1
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Enriquez BAB, Halling HK, Lund CG, Tennøe B, Brunborg C, Skjelland ME, Aamodt AH, Skagen K. Exploring the Impact of Age and Pre-Stroke Modified Rankin Scale in Elderly Thrombectomy: A 15-Year Single-Center Experience. Cerebrovasc Dis Extra 2024; 14:125-133. [PMID: 39191213 DOI: 10.1159/000540992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 07/30/2024] [Indexed: 08/29/2024] Open
Abstract
INTRODUCTION The selection of endovascular thrombectomy (EVT) for acute ischemic stroke in the elderly remains challenging due to the underrepresentation of these patients in landmark randomized trials. The aim of this study was to assess the association between age and the pre-stroke modified Rankin scale score with functional outcomes after EVT in elderly patients aged ≥80 years. METHODS We prospectively collected data from consecutive elderly patients who underwent EVT of the anterior or posterior circulation at our institution between 2007 and 2022. Clinical and radiological parameters were analyzed using a fair outcome (mRS ≤3 or retained pre-stroke mRS score of 4) as the primary outcome. RESULTS In total, 307 elderly patients were included in the analysis. Fair functional outcomes were achieved in 162 (53%) patients. Eighty-four (27.4%) patients were deceased at 3-month follow-up and the mortality rate increased to 37.1% (114 deceased) at 1-year follow-up. The likelihood of achieving a fair functional outcome decreased by 8% for every 1-year age increase (OR 0.81, 95% CI 0.73-0.90). Lower National Institutes of Health Stroke Scale (OR 0.89, 95% CI 0.85-0.93, p < 0.001) and pre-stroke mRS (OR 0.67, 95% CI 0.53-0.84, p < 0.001) were associated with fair outcomes. CONCLUSIONS EVT in elderly patients with stroke is beneficial in selected cases. Increasing age was associated with an increased risk of an mRS change to 4 or worse and death within 1 year. The pre-stroke mRS may aid clinicians in the selection of elderly patients for EVT.
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Affiliation(s)
- Brian Anthony B Enriquez
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | | | - Bjørn Tennøe
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Cathrine Brunborg
- Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Mona Elisabeth Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway
| | - Karolina Skagen
- Department of Neurology, Oslo University Hospital, Oslo, Norway
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Jiang X, Wang J, Hu Y, Lang H, Bao J, Chen N, He L. Is endovascular treatment still good for acute ischemic stroke in the elderly? A meta-analysis of observational studies in the last decade. Front Neurosci 2024; 17:1308216. [PMID: 38249587 PMCID: PMC10796798 DOI: 10.3389/fnins.2023.1308216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Background The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for endovascular treatment (EVT) in elderly patients. This meta-analysis aims to evaluate the therapeutic effects of endovascular treatment for acute ischemic stroke in the elderly compared with younger patients. Methods Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT in elderly patients and those aged <80 years. The primary outcome was functional independence, defined as mRS 0-2 at 90 days after EVT. The secondary outcomes were the rate of successful recanalization, symptomatic intracranial hemorrhage (sICH) and mortality. Odds ratios (ORs) were estimated using a random effects model. Results In total, twenty-six studies with 9,492 enrolled participants were identified. Our results showed that, compared with patients aged <80 years undergoing EVT, EVT was associated with a lower rate of functional independence at 90 days (OR = 0.38; 95% CI, 0.33-0.45; p < 0.00001) and a higher mortality rate (OR = 2.51; 95% CI, 1.98-3.18; p < 0.00001) in the elderly. Furthermore, even without a significantly observed increase in sICH (OR = 1.19; 95% CI, 0.96-1.47; p = 0.11), EVT appeared to be associated with a lower rate of successful recanalization (OR = 0.81; 95% CI, 0.68-0.96; p = 0.02). Conclusion Evidence from observational studies revealed that EVT has less functional outcomes in elderly patients with acute ischemic stroke. Further studies are needed to better identify patients aged ≥80 years who could potentially benefit from EVT.
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Affiliation(s)
| | | | | | | | | | - Ning Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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3
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Weyland CS, Mutke MA, Zimmermann-Miotk A, Schmitt N, Chen M, Schönenberger S, Möhlenbruch M, Bendszus M, Jesser J. Clinical outcome and outcome prediction of octogenarians with acute basilar artery occlusion and endovascular stroke treatment compared to younger patients. Front Neurol 2023; 14:1266105. [PMID: 37840915 PMCID: PMC10570514 DOI: 10.3389/fneur.2023.1266105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
Background and aims Octogenarians are underrepresented in recently published studies that showed the benefit of endovascular stroke treatment (EST) for patients with acute basilar artery occlusion (BAO). We aimed to compare the clinical outcome of octogenarians with BAO and EST compared to younger patients (YPs) and identify independent outcome predictors. Methods This is a retrospective, single-center analysis of patients treated for BAO with EST from January 2013 until June 2021 in a tertiary stroke center. Octogenarians (80-89 years) were compared to YPs. A study endpoint was a favorable clinical outcome as per the modified Rankin Scale (mRS 0-3), 90 days after stroke onset. The study groups were compared using univariate analysis, and a multivariable logistic regression analysis was performed to define independent predictors for favorable and unfavorable (mRS 5-6) clinical outcomes. Results In this study cohort, 74/191 (38.7%) octogenarians had a higher pre-stroke mRS [median, interquartile range (IQR): 2, 1-3 octogenarians vs. 0, 0-1 YP, p < 0.001] and a comparable National Institutes of Health Stroke Scale (NIHSS) before EST (median, IQR: 21, 10-38 vs. 20, 8-35 in YP, p = 0.487). They showed a comparable rate of favorable outcome (mRS 0-3, 90 days, 23.0 vs. 25.6% in YP, p = 0.725), but were less often functionally independent (mRS 0-2: 10.8% in octogenarians vs. 23.0% in YP, p = 0.049). The rate of unfavorable clinical outcome was comparable (mRS 5-6, n = 40, 54.1% in octogenarians vs. n = 64, 54.7% in YP, p = 0.831). A baseline NIHSS was an independent predictor for clinical outcome in YPs [e.g., for unfavorable clinical outcome: odds ratio (OR) 1.061, confidence interval (CI) 1.027-1.098, p = 0.005] and for favorable clinical outcome in octogenarians. Pre-stroke mRS predicted favorable outcomes in octogenarians (OR 0.54, CI 0.30-0.90, p = 0.0291), while age predicted unfavorable outcomes in YPs (OR 1.045, CI 1.011-1.086, p = 0.0137). Conclusion Octogenarians with acute BAO eligible for EST are as likely to achieve a favorable outcome as YPs, and the rate of death or severe disability is comparable. The admission NIHSS is an independent predictor for favorable and unfavorable outcomes in YP and for favorable outcomes in octogenarians. In this study cohort, pre-stroke mRS predicted favorable outcomes in octogenarians while age predicted an unfavorable outcome in YPs.
