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Meta-Analysis
. 2023 Mar;15(3):214-220.
doi: 10.1136/neurintsurg-2021-018428. Epub 2022 Feb 24.

Clinical outcome of patients with mild pre-stroke morbidity following endovascular treatment: a HERMES substudy

Rosalie V McDonough #  1   2 , Johanna M Ospel #  3 , Charles B L M Majoie  4 , Jeffrey L Saver  5 , Philip White  6 , Diederik W J Dippel  7 , Scott B Brown  8 , Andrew M Demchuk  9 , Tudor G Jovin  10 , Peter J Mitchell  11 , Serge Bracard  12 , Bruce C V Campbell  13   14 , Keith W Muir  15 , Michael D Hill  9 , Francis Guillemin  16 , Mayank Goyal  17 ; HERMES collaborators
Collaborators, Affiliations
Meta-Analysis

Clinical outcome of patients with mild pre-stroke morbidity following endovascular treatment: a HERMES substudy

Rosalie V McDonough et al. J Neurointerv Surg. 2023 Mar.

Abstract

Background: Analyses of the effect of pre-stroke functional levels on the outcome of endovascular therapy (EVT) have focused on the course of patients with moderate to substantial pre-stroke disability. The effect of complete freedom from pre-existing disability (modified Rankin Scale (mRS) 0) versus predominantly mild pre-existing disability/symptoms (mRS 1-2) has not been well delineated.

Methods: The HERMES meta-analysis pooled data from seven randomized trials that tested the efficacy of EVT. We tested for a multiplicative interaction effect of pre-stroke mRS on the relationship between treatment and outcomes. Ordinal regression was used to assess the association between EVT and 90-day mRS (primary outcome) in the subgroup of patients with pre-stroke mRS 1-2. Multivariable regression modeling was then used to test the effect of mild pre-stroke disability/symptoms on the primary and secondary outcomes (delta-mRS, mRS 0-2/5-6) compared with patients with pre-stroke mRS 0.

Results: We included 1764 patients, of whom 199 (11.3%) had pre-stroke mRS 1-2. No interaction effect of pre-stroke mRS on the relationship between treatment and outcome was observed. Patients with pre-stroke mRS 1-2 had worse outcomes than those with pre-stroke mRS 0 (adjusted common OR (acOR) 0.53, 95% CI 0.40 to 0.70). Nonetheless, a significant benefit of EVT was observed within the mRS 1-2 subgroup (cOR 2.08, 95% CI 1.22 to 3.55).

Conclusions: Patients asymptomatic/without disability prior to onset have better outcomes following EVT than patients with mild disability/symptoms. Patients with pre-stroke mRS 1-2, however, more often achieve good outcomes with EVT compared with conservative management. These findings indicate that mild pre-existing disability/symptoms influence patient prognosis after EVT but do not diminish the EVT treatment effect.

Keywords: stroke; thrombectomy.

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Conflict of interest statement

Competing interests: No authors received any payments for work on the submitted manuscript. RVM reports no conflicts. JMO reports support from the University of Basel Research Foundation, Julia Bangerter Rhyner Foundation, and Freiwillige AkademischeGesellschaft Basel. JLS reports being an employee of the University of California; serving as an unpaid site investigator in multicenter trials run by Medtronic and Stryker for which the University of California Regents received payments on the basis of clinical trial contracts for the number of subjects enrolled; receiving funding for services as a scientific consultant regarding trial design and conduct to Medtronic, Stryker, Cerenovus and Rapid Medical. The UC Regents have patent rights in endovascular retrievers. DWJD reports that his institution has received honoraria for his speaking from Stryker and grant funding from the Dutch Heart Foundation, AngioCare BV, Medtronic/EV3, MEDAC GmbH/LAMEPRO, Penumbra, Stryker, and Top Medical/ Concentric. CBLMM reports grants paid to the institution from the Netherlands Cardiovascular Research Committee (CVON)/Dutch Heart Foundation, the European Commission, Stichting Toegepast Wetenschappelijk Instituut voor Neuromodulatie (TWIN) foundation and Stryker. He is shareholder of Nicolab, a company that focuses on the use of artificial intelligence for medical image analysis. TGJ reports receiving grants from Stryker Neurovascular and consultant fees for Anaconda, VizAI, FreeOx Biotech, Corindus, Cerenovus, Route92, Blockade Medical and Medtronic. SB reports grants from the French Ministry of Health during the conduct of the THRACE study (Trial and Cost Effectiveness Evaluation of Intraarterial Thrombectomy in Acute Ischemic Stroke) and personal fees from General Electric Medical Systems and non-financial support from Microvention Europe outside the submitted work. FG reports grants from the French Ministry of Health during the conduct of the THRACE study. BCVC reports that his institution received a grant to support the EXTEND-IA trial (Extending the Time for Thrombolysis in Emergency Neurological Deficits - Intra-Arterial) from Covidien/Medtronic. He reports grant funding from the National Health and Medical Research Council of Australia and Medtronic and fellowships from the National Heart Foundation of Australia, National Stroke Foundation of Australia, and Royal Australasian College of Physicians. PJM reports that his institution received grants from Medtronic and Stryker; he received consultant fees from Stryker and Microvention. PW reports grants from UK National Institutes for Health Research, Microvention Terumo, Stryker, Medtronic, and Penumbra; he received consultation fees from Microvention Terumo and is an Editorial Board member of JNIS. KWM has received consultant fees from Boehringer Ingelheim, Bayer and Daiichi-Sankyo. SBB reports receiving consulting fees from Medtronic/Covidien and personal fees from the University of Calgary. AMD reports receiving grant support and personal fees from Medtronic and has a patent with Circle Cardiovascular Imaging on stroke imaging software. MDH reports unrestricted grant funding for the ESCAPE trial to University of Calgary from Covidien/Medtronic and active/in-kind support consortium of public/charitable sources (Heart and Stroke Foundation, Alberta Innovates Health Solutions, Alberta Health Services) and the University of Calgary (Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, and Calgary Stroke Program); grant funding from Boehringer Ingelheim, NoNo, Inc, and Stryker; personal fees from Merck, non-financial support from Hoffmann-La Roche Canada. In addition, MDH has a submitted patent for triaging systems in ischemic stroke and owns stock in Calgary Scientific, a company that focuses on medical imaging software. MG reports receiving an unrestricted institutional grant from Medtronic; he received a grant from Stryker and consulting fees from Stryker, Microvention, Mentice; and he holds patent rights in systems and methods for acute stroke diagnosis with GE Healthcare.

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