Endovascular thrombectomy for large vessel occlusion stroke patients with baseline disability: Long-term outcomes and end-of-life care

Background: One third of all patients with acute ischemic strokes have a pre-existing disability. Patients with pre-existing disabilities have historically been excluded from landmark clinical trials of acute stroke interventions, leading to ongoing controversy about the risks and benefits of acute stroke interventions such as endovascular thrombectomy (EVT). To address this controversy, we compared long-term outcomes and end-of-life care in large vessel occlusion (LVO) patients with moderate-to-severe baseline disability treated with EVT versus medical management alone. Methods: Patients who presented with an LVO to our comprehensive stroke center between January 2017 and December 2020 were retrospectively identified from a prospectively maintained database. Moderate-to-severe baseline disability was defined as a pre-stroke modified Rankin Scale (mRS) of 3–5. Delta mRS was defined as the difference between the 90-day and baseline mRS. Logistic and ordinal regressions were performed to evaluate the relationships between EVT and outcomes. An analysis of rates and reasons for transitions to comfort care was also performed, where applicable. Results: A total of 175/1008 (17 %) LVO patients with moderate-to-severe baseline disability were identified. The median age was 82 (IQR 70–89), and 59 % were female. Thirty-two patients (18 %) with moderate-to-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) 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) accounting for age and NIHSS. Seventy-six (43 %) patients were transitioned to comfort care during their hospitalization. Of the 99 who were not transitioned to comfort care, 18 were treated with EVT, and EVT was independently associated with improved delta mRS (B=-2.794; 95 %CI=-4.002,-1.586; p < 0.0001). The median time from presentation to transition to comfort care was 2 days (IQR 1–7) in the non-EVT group, compared to 7 (IQR 4–11) in the EVT group (H(1)= 5.46, p = 0.019). The primary reasons for transitions to comfort care were poor perceived prognosis and medical complications. Conclusions: Among patients with moderate-to-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 and should not be routinely withheld because of baseline disability alone.