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Affiliation(s)
- Charlotte Sabine Weyland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
- Department of Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Matthias Anthony Mutke
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
- Department of Neuroradiology, University Hospital of Basel, Basel, Switzerland
| | - Amanda Zimmermann-Miotk
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Niclas Schmitt
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Min Chen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
| | - Jessica Jesser
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Wuürttemberg, Germany
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Rhiner N, Thut MZ, Thurner P, Madjidyar J, Schubert T, Globas C, Wegener S, Luft AR, Michels L, Kulcsar Z. Impact of age on mechanical thrombectomy and clinical outcome in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107248. [PMID: 37441892 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107248] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/22/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy is less effective in patients aged 80 years or older. Our goal was to better understand the impact of age in general on recanalization rates and clinical outcome. METHODS We performed a retrospective analysis of our prospective database of adult patients with acute ischemic stroke due to large vessel occlusions, who had undergone mechanical thrombectomy between 2019 and mid-2021. The cohort was categorized into five age groups: 18 - 49, 50 - 59, 60 - 69, 70 - 79 and ≥ 80 years. Our primary outcome measure was clinical outcome at three months after mechanical thrombectomy, measured by the mRS score. Secondary outcomes were procedure times and rates of successful recanalization, defined by mTICI ≥ 2b. RESULTS Data of 264 patients were analyzed. There were no significant differences in procedure times (p = 0.46) or in rates of successful recanalization (p = 0.49) between age groups. There was a significant association of age and mRS score at three months (p < 0.0001): From youngest to oldest group, odds of functional independence (mRS ≤ 2) decreased (80.0% vs. 21.3%) and odds of death (mRS 6) increased (13.3% vs. 57.3%). Increasing age was significantly associated with lower rates of functional independence (OR 0.93; [95% CI 0.90 - 0.95]), higher rates of care dependency (OR 1.04; [95% CI 1.01 - 1.07]) and higher mortality rates (OR 1.06; [95% CI 1.04 - 1.09]). CONCLUSION Higher age had no significant impact on recanalization times or recanalization rates but was strongly associated with worse clinical outcome after mechanical thrombectomy.
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Affiliation(s)
- Nadine Rhiner
- Faculty of Medicine, University of Zurich, Raemistrasse 71, Zurich 8006, Switzerland
| | - Mara Z Thut
- Faculty of Medicine, University of Zurich, Raemistrasse 71, Zurich 8006, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Jawid Madjidyar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Christoph Globas
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland
| | - Susanne Wegener
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland
| | - Andreas R Luft
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland; Cereneo Center of Neurology and Rehabilitation, Seestrasse 18, Vitznau 6354, Switzerland
| | - Lars Michels
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland.
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Lai YJ, Peng SH, Lai WJ, Li AH, Yen HH, Huang LW, Tang CW. Predictors of 30-day mortality after endovascular thrombectomy for large vessel occlusion in the elderly. Interv Neuroradiol 2023; 29:37-42. [PMID: 34967236 PMCID: PMC9893232 DOI: 10.1177/15910199211069259] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Elderly acute ischemic stroke (AIS) patients (≥80 years) would have dismal clinical outcomes even after successful endovascular revascularization for large vessel occlusion (LVO) in the anterior circulation. We aimed to identify predictors of 30-day mortality after endovascular thrombectomy (EVT) in the elderly. MATERIALS AND METHODS We included older patients who underwent EVT for AIS due to LVO within 6 h after stroke onset in the anterior circulation between 2017 and 2019. Patients due to posterior circulation stroke, with intracerebral hemorrhage (ICH) or pre-stroke modified Rankin Scale (mRS) score of 4 and 5 were excluded. The primary outcome was mortality within 30 days of EVT. The association between clinical, imaging, procedural, follow-up imaging and mortality were analyzed. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3. Possible predictors of 30-day mortality were assessed by univariate and multivariable logistic regression. RESULTS Total 238 AIS patients eligible for EVT were identified with 58 patients aged 80 years or more. 48 patients met inclusion criteria. Median age was 86 years (age range, 82-102 years). Successful reperfusion was achieved in 38 (79.2%) patients. The 30-day and 90-day mortality rate were 25% and 33.3%, respectively. The independent predictors of 30-day mortality were collateral scores <3 on mCTA (adjusted OR, 16.571; 95% CI, 1.041-263.868; p = 0.047) and number of passes (adjusted OR, 2.475; 95% CI, 1.047-5.847; p = 0.039). CONCLUSIONS Lower collateral scores on mCTA and higher number of passes in thrombectomy were independently predictive of 30-day mortality in the elderly.
