Endovascular Thrombectomy Versus Medical Management for Large Vessel Occlusion Stroke Patients with Severe Baseline Disability (S24.008)

Abstract

<h3>Objective:</h3> To compare the long-term outcomes and likelihood of transitions to comfort care for large vessel occlusion (LVO) stroke patients with severe baseline disability treated with endovascular thrombectomy (EVT) versus medical management. <h3>Background:</h3> Patients with baseline disability account for up to one-third of stroke presentations, but have traditionally been excluded from early clinical trials of acute stroke interventions. Despite growing evidence supporting a benefit from endovascular thrombectomy, there remains significant controversy in treatment selection. <h3>Design/Methods:</h3> Individuals who presented with LVO were identified from a prospectively maintained database from January 2017 to December 2020. Severe baseline disability was defined as modified Rankin Scale (mRS) 3–5. Delta mRS was defined as the difference between baseline and 90-day mRS. Logistic and ordinal regressions were performed to evaluate the relationships between EVT and clinical outcomes. <h3>Results:</h3> A total of 175/1007 (17%) patients were identified with severe baseline disability. The median age was 82 (IQR 70–89), and 59% were female. Thirty-two (18%) patients with severe baseline disability were treated with EVT. EVT was independently associated with improved delta mRS (B=−1.048; 95%CI=−1.777,−0.318; p=0.005) when accounting for age and NIHSS. However, EVT did not reduce the odds of transitioning to comfort care (aOR=0.794; 95%CI=0.347,1.818; p=0.585) when accounting for age and NIHSS. Seventy-six (43%) patients with severe baseline disability were transitioned to comfort care. Of the 99 patients who were not transitioned to comfort care, 18 were treated with EVT. In this subgroup not transitioned to comfort care, EVT was independently associated with improved delta mRS (B=−2.794; 95%CI=−4.002,−1.586; p&lt;0.0001) when accounting for age and NIHSS. <h3>Conclusions:</h3> Among patients with severe baseline disability, EVT is associated with less post-stroke accumulated disability without limiting transitions to comfort care. EVT is compatible with goal-concordant care in patients with severe baseline disability; it should not be routinely withheld on the sole basis of baseline disability. <b>Disclosure:</b> Dr. Awad has nothing to disclose. Dr. Young has nothing to disclose. Dr. Andreev has nothing to disclose. Dr. Dmytriw has nothing to disclose. Dr. Vranic has nothing to disclose. James D. Rabinov has stock in Pfizer. Dr. Stapleton has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Zoll Circulation. Dr. Das has nothing to disclose. An immediate family member of Dr. Singhal has received personal compensation for serving as an employee of Biogen. Dr. Singhal has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Medicolegal Firms. Dr. Singhal has received research support from NIH-NINDS. Dr. Singhal has received publishing royalties from a publication relating to health care. Dr. Singhal has received publishing royalties from a publication relating to health care. Dr. Singhal has received personal compensation in the range of $500-$4,999 for serving as a Honorarium (Education) with Biogen. Dr. Rost has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Stroke - AHA/ASA Journal. The institution of Dr. Rost has received research support from NIH. Dr. Rost has received publishing royalties from a publication relating to health care. Aman Patel has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Penumbra. Aman Patel has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Microvention. Aman Patel has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Medtronic. The institution of Aman Patel has received research support from Siemens. Dr. Regenhardt has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Rapid Medical. Dr. Regenhardt has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Johnson and Bell Trial Lawyers. The institution of Dr. Regenhardt has received research support from National Institutes of Health. The institution of Dr. Regenhardt has received research support from Society of Vascular and Interventional Neurology. The institution of Dr. Regenhardt has received research support from Heitman Foundation.