Prestroke Disability Research Articles

Abstract 122: Mechanical Thrombectomy for Acute Stroke in the Elderly: A Single‐Center Case Series in the Philippines

Introduction Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke (AIS) caused by large‐vessel occlusion. However, the extent of its benefits in elderly populations remains uncertain, as most landmark trials on MT have focused on younger individuals. This single‐center case series aims to shed light on the advantages and disadvantages of MT in higher age groups, particularly within the context of low‐ or middle‐income countries. Methods Between January 2018 and June 2023, we conducted a chart review of five patients aged ≥80 years who underwent MT for stroke. The study analyzed the patients' premorbid comorbidities, time to treatment, revascularization rates, procedural complications, mortality, and 90‐day modified Rankin Scale (mRS) scores. Results The five cases included individuals aged between 81 and 94 years. Among them, two had mild baseline disability (mRS score 0‐1), and three had moderate baseline disability (mRS score 2‐4). Upon admission, the National Institutes of Health Stroke Scale (NIHSS) scores ranged from 14 to 24. Three of the patients received pre‐thrombectomy intravenous thrombolysis with Alteplase and subsequently underwent MT within 4 to 7 hours of symptom onset. Successful recanalization (TICI score 2b‐3) was achieved in all five patients. However, two patients developed symptomatic intracranial hemorrhage post‐thrombectomy, and one of them succumbed to the complication. Three out of the four discharged patients attained favorable clinical outcomes with a 90‐day mRS score of 0‐2 or equivalent to their prestroke disability. Conclusion Our case series suggests that elderly individuals can potentially achieve favorable functional outcomes after MT. Nevertheless, this potential is influenced by stroke severity and the success of the treatment. As the elderly population, including octogenarians, nonagenarians, and centenarians, is expected to grow in the future, cautious patient selection should be exercised when considering thrombectomy in this age group. Further research comparing endovascular and conventional treatments in the elderly is imperative to inform better clinical decisions.

Black Americans have worse stroke outcome compared with non-Hispanic whites

IntroductionWe studied racial differences in post-stroke outcomes using a prospective, population-based cohort of stroke survivors as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. MethodsNeurologic (NIHSS, range of 0–42, higher scores are worse), functional (ADLs/IADLs, range 1–4, higher scores are worse), and cognitive (3MSE, range 0–100, higher scores are better) outcomes were measured 90 days after stroke. Cox proportional hazards and negative binomial linear regression models were used to examine the associations between race and 90-day all-cause mortality and NIHSS, respectively, whereas linear regression was used for ADLs/IADLs and 3MSE scores. Covariates included demographics, initial NIHSS, comorbidities, prior stroke history, tPA treatment status, pre-stroke disability, and pre-stroke cognition. The mortality model was also adjusted for DNR status. ResultsAt 90 days post-stroke, Black American individuals (BAs) (n = 122) had a median (IQR) NIHSS of 2 (1,6) compared to NIHSS of 1 (0,3) in non-Hispanic White American individuals (NHWs) (n = 795). BAs had a median (IQR) ADL/IADL score of 2.41 (1.50, 3.39) compared to 2.00 (1.27, 2.95) in NHWs. BAs scored a median of 84 (75, 92) on the 3MSE compared to NHWs’ score of 91.5 (83, 96). Death occurred in 23 (8%) of BAs and 268 (15%) of NHWs within 90 days among those who participated in baseline. After adjustment for covariates, functional outcomes at 90 days were worse in BAs compared to NHWs, with 15.8% (95% CI=5.2, 26.4) greater limitations in ADLs/IADLs and 43.9% (95% CI=12.0, 84.9) greater severity of stroke symptoms. Cognition at 90 days was 6.5% (95% CI=2.4, 10.6) lower in BAs compared to NHWs. BAs had a 35.4% lower (95% CI=-9.8, 61.9) hazard rate of mortality than NHWs. ConclusionsIn this prospective, population-based community sample, BAs had worse neurologic, functional and cognitive outcomes at 90 days compared to NHWs. Future research should investigate how social determinants of health including structural racism, neighborhood factors and access to preventive and recovery services influences these racial disparities.

What would other emergency stroke teams do? Using explainable machine learning to understand variation in thrombolysis practice.

