Top Things to Know: Endovascular Treatment and Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability or Dementia
Published: March 28, 2022
Prepared by Anne Leonard MPH, BSN, RN, FAHA – Senior Science and Medicine Advisor - Lead
- Disability can be characterized as having a physical or cognitive impairment The World health Organization estimates that 15% of the world’s population lives with a disability, and in the United States, about 22% of adults have reported disability. Disability can be characterized as having a physical or cognitive impairment as well.
- The most common type of acquired pre-morbid cognitive disability
isin the setting of ischemic stroke is dementia. Observational studies indicate that pre-existing disabilities are apparent in approximately one-third of ischemic stroke patients, while pre-existing dementia is present in approximately one-tenth. - This statement discusses the definitions of pre-morbid disability and dementia and the clinical trial exclusions as related to these definitions. In the setting of pre-morbid disability or dementia, there is an absence of evidence for the use of acute therapies such as thrombolysis or endovascular therapy (EVT) in this excluded patient population.
- Historically, based on functional outcome measures in clinical trial design, patients have been excluded from trials who have a modified Rankin Scale (mRS) score of >2 (moderate disability) or a Barthel Index score of <95. While this seems rational, these exclusions do not capture how disability and dementia result in a setting outside of a clinical trial.
- There are various ethical considerations that come into question when providing or withholding therapies for patients with pre-stroke disability or dementia. As an example, in the absence of definitive evidence regarding the balance of risk versus benefits of therapy, it is challenging to make decisions based only on the ethical pillars of beneficence and non-maleficence. Stroke teams then should seek to respect a patient’s autonomy or their wishes and values as expressed by their proxies in the acute care setting whenever possible.
- On the other hand, enthusiasm to treat these patients must be tempered by the reality that some patients with multiple comorbidities and disability are more likely to succumb to complication of acute stroke. Many aspects should be taken into consideration in these unique clinical settings, and it is important to acknowledge the potential added risks involved in treating these patients who have higher mortality.
- An important aspect of this entire discussion of the provision of good end-of-life palliative care for stroke patients and their families is a moral obligation of the stroke community.
- Several biases can influence a clinician or caregiver decision-making process when considering the use of acute stroke therapies in this patient population.
- Based on the best available literature it seems reasonable to conclude that a blanket disability cut-off, such as a pre-morbid mRS of 2, probably should not be used as a protocolized threshold to exclude patients from acute stroke therapies. Ideally a case-by-case approach to the use of acute stroke therapies in patients with pre-morbid disability or dementia, pending more definitive evidence would be appropriate.
- By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, research teams can work towards a more inclusive paradigm of patient-centered care for this often-neglected patient population.
Citation
Ganesh A, Fraser JF, Gordon Perue GL, Amin-Hanjani S, Leslie-Mazwi TM, Greenberg SM, Couillard P, Asdaghi N, Goyal M; on behalf of the American Heart Association Stroke Council. Endovascular treatment and thrombolysis for acute ischemic stroke in patients with premorbid disability or dementia: a scientific statement from the American Heart Association/American Stroke Association [published online ahead of print March 28, 2022]. Stroke. 2022;53:e•••–e•••. doi: 10.1161/STR.0000000000000406