Trade-Offs in Quality-of-Life Assessment Between the Modified Rankin Scale and Neuro-QoL Measures

Endovascular thrombectomy for large vessel occlusion stroke in patients with pre-existing disability

BACKGROUND

Approximately one in three patients with acute ischemic stroke (AIS) suffer from a premorbid disability prior to their incident AIS. These patients have largely been excluded from clinical trials of endovascular thrombectomy (EVT) for the treatment of AIS and current literature remains unclear regarding the safety and efficacy of EVT in these patients.

METHODS

We queried our prospectively maintained registry of patients with AIS from December 1, 2014 to October 31, 2023 to identify all patients who underwent EVT. Patients were stratified by their baseline modified Rankin Scale (mRS) score into those with (mRS 2-5) and without (mRS 0-1) baseline disability. Univariate analyses using the χ2 test for categorical variables and the Wilcoxon rank-sum test for continuous variables were performed to compare demographics between the two groups. Generalized logistic and linear regression models for multivariable analysis were used to compare outcomes between the groups.

RESULTS

Of a total of 1489 patients, 367 (24.6%) had a pre-existing disability. Patients with baseline disability were older (79.6 years vs 67.7 years, P<0.001), more likely to be female (65.7% vs 45.9%, P<0.001), and had higher rates of stroke risk factors. There were higher odds of return to baseline (90-day ΔmRS =<0: OR 2.83, P<0.001) and 90-day ΔmRS =<1 (OR 2.94, P<0.001) for patients with baseline disability post-EVT compared with their healthier counterparts. There was no relative adjusted increase in symptomatic intracerebral hemorrhage or 90-day mortality.

CONCLUSIONS

EVT appears to be safe and effective in patients with baseline disability, often associated with a return to their premorbid functional status at 90 days.

An exploratory review of resiliency assessments after brain injury

BACKGROUND

People with brain injury can have lower resiliency compared to the general public. Yet, resiliency facilitates positive processes to negotiate adversity after brain injury. Therefore, measuring resiliency after a brain injury is important.

OBJECTIVE

The review aimed to (1) identify self-report resiliency outcome measures for use with people after acquired brain injury, using the process-based Traumatic Brain Injury Resiliency Model as the guiding conceptual framework, and (2) summarize the psychometric properties of the identified outcome measures and the utility of these measures in clinical rehabilitation.

METHOD

The COSMIN guidelines for systematic reviews were followed to ensure appropriate reporting for each measure. Databases CINAHL, EMBASE, Medline, and PsychINFO were searched and independently reviewed by two people. Articles providing data on psychometric properties for measures of resilience for people with brain injury were retrieved. Psychometric properties and clinical utility (number of items, scoring details) were summarized.

RESULTS

Thirty-two articles were retrieved, including nine measures of resiliency: Acceptance and Action Questionnaire-Acquired Brain Injury, Confidence after Stroke Measure, Connor-Davidson Resilience Scale, Daily Living Self-Efficacy Scale, General Self-Efficacy Scale, Participation Strategies Self-Efficacy Scale, Resilience Scale, Robson Self-Esteem Scale, and the Stroke Self-Efficacy Questionnaire. All measures have acceptable to excellent psychometric properties in accordance with the COSMIN guidelines.

CONCLUSION

There are established measures of resiliency in brain injury rehabilitation. Future work may explore use of these measures in a clinical context and implementation of rehabilitation goals for improving resiliency after brain injury.