The aim of this work was to understand between-hospital variation in thrombolysis use among emergency stroke admissions in England and Wales. A total of 88,928 patients who arrived at all 132 emergency stroke hospitals in England Wales within 4 h of stroke onset, from 2016 to 2018. Machine learning was applied to the Sentinel Stroke National Audit Programme (SSNAP) data set, to learn which patients in each hospital would likely receive thrombolysis. We used XGBoost machine learning models, coupled with a SHAP model for explainability; Shapley (SHAP) values, providing estimates of how patient features, and hospital identity, influence the odds of receiving thrombolysis. Thrombolysis use in patients arriving within 4 h of known or estimated stroke onset ranged 7% -49% between hospitals. The odds of receiving thrombolysis reduced 9-fold over the first 120 min of arrival-to-scan time, varied 30-fold with stroke severity, reduced 3-fold with estimated rather than precise stroke onset time, fell 6-fold with increasing pre-stroke disability, fell 4-fold with onset during sleep, fell 5-fold with use of anticoagulants, fell 2-fold between 80 and 110 years of age, reduced 3-fold between 120 and 240 min of onset-to-arrival time and varied 13-fold between hospitals. The majority of between-hospital variance was explained by the hospital, rather than the differences in local patient populations. Using explainable machine learning, we identified that the majority of the between-hospital variation in thrombolysis use in England and Wales may be explained by differences in in-hospital processes and differences in attitudes to judging suitability for thrombolysis.

Osteoarthritis is associated with lower likelihood of receiving stroke thrombectomy despite similar post-thrombectomy outcomes: a national study (P8-5.023)

<h3>Objective:</h3> To investigate whether osteoarthritis (OA) impacts stroke thrombectomy treatment rates or post-thrombectomy outcomes. <h3>Background:</h3> Osteoarthritis (OA) is a common condition affecting as many as 30 million Americans. While OA is not a direct risk factor for acute ischemic stroke, it can be associated with pre-stroke disability and influence patient selection for endovascular thrombectomy (EVT). Whether OA impacts post-EVT outcomes is currently unknown. <h3>Design/Methods:</h3> This was a retrospective study of the 2016–2019 National Inpatient Sample database. Adult patients with large vessel acute ischemic stroke were included. Patients with osteoarthritis were identified. Primary outcome was rate of EVT treatment in OA patients versus non-OA patients. Secondary outcomes include rates of discharge to home and in-hospital mortality after EVT treatment. Propensity score-matching (PSM) and multivariable logistic regression models were used to account for possible confounders. <h3>Results:</h3> 252,505 large vessel ischemic stroke patients were identified, of whom 21,500 patients (8.5% of study population) were diagnosed with OA. After PSM for 27 clinical variables, OA patients were 21.3% less likely to receive EVT than non-OA patients (14.4% vs. 18.3%, respectively; p&lt;0.001). In multivariable logistic regression analysis, OA was associated with 31% lower odds of receiving EVT (OR 0.69 [95%CI 0.63 to 0.76], p&lt;0.001), an effect size second only to dementia and larger than that of any other comorbidity captured in this study. Among patients who received EVT, multivariable logistic regression models showed that OA was not associated with different odds of being discharged home (OR 1.01 [95%CI 0.83 to 1.23], p=0.92); however, OA was associated with lower odds of in-hospital mortality compared to non-OA patients (OR 0.74 [95%CI 0.55 to 0.99], p=0.044). <h3>Conclusions:</h3> Large vessel ischemic stroke patients with OA were significantly less likely to receive EVT therapy despite similar post-EVT outcomes. These results warrant further investigation and prompt a critical review of current patient selection practices for EVT. <b>Disclosure:</b> Mr. Chen has received research support from National Institues of Health. Mr. Khunte has nothing to disclose. Dr. Colasurdo has nothing to disclose. Gaurav Jindal has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Penumbra. Ajay Malhotra, 9122 has nothing to disclose. Dheeraj Gandhi has nothing to disclose. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Astra Zeneca. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for University of Calgary. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Ramar &amp; Paradiso. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Cole, Scott, Kissane. The institution of Dr. Chaturvedi has received research support from NINDS.

