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

Discussion

In this single-center experience, endovascular treatment resulted in a similar rate of functional independence in elderly (30.6%) and younger (34.3%) adults. The rate of favorable outcomes obtained in the older adults was comparable with that of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands trial.[17] Global mortality was comparable with that observed in previous studies,[18] although it tended to be higher in the older group. Moreover, mortality from nonneurological causes tended to be higher in the older group, suggesting the effect of preexisting comorbidities on clinical outcomes in elderly adults. In addition, hypertension, the most important risk factor for stroke, and atrial fibrillation, the most frequent cause of cardioembolic stroke, were more frequent in elderly adults, as described previously.[2]

Despite more-frequent use of IVT (a finding in countertrend to the above-mentioned skepticism) and intravenous heparin during procedures in the older group, similar rates of ICH, including the most serious parenchymal hematoma-2, were observed in the two groups.[16] This finding is in line with a metaanalysis of IVT RCT data reporting how the risk of ICH is irrespective of age[19] and with a recent metaanalysis of five endovascular stroke trials showing no difference in the risk of parenchymal hematoma and sICH between populations.[6]

The older adults were treated more frequently without general anesthesia, probably to reduce risk of overall complications in a population with other comorbidities and with a greater risk of stroke-associated pneumonia.[20,21] Moreover, elderly adults had shorter reperfusion times. Although avoiding general anesthesia could have shortened reperfusion times, in the older adults, reperfusion was achieved with fewer device passages. Nevertheless, it is not clear whether this was an effect or a cause of shorter reperfusion times because it lies outside the scope of this study.

The older group had higher 24-hour ASPECTS, indicating a smaller infarct size than the younger group after treatment, this could be due to shorter reperfusion times and more-frequent use of IVT, with consequently salvage of ischemic penumbra, resulting in limitation of infarct burden.

The multivariate analysis indicates that onset NIHSS score and 24-hour clinical improvement are the sole independent predictors of good outcomes in elderly adults with stroke, whereas 24-hour clinical improvement and the number of device passages were independent predictors in the younger group. Although 24-hour clinical improvement was predictive of functional outcome in both groups, the odds were much higher for elderly adults than for younger adults. This finding suggests that, for elderly adults showing remarkable clinical improvement in the early period after the procedure, all efforts should be made to prevent or treat poststroke complications, which are known to strongly affect short-, intermediate-, and long-term morbidity and mortality.[8,22] The analysis also revealed onset NIHSS score to be a predictor of outcome in elderly but not younger adults. Onset NIHSS score is a well-known, accurate predictor of outcome because it is related to infarct size and to the ability of collaterals to sustain ischemic penumbra, which is known to be worse in elderly adults.[23,24] Despite this, shorter times needed for reperfusion could have offset this assumption and could explain the high rate of 3-month functional independence and the surprising higher 24-hour ASPECTS observed in the older group. Particular attention to onset NIHSS score and baseline ASPECTS could therefore be of great value for proper participant selection, but speed of endovascular procedure seems to be of relevance in achieving reperfusion and good clinical outcomes in this subgroup.

The main limitation of this study is its retrospective nature and the relatively small number of participants in the older group. The strict selection criteria could have led to misleading results, limiting the generalizability of conclusions, but these criteria were chosen to adhere, as much as possible, to updated guidelines and current real practice. Moreover, only four individuals out of 35excluded were aged 80 and older. (Two died, and two were independent at 3-month follow-up.) Furthermore the 7-year period analyzed included the use of first-generation devices and different levels of interventionalist skill over the years.[25] All this could have affect outcome measures such as successful reperfusion and good clinical outcome, but to the knowledge of the authors, this is one of the largest single-center controlled studies of endovascular treatment in elderly adults who have had an acute ischemic stroke.

In conclusion, this study seems to suggest that endovascular treatment for large-vessel occlusion stroke in elderly adults could be safe and effective. Major determinants of outcomes in this population are presentation NIHSS score and 24-hour clinical improvement. Further studies in larger series are warranted to confirm the results and to evaluate the safety and efficacy of endovascular treatment also in the oldest adults.

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