J Stroke.  2024 May;26(2):269-279. 10.5853/jos.2023.04259.

Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability

• Tanaka K
• Yamagami H
• Qureshi MM
• Uchida K
• Siegler JE
• Nogueira RG
• Yoshimura S
• Sakai N
• Martinez-Majander N
• Nagel S
• Demeestere J
• Puetz V
• Haussen DC
• Abdalkader M
• Olive-Gadea M
• Mohammaden MH
• Marto JP
• Dusart A
• Winzer S
• Tomppo L
• Caparros F
• Henon H
• Bellante F
• Ramos JN
• Ortega-Gutierrez S
• Sheth SA
• Nannoni S
• Kaesmacher J
• Vandewalle L
• Salazar-Marioni S
• Farooqui M
• Virtanen P
• Ventura R
• Zaidi S
• Castonguay AC
• Puri AS
• Farzin B
• Masoud HE
• Klein P
• Jesser J
• Requena M
• Dobrocky T
• Kaiser DP
• Peltola E
• Strambo D
• Möhlenbruch MA
• Lin E
• Ringleb PA
• Zaidat OO
• Cordonnier C
• Roy D
• Lemmens R
• Ribo M
• Strbian D
• Fischer U
• Michel P
• Raymond J
• Nguyen TN

• KMID: 2556047
• DOI: http://doi.org/10.5853/jos.2023.04259

Abstract

Background and Purpose
We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability.
Methods
In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0–4 and LVO who underwent EVT 6–24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0–2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2–4) and those without (mRS score 0–1).
Results
A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P<0.001). In multivariable logistic regression analysis with inverse probability of treatment weighting, pre-stroke disability was not associated with significantly lower odds of achieving FI or RoR (adjusted odds ratio 0.73, 95% confidence interval 0.43–1.25). Symptomatic intracranial hemorrhage occurred in 6.3% of both groups (P=0.995).
Conclusion
A considerable proportion of patients with late-presenting LVO and pre-stroke disability regained pre-stroke mRS scores after EVT. EVT may be appropriate for patients with pre-stroke disability presenting in the extended time window.

Keyword

Activities of daily living; Ischemic stroke; Endovascular therapy; Reperfusion; Outcome

Figure

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  Figure 1. Flow diagram of patient selection. CLEAR, CT for Late Endovascular Reperfusion; NIHSS, National Institutes of Health Stroke Scale; mRS, modified Rankin Scale; ASPECTS, Alberta Stroke Program Early CT Score.

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  Figure 2. Distribution of modified Rankin Scale (mRS) at 90 days according to the pre-stroke mRS.

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  Figure 3. The rate of primary outcome of functional independence or return of Rankin by reperfusion status with and without pre-stroke disability. mRS, modified Rankin Scale; eTICI, expanded Thrombolysis In Cerebral Infarction.

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