Clinical and Demographic Characteristics, Mechanisms, and Outcomes in Patients With Acute Ischemic Stroke and Newly Diagnosed or Known Active Cancer.

Patients with a new diagnosis of cancer carry an increased risk of acute ischemic stroke (AIS), and this risk varies depending on age, cancer type, stage, and time from diagnosis. Whether patients with AIS with a new diagnosis of neoplasm represent a distinct subset from those with a previously known active malignancy remains unclear. We aimed to estimate the rate of stroke in patients with newly diagnosed cancer (NC) and previously known active cancer (KC) and to compare the demographic and clinical features, stroke mechanisms, and long-term outcomes between groups. Using 2003-2021 data from the Acute STroke Registry and Analysis of Lausanne registry, we compared patients with KC with patients with NC (cancer identified during AIS hospitalization or within the following 12 months). Patients with inactive and no history of cancer were excluded. Outcomes were the modified Rankin scale (mRS) score at 3 months and mortality and recurrent stroke at 12 months. We used multivariable regression analyses to compare outcomes between groups while adjusting for important prognostic variables. Among 6,686 patients with AIS, 362 (5.4%) had active cancer (AC), including 102 (1.5%) with NC. Gastrointestinal and genitourinary cancers were the most frequent cancer types. Among all patients with AC, 152 (42.5%) AISs were classified as cancer related, with nearly half of these cases attributed to hypercoagulability. In multivariable analysis, patients with NC had less prestroke disability (adjusted odds ratio [aOR] 0.62, 95% CI 0.44-0.86) and fewer prior stroke/transient ischemic attack events (aOR 0.43, 95% CI 0.21-0.88) than patients with KC. Three-month mRS scores were similar between cancer groups (aOR 1.27, 95% CI 0.65-2.49) and were predominantly driven by the presence of newly diagnosed brain metastases (aOR 7.22, 95% CI 1.49-43.17) and metastatic cancer (aOR 2.19, 95% CI 1.22-3.97). At 12 months, mortality risk was higher in patients with NC vs patients with KC (hazard ratio [HR] 2.11, 95% CI 1.38-3.21), while recurrent stroke risk was similar between groups (adjusted HR 1.27, 95% CI 0.67-2.43). In a comprehensive institutional registry spanning nearly 2 decades, 5.4% of patients with AIS had AC, a quarter of which were diagnosed during or within 12 months after the index stroke hospitalization. Patients with NC had less disability and prior cerebrovascular disease, but a higher 1-year risk of subsequent death than patients with KC.

Editors' Note: Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan.

Dr. Siegler and colleagues evaluated outcomes of mechanical thrombectomy (MT) vs medical management in a multinational cohort of 554 patients with a prestroke modified Rankin Scale (mRS) score of 2–4 and anterior circulation large vessel occlusion, treated 6–24 hours from the time last seen well. They found that MT was associated with higher odds of return to prestroke mRS by 90 days. In response, Drs. Bruno and Nichols noted that there is no clear guidance for scoring a baseline or prestroke mRS (indeed, the mRS was originally intended for evaluating poststroke outcomes). They also contend that scoring a 90-day mRS in patients with prestroke disability is not clearly defined. Responding to these comments, the authors agree that the prestroke mRS has important limitations, but point to the fact that this measure has been used in various studies, including in the selection of patients for interventional stroke trials. They correctly note that current guidelines to score the poststroke mRS are intended simply to score how the patient is functioning at the time in question, rather than making judgments about how they are doing in relation to their prestroke status. Overall, this exchange demonstrates important nuances in the assessment of prestroke status and poststroke outcomes in patients with prestroke disability—a population that has been poorly represented in acute stroke trials. Dr. Siegler and colleagues evaluated outcomes of mechanical thrombectomy (MT) vs medical management in a multinational cohort of 554 patients with a prestroke modified Rankin Scale (mRS) score of 2–4 and anterior circulation large vessel occlusion, treated 6–24 hours from the time last seen well. They found that MT was associated with higher odds of return to prestroke mRS by 90 days. In response, Drs. Bruno and Nichols noted that there is no clear guidance for scoring a baseline or prestroke mRS (indeed, the mRS was originally intended for evaluating poststroke outcomes). They also contend that scoring a 90-day mRS in patients with prestroke disability is not clearly defined. Responding to these comments, the authors agree that the prestroke mRS has important limitations, but point to the fact that this measure has been used in various studies, including in the selection of patients for interventional stroke trials. They correctly note that current guidelines to score the poststroke mRS are intended simply to score how the patient is functioning at the time in question, rather than making judgments about how they are doing in relation to their prestroke status. Overall, this exchange demonstrates important nuances in the assessment of prestroke status and poststroke outcomes in patients with prestroke disability—a population that has been poorly represented in acute stroke trials.

