Introduction Patients with baseline disability account for up to one-third of stroke presentations. Despite growing evidence supporting their benefit from endovascular thrombectomy (EVT), there remains controversy in treatment selection. We compared the long-term outcomes and the likelihood of comfort care for large vessel occlusion (LVO) stroke patients who presented with severe baseline disability treated with EVT versus medical management.
Methods Individuals who presented with LVO were identified from a prospectively maintained database from January 2017 to December 2020. Severe baseline disability was defined as modified Rankin Scale (mRS) 3-5. Delta mRS was defined as the difference between baseline and 90-day mRS. Logistic and ordinal regressions were performed to evaluate the relationships between EVT and outcomes.
Results A total of 175/1007 (17%) patients were identified with severe baseline disability. The median age was 82 (IQR 70-89), and 59% were female. Thirty-two (18%) patients with severe baseline disability were treated with EVT. EVT was independently associated with improved delta mRS (B=-1.048; 95%CI=-1.777,-0.318; p=0.005) when accounting for age and NIHSS. However, EVT did not reduce the odds of transitioning to comfort care (aOR=0.794; 95%CI=0.347,1.818; p=0.585) when accounting for age and NIHSS. Seventy-six (43%) patients with severe baseline disability were transitioned to comfort care. Of the 99 patients who were not transitioned to comfort care, 18 were treated with EVT. In this subgroup not transitioned to comfort care, EVT was independently associated with improved delta mRS (B=-2.794; 95% CI=-4.002,-1.586; p<0.0001) when accounting for age and NIHSS.
Conclusions Among patients with severe baseline disability, EVT is associated with less post-stroke accumulated disability without limiting transitions to comfort care. EVT is compatible with goal-concordant care in patients with severe baseline disability; it should not be routinely withheld on the sole basis of baseline disability.
Disclosures A. Awad: None. M. Young: None. A. Andreev: None. A. Dmytriw: None. J. Vranic: None. C. Stapleton: None. A. Das: None. A. Singhal: None. N. Rost: None. A. Patel: None. R. Regenhardt: None.
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