The economic impact associated with stent retriever selection for the treatment of acute ischemic stroke: a cost-effectiveness analysis of MASTRO I data from a Chinese healthcare system perspective

Aim: The aim of this analysis was to assess the cost-effectiveness of the EmboTrap® Revascularization Device compared with the Solitaire™ Revascularization Device and Trevo® Retriever for the treatment of acute ischemic stroke (AIS) from the perspective of the Chinese healthcare system. Methods: According to MASTRO I, a recent living systematic literature review and meta-analysis, mechanical thrombectomy (MT) with EmboTrap in the treatment of AIS resulted in better functional outcomes compared with the use of Solitaire or Trevo. Based on the proportion of patients that achieved 90-day modified Rankin Scale (mRS) scores of 0-2, 3-5 and 6 reported in MASTRO I, a combined 90-day short-term decision tree and Markov model with a 10-year time horizon was used to compare the cost-effectiveness of the three devices. The primary outcome was the incremental cost-effectiveness ratio (ICER), representing the incremental cost (in 2022 Chinese Yuan [CNY]) per incremental quality-adjusted life-year (QALY). The ICERs were compared against willingness-to-pay (WTP) thresholds of 1, 1.5 and 3-times the 2022 national gross domestic product (GDP) per capita in China. Results: Treatment with EmboTrap resulted in total QALYs of 3.28 and total costs of 110,058 CNY per patient. Treatment with Trevo resulted in total QALYs of 3.05 and total costs of 116,941 CNY per patient. Treatment with Solitaire resulted in total QALYs of 2.81 and total costs of 99,090 CNY per patient. Trevo was dominated by EmboTrap as it was a more costly and less effective intervention. As such, Trevo was not cost-effective at any WTP threshold. Compared with Solitaire, EmboTrap was more effective and more costly, with an ICER of 23,615 CNY per QALY. This result suggests that EmboTrap is cost-effective when compared with Solitaire since the ICER was lower than all WTP thresholds assessed. Conclusion: EmboTrap dominated Trevo and is cost-effective for the treatment of patients with AIS compared with Solitaire when assessed from the perspective of the Chinese healthcare system and based on the device-level meta-analysis MASTRO I. Selecting a stent retriever (SR) that optimizes 90-day mRS score is an important consideration from both a clinical and healthcare payer perspective in China as it is associated with reduced long-term costs and increased quality of life.

Clinical Outcome Assessments in Encephalitis: A Systematic Review

BACKGROUND AND OBJECTIVES

Most patients with encephalitis experience persisting neurocognitive and neuropsychiatric sequelae in the years following this acute illness. Reported outcomes are often based on generic clinical outcome assessments that rarely capture the patient perspective. This may result in an underestimation of disease-specific sequelae. Disease-specific clinical outcome assessments can improve clinical relevance of reported outcomes and increase the power of research and trials. There are no patient-reported outcome measures (PROMs) developed or validated specifically for patients with encephalitis. The primary objective of this systematic literature review was to identify PROMs that have been developed for or validated in patients with encephalitis.

METHODS

We performed a systematic review of the literature published from inception until May 2023 in 3 large international databases (MEDLINE, EMBASE and Cochrane libraries). Eligible studies should have developed or validated a PROM in patients with encephalitis or encephalopathy. Methodologic quality was evaluated using the Consensus-based Standards for the selection of health status Measurement Instruments study design checklist for PROMs.

RESULTS

We identified no disease-specific PROMs developed or validated for patients with encephalitis. We identified one study on the development and validation of a disease-specific PROM for hepatic encephalopathy, although this disease course is substantially different to that of patients with encephalitis. The methodologic quality of the included study was generally rated as "doubtful." We identified 30 PROMs that have been applied in 46 studies on encephalitis or encephalopathy, although not validated in these populations. The most commonly applied PROMs for measuring Health-Related Quality of Life were the Medical Outcomes Study Short Form-36 and the Sickness Impact Profile. Emotional well-being was often assessed with the Beck Depression Inventory (BDI-II). Sporadically, PROMs were applied to address other aspects of outcome including daily functioning and sleep quality.

DISCUSSION

This systematic review confirms a critical gap in clinical outcome assessments in patients with encephalitis, failing to identify a validated measuring tool for detecting neurocognitive, functional, and health status. It is therefore essential to develop and/or validate disease-specific PROMs for the population with encephalitis to capture relevant information for patient management and clinical trials about the effects of disease that are at risk of being overlooked.

When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative?

Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.