Author Response: Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan.

We thank Dr. Bruno and Dr. Nichols for their thoughtful comment of our CLEAR and RESCUE-Japan analysis on endovascular therapy of late large vessel occlusion with prestroke disability.1

Reader Response: Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan.

We were intrigued with the study conducted by Siegler et al.1 who analyzed the potential benefits of mechanical thrombectomy among patients with acute stroke with preexisting disabilities. We would like to outline important limitations in comparing baseline (prestroke) and poststroke modified Rankin scale (mRS) scores.

Incidence and predictors of poor functional outcome despite complete recanalisation following endovascular thrombectomy for acute ischaemic stroke

BackgroundNumerous ischaemic stroke patients experience poor functional outcome despite successful recanalisation following endovascular thrombectomy (EVT). We aimed to identify the incidence and predictors of futile complete recanalisation (FCR) in a national stroke registry. MethodsPatients who achieved complete recanalisation (mTICI 3) following EVT, between October 2015 and March 2020, were included from a United Kingdom national stroke registry. Modified Rankin Scale of 4-6 at discharge was defined as a ‘poor/futile outcome’. Backward stepwise multivariable logistic regression analysis was performed with FCR as the dependent variable, incorporating all baseline characteristics, procedural time metrics and post-procedural events. ResultsWe included 2132 of 4383 patients (48.8%) with complete recanalisation post-EVT, of which 948 patients (44.4%) developed FCR. Following multivariable regression analysis adjusted for potential confounders, patients with FCR were associated with multiple baseline patient, imaging and procedural factors: age (p=0.0001), admission NIHSS scores (p=0.0001), pre-stroke disability (p=0.007), onset-to-puncture (p=0.0001) and procedural times (p=0.0001), presence of diabetes (p=0.005), and use of general anaesthesia (p=0.0001). Although not predictive of outcome, post-procedural events including development of any intracranial haemorrhage (ICH) (p=0.0001), symptomatic ICH (sICH) (p=0.0001) and early neurological deterioration (END) (p=0.007) were associated with FCR. ConclusionNearly half of patients in this national registry experienced FCR following EVT. Significant predictors of FCR included increasing age, admission NIHSS scores, pre-stroke disability, onset-to-puncture and procedural times, presence of diabetes, atrial fibrillation, and use of general anaesthesia. Post procedural development of any ICH, sICH, and END were associated with FCR.

Basilar artery occlusion management: Specialist perspectives from an international survey.

Two early basilar artery occlusion (BAO) randomized controlled trials did not establish the superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to EVT versus medical management may differ between clinician specialties. We conducted an international survey (January 18, 2022 to March 31, 2022) regarding management strategies in acute BAO prior to the announcement of two trials indicating the superiority of EVT, and compared responses between interventionalists (INTs) and non-interventionalists (nINTs). Selection practices for routine EVT and perceptions of equipoise regarding randomizing to medical management based on neuroimaging and clinical features were compared between the two groups using descriptive statistics. Among the 1245 respondents (nINTs=702), INTs more commonly believed that EVT was superior to medical management in acute BAO (98.5%vs. 95.1%, p<.01). A similar proportion of INTs and nINTs responded that they would not randomize a patient with BAO to EVT (29.4%vs. 26.7%), or that they would only under specific clinical circumstances (p=.45). Among respondents who would recommend EVT for BAO, there was no difference in the maximum prestroke disability, minimum stroke severity, or infarct burden on computed tomography between the two groups (p>.05), although nINTs more commonly preferred perfusion imaging (24.2%vs. 19.7%, p=.04). Among respondents who indicated they would randomize to medical management, INTs were more likely to randomize when the National Institutes of Health Stroke Scale was ≥10 (15.9%vs. 6.9%, p<.01). Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a BAO patient to medical treatment. There were small differences in preference for advanced neuroimaging for patient selection, although these preferences were unsupported by clinical trial data at the time of the survey.