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Affiliation(s)
- Yen-Jun Lai
- Department of Medical Imaging, Far Eastern Memorial
Hospital, New Taipei City
| | - Szu-Hsiang Peng
- Department of Medical Imaging, Far Eastern Memorial
Hospital, New Taipei City
| | - Wei-Jen Lai
- Department of Medical Imaging, Far Eastern Memorial
Hospital, New Taipei City
| | - Ai-Hsien Li
- Department of Cardiology, Far Eastern Memorial
Hospital, New Taipei City
| | - Ho-Hsian Yen
- Department of Medical Imaging, Far Eastern Memorial
Hospital, New Taipei City
| | - Lih-Wen Huang
- Department of Neurology, Far Eastern Memorial
Hospital, New Taipei City
| | - Chih-Wei Tang
- Department of Neurology, Far Eastern Memorial
Hospital, New Taipei City
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McDonough RV, Ospel JM, Campbell BCV, Hill MD, Saver JL, Dippel DWJ, Demchuk AM, Majoie CBLM, Brown SB, Mitchell PJ, Bracard S, Guillemin F, Jovin TG, Muir KW, White P, Goyal M. Functional Outcomes of Patients ≥85 Years With Acute Ischemic Stroke Following EVT: A HERMES Substudy. Stroke 2022; 53:2220-2226. [PMID: 35703094 DOI: 10.1161/strokeaha.121.037770] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Observational studies have shown endovascular treatment (EVT) for acute ischemic stroke to be effective in the elderly, despite resulting in poorer outcomes and higher rates of mortality compared with younger patients. Randomized data on the effect of advanced age on outcomes following EVT are, however, lacking. Our aim was to assess the EVT effect for ischemic stroke in patients aged ≥85 years and the influence of age on outcome in a large, randomized trial dataset. METHODS Data were from the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration, a meta-analysis of 7 randomized trials published between January 1, 2010, and May 31, 2017, that tested the efficacy of EVT. A possible multiplicative interaction effect of age on the relationship between treatment and outcome was investigated. Ordinal logistic regression tested the association between EVT and 90-day functional outcome (modified Rankin Scale, primary outcome) in patients ≥85 years. Multivariable binary logistic regression was performed to compare primary and secondary outcomes (modified Rankin Scale score of 0-2/5-6) of patients ≥85 years versus those <85 years. RESULTS We included 1764 patients in the analysis, of whom 77 (4.4%) were ≥85 years old. A significant interaction of age and treatment on poor outcome (modified Rankin Scale score of 5-6, P=0.020) and mortality (P=0.031) was observed, with older adults having worse functional outcomes at 90 days compared with younger patients (adjusted common odds ratio, 0.20 [95% CI, 0.13-0.33]). However, a benefit of EVT was observed in the ≥85-year-old patient subgroup (common odds ratio, 4.20 [95% CI, 1.56-11.32]). Age ≥85 years was not significantly associated with differing rates of symptomatic intracerebral hemorrhage or reperfusion (adjusted odds ratio, 1.92 [95% CI, 0.71-5.15] and adjusted odds ratio, 0.91 [95% CI, 0.40-2.06], respectively). CONCLUSIONS Patients ≥85 years old with independent premorbid function more often achieve good functional outcomes and have lower rates of mortality when treated with EVT compared with conservative management, with an observed treatment effect modification of age on outcome. EVT should therefore not be withheld in this subgroup.
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Affiliation(s)
- Rosalie V McDonough
- Department of Diagnostic Imaging (R.V.M., J.M.O.), Foothills Medical Center, University of Calgary, AB, Canada.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (R.V.M.)
| | - Johanna M Ospel
- Department of Diagnostic Imaging (R.V.M., J.M.O.), Foothills Medical Center, University of Calgary, AB, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Australia (B.C.V.C.)
| | - Michael D Hill
- Department of Clinical Neurosciences (M.D.H., A.M.D., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles Medical Center (J.L.S.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands (D.W.J.D.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (M.D.H., A.M.D., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands (C.B.L.M.M.)
| | - Scott B Brown
- BRIGHT Research Partners, Inc, Mooresville, NC (S.B.B.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia (P.J.M.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology (S.B.), University of Lorraine and University Hospital of Nancy, France
| | - Francis Guillemin
- Department of Clinical Epidemiology (F.G.), University of Lorraine and University Hospital of Nancy, France
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center Stroke Institute, Presbyterian University Hospital, PA (T.G.J.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (K.W.M.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Mayank Goyal
- Department of Clinical Neurosciences (M.D.H., A.M.D., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
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Mohammaden MH, Haussen DC, Pisani L, Al-Bayati AR, Bianchi N, Liberato B, Bhatt N, Frankel MR, Nogueira RG. No Racial Disparity in Outcome Measures After Endovascular Treatment for Stroke in the Elderly. Stroke 2021; 53:128-133. [PMID: 34610754 DOI: 10.1161/strokeaha.120.033537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Despite the lower rates of good outcomes and higher mortality in elderly patients, age does not modify the treatment effect of mechanical thrombectomy for large vessel occlusion strokes. We aimed to study whether racial background influences the outcome after mechanical thrombectomy in the elderly population. METHODS We reviewed a prospectively maintained database of patients with acute ischemic stroke treated with mechanical thrombectomy from October 2010 through June 2020 to identify all consecutive patients with age ≥80 years and anterior circulation large vessel occlusion strokes. The patients were categorized according to their race as Black and White. Univariable and multivariable analyses were performed to define the predictors of 90-day modified Rankin Scale and mortality in the overall population and in each race separately. RESULTS Among 2241 mechanical thrombectomy, a total of 344 patients (median [interquartile range]; age 85 [82-88] years, baseline National Institutes of Health Stroke Scale score of 19 [15-23], Alberta Stroke Program Early CT Score 9 [7-9], 69.5% females) were eligible for the analysis. White patients (n=251; 73%) had significantly lower median body mass index (25.37 versus 26.89, P=0.04) and less frequent hypertension (78.9% versus 90.3%, P=0.01) but more atrial fibrillation (64.5% versus 44.1%, P=0.001) compared with African Americans (n=93; 27%). Other clinical, imaging, and procedural characteristics were comparable between groups. The rates of symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score of 0 to 2, and mortality were comparable among both groups. On multivariable analysis, race was neither a predictor of 90-day modified Rankin Scale score of 0 to 2 (White race: odds ratio, 0.899 [95% CI, 0.409-1.974], P=0.79) nor 90-day mortality (White race: odds ratio, 1.368; [95% CI, 0.715-2.618], P=0.34). CONCLUSIONS In elderly patients undergoing mechanical thrombectomy for acute ischemic stroke, there was no racial difference in terms of outcome.
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Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.).,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.)
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.).,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.)
| | - Leonardo Pisani
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.).,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.)
| | - Alhamza R Al-Bayati
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.).,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.)
| | - Nicolas Bianchi
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.).,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.)
| | - Bernardo Liberato
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.).,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.)
| | - Nirav Bhatt
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.).,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.)
| | - Michael R Frankel
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.).,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.)
