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Original research
Toward a more inclusive paradigm: thrombectomy for stroke patients with pre-existing disabilities
  1. Robert W Regenhardt1,2,
  2. Michael J Young1,
  3. Mark R Etherton1,
  4. Alvin S Das1,
  5. Christopher J Stapleton2,
  6. Aman B Patel2,
  7. Michael H Lev3,
  8. Joshua A Hirsch3,
  9. Natalia S Rost1,
  10. Thabele M Leslie-Mazwi1,2
  1. 1Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Robert W Regenhardt, Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; robert.regenhardt{at}mgh.harvard.edu

Abstract

Background Persons with pre-existing disabilities represent over one-third of acute stroke presentations, but account for a far smaller proportion of those receiving endovascular thrombectomy (EVT) and thrombolysis. This is despite existing ethical, economic, legal, and social directives to maximize equity for this vulnerable population. We sought to determine associations between baseline modified Rankin Scale (mRS) and outcomes after EVT.

Methods Individuals who underwent EVT were identified from a prospectively maintained database. Demographics, medical history, presentations, treatments, and outcomes were recorded. Baseline disability was defined as baseline mRS≥2. Accumulated disability was defined as the delta between baseline mRS and absolute 90-day mRS.

Results Of 381 individuals, 49 had baseline disability (five with mRS=4, 23 mRS=3, 21 mRS=2). Those with baseline disability were older (81 vs 68 years, P<0.0001), more likely female (65% vs 49%, P=0.032), had more coronary disease (39% vs 20%, P=0.006), stroke/TIA history (35% vs 15%, P=0.002), and higher NIH Stroke Scale (19 vs 16, P=0.001). Baseline mRS was associated with absolute 90-day mRS ≤2 (OR=0.509, 95%CI=0.370–0.700). However, baseline mRS bore no association with accumulated disability by delta mRS ≤0 (ie, return to baseline, OR=1.247, 95%CI=0.943–1.648), delta mRS ≤1 (OR=1.149, 95%CI=0.906–1.458), delta mRS ≤2 (OR 1.097, 95% CI 0.869–1.386), TICI 2b–3 reperfusion (OR=0.914, 95%CI=0.712–1.173), final infarct size (P=0.853, β=−0.014), or intracerebral hemorrhage (OR=0.521, 95%CI=0.244–1.112).

Conclusions While baseline mRS was associated with absolute 90-day disability, there was no association with accumulated disability or other outcomes. Patients with baseline disability should not be routinely excluded from EVT based on baseline mRS alone.

  • thrombectomy
  • stroke

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Footnotes

  • Twitter @rwregen, @alvindasMD, @JoshuaAHirsch

  • RWR and MJY contributed equally.

  • Contributors All authors have made significant contributions to this work. All have read and approved the final version of this manuscript.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the local institutional review board. Informed consent was waived based on minimal patient risk and practical inability to perform the study without the waiver. Data are available upon reasonable request.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request and pending local IRB approval.

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