Mechanical Thrombectomy in Ischemic Stroke Patients with Severe Pre-Stroke Disability

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.

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

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

Bala

Beland

Mistry

et al. 2022

“…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%

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

McDonough

Ospel

Majoie

et al. 2022

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.

“…However, in clinical practice, patients with AIS and pre-stroke mRS 0–2 are routinely offered EVT 9. Furthermore, most evidence for EVT in patients with pre-stroke mRS 3–5 has been gathered from observational studies 10–13. In these studies, pre-stroke dependent patients with the full range of dependence (mRS 3–5) were included and compared with pre-stroke independent patients (mRS 0–2), showing that the latter fare better than the former 13–15.…”

Section: Introductionmentioning

confidence: 99%

Benefit of successful reperfusion achieved by endovascular thrombectomy for patients with ischemic stroke and moderate pre-stroke disability (mRS 3): results from the MR CLEAN Registry

Benali

Kappelhof

Ospel

et al. 2022

BackgroundPre-stroke dependent patients (modified Rankin Scale score (mRS) ≥3) were excluded from most trials on endovascular treatment (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Therefore, little evidence exists for EVT in those patients. We aimed to investigate the safety and benefit of EVT in pre-stroke patients with mRS score 3.MethodsWe used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic stroke in the Netherlands (MR CLEAN) Registry. All patients treated with EVT for anterior circulation AIS with pre-stroke mRS 3 were included. We assessed causes for dependence and compared patients with successful reperfusion (defined as expanded Thrombolysis in Cerebral Ischemia scale (eTICI) 2b–3) to patients without successful reperfusion. We used regression analyses with pre-specified adjustments. Our primary outcome was 90-day mRS 0–3 (functional improvement or return to baseline).ResultsA total of 192 patients were included, of whom 82 (43%) had eTICI <2b and 108 (56%) eTICI ≥2b. The median age was 80 years (IQR 73–87). Fifty-one of the 192 patients (27%) suffered from previous stroke and 36/192 (19%) had cardiopulmonary disease. Patients with eTICI ≥2b more often returned to their baseline functional state or improved (n=26 (26%) vs n=15 (19%); adjusted odds ratio (aOR) 2.91 (95% CI 1.08 to 7.82)) and had lower mortality rates (n=49 (49%) vs n=50 (64%); aOR 0.42 (95% CI 0.19 to 0.93)) compared with patients with eTICI <2b.ConclusionsAlthough patients with AIS with pre-stroke mRS 3 comprise a heterogenous group of disability causes, we observed improved outcomes when patients achieved successful reperfusion after EVT.