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.).,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., D.C.H., L.P., A.R.A.-B., N.B., B.L., N.B., M.R.F., R.G.N.)
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Groot AE, Treurniet KM, Jansen IG, Lingsma HF, Hinsenveld W, van de Graaf RA, Roozenbeek B, Willems HC, Schonewille WJ, Marquering HA, van den Berg R, Dippel DW, Majoie CB, Roos YB, Coutinho JM. Endovascular treatment in older adults with acute ischemic stroke in the MR CLEAN Registry. Neurology 2020; 95:e131-e139. [DOI: 10.1212/wnl.0000000000009764] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 01/26/2020] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo explore clinical outcomes in older adults with acute ischemic stroke treated with endovascular thrombectomy (EVT).MethodsWe included consecutive patients (2014–2016) with an anterior circulation occlusion undergoing EVT from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry. We assessed the effect of age (dichotomized at ≥80 years and as continuous variable) on the modified Rankin Scale (mRS) score at 90 days, symptomatic intracranial hemorrhage (sICH), and reperfusion rate. The association between age and mRS was assessed with multivariable ordinal logistic regression, and a multiplicative interaction term was added to the model to assess modification of reperfusion by age on outcome.ResultsOf the 1,526 patients, 380 (25%) were ≥80 years of age (referred to here as older adults). Older adults had a worse functional outcome than younger patients (adjusted common odds ratio [acOR] for an mRS score shift toward better outcome 0.31, 95% confidence interval [CI] 0.24–0.39). Mortality was also higher in older adults (51% vs 22%, adjusted odds ratio 3.12, 95% CI 2.33–4.19). There were no differences in proportion of patients with mRS scores of 4 to 5, sICH, or reperfusion rates. Successful reperfusion was more strongly associated with a shift toward good functional outcome in older adults than in younger patients (acOR 3.22, 95% CI 2.04–5.10 vs 2.00, 95% CI 1.56–2.57, pinteraction = 0.026).ConclusionOlder age is associated with an increased absolute risk of poor clinical outcome, while the relative benefit of successful reperfusion seems to be higher in these patients. These results should be taken into consideration in the selection of older adults for EVT.
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9
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Yang W, Zhang L, Yao Q, Chen W, Yang W, Zhang S, He L, Li H, Zhang Y. Endovascular treatment or general treatment: how should acute ischemic stroke patients choose to benefit from them the most?: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20187. [PMID: 32443338 PMCID: PMC7254577 DOI: 10.1097/md.0000000000020187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Acute ischemic stroke due to large-vessel occlusion is a leading cause of death and disability, and therapeutic time window was limited to 4.5 hour when treated with intravenous thrombolysis. It has been acknowledged that endovascular treatment (EVT) is superior to general treatment (only medication, including intravenous recombinant tissue plasminogen activator (rt-PA)) in improving the outcome of AIS since 2015. However, the benefits were limited to improvement of functional outcomes and functional independence. Hence, this meta-analysis was conducted to summarize the benefits of EVT for acute ischemic stroke, explore underlying indications of EVT for AIS patients and suggest implications for clinical practice and future research. METHODS A search was performed to identify eligible studies in PubMed, Scopus and Web of Science updated to February 5, 2019. Functional outcomes, the modified Rankin Scale (mRS) 0-1, mRS 0-2, all-cause mortality, symptomatic intracerebral hemorrhage and asymptomatic intracerebral hemorrhage (aICH) at 90 days were selected as outcomes. Data was pooled to calculate the odds ratio (OR) and 95% confidence interval (CI). Heterogeneity, subgroup analysis, sensitivity analysis and publication bias were also performed in this meta-analysis. RESULTS Eighteen studies comprising 3831 patients were included and analyzed in this meta-analysis. In comparison with general treatment, improved functional outcomes (mRS 0-1: OR = 1.68, 95% CI = 1.43-1.97, inconsistency index [I = 57%, P < .00001; mRS 0-2: OR = 1.78, 95% CI = 1.55-2.03, I = 69%, P < .00001), reduced risk of all-cause mortality (OR = 0.82, 95% CI = 0.70-0.98, I = 27%, P = .03) but higher risk of aICH (OR = 1.43, 95% CI = 1.05-1.95, I = 0%, P = .02) at 90 days were found in AIS patients treated with EVT. Age < 70, National Institutes of Health Stroke Scale ≥20 and maximum delay for invention>5 hours could improve clinical outcomes following EVT. In sensitivity analysis, it showed that 2 studies had a great influence on the pooled ORs. No potential publication bias was found in this meta-analysis. CONCLUSION Taken together, EVT, which led to improved functional outcomes and decreased risk of death, is superior to general treatment for AIS patients with age < 70, National Institutes of Health Stroke Scale ≥20 and maximum delay for invention>5 hours. Moreover, it suggests that "with mechanical thrombectomy" is potential favorable factor for improving aICH in comparison with general treatment.
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Affiliation(s)
| | | | | | | | - Weiji Yang
- College of Life Sciences, Zhejiang Chinese Medical University
| | | | - Lan He
- Second Clinical Medical College
| | - Hong Li
- School of Stomatology, Zhejiang Chinese Medical University, Zhejiang, China
| | - Yuyan Zhang
- College of Life Sciences, Zhejiang Chinese Medical University
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10
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Andrews CE, Mouchtouris N, Fitchett EM, Al Saiegh F, Lang MJ, Romo VM, Herial N, Jabbour P, Tjoumakaris SI, Rosenwasser RH, Gooch MR. Revascularization and functional outcomes after mechanical thrombectomy for acute ischemic stroke in elderly patients. J Neurosurg 2020; 132:1182-1187. [PMID: 30925465 DOI: 10.3171/2018.12.jns182399] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 12/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Mechanical thrombectomy (MT) is now the standard of care for acute ischemic stroke (AIS) secondary to large-vessel occlusion, but there remains a question of whether elderly patients benefit from this procedure to the same degree as the younger populations enrolled in the seminal trials on MT. The authors compared outcomes after MT of patients 80-89 and ≥ 90 years old with AIS to those of younger patients. METHODS The authors retrospectively analyzed records of patients undergoing MT at their institution to examine stroke severity, comorbid conditions, medical management, recanalization results, and clinical outcomes. Univariate and multivariate logistic regression analysis were used to compare patients < 80 years, 80-89 years, and ≥ 90 years old. RESULTS All groups had similar rates of comorbid disease and tissue plasminogen activator (tPA) administration, and stroke severity did not differ significantly between groups. Elderly patients had equivalent recanalization outcomes, with similar rates of readmission, 30-day mortality, and hospital-associated complications. These patients were more likely to have poor clinical outcome on discharge, as defined by a modified Rankin Scale (mRS) score of 3-6, but this difference was not significant when controlled for stroke severity, tPA administration, and recanalization results. CONCLUSIONS Octogenarians, nonagenarians, and centenarians with AIS have similar rates of mortality, hospital readmission, and hospital-associated complications as younger patients after MT. Elderly patients also have the capacity to achieve good functional outcome after MT, but this potential is moderated by stroke severity and success of treatment.
