Utilization, Workflow, and Outcomes of Endovascular Thrombectomy in Patients With vs Without Premorbid Disability in a National Registry

Aravind Ganesh; Ondrej Volny; Ingrid Kovacova; Aleš Tomek; Michal Bar; Radek Pádr; Filip Cihlar; Miroslava Nevsimalova; Lubomir Jurak; Roman Havlicek; Martin Kovar; Petr Sevcik; Vladimír Rohan; Jan Fiksa; David Cerník; Rene Jura; Daniel Vaclavik; Michael D Hill; Robert Mikulík

doi:10.1212/CPJ.0000000000200341

Utilization, Workflow, and Outcomes of Endovascular Thrombectomy in Patients With vs Without Premorbid Disability in a National Registry

Neurol Clin Pract. 2024 Dec;14(6):e200341. doi: 10.1212/CPJ.0000000000200341. Epub 2024 Aug 16.

Authors

Aravind Ganesh¹, Ondrej Volny¹, Ingrid Kovacova¹, Aleš Tomek¹, Michal Bar¹, Radek Pádr¹, Filip Cihlar¹, Miroslava Nevsimalova¹, Lubomir Jurak¹, Roman Havlicek¹, Martin Kovar¹, Petr Sevcik¹, Vladimír Rohan¹, Jan Fiksa¹, David Cerník¹, Rene Jura¹, Daniel Vaclavik¹, Michael D Hill¹, Robert Mikulík¹

Affiliation

¹ Calgary Stroke Program (AG, MDH), Departments of Clinical Neurosciences and Community Health Sciences, the Hotchkiss Brain Institute, and the O'Brien Institute for Public Health, University of Calgary Cumming School of Medicine, Canada; Department of Neurology (OV, MB), University Hospital Ostrava, Ostrava; International Clinical Research Centre (OV, IK, RM), Stroke Research Program, St. Anne's University Hospital, Brno; Faculty of Medicine (OV, MB), University Ostrava; Department of Neurology (OV), Charles University, 2nd Medical Faculty; Institute of Health Information and Statistics of the Czech Republic (AT), Prague; Department of Radiology (RP), 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital; Department of Radiology (FC), Masaryk Hospital, Usti nad Labem; Department of Neurology (MN), Hospital Ceske Budejovice; Neurocenter (LJ), Regional Hospital Liberec; Department of Neurology (RH), Military University Hospital; Department of Neurology (MK), Na Homolce Hospital, Prague; Department of Neurology (PS, VR), Faculty of Medicine in Pilsen, Charles University in Prague; Department of Neurology (JF), Charles University, First Faculty of Medicine and General University Hospital, Prague; Masaryk Hospital Usti nad Labem - KZ a.s. (DC), Department of Neurology-Comprehensive Stroke Center; Department of Neurology (RJ), University Hospital Brno and Faculty of Medicine Masaryk University, Brno; Department of Neurology (DV), AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Czech Republic; Departments of Radiology and Medicine (MDH), University of Calgary Cumming School of Medicine, Alberta, Canada; and Department of Neurology (RM), Tomas Bata Regional Hospital Zlin, Czech Republic.

PMID: 39185095
PMCID: PMC11341008 (available on 2025-12-01)
DOI: 10.1212/CPJ.0000000000200341

Abstract

Background and objectives: Given the paucity of high-quality safety/efficacy data on acute stroke therapies in patients with premorbid disability, they risk being routinely excluded from such therapies. We examined utilization of endovascular thrombectomy (EVT), associated workflow, and poststroke outcomes among patients with vs without premorbid disability.

Methods: We used national registry data on thrombolysis/EVT for the Czech Republic from 1 January 2016 to 31 December 2020. Premorbid disability was defined as prestroke modified Rankin Scale score (mRS) ≥3. We compared proportions of patients with vs without premorbid disability who received EVT and examined workflow times. We compared ΔmRS-change in mRS from prestroke to 3 months-in patients with vs without premorbid disability, in addition to intracerebral hemorrhage (ICH), mortality, and discharge NIHSS (National Institutes of Health Stroke Scale score), adjusting for age, sex, baseline NIHSS, and comorbidities, and verified using propensity score weighting (PSW) and matching for differences in treatment assignment. We stratified by age group (<65, 65-74, 75-84, ≥85 years) to explore outcome heterogeneity with vs without premorbid disability.

Results: Among 22,405 patients with ischemic stroke who received thrombolysis/EVT/both, 1,712 (7.6%) had prestroke mRS ≥ 3. Patients with prestroke disability were less likely to receive EVT vs those without (10.1% vs 20.7%, aOR: 0.30, 95% CI 0.24-0.36). When treated, they had longer door-to-arterial puncture times (median: 75 minutes, IQR: 58-100 vs 54, IQR: 27-77, adjusted difference: 12.5, 95% CI 2.68-22.3). Patients with prestroke disability receiving thrombolysis/EVT/both had worse ΔmRS (adjusted rate ratio, aIRR on PSW: 1.57, 95% CI 1.43-1.72), rates of 3-month mRS 5-6, discharge NIHSS, and mortality (aOR-PSW [mortality]: 2.54, 95% CI 1.92-3.34), while ICH did not significantly differ. 32.1% of patients with prestroke disability receiving thrombolysis/EVT/both successfully returned to prestroke state, but this proportion ranged from 19.6% for those older than 85 years to 66.0% for those younger than 65 years. Regardless of premorbid disability, EVT was associated with better outcomes including lower ΔmRS (aIRR-PSW: 0.87, 95% CI 0.83-0.91) and mortality, with no interaction of treatment effect by premorbid disability status (e.g., mortality p_interaction = 0.73). EVT recipients with premorbid disability did not differ significantly for several outcomes including ΔmRS (aIRR: 0.99, 95% CI 0.84-1.17) but were more likely to have 3-month mRS 5-6 (70.1% vs 39.5% without premorbid disability, aOR: 1.85, 95% CI 1.12-3.04).

Discussion: Patients with premorbid disability were less likely to receive EVT, had slower treatment times, and had worse outcomes compared with patients without premorbid disability. However, regardless of premorbid disability, patients fared better with EVT vs medical management and one-third with prestroke disability returned to their prestroke status.