Abstract WP140: Coma As A Presentation For Large Vessel Occlusion Stroke

Introduction: Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. While coma has been studied in the context of traumatic brain injury, the epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke. Methods: Individuals who presented with LVO were identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIHSS item 1a: responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic. Results: A total of 28/638 (4.4%) patients with large vessel occlusion stroke were identified as presenting with coma. The median age was 65 (IQR 48-78), and 57% were female. The median NIHSS was 32 (IQR 29-34). Occlusion locations included basilar (10), vertebral (2), P1 posterior cerebral (2), internal carotid (4), M1 middle cerebral (6), and M2 middle cerebral arteries (4). In all 14 patients with anterior LVO, the acute LVO was unilateral. Of these 14, 6 had evidence of acute or chronic stroke involving the contralateral hemisphere; 1 experienced seizure; 1 experienced cardiac arrest; and 1 had chronic occlusion of the contralateral ICA. Overall, 20/28 died during the admission. Of those who died, 9 presented with anterior LVO and 11 with posterior LVO. Eight patients were treated with EVT. For those not treated, reasons included established infarct with ASPECTS &lt;6 (11), delayed presentation (2), pre-stroke disability and goals of care (3), and absence of intracranial proximal occlusion on repeat imaging (2). Conclusions: It is not uncommon for patients with LVO stroke to present with coma, and 65% of patients not treated with EVT had delayed presentations or large established infarcts, emphasizing the need for maintaining a high index of suspicion. While more commonly thought to result from posterior LVO, coma in our cohort was similarly likely to result from anterior LVO. Further study of these patients may shed light on the pathophysiology of coma. Efforts to improve early diagnosis and care are crucial given their poor outcomes.

Abstract WP90: Black Americans Have Worse Functional And Cognitive Outcomes Than White Americans After Stroke

Introduction: We studied racial differences in post-stroke outcomes using a prospective, population-based cohort of stroke survivors as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. Methods: Neurologic (NIHSS, range of 0-42, higher scores are worse), functional (ADLs/IADLs, range 1-4, higher scores are worse), and cognitive (3MSE, range 0-100, higher scores are better) outcomes were measured 90 days after stroke. Cox proportional hazards and negative binomial linear regression models were used to examine the associations between race and 90-day all-cause mortality and NIHSS, respectively, whereas linear regression was used for ADLs/IADLs and 3MSE scores. Covariates included demographics, initial NIHSS, comorbidities, prior stroke history, tPA, pre-stroke disability, and pre-stroke cognition. The mortality model also adjusted for DNR status. Results: At 90 days post-stroke, Black Americans (BAs) (n=130) had a median (IQR) NIHSS of 2 (1,6) compared to NIHSS of 1 (0,3) in non-Hispanic white Americans (NHWs) (n=868). BAs had a median (IQR) ADL/IADL score of 2.4 (1.5, 3.4) compared to 2 (1.3, 3.0) in NHWs. BAs scored a median of 85.0 (75.0, 92.5) on the 3MSE compared to NHWs’ score of 92.0 (83.0, 96.0). Death occurred in 23 (11%) of BAs and 268 (19%) of NHWs within 90 days. After adjustment for covariates, functional outcomes at 90 days were worse in BAs compared to NHWs, with 14% (95% CI=4.9, 23) greater limitations in ADLs/IADLs and 47.9% (95% CI=16.3, 88.1) greater severity of stroke symptoms. Cognition at 90 days was 7% (95% CI=2.7, 11.3) lower in BAs compared to NHWs. BAs had a 25.2% lower (95% CI=-19.9, 53.3) hazard rate of mortality than NHWs (Figure). Conclusions: In this prospective, population-based community sample, BAs had worse functional and cognitive outcomes at 90 days compared to NHWs. Future research should investigate the cause of these racial disparities.