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Affiliation(s)
- Carrie E Andrews
- 1Sidney Kimmel Medical College, Thomas Jefferson University; and
| | | | - Evan M Fitchett
- 1Sidney Kimmel Medical College, Thomas Jefferson University; and
| | | | | | - Victor M Romo
- 3Division of Neurological Anesthesia, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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11
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Pedraza MI, de Lera M, Bos D, Calleja AI, Cortijo E, Gómez-Vicente B, Reyes J, Coco-Martín MB, Calonge T, Agulla J, Martínez-Pías E, Talavera B, Pérez-Fernández S, Schüller M, Galván J, Castaño M, Martínez-Galdámez M, Arenillas JF. Brain Atrophy and the Risk of Futile Endovascular Reperfusion in Acute Ischemic Stroke. Stroke 2020; 51:1514-1521. [PMID: 32188368 DOI: 10.1161/strokeaha.119.028511] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background and Purpose- We aimed to evaluate the impact of brain atrophy on long-term clinical outcome in patients with acute ischemic stroke treated with endovascular therapy, and more specifically, to test whether there are interactions between the degree of atrophy and infarct volume, and between atrophy and age, in determining the risk of futile reperfusion. Methods- We studied consecutive patients with acute ischemic stroke with proximal anterior circulation intracranial arterial occlusions treated with endovascular therapy achieving successful arterial recanalization. Brain atrophy was evaluated on baseline computed tomography with the global cortical atrophy scale, and Evans index was calculated to assess subcortical atrophy. Infarct volume was assessed on control computed tomography at 24 hours using the formula for irregular volumes (A×B×C/2). Main outcome variable was futile recanalization, defined by functional dependence (modified Rankin Scale score >2) at 3 months. The predefined interactions of atrophy with age and infarct volume were studied in regression models. Results- From 361 consecutive patients with anterior circulation acute ischemic stroke treated with endovascular therapy, 295 met all inclusion criteria. Futile reperfusion was observed in 144 out of 295 (48.8%) patients. Cortical atrophy affecting parieto-occipital and temporal regions was associated with futile recanalization. Total global cortical atrophy score and Evans index were independently associated with futile recanalization in an adjusted logistic regression. Multivariable adjusted regression models disclosed significant interactions between global cortical atrophy score and infarct volume (odds ratio, 1.003 [95%CI, 1.002-1.004], P<0.001) and between global cortical atrophy score and age (odds ratio, 1.001 [95% CI, 1.001-1.002], P<0.001) in determining the risk of futile reperfusion. Conclusions- A higher degree of cortical and subcortical brain atrophy is associated with futile endovascular reperfusion in anterior circulation acute ischemic stroke. The impact of brain atrophy on insufficient clinical recovery after endovascular reperfusion appears to be independently amplified by age and by infarct volume.
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Affiliation(s)
- María I Pedraza
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.)
| | - Mercedes de Lera
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.)
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine and Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, the Netherlands (D.B.).,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (D.B.)
| | - Ana I Calleja
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.)
| | - Elisa Cortijo
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.)
| | - Beatriz Gómez-Vicente
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.).,Neurovascular Research Laboratory, Instituto de Biología y Genética Molecular, Universidad de Valladolid-Consejo Superior de Investigaciones Científicas, Madrid, Spain (B.G.-V., J.A., J.F.A.)
| | - Javier Reyes
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.)
| | - María Begoña Coco-Martín
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.)
| | - Teodoro Calonge
- Department of Informatics, University of Valladolid, Spain (T.C.)
| | - Jesús Agulla
- Neurovascular Research Laboratory, Instituto de Biología y Genética Molecular, Universidad de Valladolid-Consejo Superior de Investigaciones Científicas, Madrid, Spain (B.G.-V., J.A., J.F.A.)
| | - Enrique Martínez-Pías
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.)
| | - Blanca Talavera
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.)
| | - Santiago Pérez-Fernández
- Neuroradiology Unit, Department of Radiology, Hospital Clínico Universitario, Valladolid, Spain (S.P.-F., M.S., J.G., M.C., M.M.G.)
| | - Miguel Schüller
- Neuroradiology Unit, Department of Radiology, Hospital Clínico Universitario, Valladolid, Spain (S.P.-F., M.S., J.G., M.C., M.M.G.)
| | - Jorge Galván
- Neuroradiology Unit, Department of Radiology, Hospital Clínico Universitario, Valladolid, Spain (S.P.-F., M.S., J.G., M.C., M.M.G.)
| | - Miguel Castaño
- Neuroradiology Unit, Department of Radiology, Hospital Clínico Universitario, Valladolid, Spain (S.P.-F., M.S., J.G., M.C., M.M.G.)
| | - Mario Martínez-Galdámez
- Neuroradiology Unit, Department of Radiology, Hospital Clínico Universitario, Valladolid, Spain (S.P.-F., M.S., J.G., M.C., M.M.G.)
| | - Juan F Arenillas
- From the Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain (M.I.P., M.d.L., A.I.C., E.C., B.G.-V., J.R., M.B.C.-M., E.M.-P., B.T., J.F.A.).,Neurovascular Research Laboratory, Instituto de Biología y Genética Molecular, Universidad de Valladolid-Consejo Superior de Investigaciones Científicas, Madrid, Spain (B.G.-V., J.A., J.F.A.)
