Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Havenon, Adam de; Castonguay, Alicia C.; Nogueira, Raul G; Nguyen, Thanh N.; English, Joey; Satti, Sudhakar R; Veznedaroglu, Erol; Saver, Jeffrey L.; Mocco, J; Khatri, Pooja; Mistry, Eva; Zaidat, Osama O.

doi:10.1212/wnl.0000000000012827

Cited by 35 publications

(56 citation statements)

References 18 publications

(32 reference statements)

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“…We applaud the TRACK Registry investigators for their evaluation of outcomes after thrombectomy in patients with prestroke disability. 1 Although we strongly agree with the investigators that patients with preexisting disability will benefit more from endovascular therapy than they otherwise would from medical management, we are curious as to why the investigators selected the primary outcome of accumulated disability. For a condition in which patients are more likely to have long-term disability (modified Rankin Score >2) than to regain functional independence-despite thrombectomy-assessing for zero functional decline introduces an outcome misclassification bias that preferentially favors patients with prestroke disability.…”

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confidence: 69%

“…We read with interest the article by de Havenon et al 1 In this study, the authors performed a post hoc analysis in patients with thrombectomy to examine the relationship between premorbid disability and outcome of endovascular therapy by using the modified Rankin Scale (mRS). They found that patients without premorbid disability were more likely to accumulate further disability than those patients with premorbid disability, but patients with premorbid disability had a higher mortality.…”

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confidence: 99%

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Editors' Note: Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Lewis¹,

Galetta²

2022

Neurology

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In “Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke,” de Havenon et al. reported that of 407 patients with anterior circulation strokes, premorbid disability (defined as a modified Rankin Scale (mRS) score ≥2) was associated with a higher likelihood that the 90-day mRS score would not be increased from the premorbid mRS score compared with patients without premorbid disability. However, those with premorbid disability had a higher risk of death. Feng et al. suggest that it would be helpful to evaluate the relationship between the etiology of prestroke disability and postthrombectomy outcome, but de Havenon notes that data are not included in the TRACK registry. Siegler et al. question the use of accumulated disability as the outcome measure in this study given that patients with prestroke disability are more likely to have zero functional decline than patients with no prestroke disability. They note that the results of this study could be interpreted to mean patients who do not have prestroke disability benefit less from thrombectomy, but that this conclusion would be inaccurate given that the absence of prestroke disability is associated with a lower risk of death. They suggest that the lack of new disability or an mRS score 0–2 might have been a better outcome. de Havenon responds that these end points would not be optimal either. They further comment that it would be ideal for a future study to compare outcomes among patients with premorbid disability via matched analysis of medical management vs thrombectomy. Additional research may facilitate a better understanding of factors associated with postthrombectomy outcome and impact selection criteria. Furthermore, this exchange demonstrates the fact that there are limitations of the scales that we use to assess disability following stroke.

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confidence: 69%

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confidence: 99%

Editors' Note: Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Lewis¹,

Galetta²

2022

Neurology

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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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“…Future RCTs should pay closer attention to these details so that findings can be more relatable between studies and increase eligibility. Fewer studies have investigated the clinical outcome of EVT in PSD patients with an mRS score ≥ 2 ( 25 – 28 ). Their conclusions were consistent and in agreement with the findings of the present meta-analysis.…”

Section: Discussionmentioning

confidence: 99%

Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

et al. 2022

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IntroductionEndovascular thrombectomy (EVT) is a well-established and effective therapeutic option for patients that meet certain criteria. However, this modality is not well studied in patients with pre-existing disability. The aim of the present study was to investigate the impact of mechanical thrombectomy in patients with acute onset ischemic stroke and pre-stroke dependency (PSD) in regard to their clinical outcome and mortality.Materials and MethodsThe MEDLINE, Scopus, and Cochrane Library databases were comprehensively searched with a cut-off date of December 11th, 2021. We performed meta-analysis to investigate the 90-day clinical outcome, the 90-day mortality, and the rate of symptomatic intracerebral hemorrhage (sICH) between the PSD (modified Rankin Scale score ≥ 3) and non-PSD (modified Rankin Scale score = 0–2) groups who underwent EVT for acute onset ischemic stroke.ResultsSix studies were included in the meta-analysis involving 4,543 cases with no PSD and 591 cases with PSD. The non-PSD group showed a statistically significant better clinical outcome at 90 days compared to the PSD group [RR (95% CI) = 1.44 (1.06, 1.85); pz = 0.02]. The non-PSD group demonstrated a statistically significant lower risk of death at 90 days in comparison to the PSD group [RR (95% CI) = 0.45 (0.41, 0.50); pz < 0.01]. Lastly, the rate of sICH was comparable between the two groups [RR (95% CI) = 0.89 (0.64, 1.24); pz = 0.48].DiscussionWe report a higher rate of unfavorable clinical outcome and a higher mortality rate in patients with PSD undergoing EVT compared to those with no previous disability. However, there was a significant proportion of PSD cases who fared well post-procedurally, indicating that PSD patients should not be routinely excluded from mechanical thrombectomy.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021284181, identifier: CRD42021284181.

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Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Cited by 35 publications

References 18 publications

Editors' Note: Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Editors' Note: Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

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

Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

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