Impact of pre-stroke dependency on outcome after endovascular therapy in acute ischemic stroke

Oesch, Lisa; Arnold, Marcel; Bernasconi, Corrado; Kaesmacher, Johannes; Fischer, Urs; Mosimann, Pascal J.; Jung, Simon; Meinel, Thomas; Goeldlin, Martina; Heldner, Mirjam R; Volbers, Bastian; Gralla, Jan; Sarıkaya, Hakan

doi:10.1007/s00415-020-10172-3

Cited by 17 publications

(25 citation statements)

References 44 publications

(54 reference statements)

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“…In this study, mortality rates differed according to the reason for pre-stroke dependence, data which was unfortunately unavailable for the HERMES cohort. Another study involving 84 pre-stroke dependent (mRS 3–5) patients found no differences in 90-day outcome, mortality, or rates of sICH following adjustment for potential confounders 10. While generally in line with the results of the literature, a considerable strength of this study is the presentation of the control group, allowing for the determination of treatment effect.…”

Section: Discussionsupporting

confidence: 70%

“…In the HERMES meta-analysis, the positive effect of EVT on outcome was maintained across multiple pre-specified subgroups, including patients of either sex, aged >80 years, those randomized more than 5 hours after symptom onset, and those who did not receive IV alteplase 11. Trials on other subgroups, such as those with low ASPECTS (LASTE, ClinicalTrials.gov Identifier: NCT03811769), low baseline NIHSS (ENDOLOW, ClinicalTrials.gov Identifier: NCT04167527; MOSTE, ClinicalTrials.gov Identifier: NCT03796468), and medium vessel occlusions (ESCAPE-MeVO, ClinicalTrials.gov Identifier: NCT05151172) have either been initiated or are currently underway, with an increasing amount of supportive evidence being generated from observational prospective and retrospective studies, including those involving patients with pre-stroke disability 8 10 15–20. This suggests that EVT is already being applied to a heterogenous population in clinical practice, which is required before we can examine its true effect on the broader population of patients with AIS.…”

Section: Discussionmentioning

confidence: 99%

“…Several studies have been published on the effects of EVT on outcome for patients with pre-stroke disability, the majority of which provide no convincing evidence for a reduced treatment effect in these patient subgroups 8–10. These studies were either observational or retrospective in nature, however, with varying inclusion criteria and outcome measures.…”

Section: Introductionmentioning

confidence: 99%

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

McDonough

Ospel

Majoie

et al. 2022

J NeuroIntervent Surg

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BackgroundAnalyses of the effect of pre-stroke functional levels on the outcome of endovascular therapy (EVT) have focused on the course of patients with moderate to substantial pre-stroke disability. The effect of complete freedom from pre-existing disability (modified Rankin Scale (mRS) 0) versus predominantly mild pre-existing disability/symptoms (mRS 1–2) has not been well delineated.MethodsThe HERMES meta-analysis pooled data from seven randomized trials that tested the efficacy of EVT. We tested for a multiplicative interaction effect of pre-stroke mRS on the relationship between treatment and outcomes. Ordinal regression was used to assess the association between EVT and 90-day mRS (primary outcome) in the subgroup of patients with pre-stroke mRS 1–2. Multivariable regression modeling was then used to test the effect of mild pre-stroke disability/symptoms on the primary and secondary outcomes (delta-mRS, mRS 0–2/5–6) compared with patients with pre-stroke mRS 0.ResultsWe included 1764 patients, of whom 199 (11.3%) had pre-stroke mRS 1–2. No interaction effect of pre-stroke mRS on the relationship between treatment and outcome was observed. Patients with pre-stroke mRS 1–2 had worse outcomes than those with pre-stroke mRS 0 (adjusted common OR (acOR) 0.53, 95% CI 0.40 to 0.70). Nonetheless, a significant benefit of EVT was observed within the mRS 1–2 subgroup (cOR 2.08, 95% CI 1.22 to 3.55).ConclusionsPatients asymptomatic/without disability prior to onset have better outcomes following EVT than patients with mild disability/symptoms. Patients with pre-stroke mRS 1–2, however, more often achieve good outcomes with EVT compared with conservative management. These findings indicate that mild pre-existing disability/symptoms influence patient prognosis after EVT but do not diminish the EVT treatment effect.

