ABSTRACT
OBJECTIVES: Pre-stroke dependency (PSD) is associated with poor outcome after stroke. The aim of the study was to evaluate the clinical outcomes and safety of mechanical thrombectomy (MT) in pre-stroke dependent patients compared to pre-stroke independent patients. MATERIAL AND METHODS: We included consecutive patients with anterior circulation acute ischaemic stroke related to large vessel occlusion (AIS-LVO), treated by MT between January 1st 2015 and July 1st 2018 in our single comprehensive stroke center. PSD was defined as a mRS score of 3 to 5 before stroke onset. We studied outcome variables in pre-stroke dependent vs. independent patients, by using logistic regression models. Clinical outcomes included clinical favorable outcome at 3 months (defined as modified Rankin Score 0-2 or equal to pre-stroke mRS score), successful recanalization rates and safety outcomes. RESULTS: Of 922 patients with anterior circulation AIS-LVO, 155 (16.8%) had PSD. Favorable outcome was less often achieved in patients with PSD (25.8% vs. 44.7%, p <0.001); but the difference did not remain significant in multivariable analysis (adjusted OR, 0.70; 95%CI, 0.44 to 1.12). Mortality at 90-days was significantly higher in patients with PSD (49.0% vs. 18.8%, adjusted OR, 2.63; 95%CI, 1.69 to 4.00). Successful recanalization was strongly associated with favorable outcome (adjusted OR, 8.15; 95%CI 4.97 to 13.34). CONCLUSIONS: One out of four patients with PSD had a favorable outcome after MT. Despite higher mortality rates compared to pre-stroke independent patients, PSD alone should not be used alone to deny mechanical thrombectomy.
Subject(s)
Disability Evaluation , Functional Status , Ischemic Stroke/therapy , Thrombectomy , Aged , Aged, 80 and over , Clinical Decision-Making , Female , Humans , Ischemic Stroke/diagnosis , Ischemic Stroke/mortality , Ischemic Stroke/physiopathology , Male , Middle Aged , Predictive Value of Tests , Recovery of Function , Risk Assessment , Risk Factors , Thrombectomy/adverse effects , Thrombectomy/mortality , Time Factors , Treatment OutcomeABSTRACT
The benefits of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) and a large ischemic core (LIC) at presentation are uncertain. We aimed to obtain up-to-date aggregate estimates of the outcomes following MT in patients with volumetrically assessed LIC. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)-conformed, PROSPERO-registered, systematic review and meta-analysis of studies that included patients with AIS and a baseline LIC treated with MT, reported ischemic core volume quantitatively, and included patients with a LIC defined as a core volume ≥50 mL. The search was restricted to studies published between January 2015 and June 2020. Random-effects-meta-analysis was used to assess the effect of MT on 90-day unfavorable outcome (i.e., modified Rankin Scale [mRS] 3–6), mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. Sensitivity analyses were performed for imaging-modality (computed tomography-perfusion or magnetic resonance-diffusion weighted imaging) and LIC-definition (≥50 or ≥70 mL). We analyzed 10 studies (954 patients), including six (682 patients) with a control group, allowing to compare 332 patients with MT to 350 who received best-medical-management alone. Overall, after MT the rate of patients with mRS 3–6 at 90 days was 74% (99% confidence interval [CI], 67 to 84; Z-value=7.04; I2=92.3%) and the rate of 90-day mortality was 36% (99% CI, 33 to 40; Z-value=–7.07; I2=74.5). Receiving MT was associated with a significant decrease in mRS 3–6 odds ratio (OR) 0.19 (99% CI, 0.11 to 0.33; P<0.01; Z-value=–5.92; I2=62.56) and in mortality OR 0.60 (99% CI, 0.34 to 1.06; P=0.02; Z-value=–2.30; I2=58.72). Treatment group did not influence the proportion of patients experiencing sICH, OR 0.96 (99% CI, 0.2 to 1.49; P=0.54; Z-value=–0.63; I2=64.74). Neither imaging modality for core assessment, nor LIC definition influenced the aggregated outcomes. Using aggregate estimates, MT appeared to decrease the risk of unfavorable functional outcome in patients with a LIC assessed volumetrically at baseline.
ABSTRACT
The benefits of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) and a large ischemic core (LIC) at presentation are uncertain. We aimed to obtain up-to-date aggregate estimates of the outcomes following MT in patients with volumetrically assessed LIC. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)-conformed, PROSPERO-registered, systematic review and meta-analysis of studies that included patients with AIS and a baseline LIC treated with MT, reported ischemic core volume quantitatively, and included patients with a LIC defined as a core volume ≥50 mL. The search was restricted to studies published between January 2015 and June 2020. Random-effects-meta-analysis was used to assess the effect of MT on 90-day unfavorable outcome (i.e., modified Rankin Scale [mRS] 3–6), mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. Sensitivity analyses were performed for imaging-modality (computed tomography-perfusion or magnetic resonance-diffusion weighted imaging) and LIC-definition (≥50 or ≥70 mL). We analyzed 10 studies (954 patients), including six (682 patients) with a control group, allowing to compare 332 patients with MT to 350 who received best-medical-management alone. Overall, after MT the rate of patients with mRS 3–6 at 90 days was 74% (99% confidence interval [CI], 67 to 84; Z-value=7.04; I2=92.3%) and the rate of 90-day mortality was 36% (99% CI, 33 to 40; Z-value=–7.07; I2=74.5). Receiving MT was associated with a significant decrease in mRS 3–6 odds ratio (OR) 0.19 (99% CI, 0.11 to 0.33; P<0.01; Z-value=–5.92; I2=62.56) and in mortality OR 0.60 (99% CI, 0.34 to 1.06; P=0.02; Z-value=–2.30; I2=58.72). Treatment group did not influence the proportion of patients experiencing sICH, OR 0.96 (99% CI, 0.2 to 1.49; P=0.54; Z-value=–0.63; I2=64.74). Neither imaging modality for core assessment, nor LIC definition influenced the aggregated outcomes. Using aggregate estimates, MT appeared to decrease the risk of unfavorable functional outcome in patients with a LIC assessed volumetrically at baseline.