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12
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Maurer CJ, Dobrocky T, Joachimski F, Neuberger U, Demerath T, Brehm A, Cianfoni A, Gory B, Berlis A, Gralla J, Möhlenbruch MA, Blackham KA, Psychogios MN, Zickler P, Fischer S. Endovascular Thrombectomy of Calcified Emboli in Acute Ischemic Stroke: A Multicenter Study. AJNR Am J Neuroradiol 2020; 41:464-468. [PMID: 32029470 DOI: 10.3174/ajnr.a6412] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Large intracranial vessel occlusion due to calcified emboli is a rare cause of major stroke. We assessed the prevalence, imaging appearance, the effectiveness of mechanical thrombectomy, and clinical outcome of patients with large-vessel occlusion due to calcified emboli. MATERIALS AND METHODS We performed a retrospective analysis of clinical and procedural data of consecutive patients who underwent mechanical thrombectomy due to calcified emboli in 7 European stroke centers. RESULTS We screened 2969 patients, and 40 patients matched the inclusion criteria, accounting for a prevalence of 1.3%. The mean maximal density of the thrombus was 327 HU (range, 150-1200 HU), and the mean thrombus length was 9.2 mm (range, 4-20 mm). Four patients had multiple calcified emboli, and 2 patients had an embolic event during an endovascular intervention. A modified TICI score of ≥2b was achieved in 57.5% (23/40), with minimal-to-no reperfusion (modified TICI 0-1) in 32.5% (13/40) and incomplete reperfusion (modified TICI 2a) in 10% (4/40). Excellent outcome (mRS 0-1) was achieved in only 20.6%, functional independence (mRS 0-2) in 26.5% and 90-day mortality was 55.9%. CONCLUSIONS Acute ischemic stroke with large-vessel occlusion due to calcified emboli is a rare entity in patients undergoing thrombectomy, with considerably worse angiographic outcome and a higher mortality compared with patients with noncalcified thrombi. Good functional recovery at 3 months can still be achieved in about a quarter of patients.
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Affiliation(s)
- C J Maurer
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - T Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology (T.Dobrocky, J.G.), University of Bern, Inselspital, Bern, Switzerland
| | - F Joachimski
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - U Neuberger
- Department of Neuroradiology (U.N., M.A.M.), University of Heidelberg, Heidelberg, Germany
| | - T Demerath
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - A Brehm
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Neuroradiology (A.Brehm, M.N.P.), University Medical Center Göttingen, Göttingen, Germany
| | - A Cianfoni
- Department of Neuroradiology (A.C.), Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), University Hospital of Nancy, Institut National de la Santé et de la Recherche Médicale U1254, Nancy, France
| | - A Berlis
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - J Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (T.Dobrocky, J.G.), University of Bern, Inselspital, Bern, Switzerland
| | - M A Möhlenbruch
- Department of Neuroradiology (U.N., M.A.M.), University of Heidelberg, Heidelberg, Germany
| | - K A Blackham
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - M N Psychogios
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Neuroradiology (A.Brehm, M.N.P.), University Medical Center Göttingen, Göttingen, Germany
| | - P Zickler
- Neurology and Neurophysiology (P.Z.), Universitätsklinikum Augsburg, Augsburg, Germany
| | - S Fischer
- Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie (S.F.), Nuklearmedizin, Knappschaftskrankenhaus Bochum-Langendreer, Universitätsklinik, Bochum, Germany
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13
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Zhao W, Ma P, Zhang P, Yue X. Mechanical Thrombectomy for Acute Ischemic Stroke in Octogenarians: A Systematic Review and Meta-Analysis. Front Neurol 2020; 10:1355. [PMID: 32038452 PMCID: PMC6993560 DOI: 10.3389/fneur.2019.01355] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/09/2019] [Indexed: 01/13/2023] Open
Abstract
Background and purpose: Multiple randomized trials have confirmed that mechanical thrombectomy (MT) is an effective treatment method for patients with acute ischemic stroke (AIS). However, evidence on the safety and efficacy of MT in elderly patients compared with younger patients is controversial. This meta-analysis is aimed to systematically compare the outcomes of elderly patients and younger patients after MT for AIS. Methods: A systematic literature search was conducted through the PubMed, EMBASE, and Cochrane Library database. The primary outcomes were favorable functional outcome at 90 days and mortality. The secondary outcomes were symptomatic intracerebral hemorrhage (sICH) and successful recanalization rate. Odds ratios (ORs) were estimated using a random effects model. Results: Sixteen studies published between 2014 and 2019 were included in this meta-analysis totally involving 3,954 patients. The pooled results showed that patients aged ≥80 years had worse functional outcome (OR = 0.40; 95% CI, 0.32–0.50; P < 0.001) and higher rates of mortality (OR = 2.26; 95% CI, 1.73–2.95; P < 0.001). There was a trend of higher rates of sICH in patients aged ≥80 years compared with patients aged <80 years, whereas this did not reach statistical significance (OR = 1.28; 95% CI, 0.89–1.84; P = 0.18). Furthermore, the frequency of successful recanalization was also lower in patients aged ≥80 years compared with patients aged <80 years (OR = 0.72; 95% CI, 0.55–0.95; P = 0.02). The subgroup analysis indicated that in comparison with those studies published between 2014 and 2016, elderly patients undergoing MT had better outcomes in studies published between 2017 and 2019. Conclusion: Elderly patients undergoing MT had higher risk of mortality and worse functional outcome. Meanwhile, there was a trend toward higher rates of sICH and lower probability of achieving successful recanalization in elderly patients. These findings emphasize the need for improving the rates of successful recanalization in elderly patients with AIS. In addition, advanced technology of endovascular intervention and peri-interventional management might be associated with the prognosis in elderly patients. However, more prospective or randomized studies should be conducted to further explore this issue.