Abstract TP153: Basilar Artery Occlusion Management: Specialist Perspectives From After The BEST Of BASICS Study

Background: Two early basilar artery occlusion (BAO) randomized controlled trials did not establish superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to medical management may differ between clinician specialties. Methods: We conducted an international survey (1/1/22-3/31/22) regarding management strategies in acute BAO prior to the announcement of 2 trials indicating superiority of EVT, and compared responses between interventionalists (INT) and non-interventionalists (nINT). Selection practices for routine EVT based on neuroimaging and clinical features were compared between the two groups using descriptive statistics. Results: Among the 1245 respondents (nINT=702), INT more commonly believed that EVT was superior to medical management in acute BAO (98.5% vs. 95.1%, p&lt;0.01). A similar proportion of INT and nINT responded that they would not randomize a patient with BAO to EVT (29.4% vs. 26.7%), or that they would only under specific circumstances (p=0.45). Among respondents who would recommend EVT, there was no difference in the maximum pre-stroke disability, minimum stroke severity, or infarct burden on computed tomography between the two groups (p&gt;0.05), although nINT more commonly preferred perfusion imaging (24.2% vs. 19.7%, p=0.04). Among respondents who indicated they would randomize to medical management, INT were more likely to randomize when the NIHSS was ≥10 (15.9% vs. 6.9%, p&lt;0.01). Conclusions: Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a patient to medical treatment. There were small differences in preference of advanced neuroimaging, although these preferences were unsupported by clinical trial data.

Outcomes following thrombectomy for acute large vessel occlusion beyond 24 hours or with unknown time of onset

BackgroundEndovascular thrombectomy (EVT) is recommended in medically eligible patients with large vessel occlusions (LVO) within 24 hours of symptom onset. While there is evidence that EVT ≥24h after last known well (LKW) is associated with favorable outcomes in patients who meet DAWN/DEFUSE-3 criteria, it is unknown if more liberal criteria can be applied. MethodsA single center, prospective observational cohort of consecutive adult stroke patients was queried for symptomatic occlusions of the internal carotid (ICA) or proximal middle cerebral (M1) arteries (October 2019-January 2022), with a National Institutes of Health Stroke Scale (NIHSS) ≥6, pre-stroke modified Rankin Scale (mRS) 0-2, and Alberta Stroke Program Early Computed Tomography Scale score 3-10. These inclusion criteria were extrapolated from recently published data indicating a benefit with EVT with more liberal patient selection. Patients who underwent EVT ≥24h after LKW were compared against those treated medically. The primary outcome was a good functional outcome (90-day mRS 0-2), which was evaluated using multivariable logistic regression. ResultsOf the 27 included patients, the median age was 65y (IQR 49-76) with a median NIHSS of 15 (IQR 8-26), and 17 (63.0%) underwent EVT (median LKW-to-puncture 35.5h (IQR 26.9-65.8h). The primary outcome was no different with EVT in unadjusted regression (OR 1.17, 95%CI 0.17-8.09), and there remained no association across all multivariable models tested. Age, pre-stroke disability, and M1 occlusions were non-significantly associated with the primary outcome (p>0.05). There was a non-significant trend indicating a favorable shift in 90-day mRS with EVT (proportional OR 2.04, 95%CI 0.44-9.48). ConclusionsUsing more liberal inclusion criteria for EVT in the ultra-extended window, there was no statistically significant difference in the rate of good functional outcome with EVT. Larger studies are called upon to evaluate outcomes when more liberal criteria are used to assess thrombectomy eligibility.

Associations of Osteoarthritis With Thrombectomy Utilization and Outcomes for Large Vessel Acute Ischemic Stroke.

