Increased Risk for Unfavorable Outcome in Patients with Pre- Existing Disability Undergoing Endovascular Therapy Ronen R. Leker, MD, FAHA,* Pavel Gavriliuc, MD,* Nour Eddine Yaghmour, MD,* John M. Gomori, MD,† and Jose E. Cohen, MD‡ Introduction: Most studies evaluating endovascular therapy (EVT) for stroke only included patients without pre-existing disabilities. However, in real life many pa- tients have pre-existing disabilities, and whether they can benefit from EVT remains unknown. Methods: Patients with emergent large vessel occlusions undergoing EVT were prospectively enrolled. Patients with no or mild pre-existing disabili- ties (modified Rankin Scale [mRS], 0-2) were compared with patients presenting with pre-existing moderate disability (mRS ≥ 3). Baseline demographics and risk factors, stroke severity (studied with the National Institutes of Health Stroke Scale [NIHSS]), imaging data including pretreatment Alberta Stroke Program Early Com- puterized Tomography Score (ASPECTS) and ASPECTS collateral scores, as well as procedure-related variables were accrued. Unfavorable outcome was defined as mRS ≥ 4 at day 90. Results: Of 131 enrolled patients, 108 had a baseline mRS of 2 or lower, and 23 had a prestroke mRS score of 3 or higher. Patients with pre-existing mRS scores of 3 or higher were significantly older (80.3 ± 10 versus 66.9 ± 13.7; P = .001) and more often had previous strokes (39% versus 16%; P = .02). Patients with mRS scores of 3 or higher were more likely to have poor outcomes or death (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.3-15.0). Of the 23 patients with pre-existing moderate disability, 8 (35%) maintained their previous degree of disability. On multivariate analysis, age (OR, .92; 95% CI, .88-.97; P = .001), admission NIHSS (OR, .92; 95% CI, .85-.99; P = .042) and pretreatment ASPECTS (OR, 6.4; 95% CI, 1.4-29.5; P = .017) remained significant modifiers of favorable outcome. Discussion and Conclusions: Patients with pre-existing moderate dis- abilities have higher chances of sustaining unfavorable outcomes despite EVT. Nevertheless, some patients maintain the same level of moderate disabilities, and therefore, patients with pre-existing moderate disabilities should not be ex- cluded from EVT. Key Words: Stroke—endovascular therapy—disability—outcome. © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved. Introduction Large hemispheric ischemic stroke, secondary to in- ternal carotid or proximal middle cerebral artery occlusions, carries a mortality rate close to 80% if left untreated. 1,2 Systemic thrombolysis is of limited benefit in these patients, 3-6 but endovascular therapy (EVT) has recently proved effective in several prospective studies 7-12 that used rigorous selection criteria. However, many patients pre- senting with large hemispheric strokes have had a prior stroke, and the frequency of moderate disabilities is rel- atively high. 13-17 Furthermore, another group of patients have pre-existing non-neurological disabilities that may render them ineligible for EVT based on the criteria used From the *Department of Neurology; †Department of Radiology; and ‡Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Received June 12, 2017; revision received July 12, 2017; accepted August 7, 2017. Funding: This work was supported by the Peritz and Chantal Scheinberg Cerebrovascular Research Fund and by the Sol Irwin Juni Trust Fund. Address correspondence to R.R. Leker MD, Department of Neurology, Hebrew University-Hadassah Medical Center, P.O. Box 12000, Jerusalem 91120, Israel. E-mail: leker@hadassah.org.il. 1052-3057/$ - see front matter © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.08.007 ARTICLE IN PRESS Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2017: pp ■■–■■ 1