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Affiliation(s)
- Weisong Zhao
- Department of Pediatrics, The First Clinic College of Xinxiang Medical University, Xinxiang, China
| | - Pengju Ma
- Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Ping Zhang
- Department of Neurology, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Xuejing Yue
- School of Basic Medicine, Xinxiang Medical University, Xinxiang, China
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14
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Waqas M, Mokin M, Primiani CT, Gong AD, Rai HH, Chin F, Rai AT, Levy EI, Siddiqui AH. Large Vessel Occlusion in Acute Ischemic Stroke Patients: A Dual-Center Estimate Based on a Broad Definition of Occlusion Site. J Stroke Cerebrovasc Dis 2019; 29:104504. [PMID: 31761735 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104504] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/27/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery. METHODS We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported. RESULTS Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02). CONCLUSIONS The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida
| | - Christopher T Primiani
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida
| | - Andrew D Gong
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Hamid H Rai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Felix Chin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Ansaar T Rai
- Department of Neurosurgery, West Virginia University Hospital, Morgantown, West Virginia
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York; Jacobs Institute, Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York; Jacobs Institute, Buffalo, New York.
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15
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Velasco González A, Buerke B, Görlich D, Chapot R, Smagge L, Velasco MDV, Sauerland C, Heindel W. Variability in the decision-making process of acute ischemic stroke in difficult clinical and radiological constellations: analysis based on a cross-sectional interview-administered stroke questionnaire. Eur Radiol 2019; 29:6275-6284. [PMID: 31076863 DOI: 10.1007/s00330-019-06199-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 03/11/2019] [Accepted: 03/25/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Notwithstanding guidelines, indications for mechanical thrombectomy (MT) in acute ischemic stroke are multifactorial and can be complex. Our aim was to exploratively evaluate decision-making on the advisability of performing MT in cases presented as an interview-administered questionnaire. METHODS Fifty international raters assessed 12 cases and decided to recommend or exclude MT. Each case contained a brief summary of clinical information and eight representative images of the initial multimodal CT. The demographic characteristics and stroke protocols were recorded for raters. For each case, the reasons for excluding MT were recorded. Uni- and multivariate logistic regression analysis were performed for the different demographic and case characteristics to identify factors that might influence decision-making. RESULTS All raters performed MT (median MTs/hospital/year [IQR], 100 [50-141]) with a median of 7 years of experience as first operator (IQR, 4-12). Per case, diversity in decision-making ranged between 1 (case 6, 100% yes MT) and 0.50 (case 12, 54.2% yes MT and 45.8% no MT). The most common reasons for excluding MT were small CBV/CBF mismatch (17%, 102/600), size of infarct core on the CBV map (15.2%, 91/600), and low NIHSS score (National Institute of Health Stroke Scale, 8.3%, 50/600). All clinical and radiological characteristics significantly affected the decision regarding MT, but the general characteristics of the raters were not a factor. CONCLUSIONS Clinical and imaging characteristics influenced the decision regarding MT in stroke. Nevertheless, a consensus was reached in only a minority of cases, revealing the current divergence of opinion regarding therapeutic decisions in difficult cases. KEY POINTS • This is the first study to explore differences in decision-making in respect of mechanical thrombectomy in ischemic stroke with complex clinical and radiological constellations. • Fifty experienced international neurointerventionalists answered this interview-administered stroke questionnaire and made decisions as to whether to recommend or disadvise thrombectomy in 12 selected cases. • Diversity in decision-making for thrombectomy ranged from 1 (100% of raters offered the same answer) to 0.5 (50% indicated mechanical thrombectomy). There was a consensus in only a minority of cases, revealing the current disparity of opinion regarding therapeutic decisions in difficult cases.
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Affiliation(s)
- Aglaé Velasco González
- Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany.
| | - Boris Buerke
- Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstraße 56, 48149, Muenster, Germany
| | - Rene Chapot
- Department of Neuroradiology, Alfried-Krupp Krankenhaus Hospital, Alfried-Krupp Straße 21, 45131, Essen, Germany
| | - Lucas Smagge
- Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
| | - Maria Del Valle Velasco
- University Hospital of the Canary Islands, Carretera de la Cuesta, Taco 0, 38320, Santa Cruz de Tenerife, Spain
| | - Cristina Sauerland
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstraße 56, 48149, Muenster, Germany
| | - Walter Heindel
- Institute of Clinical Radiology and Neuroradiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
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Kawabata Y, Nakajima N, Miyake H, Fukuda S, Tsukahara T. Endovascular treatment of acute ischaemic stroke in octogenarians and nonagenarians compared with younger patients. Neuroradiol J 2019; 32:303-308. [PMID: 30987508 DOI: 10.1177/1971400919840847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose: Endovascular therapy for emergent large vessel occlusion has been established as the standard approach for acute ischaemic stroke. However, the effectiveness and safety of endovascular therapy in the very elderly population has not been proved. Objective: To determine the safety and effectiveness of endovascular therapy in octogenarians and nonagenarians. Methods: We retrospectively reviewed all patients who underwent endovascular therapy at two stroke centres between April 2012 and July 2018. Functional outcome was assessed using the modified Rankin scale at 90 days after stroke or at discharge. A favourable outcome was defined as a modified Rankin scale score of 0-2 or not worsening of the modified Rankin scale score before stroke. Outcome was compared between younger patients (aged 46-79 years, n = 40) and octogenarians and nonagenarians (aged 80-97 years, n = 19). Results: Octogenarian and nonagenarian patients had pre-stroke functional deficit (modified Rankin scale score >1) more frequently than younger patients (57.9% vs. 20.0%, respectively, P = 0.0059). No difference was observed between very elderly and younger patients in the rate of successful reperfusion (89.5% vs. 67.5%, respectively, P = 0.11), favourable functional outcome (47.4% vs. 45.0%, respectively, P = 1.00) and mortality (21.1% vs. 27.5%, respectively, P = 1.00). On multiple regression analysis, successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were independent predictors of favourable outcome (P = 0.0003, 0.015 and 0.028, respectively). Conclusions: Successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were clinical predictors of favourable outcome. However, we did not observe an age-dependent effect of clinical outcome after endovascular therapy.
