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Original research
Endovascular treatment of acute ischemic stroke in patients with pre-morbid disability: a meta-analysis
  1. Fouzi Bala1,
  2. Benjamin Beland1,
  3. Eva Mistry2,
  4. Mohammed A Almekhlafi1,3,
  5. Mayank Goyal1,3,
  6. Aravind Ganesh1,3
  1. 1Calgary Stroke Program, Departments of Clinical Neurosciences, Community Health Sciences, and Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  2. 2Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
  3. 3Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  1. Correspondence to Dr Aravind Ganesh, University of Calgary Cumming School of Medicine, Calgary, AB T2N 1N4, Canada; aganesh{at}ucalgary.ca

Abstract

Background Trials of endovascular thrombectomy (EVT) for acute stroke have excluded patients with pre-morbid disability. Observational studies may help inform consideration of EVT in this population. We aimed to assess the effectiveness and safety of EVT in patients with pre-morbid disability.

Methods According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE and Embase for studies describing outcomes in patients with pre-morbid disability (modified Rankin Scale (mRS) 2–5), treated with EVT or medical management (MM). Random-effects meta-analysis was used to pool outcomes including 90-day return to baseline mRS, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality.

Results We analyzed 14 studies of patients with pre-morbid disability (mRS 2–5, 1373 EVT and 253 MM). The rate of return to baseline mRS was 30.0% (95% CI 25.3% to 34.7%) in patients treated with EVT. Compared with medical therapy, EVT was associated with a higher likelihood of return to baseline mRS (OR 2.37, 95% CI 1.39 to 4.04) and a trend towards lower mortality (OR 0.68, 95% CI 0.46 to 1.02), with similar odds of sICH (OR 1.01, 95% CI 0.49 to 2.08). In studies comparing patients with versus without pre-morbid disability treated with EVT, similar results were found except that pre-morbid disability, when defined more strictly as mRS 3–5, was associated with mortality (OR 3.49, p<0.001).

Conclusion In eligible patients with pre-morbid disability, observational studies suggest that EVT carries a higher chance of return to baseline mRS compared with patients treated with MM or without pre-morbid disability, although with higher mortality than patients without pre-morbid disability. These findings argue against the routine exclusion of such patients from EVT and merit validation with randomized trials.

  • Stroke
  • Thrombectomy

Data availability statement

Data are available upon reasonable request. Not applicable.

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Data availability statement

Data are available upon reasonable request. Not applicable.

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Footnotes

  • Twitter @FouziBala, @BenFBeland, @eva_mistry, @AlmekhlafiMa, @draravindganesh

  • FB and BB contributed equally.

  • Contributors Conception and design: FB, BB, MAA, MG, AG. Acquisition of the data: FB, EAM, BB, AG. Analysis and interpretation of the data: FB, BB, AG. Critical revision of the manuscript: FB, BB, EAM, MAA, MG, AG. Study supervision: AG. All authors approved the final version of the manuscript. AG is the guarantor.

  • Funding FB is supported by La Société Française de Neuroradiologie (Bourse de recherche Anne Bertrand SFNR) et La Société Française de Radiologie (Bourse de Recherche Alain Rahmouni SFR-CERF).

  • Competing interests Benjamin Beland: travel grant from the American Academy of Neurology. Eva A Mistry: funding from NIH/NINDS (K23NS113858). Mohammed A Almekhlafi: none. Mayank Goyal reports consulting fees from Medtronic, Stryker, Microvention, and Mentice; and has a patent for systems of stroke diagnosis licensed to GE Healthcare. Aravind Ganesh reports membership of editorial boards of Neurology, Neurology: Clinical Practice, and Stroke; research support from the Canadian Institutes of Health Research (CIHR), Canadian Cardiovascular Society, Campus Alberta Neuroscience, Alberta Innovates, and the Sunnybrook Research Institute INOVAIT program; consultation fees from MD Analytics, MyMedicalPanel, and Atheneum; stock options from SnapDx, TheRounds.com, and Advanced Health Analytics (AHA Health Ltd); and a provisional patent application for a system for delivery of remote ischemic conditioning or other cuff-based therapies.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.