Abstract Details

Title Endovascular Thrombectomy Versus Medical Management for Large Vessel Occlusion Stroke Patients with Severe Baseline Disability

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) S24 - Cerebrovascular Disease and Interventional Neurology: Endovascular Thrombectomy and Large Vessel Occlusions (2:24 PM-2:36 PM)

Poster/Presentation
Number 008

Background

Patients with baseline disability account for up to one-third of stroke presentations, but have traditionally been excluded from early clinical trials of acute stroke interventions. Despite growing evidence supporting a benefit from endovascular thrombectomy, there remains significant controversy in treatment selection.

Objective

To compare the long-term outcomes and likelihood of transitions to comfort care for large vessel occlusion (LVO) stroke patients with severe baseline disability treated with endovascular thrombectomy (EVT) versus medical management.

Design/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 clinical 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.

Authors/Disclosures
Amine Mohamed Marc Awad, BM BCh PRESENTER	Dr. Awad has nothing to disclose.
Michael Young, MD (Massachusetts General Hospital, Brigham, Harvard)	Dr. Young has nothing to disclose.
Alexander Andreev, MD (BIDMC)	Dr. Andreev has nothing to disclose.
Adam Dmytriw (Massachusetts General Hospital)	No disclosure on file
Justin Vranic (Massachusetts General Hospital)	No disclosure on file
James Rabinov	No disclosure on file
Christopher Stapleton (Massachusetts General Hospital)	No disclosure on file
Alvin Das, MD (Beth Israel Deaconess Medical Center)	Dr. Das has nothing to disclose.
Aneesh B. Singhal, MD, FAAN (Massachusetts General Hospital)	An immediate family member of Dr. Singhal has received personal compensation for serving as an employee of Biogen. Dr. Singhal has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Medicolegal Firms. Dr. Singhal has received research support from NIH-NINDS. Dr. Singhal has received publishing royalties from a publication relating to health care. Dr. Singhal has received publishing royalties from a publication relating to health care. Dr. Singhal has received personal compensation in the range of $500-$4,999 for serving as a Honorarium (Education) with Biogen.
Natalia S. Rost, MD, MPH, FAHA, FAAN (Massachusetts General Hospital)	Dr. Rost has received personal compensation in the range of $50,000-$99,999 for serving as an officer or member of the Board of Directors for American Academy of Neurology. Dr. Rost has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Stroke - AHA/ASA Journal. The institution of Dr. Rost has received research support from NIH. Dr. Rost has received publishing royalties from a publication relating to health care.
Aman Patel	No disclosure on file
Robert W. Regenhardt, MD, PhD (Massachusetts General Hospital)	Dr. Regenhardt has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Rapid Medical. Dr. Regenhardt has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Johnson and Bell Trial Lawyers. The institution of Dr. Regenhardt has received research support from National Institutes of Health. The institution of Dr. Regenhardt has received research support from Society of Vascular and Interventional Neurology. The institution of Dr. Regenhardt has received research support from Heitman Foundation.