Efficacy and Safety of Mechanical Thrombectomy in Older Adults With Acute Ischemic Stoke

Fabrizio Sallustio, MD; Giacomo Koch, PhD; Caterina Motta, MD; Marina Diomedi, MD; Fana Alemseged, MD; Vittoria C. D'Agostino, MD; Simone Napolitano, MD; Domenico Samà, MD; Alessandro Davoli, MD; Daniel Konda, MD; Daniele Morosetti, MD; Enrico Pampana, MD; Roberto Floris, MD; Roberto Gandini, MD

Disclosures

J Am Geriatr Soc. 2017;65(8):1816-1820. 

In This Article

Abstract and Introduction

Abstract

Objectives To evaluate the safety and efficacy of endovascular therapy in elderly adults treated for acute ischemic stroke.

Design Retrospective cohort study.

Setting Comprehensive Stroke Center, University of Tor Vergata, Rome, Italy.

Participants Elderly adults treated for acute ischemic stroke (N = 219).

Measurements Participants were divided into two groups based on their age (n = 62, ≥80; n = 157, <80). Baseline and procedural characteristics, safety outcomes such as intracranial hemorrhage (ICH) and mortality and efficacy outcomes such as successful reperfusion and 3-month good clinical outcome of the two groups were compared. Mutivariable analysis was performed to identify predictors of clinical outcome.

Results Intravenous thrombolysis was more frequent (67.7% vs 52.8%, P = .04), and onset to reperfusion time was shorter (318.7 ± 128.7 vs 282 ± 53.5, P = .02) in participants aged 80 and older, but no between-group differences were found in terms of successful reperfusion (69% vs 63%, P = .4), good clinical outcome (30.6% vs 34.3%, P = .6), any (37% vs 37.5%, P > .99) or symptomatic (11% vs 14%, P = .6) ICH, or mortality (40.3% vs 29.2%, P = .14). Multivariable analysis revealed that, in the older group, onset National Institute of Health Stroke Scale (NIHSS) score (odds ratio (OR) = 0.65, 95% confidence interval (CI) = 0.44–0.96, P = .03) and 24-hour clinical improvement (OR = 141.13, 95% CI = 2.96–6,720.7, P = .01) were independent predictors of 3-month functional independence.

Conclusion These findings suggest that endovascular treatment for stroke in selected elderly adults could be safe and effective. Major determinants of outcome in this subgroup of elderly patients are presentation NIHSS score and 24-hour clinical improvement.

Introduction

Because of the aging of the population and the increasing incidence and prevalence of ischemic stroke with age,[1,2] the burden of stroke care is growing dramatically. Skepticism about the efficacy of treatment in elderly adults with stroke in recent decades has led to the inclusion of a limited number of participants in randomized controlled trials (RCTs).[3] The Third International Stroke Trial has been the largest RCT providing evidence of benefit of intravenous thrombolysis (IVT) for individuals aged 80 and older.[4] In a metaanalysis of six RCTs, benefit of IVT within a 3-hour window was demonstrated for younger and older adults.[5] Similar limitations have been noticed in recent endovascular stroke trials, in which the median age of recruited individuals who had had a stroke was 68.[6] In a recent metaanalysis of data collected from five large RCTs, only 15% of 1287 participants were included in subgroup analysis restricted to elderly adults (≥80), and superiority of intervention over control group was claimed.[6] One of the main reasons for not including elderly adults in RCTs has been the fear that they are more likely to experience complications such as intracranial hemorrhage (ICH), in-hospital death, and discharge home with poor functional independence at 3 months than younger adults.[7–10] Studies showing higher risk of ICH after IVT have been the reason of a limited number of elderly stroke patients in the past. This trend has been changing in recent years, as the Third International Stroke Trial, in which more than half of recruited participants were aged 80 and older, and 7% were aged 90 and older in the active and control groups, revealed. The aim of the present study was therefore to assess the safety and efficacy of endovascular therapy by evaluating determinants of successful outcomes in elderly adults with acute ischemic stroke.

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