Acute Stroke Treatments for Patients with Pre-Stroke Disability: Are We Discriminating Against the Disabled?
Robert W. Regenhardt, MD, PhD
Goldhoorn R-JB, Verhagen M, Dippel DWJ, van der Lugt A, Lingsma HF, Roos YBWEM, et al. Safety and Outcome of Endovascular Treatment in Prestroke-Dependent Patients: Results From MR CLEAN Registry. Stroke. 2018
Robust, randomized trial evidence exists supporting the efficacy of thrombolysis and thrombectomy to reduce disability after acute ischemic stroke for select patients. However, there is a paucity of evidence for patients with pre-stroke disability since patients with baseline mRS 2-5 are often excluded from trials. Like many acute stroke care providers, I have found myself in several situations in which our team pauses as we learn the pre-stroke mRS is not perfect. It spurs some debate, as in many cases the pre-stroke disability seems to have little implications for hemorrhage risk, procedural risk, or treatment efficacy. Ganesh et al. point out that exclusion of patients with mRS 2-5 is not based on mechanistic hypotheses about reduced benefit for this population necessarily, but reflects that pre-stroke disability prevents patients from contributing to the typical dichotomized mRS analyses. They further discuss that patients with mRS 2-4 would likely consider retaining their pre-stroke status a favorable outcome, but pre-stroke disability is often cited as a reason for withholding treatment.