Despite higher mortality and recanalisation failure, prestroke-dependent patients did not have worse functional outcomes among survivors or higher sICH risk, suggesting that EVT should not be withheld solely on the basis of prestroke dependency.
Key Findings
Results
Prestroke-dependent patients comprised 10.6% of the eligible EVT cohort and were older, more often female, and had higher stroke severity than prestroke-independent patients.
Of 13,525 eligible patients, 1,436 (10.6%) were prestroke-dependent (prestroke mRS 3-4).
Prestroke-dependent patients had a median age of 84 years versus 73 years for prestroke-independent patients.
Women made up 61.0% of prestroke-dependent patients versus 46.7% of prestroke-independent patients.
Median NIHSS score was 16 points in prestroke-dependent versus 14 points in prestroke-independent patients.
Study was a multicentre international observational study from the EVA-TRISP collaboration.
Results
Prestroke-dependent patients had significantly higher odds of 3-month mortality compared to prestroke-independent patients.
Adjusted OR for death was 2.33 (95% CI, 2.04–2.66).
Mortality rate was 48.6% in prestroke-dependent patients versus 19.6% in prestroke-independent patients.
Multivariate logistic regression analysis was used to calculate adjusted odds ratios.
Results
Prestroke-dependent patients had significantly higher odds of unsuccessful recanalisation compared to prestroke-independent patients.
Adjusted OR for unsuccessful recanalisation was 1.16 (95% CI, 1.02–1.33).
Unsuccessful recanalisation occurred in 31.0% of prestroke-dependent patients versus 26.6% of prestroke-independent patients.
Results
Among survivors, prestroke-dependent patients did not have higher odds of poor functional outcome relative to their prestroke mRS compared to prestroke-independent patients.
Adjusted OR for poor functional outcome in survivors was 0.68 (95% CI, 0.57–0.81), indicating lower odds in prestroke-dependent patients.
Poor functional outcome (defined relative to the prestroke mRS) occurred in 42.8% of prestroke-dependent survivors versus 40.0% of prestroke-independent survivors.
Outcome was defined relative to prestroke mRS to account for baseline functional status.
Results
Prestroke-dependent patients did not have higher odds of symptomatic intracranial haemorrhage (sICH) following EVT.
Adjusted OR for sICH was 0.72 (95% CI, 0.53–0.98), indicating no increased risk in prestroke-dependent patients.
sICH occurred in 3.8% of prestroke-dependent patients versus 4.6% of prestroke-independent patients.
Conclusions
The authors conclude that EVT should not be withheld solely on the basis of prestroke dependency.
Despite higher mortality and recanalisation failure in prestroke-dependent patients, functional outcomes among survivors were not worse.
The study used a large registry (EVA-TRISP) with 13,525 eligible patients across multiple international centres.
The findings aim to improve evidence for EVT decision-making in prestroke-dependent patients, for whom randomised evidence is insufficient.
What This Means
This research examined whether stroke patients who were already dependent on others for daily activities before their stroke (for example, due to prior disability) benefit from endovascular therapy (EVT), a procedure that physically removes blood clots from blocked brain arteries. Using data from over 13,500 stroke patients across many international hospitals, the study compared outcomes between patients who were dependent before their stroke and those who were independent. About 1 in 10 patients fell into the prestroke-dependent group, and these patients tended to be older, more often female, and have more severe strokes.
The study found that prestroke-dependent patients were about twice as likely to die within 3 months and slightly more likely to have incomplete restoration of blood flow compared to independent patients. However, among those who survived, prestroke-dependent patients were no more likely to end up with a poor functional outcome relative to how they were functioning before the stroke — in fact, their odds of poor outcome were somewhat lower. Additionally, prestroke-dependent patients did not face a higher risk of dangerous bleeding in the brain (symptomatic intracranial haemorrhage), a major safety concern with clot-removal procedures.
This research suggests that having a pre-existing dependency on others for daily activities should not automatically disqualify a stroke patient from receiving EVT. While these patients face higher mortality and some procedural challenges, those who survive do not appear to have worse functional recovery relative to their baseline, and the procedure does not appear less safe for them in terms of bleeding risk. These findings could support more individualized decision-making about EVT eligibility for patients who were not fully independent before their stroke.