Reperfusion Therapy for Acute Ischemic Stroke in Older People

An Observational Real-life Study

Justine Sudre MD; Laura Venditti MD; Claire Ancelet MD; Olivier Chassin MD; Mariana Sarov MD; Didier Smadja MD; Nicolas Chausson MD; François Lun MD; Olga Laine MD; Emmanuelle Duron MD; Christiane Verny MD; Laurent Spelle MD; Alexandra Rouquette MD; Nicolas Legris MD; Christian Denier MD

Disclosures

J Am Geriatr Soc. 2021;69(11):3167-3176. 

In This Article

Abstract and Introduction

Abstract

Background: While randomized clinical trials have shown the benefit of thrombolysis and endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS), we aimed to describe in a real-life study the differences between older (>80 years old) and younger patients treated for AIS.

Methods: Thousand patients treated with thrombolysis and/or EVT were consecutively included in a prospective monocentric database (admitted from December 2015 to May 2019 in our comprehensive stroke center). Demographic data with detailed history, baseline physical examinations and treatments, laboratory and imaging data, prestroke functional status, and outcome 3 months after stroke were analyzed.

Results: Older patients (n = 357) had more baseline comorbidities and lower levels of prestroke independence (modified Rankin scale ≤2; 67.2% vs. 96.1%) and more severe strokes (median National Institute of Health Stroke Score [NIHSS] 15 vs. 12; p < 0.001) than younger patients (n = 643). There was no difference in the reperfusion treatments used or treatment timelines. In older patients, good functional status at 3 months was less common (29.7% vs. 61.3%) and mortality was higher (37.1% vs. 11.4%) than in younger patients. Younger age was independently associated with better prognosis (odds ratio [OR] 0.37, 95% confidence interval [CI]: 0.20–0.67; p = 0.001) and lower mortality (OR 4.38, 95% CI: 2.11–9.09; p < 0.001). Among older adults, features associated with good outcome at 3 months were age (OR 0.89, 95% CI: 0.81–0.97; p = 0.01), initial NIHSS (OR 0.89, 95% CI: 0.83–0.94; p < 0.0001), and absence of severe leukoaraiosis, anticoagulant treatment, and symptomatic intracerebral hemorrhage following reperfusion therapy (respectively, OR 0.42, 95% CI: 0.19–0.93; p = 0.03; OR = 0.07, 95% CI: 0.01–0.70; p = 0.02; and OR = 0.07, 95% CI: 0.01–0.61; p = 0.02).

Conclusion: Although reperfusion therapy was less successful in older patients, these patients may benefit from acute recanalization despite their age. With an increasing older adult population, high-quality prospective studies are still required to better predict functional outcome and clarify the criteria that would allow better selection of appropriate treatment.

Introduction

Strokes are the second leading cause of death and the third leading cause of disability.[1] The proportion of older adults (defined as individuals 80 years old or older) is expected to dramatically increase in the European Union by 2050, from 4.0% in 2004 to 11.4% in 2050.[2] As one in three strokes occurs after the age of 80, the continuing increase in the older adult population is associated with an increase in the absolute number of stroke cases.[1,3,4] Rationally, the number of older patients requiring thrombolysis and/or endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) is bound to increase in the coming decades. To date, older patients have been globally under-represented in randomized clinical trials of acute stroke therapy. Thrombolysis proved to be beneficial if administrated within 4.5 h of the AIS but was initially contraindicated in patients over 80 years old.[5,6] More recently, it has become a standard treatment for older adults after clinical trials and meta-analyses in this population demonstrated its efficacy and safety.[7–9] Since 2015, EVT has been the new standard of care for large vessel occlusion (LVO),[7] with no age restrictions, even though only a small number of older patients were included in randomized trials. In most of those clinical trials, exclusion criteria relating to previous autonomy meant that older patients who only partially represented this population were selected. Since these trials, EVT has been increasingly used in patients over 80 years old and has proven its relevance.[10–13]

We herein conducted an observational real-life study to assess the differences, in terms of radiological and clinical features, management, and outcome, between older and younger patients consecutively treated for AIS by thrombolysis, EVT, or both in our comprehensive stroke center.

processing....