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

Methods

Information was collected on individuals with anterior circulation acute ischemic stroke from a prospective endovascular stroke registry (started in August 2009). Participants were selected based on the following criteria: computed tomography (CT) angiography (CTA) documentation of occlusion of the middle cerebral artery (M1 or M2 segment), anterior cerebral artery (A1 or A2 segment), terminal internal carotid artery, or any combination of these arteries or conventional angiography documentation of occlusion of the proximal internal carotid artery in combination with an intracranial vessel; groin puncture within 5 hours of symptom onset; National Institutes of Health Stroke Scale (NIHSS) score of 10 or greater; prestroke modified Rankin Scale (mRS) score of 2 or less; and available for 3-month follow-up. Participants were divided into two groups based on their age (≥80, <80). Baseline characteristics included in the analysis were age; sex; NIHSS score; rate of tandem lesion; history of hypertension, diabetes mellitus, smoking, and atrial fibrillation; Alberta Stroke Program Early CT score (ASPECTS) on noncontrast CT;[11] and collateral flow adequacy on pretreatment CTA. Collaterals were defined using a scale from 0 to 3 derived from the Prolyse in Acute Cerebral Thromboembolism II trial (0 = no collaterals; 1 = collaterals to the periphery of ischemia; 2 = collaterals filling 50–100% of ischemic area; 3 = collaterals filling 100% of ischemic area).[12] Thereafter, collateral score was dichotomized as poor (0–1) vs good (2–3). The validity of this dichotomization in terms of functional outcomes has been shown.[13] Based on current guidelines, a full dose (0.9 mg/kg, 10% as a bolus and the rest in a 1-hour infusion) of IVT was administered within 4.5 hours after stroke onset[10] and continued during endovascular procedure.[14] Use of intravenous heparin during the procedure, symptom onset to groin puncture time, symptom onset to reperfusion time, groin puncture to reperfusion time, and type of device used for thrombectomy were used as procedural variables. Outcome measures included successful reperfusion, defined according to Thrombolysis in Cerebral Infarction grading as a score of 2b or greater;[15] ASPECTS on 24-hour noncontrast CT; hemorrhagic complications, defined according to the European Cooperative Acute Stroke Study criteria (no hemorrhage, hemorrhagic infarction-1, hemorrhagic infarction-2, parenchymal hematoma-1, parenchymal hematoma-2);[16] symptomatic ICH (sICH), defined as a hemorrhage associated with an increase of at least 4 points in NIHSS score; 24-hour clinical improvement, defined as a reduction of at least 4 points in NIHSS score; 3-month functional independence, defined as a mRS score of 2 or less; and global mortality. Because elderly adults often have comorbidities, mortality from neurological deterioration for malignant stroke or hemorrhagic transformation of the ischemic lesion was differentiated from mortality from other causes (pneumonia, sepsis, myocardial infarction). The local ethical committee approved the study. Informed consent was obtained from all participants or their relatives.

Statistical Analysis

All data were initially entered into an Excel database (Microsoft Corp., Redmond, WA), and the analysis was performed using Stata/IC version 13 (StataCorp, College Station, TX). Descriptive statistics consisted of means ± standard deviations or medians with interquartile ranges for parameters with gaussian distributions (after confirmation using histograms and the Kolmogorov–Smirnov test) or frequencies (%), as appropriate. Comparison of continuous variables was performed using the Student t-test or Mann–Whitney U test. Categorical variables were compared using the Fisher exact test. Variables with a univariate P value <.01 were further tested for the prediction of good outcome (mRS score ≤2) and symptomatic ICH in different multivariate logistic regression analyses. P < .05 was considered statistically significant for all analyses.

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