Utilization, Workflow, and Outcomes of Endovascular Thrombectomy in Patients With vs Without Premorbid Disability in a National Registry.

Background and Objectives

Given the paucity of high-quality safety/efficacy data on acute stroke therapies in patients with premorbid disability, they risk being routinely excluded from such therapies. We examined utilization of endovascular thrombectomy (EVT), associated workflow, and poststroke outcomes among patients with vs without premorbid disability.

Methods

We used national registry data on thrombolysis/EVT for the Czech Republic from 1 January 2016 to 31 December 2020. Premorbid disability was defined as prestroke modified Rankin Scale score (mRS) ≥3. We compared proportions of patients with vs without premorbid disability who received EVT and examined workflow times. We compared ΔmRS-change in mRS from prestroke to 3 months-in patients with vs without premorbid disability, in addition to intracerebral hemorrhage (ICH), mortality, and discharge NIHSS (National Institutes of Health Stroke Scale score), adjusting for age, sex, baseline NIHSS, and comorbidities, and verified using propensity score weighting (PSW) and matching for differences in treatment assignment. We stratified by age group (<65, 65-74, 75-84, ≥85 years) to explore outcome heterogeneity with vs without premorbid disability.

Results

Among 22,405 patients with ischemic stroke who received thrombolysis/EVT/both, 1,712 (7.6%) had prestroke mRS ≥ 3. Patients with prestroke disability were less likely to receive EVT vs those without (10.1% vs 20.7%, aOR: 0.30, 95% CI 0.24-0.36). When treated, they had longer door-to-arterial puncture times (median: 75 minutes, IQR: 58-100 vs 54, IQR: 27-77, adjusted difference: 12.5, 95% CI 2.68-22.3). Patients with prestroke disability receiving thrombolysis/EVT/both had worse ΔmRS (adjusted rate ratio, aIRR on PSW: 1.57, 95% CI 1.43-1.72), rates of 3-month mRS 5-6, discharge NIHSS, and mortality (aOR-PSW [mortality]: 2.54, 95% CI 1.92-3.34), while ICH did not significantly differ. 32.1% of patients with prestroke disability receiving thrombolysis/EVT/both successfully returned to prestroke state, but this proportion ranged from 19.6% for those older than 85 years to 66.0% for those younger than 65 years. Regardless of premorbid disability, EVT was associated with better outcomes including lower ΔmRS (aIRR-PSW: 0.87, 95% CI 0.83-0.91) and mortality, with no interaction of treatment effect by premorbid disability status (e.g., mortality p

Discussion

Patients with premorbid disability were less likely to receive EVT, had slower treatment times, and had worse outcomes compared with patients without premorbid disability. However, regardless of premorbid disability, patients fared better with EVT vs medical management and one-third with prestroke disability returned to their prestroke status.

Informations de copyright

© 2024 American Academy of Neurology.

Déclaration de conflit d'intérêts

O. Volny and R. Mikulik report a financial support from the STROCZECH research infrastructure within the CZECRIN Large Research Infrastructure (No. LM2023049), funded by the state budget of the Czech Republic. O. Volny reports a research support from the University Ostrava—The Rector's Award 2022 for young academic researchers aged younger than 35 and The Quality assurance frameworks for health services and patient safety based on systematic support for data-driven and informed decision-making relevant to published work. M.D. Hill reports research funding from the NoNO Inc., Medtronic LLC, Boehringer-Ingelheim Canada, and Biogen Inc.—all outside the scope of the published work. A. Ganesh reports salary support from the Heart and Stroke Foundation of Canada New Investigator Award relevant to the published work. He also reports membership in the editorial boards of Stroke, Neurology, and Neurology Clinical Practice; consulting fees and honoraria from Atheneum, AlphaSights, MD Analytics, Figure 1, MyMedicalPanel, Creative Research Designs, CTC Communications Corp, Alexion, Biogen, and Servier Canada; research support from Alberta Innovates, the Alzheimer Society of Canada, Campus Alberta Neuroscience, Brain Canada, the Canadian Cardiovascular Society, Panmure House, the Government of Canada INOVAIT and New Frontiers in Research Fund programs, and the Canadian Institutes of Health Research; stock/stock options from SnapDx and Let's Get Proof (Collavidence Inc); and a patent application for a system for patient monitoring and cuff-based therapies—all outside the scope of the published work. The other authors report no disclosures relevant to this manuscript. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.