Osteoarthritis and other musculoskeletal disorders are the leading causes of disability in the United States. While osteoarthritis is not a direct risk factor for stroke, osteoarthritis may impact patient selection for endovascular thrombectomy (EVT) due to prestroke disability. This study investigates associations of osteoarthritis with EVT utilization and outcomes. This was a large-scale cross-sectional study of the 2016 to 2019 National Inpatient Sample database. Adult patients with anterior large vessel ischemic strokes were identified. Patient demographics, stroke risk factors, stroke etiology, presence of osteoarthritis, medical comorbidities, EVT, intravenous thrombolysis treatments, and discharge destinations were recorded. Primary outcome was the rate of EVT treatment. Secondary outcomes include rates of discharge to home and in-hospital mortality. Propensity score matching and multivariable logistic regression models were used to account for possible confounders. Two hundred fifty-two thousand five hundred five patients were identified, of whom 8.5% (21 500 patients) had osteoarthritis. After propensity score matching for 32 clinical variables, osteoarthritis patients were found to be 17.3% less likely to receive EVT than non-osteoarthritis patients (14.4% versus 17.3%, respectively; P<0.001). In multivariable logistic regression analysis, osteoarthritis was associated with 22.6% lower odds of receiving EVT (OR, 0.77 [95% CI, 0.70-0.86]; P<0.001), an effect size larger than any medical comorbidity captured in this study other than dementia and nonstroke neurological disease. Among those treated with EVT, multivariable logistic regression models showed that osteoarthritis was not associated with different odds of being discharged home (OR, 0.99 [95% CI, 0.81-1.21]; P=0.93); however, osteoarthritis was marginally associated with lower odds of in-hospital mortality (OR, 0.74 [95% CI, 0.54-1.01]; P=0.054). Large vessel ischemic stroke patients with osteoarthritis were significantly less likely to receive EVT therapy despite similar post-EVT outcomes. These results warrant further investigation and prompt a critical review of current patient selection practices for stroke EVT therapy, specifically for patients with baseline disability due to musculoskeletal conditions such as osteoarthritis.

Cost-Effectiveness of Endovascular Treatment in Large Vessel Occlusion Stroke With Mild Prestroke Disability: Results From the HERMES Collaboration.

The clinical and economic benefit of endovascular treatment (EVT) in addition to best medical management in patients with stroke with mild preexisting symptoms/disability is not well studied. We aimed to investigate cost-effectiveness of EVT in patients with large vessel occlusion and mild prestroke symptoms/disability, defined as a modified Rankin Scale score of 1 or 2. Data are from the HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials), which pooled patient-level data from 7 large, randomized EVT trials. We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes from a health care and a societal perspective. Incremental cost-effectiveness ratio and net monetary benefits were calculated, and a probabilistic sensitivity analysis was performed. EVT in addition to best medical management resulted in lifetime cost savings of $2821 (health care perspective) or $5378 (societal perspective) and an increment of 1.27 quality-adjusted life years compared with best medical management alone, indicating dominance of additional EVT as a treatment strategy. The net monetary benefits were higher for EVT in addition to best medical management compared with best medical management alone both at the higher (100 000$/quality-adjusted life years) and lower (50 000$/quality-adjusted life years) willingness to pay thresholds. Probabilistic sensitivity analysis showed decreased costs and an increase in quality-adjusted life years for additional EVT compared with best medical management only. From a health-economic standpoint, EVT in addition to best medical management should be the preferred strategy in patients with acute ischemic stroke with large vessel occlusion and mild prestroke symptoms/disability.

Sex differences in onset to hospital arrival time, prestroke disability, and clinical symptoms in patients with a large vessel occlusion: a MR CLEAN Registry substudy

BackgroundWomen have been reported to have worse outcomes after endovascular treatment (EVT), despite a similar treatment effect in non-clinical trial populations. We aimed to assess sex differences at hospital presentation...

Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan.

Current guidelines do not address recommendations for mechanical thrombectomy (MT) in the extended time window (>6 hours after time last seen well [TLSW]) for large vessel occlusion (LVO) patients with preexisting modified Rankin Scale (mRS) > 1. In this study, we evaluated the outcomes of MT vs medical management in patients with prestroke disability presenting in the 6- to 24-hour time window with acute LVO. We analyzed a multinational cohort (61 sites, 6 countries from 2014 to 2020) of patients with prestroke (or baseline) mRS 2 to 4 and anterior circulation LVO treated 6-24 hours from TLSW. Patients treated in the extended time window with MT vs medical management were compared using multivariable logistic regression and inverse probability of treatment weighting (IPTW). The primary outcome was the return of Rankin (ROR, return to prestroke mRS by 90 days). Of 554 included patients (448 who underwent MT), the median age was 82 years (interquartile range [IQR] 72-87) and the National Institutes of Health Stroke Scale (NIHSS) was 18 (IQR 13-22). In both MV logistic regression and IPTW analysis, MT was associated with higher odds of ROR (adjusted OR [aOR] 3.96, 95% CI 1.78-8.79 and OR 3.10, 95% CI 1.20-7.98, respectively). Among other factors, premorbid mRS 4 was associated with higher odds of ROR (aOR, 3.68, 95% CI 1.97-6.87), while increasing NIHSS (aOR 0.90, 95% CI 0.86-0.94) and decreasing Alberta Stroke Program Early Computed Tomography Scale score (aOR per point 0.86, 95% CI 0.75-0.99) were associated with lower odds of ROR. Age, intravenous thrombolysis, and occlusion location were not associated with ROR. In patients with preexisting disability presenting in the 6- to 24-hour time window, MT is associated with a higher probability of returning to baseline function compared with medical management. This investigation's results provide Class III evidence that in patients with preexisting disability presenting 6-24 hours from the TLSW and acute anterior LVO stroke, there may be a benefit of MT over medical management in returning to baseline function.