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Section: Discussionsupporting

confidence: 70%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

McDonough

Ospel

Majoie

et al. 2022

J NeuroIntervent Surg

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“…In our sample of patients, prestroke disability was associated with an increased mortality rate, especially in patients with MD that reaches 36%. Previous studies have shown higher mortality rates up to 40% to 50%, probably related to inclusion of some patients with prestroke mRS score 4 or 5 4,6–9 or vertebrobasilar stroke. 3,6,7 Although the CICAT registry did not record the causes of previous disability or a multimorbidity score, we might anticipate older age and higher frequency of previous disorders such as stroke or heart diseases in patients with prestroke disability as potential reasons for a higher mortality at 90 days.…”

Section: Discussionmentioning

confidence: 95%

Predictors of Functional Outcome After Thrombectomy in Patients With Prestroke Disability in Clinical Practice

Millán

Ramos

Dorado

et al. 2022

Stroke

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Background and Purpose: Mechanical thrombectomy (MT) in ischemic stroke patients with poor prestroke conditions remains controversial. We aimed to analyze the frequency of previously disabled patients treated with MT in clinical practice, the safety and clinical response to MT of patients with preexisting disability, and the disabled patient characteristics associated with a better response to MT. Methods: We studied all consecutive patients with anterior circulation occlusion treated with MT from January 2017 to December 2019 included in the Codi Ictus Catalunya registry—a government-mandated, prospective, hospital-based data set. Prestroke disability was defined as modified Rankin Scale score 2 or 3. Functional outcome at 90 days was centrally assessed by a blinded evaluator of the Catalan Stroke Program. Favorable outcome (to return at least to prestroke modified Rankin Scale at 90 days) and safety and secondary outcomes were compared with patients without previous disability. Logistic regression analysis was used to assess the association between prestroke disability and outcomes and to identify a disabled patient profile with favorable outcome after MT. Results: Of 2487 patients included in the study, 409 (17.1%) had prestroke disability (313 modified Rankin Scale score 2 and 96 modified Rankin Scale score 3). After adjustment for covariates, prestroke disability was not associated with a lower chance of achieving favorable outcome at 90 days (24% versus 30%; odds ratio, 0.79 [0.57–1.08]), whereas it was independently associated with a higher risk of symptomatic intracranial hemorrhage (5% versus 3%; odds ratio, 2.04 [1.11–3.72]) and long-term mortality (31% versus 18%; odds ratio, 1.74 [1.27–2.39]) compared with patients without disability. Prestroke disabled patients without diabetes, Alberta Stroke Program Early CT Score >8 and National Institutes of Health Stroke Scale score <17 showed similar safety and outcome results after MT as patients without prestroke disability. Conclusions: Despite a higher mortality and risk of symptomatic intracranial hemorrhage, prestroke-disabled patients return as often as independent patients to their prestroke level of function, especially those nondiabetic patients with favorable early ischemic signs profile. These data support a potential benefit of MT in patients with previous mild or moderate disability after large anterior vessel occlusion stroke.

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“…A total of 14 articles from 13 author groups were included. Ten studies compared outcomes between patients with versus without pre-morbid stroke disability treated with EVT 14–24. We found two studies comparing patients with pre-morbid disability treated with EVT to pre-morbidly disabled patients receiving medical management alone 25 26.…”

Section: Resultsmentioning

confidence: 99%

Endovascular treatment of acute ischemic stroke in patients with pre-morbid disability: a meta-analysis

Bala

Beland

Mistry

et al. 2022

J NeuroIntervent Surg

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BackgroundTrials of endovascular thrombectomy (EVT) for acute stroke have excluded patients with pre-morbid disability. Observational studies may help inform consideration of EVT in this population. We aimed to assess the effectiveness and safety of EVT in patients with pre-morbid disability.MethodsAccording to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE and Embase for studies describing outcomes in patients with pre-morbid disability (modified Rankin Scale (mRS) 2–5), treated with EVT or medical management (MM). Random-effects meta-analysis was used to pool outcomes including 90-day return to baseline mRS, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality.ResultsWe analyzed 14 studies of patients with pre-morbid disability (mRS 2–5, 1373 EVT and 253 MM). The rate of return to baseline mRS was 30.0% (95% CI 25.3% to 34.7%) in patients treated with EVT. Compared with medical therapy, EVT was associated with a higher likelihood of return to baseline mRS (OR 2.37, 95% CI 1.39 to 4.04) and a trend towards lower mortality (OR 0.68, 95% CI 0.46 to 1.02), with similar odds of sICH (OR 1.01, 95% CI 0.49 to 2.08). In studies comparing patients with versus without pre-morbid disability treated with EVT, similar results were found except that pre-morbid disability, when defined more strictly as mRS 3–5, was associated with mortality (OR 3.49, p<0.001).ConclusionIn eligible patients with pre-morbid disability, observational studies suggest that EVT carries a higher chance of return to baseline mRS compared with patients treated with MM or without pre-morbid disability, although with higher mortality than patients without pre-morbid disability. These findings argue against the routine exclusion of such patients from EVT and merit validation with randomized trials.

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Impact of pre-stroke dependency on outcome after endovascular therapy in acute ischemic stroke

Cited by 17 publications

References 44 publications

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

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

Predictors of Functional Outcome After Thrombectomy in Patients With Prestroke Disability in Clinical Practice

Endovascular treatment of acute ischemic stroke in patients with pre-morbid disability: a meta-analysis

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