The American Heart Association (AHA) and American Stroke Association (ASA) has issued a joint scientific statement on treatment for acute ischemic stroke (AIS) in the disability and dementia setting. The statement was published in the journal Stroke.
Currently there is a lack of evidence about the use of AIS therapies among patients with prestroke disability and dementia. Current guidelines do not address whether patients with disability should receive thrombolysis or endovascular therapy (EVT). This leaves physicians with a dilemma about how to best treat this patient population.
The first confounder for treating patients in the stroke setting is that their baseline characteristics may make it difficult for caretakers to recognize the onset of new symptoms. Once patients do present to a medical facility, their symptomology may lead to a higher grading of their stroke severity, and, in general, patients with more severe stroke are less likely to receive treatment.
Beyond clinical decisions about whether patients with disability should receive AIS care, there are also ethical decisions which need to be considered. Stroke teams should ensure that they are following the patient’s wishes and values as expressed by their proxies.
Although there remains a paucity of data, there is no consistent evidence that prestroke dementia or disability increases risk for adverse outcomes from AIS treatments. An open question remains about whether this patient population should be candidates for receiving thrombolysis or EVT.
In general, the statement authors did not endorse a strict cutoff for receiving therapy. For example, the European guidelines recommend using a modified Rankin Score of 2. Instead, the authors of this statement advocated for balancing risks and benefits on a case-by-case basis.
One key to providing optimum stroke care to ensure patients and caregivers are prepared is by counseling this population in the prestroke setting. This way, individuals have already considered potential outcomes and may make a stroke care plan for future events, such that decisions may be more informed and made more quickly in an emergency situation.
After patients present with stroke, clinicians should educate patients and caregivers about the spectrum of outcomes and disclose the fact that outcomes are relatively uncertain among this population. It is important to adopt a patient-centered care approach and to attempt to understand their wishes and values.
For the future, it is critical that more studies focus on AIS care among patients with disability and dementia. It is becoming increasingly important to understand potential outcomes especially as society ages and the population of patients with AIS and prestroke disability is likely to increase.
“By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, we can work toward a more inclusive paradigm of patient-centered care for this often-neglected patient population,” the statement authors concluded.
Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.
Ganesh A, Fraser JF, Gordon Perue GL, et al. Endovascular Treatment and Thrombolysis for Acute lschemic Stroke in Patients With Premorbid Disability or Dementia: A Scientific Statement From the American Heart Association/ American Stroke Association. Stroke. Published online March 28, 2022. doi:10.1161/STR.0000000000000406