Mechanical Thrombectomy in Acute Stroke Patients with Moderate to Severe Pre-Stroke Disability.

Background and Purpose Studies on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with preexisting disability are limited. We aimed to compare the outcomes of MT versus best medical treatment (BMT) in these patients. Methods In the nationwide Austrian registry and Swiss monocentric registry, we identified 462 AIS patients with pre-stroke disability (modified Rankin Scale [mRS] score ≥3) and acute large vessel occlusion. The primary outcome was returning to pre-stroke mRS or better at 3 months. Secondary outcomes were early neurological improvement (National Institutes of Health Stroke Scale score improvement ≥8 at 24 to 48 hours), 3-month mortality, and symptomatic intracerebral hemorrhage (sICH). Multivariable regression models and propensity score matching (PSM) were used for statistical analyses. Results Compared with the BMT group (n=175), the MT group (n=175) had younger age, more severe strokes, and lower pre-stroke mRS, but similar proportion of receiving intravenous thrombolysis. MT was associated with higher odds of returning to baseline mRS or better at 3 months (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 1.39 to 4.47), early neurological improvement (aOR, 2.62; 95% CI, 1.41 to 4.88), and lower risk of 3-month mortality (aOR, 0.29; 95% CI, 0.18 to 0.49). PSM analysis showed similar findings. MT was not associated with an increased risk of sICH (4.0% vs. 2.1% in all patients; 4.2% vs. 2.4% in the PSM cohort). Conclusions MT in patients with pre-stroke mRS ≥3 might improve the 3-month outcomes and short-term neurological impairment, suggesting that pre-stroke disability alone should not be a reason to withhold MT, but that individual case-by-case decisions may be more appropriate.

Endovascular thrombectomy in acute ischemic stroke patients with prestroke disability (mRS ≥2): A systematic review and meta-analysis

ObjectiveThe effect of endovascular thrombectomy (EVT) in acute ischemic stroke patients with prestroke disability (modified Rankin Scale score, mRS) ≥2) has not been well-studied. This study aimed to assess the safety and benefit of EVT in patients with prestroke disability.MethodsAccording to PRISMA guidelines, literature searching was performed using PubMed, Embase, and Cochrane databases, for a series of acute ischemic stroke patients with prestroke mRS ≥2 treated by EVT. Random-effects meta-analysis was used to pool the rate of return to prestroke mRS and mortality at 3-month follow-up.ResultsIn total, 13 observational studies, with 2,625 patients, were analyzed. The rates of return to prestroke mRS in patients with prestroke mRS of 2–4 were 20% (120/588), 27% (218/827), and 31% (34/108), respectively. Patients with prestroke disability treated by EVT had a higher likelihood of return to prestroke mRS (relative risk, RR, 1.86; 95% CI 1.28–2.70) and a lower likelihood of mortality (RR 0.75; 95%CI 0.58–0.97) compared with patients with standard medical treatment. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b-3) after EVT gave a higher likelihood of return to prestroke mRS (RR 2.04; 95% CI 1.17–3.55) and lower mortality (RR 0.72; 95% CI 0.62–0.84) compared with unsuccessful reperfusion.ConclusionsAcute ischemic stroke patients with prestroke disability may benefit from EVT. Withholding EVT on the sole ground of prestroke disabilities may not be justified.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/.