Decision-making should be based on prognostic evaluation, researchers say.
Patients with impaired cognitive or physical functioning prior to experiencing a stroke may still be good candidates for an endovascular intervention, according to an analysis of the MR CLEAN registry published online September 11, 2018, ahead of print in Stroke.
“In recently reported trials which led to the implementation of endovascular treatment for stroke, only a few patients were included who were functionally dependent before the current stroke,” lead author Robert-Jan B. Goldhoorn, MD (Maastricht University Medical Center, the Netherlands), told Neurovascular Exchange. In addition, thrombectomy registries have yet to report on outcome of prestroke-dependent patients, so very little is known about their outcomes.
Lacking evidence-based guidance on how to treat prestroke-dependent patients, currently “some patients would be given the benefit of the doubt on the basis of individual favorable characteristics” and treated endovascularly, he indicated.
Goldhoorn and colleagues analyzed outcomes of 1,441 patients who underwent endovascular treatment of anterior circulation stroke and who were included in the MR CLEAN registry between March 2014 and June 2016. Among these patients, they identified 157 (11%) as prestroke dependent, meaning they had an mRS score of 3-5 prior to the index stroke.
Among the prestroke-dependent patients, 27% had a favorable outcome, defined as a 90-day mRS 0-2 or no worsening of the mRS score from the time prior to the index stroke. In comparison, 42% of the patients who were prestroke independent had a favorable outcome (P < 0.05).
Not a Predictor of Unfavorable Outcome
After adjusting for age, baseline National Institutes of Health Stroke Scale score, collaterals, time to endovascular intervention, and use of intravenous thrombolysis before the intervention, prestroke dependence was not a predictor of having a less favorable outcome (adjusted OR 0.90; 95% CI 0.58-1.39). The occurrence of symptomatic intracranial hemorrhage and ischemic stroke progression was similar in both groups.
Based on these findings, prestroke-dependent patients should not be excluded from endovascular interventions out of hand, concluded Goldhoorn. “In prestroke-dependent patients in whom successful reperfusion was achieved, the mortality rate was lower and the rate of favorable outcome was slightly higher, compared to unsuccessfully reperfused patients,” he noted. Their mortality rate is high, but the risk of treatment-related complications is not elevated.
The decision to go ahead with an endovascular intervention should be made with caution, he recommended. “Patients should be selected on the basis of the prognosis of preexistent disease and expected extent of the burden from the current neurological deficit on top of the preexistent deficit.”
Unanswered questions remain that can only be addressed by a randomized trial, he acknowledged, including the issues of selection bias and treatment effect.
Source:
Goldhoorn RJB, Verhagen M, Diederik, Dippel DWJ, et al, et al. Safety and outcome of endovascular treatment in prestroke-dependent patients results from MR CLEAN registry. Stroke. 2018;Epub ahead of print.
Disclosures:
Goldhoorn reports no relevant conflicts of interest.
