations of Osteoarthritis With Thrombectomy Utilization and Outcomes for Large Vessel Acute Ischemic Stroke

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