Abstract
ObjectivesEvidence of endovascular treatment (EVT) for acute large vessel occlusion (LVO) ischemic stroke in patients harboring substantial prestroke disability is lacking due to their exclusion from randomized trials. Here, we used routine care observational data to compare outcomes in patients with and without prestroke disability receiving EVT for LVO ischemic stroke.MethodsConsecutive patients undergoing EVT for acute LVO ischemic stroke at the Sahlgrenska University Hospital from January 1st, 2015 to March 31st, 2018 were registered in the Sahlgrenska Stroke Recanalization Registry. Pre- and poststroke functional levels were assessed by the modified Rankin Scale (mRS). Outcomes were recanalization rate (mTICI = 2b/3), symptomatic intracranial hemorrhage [sICH], complications during hospital stay, and return to prestroke functional level and mortality at 3 months.ResultsAmong 591 patients, 90 had prestroke disability (mRS ≥ 3). The latter group were older, more often female, had more comorbidities and higher NIHSS scores before intervention compared to patients without prestroke disability. Recanalization rates (80.0% vs 85.0%, p = 0.211), sICH (2.2% vs 6.3% p = 0.086) and the proportion of patients returning to prestroke functional level (22.7% vs 14.8% p = 0.062) did not significantly differ between those with and without prestroke disability. Patients with prestroke disability had higher complication rates during hospital stay (55.2% vs 40.1% p < 0.01) and mortality at 3 months (48.9% vs 24.3% p < 0.001).ConclusionOne of five with prestroke disability treated with thrombectomy for a LVO ischemic stroke returned to their prestroke functional level. However, compared to patients without prestroke disability, mortality at 3 months was higher.
Highlights
Endovascular treatment (EVT) has become the gold standard for treating large vessel occlusion (LVO) ischemic stroke in the anterior circulation following the publication of several randomized trials showing it to be safe and effective [1,2,3,4,5,6,7,8]
The American Heart Association guidelines [12] do not include LVO ischemic patients harboring prestroke dependency among those with indication for EVT, the guideline states that the treatment may be reasonable, while the European Stroke Organisation does not mention prestroke disability in their guidelines on thrombectomy in acute ischemic stroke [13]
Recanalization rates, symptomatic intracranial hemorrhage (sICH), and the proportion of patients returning to their prestroke functional level were not significantly worse when compared to prestroke-independent patients
Summary
Endovascular treatment (EVT) has become the gold standard for treating large vessel occlusion (LVO) ischemic stroke in the anterior circulation following the publication of several randomized trials showing it to be safe and effective [1,2,3,4,5,6,7,8]. Despite the clear evidence of the benefit of EVT in anterior circulation LVO, in clinical daily practice, stroke physicians are often faced with acute stroke patients for whom evidence-based data do not explicitly contribute to making treatment decisions. Prestroke disability with functional dependency is relatively common among patients presenting with acute ischemic stroke, with a reported frequency between 13 and 19.5% [9,10,11]. Goldhoorn et al reported prestroke dependency in 11% of patients who underwent EVT for an anterior circulation LVO in the observational MR CLEAN registry [14]. Despite lower absolute frequency of favorable outcomes at 90 days in prestroke-dependent patients compared to prestroke-independent patients, about one in four reached their prestroke functional level after EVT, indicating benefit of the treatment
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