Instead of solving stroke recovery for all, let's let worse incoming health persons die. 'We are all going to die', just like Joni Ernst says, so why expend resources on them?
Considering Prestroke Disability in EVT Candidates: Lessons from the Italian Endovascular Stroke Registry
The efficacy and safety of endovascular therapy in patients with prestroke disability is controversial. Despite the fact that more than 1/3 of patients with acute ischemic stroke due to large vessel occlusion have prestroke disability, they were excluded from the initial clinical trials on endovascular therapy (EVT).1 As such, the American Heart Association/American Stroke Association guidelines currently recommend EVT only for those with prestroke mRS ≤1. Additionally, the standard definition of a “favorable” outcome relies on mRS 0-2 at 3 months, which precludes individuals with prestroke mRS >2 from achieving this outcome or offering EVT with goal to returning to pre-stroke mRS status. However, a recent meta-analysis showed that EVT for patients with prestroke mRS 3-4 could enable patients to return to their prestroke condition, showing potential benefit.2 However, higher quality data, including data addressing the impact of age, are lacking. This study aimed to further evaluate the benefit of mechanical thrombectomy in patients with prestroke mRS 3-4 compared to 0-2 and anterior circulation stroke due to large vessel occlusion (LVO) using data from the Italian Registry of Endovascular Treatment in Acute Stroke; it also evaluated the impact of age on outcomes.
Between January 2015 and December 2021, consecutive patients from 40 Italian centers undergoing EVT for anterior circulation LVO were enrolled. Patients were excluded if they did not have a prestroke mRS listed, or had a poststroke improvement >2 points in order to account for potential operator discrepancies in mRS evaluation. Population characteristics, demographic data, admission NIHSS, medical history, ASPECTS, site of vessel occlusion, and recanalization rate were also collected.
Functional outcomes were measured by 90-day mRS, which was obtained via follow-up visits or from provider phone calls. Primary outcomes were good clinical outcome at 90 days (defined as no change between prestroke and 90-day mRS) and 90-day mortality (mRS 6). Secondary outcomes, including safety variables (rate of symptomatic intracerebral hemorrhage) and technical efficacy (recanalization rates), were also collected.
11,411 patients with prestroke mRS 0-2 (96%) and 477 patients with prestroke mRS 3-4 (4%) were included. Compared with patients with baseline mRS 0-2, those with baseline mRS 3-4 were older (82 vs 75 yrs, p<0.001) and were more often female (71.7% vs 53%, p<0.001). They also had higher presenting NIHSS (18 vs 16; p<0.001). They were more likely to have a higher vascular risk profile and greater use of antithrombotics/anticoagulation, antihypertensives, and statins. Neither ASPECTS nor site of vascular occlusion differed between the two groups. Patients with prestroke mRS 3-4 less often received IVT compared to prestroke mRS 0-2 (32% vs 51.1%, p<0.001) and had increased door-to-imaging and door-to-groin times (32 vs 28 and 84 vs 77 minutes, respectively, both p<0.001).
There was no statistically significant difference between maintenance of mRS between the baseline mRS 3-4 group as compared to the baseline mRS 0-2 group (23.3% vs 22.1%, p=0.556). Mortality was significantly higher in the baseline mRS 3-4 group (37.1% vs 18.4%, p<0.001), even after adjusting for age, sex, NIHSS, vascular risk factors, successful recanalization, IVT, and door-to-groin time (OR 1.59[CI 1.26-2.01], p<0.001). The rate of successful recanalization (TICI>2b) was lower in the mRS 3-4 group (333 [71.6%] vs 8706 [77.7%], p=0.002). There was no difference in the rate of sICH (8.4% vs 7.6%, p=0.595).
Subgroup analysis showed that the likelihood of maintaining the same mRS poststroke as baseline was similar between the two groups for patients <80 years of age. Interestingly, in those 80-85 and >85 years, the prestroke mRS 3-4 group had a higher probability of maintaining the same mRS poststroke than the mRS 0-2 group. Additionally, mortality rates remained higher.
This study shows that patients with prestroke disability (mRS 3-4) and acute ischemic stroke due to LVO in the anterior circulation are as likely to maintain baseline mRS after EVT as those with mild or no prestroke disability, even when adjusting for age 80-85 and >85. However, there is a higher mortality rate which cannot be attributed to increased risk of sICH, nor procedural complications.
The results of this study are consistent with a recent meta-analysis demonstrating similar likelihood of returning to prestroke functional level;2 interestingly, there is suggestion of increased clinical benefit in patients with higher prestroke disability, which the authors posit may be due to selection bias (excluding very disabled patients deemed unlikely to have good outcomes) or imperfections of the mRS score itself (where transitioning from mRS 0-1 or 1-2 may be easier compared with transitioning from 3-4 given loss of independence). Limitations of this study were the retrospective design, the lack of centralized adjudication, and the lack of control group. The generalizability of a specifically Italian health care system study should also not be assumed.
It is worth noting the limitations of mRS in adequately capturing functional status. Validation studies have demonstrated moderate interobserver variability.3 Additionally, mRS may not be sensitive to subtle changes in functional status. Moreover, it overvalues physical disability related to cognitive disability. Stroke researchers have been working to develop an alternative score to better capture functional status in patients with underlying disability.
The results of this study are especially important given the changing landscape of the population in regards to age. Future randomized control trials will be important to validate the results of this study and refine patient selection moving forward.
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