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Affiliation(s)
- Yasuhiro Kawabata
- 1 Department of Neurosurgery, Kyoto Katsura Hospital, Japan.,2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
| | - Norio Nakajima
- 1 Department of Neurosurgery, Kyoto Katsura Hospital, Japan
| | | | - Shunichi Fukuda
- 2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
| | - Tetsuya Tsukahara
- 2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
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17
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Sharobeam A, Cordato DJ, Manning N, Cheung A, Wenderoth J, Cappelen-Smith C. Functional Outcomes at 90 Days in Octogenarians Undergoing Thrombectomy for Acute Ischemic Stroke: A Prospective Cohort Study and Meta-Analysis. Front Neurol 2019; 10:254. [PMID: 30949120 PMCID: PMC6435519 DOI: 10.3389/fneur.2019.00254] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 02/25/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Elderly patients account for 30% of acute ischemic stroke (AIS) but are under-represented in randomized controlled trials of endovascular thrombectomy (EVT). Meta-analysis of “real world” studies evaluating 90-day outcomes in elderly patients ≥80 years have been limited to small numbers undergoing EVT with older generation devices. Methods: A retrospective analysis of 181 prospectively collected patients who received EVT for anterior circulation AIS at an Australian center over 2.5-years. The study aims to determine (i) 90-day functional outcomes (modified Rankin Scale mRS 0–2) in patients ≥80 vs. <80 years, (ii) the interaction of prognostic factors and age and (iii) compare our data to those previously reported using a meta-analysis of outcomes in observational studies using second generation thrombectomy devices. Results: We analyzed 2,387 patients (≥80 years, n = 649; <80 years, n = 1,738) from 14 studies including our study (≥80 years, n = 71; <80 years, n = 110). Twenty-eight percent of our and 30% of the meta-analysis elderly cohort achieved good 90-day mRS compared to 55 and 52%, respectively of younger patients (p < 0.001). Twenty-seven percent of our and 26% of the meta-analysis elderly cohort died compared to 16% (p = 0.07) and 15% (p < 0.0001), respectively of younger patients. Baseline NIHSS≥16 correlated with poor prognosis in elderly (OR 16.4; 95% CI 4.49–59.91, p < 0.001) and younger (OR 8.73;95% CI 3.35–22.80, p < 0.001) patients. Prior rt-PA was associated with favorable outcome in younger (OR 2.90; 95%CI 1.29–6.52, p = 0.01) patients only. Conclusion: EVT has less favorable outcomes in elderly patients. However, results are better than outcomes in historical controls not treated with thrombectomy providing further support for EVT in the elderly.
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Affiliation(s)
- Angelos Sharobeam
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia
| | - Dennis John Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Nathan Manning
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, NSW, Australia.,Prince of Wales Clinical School, University of NSW, Sydney, NSW, Australia.,The Florey Institute of Neuroscience, Melbourne, VIC, Australia
| | - Andrew Cheung
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, NSW, Australia
| | - Jason Wenderoth
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, NSW, Australia.,Prince of Wales Clinical School, University of NSW, Sydney, NSW, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
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18
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Hilditch CA, Nicholson P, Murad MH, Rabinstein A, Schaafsma J, Pikula A, Krings T, Pereira VM, Agid R, Brinjikji W. Endovascular Management of Acute Stroke in the Elderly: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2018; 39:887-891. [PMID: 29567654 DOI: 10.3174/ajnr.a5598] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/24/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute ischemic stroke occurs more frequently, presents with more severe symptoms, and has worse outcomes in elderly patients. The safety and efficacy of endovascular therapy for acute stroke in this age group has not been fully established. PURPOSE We present the results of a systematic review and meta-analysis examining clinical, procedural, and radiologic outcomes of endovascular therapy for acute stroke in patients older than 80 years of age. DATA SOURCES We searched PubMed, MEDLINE, and EMBASE from 1992 to week 35 of 2017 for studies evaluating endovascular therapy for acute stroke in the elderly. STUDY SELECTION Two independent reviewers selected studies and abstracted data. The primary end point was good functional outcome at 3 months defined as modified Rankin Scale score of ≤2. DATA ANALYSIS Data were analyzed using random-effects meta-analysis. DATA SYNTHESIS Seventeen studies reporting on 860 patients were included. The rate of good functional outcome at 3 months was 27% (95% CI, 21%-32%). Mortality at 3 months was 34% (95% CI, 23%-44%). Successful recanalization was achieved in 78% of patients (95% CI, 72%-85%). Procedure-related complications occurred in 11% (95% CI, 4%-17%). The incidence of intracranial hemorrhage was 24% (95% CI, 15%-32%), and for symptomatic intracranial hemorrhage, it was 8% (95% CI, 5%-10%). The mean time to groin was 251 minutes (95% CI, 224-278 minutes). Procedure time was 99 minutes (95% CI, 67-131 minutes). LIMITATIONS I2 values were above 50% for all outcomes, indicating substantial heterogeneity. CONCLUSIONS Good functional recovery in octogenarians treated with endovascular therapy for acute stroke can be achieved in a high proportion of patients despite the higher incidence of comorbidity in this cohort. Outcomes are inferior to those reported for younger patients; however, endovascular therapy can allow at least 1 in 4 patients older than 80 years of age to regain independent function at 3 months. More research is required to improve patient selection in the elderly, but age should not be a discriminator when deciding to offer endovascular therapy for patients with acute stroke.
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Affiliation(s)
- C A Hilditch
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging
| | - P Nicholson
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging
| | - M H Murad
- Evidence-Based Practice Center (M.H.M.)
| | - A Rabinstein
- Department of Neurology (A.R.), Mayo Clinic, Rochester, Minnesota
| | - J Schaafsma
- Division of Neurology (J.S., A.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - A Pikula
- Division of Neurology (J.S., A.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - T Krings
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging.,Division of Neurosurgery (T.K., V.M.P.), Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - V M Pereira
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging.,Division of Neurosurgery (T.K., V.M.P.), Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - R Agid
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging
| | - W Brinjikji
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging
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19
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Slawski DE, Salahuddin H, Shawver J, Kenmuir CL, Tietjen GE, Korsnack A, Zaidi SF, Jumaa MA. Mechanical Thrombectomy in Elderly Stroke Patients with Mild-to-Moderate Baseline Disability. INTERVENTIONAL NEUROLOGY 2018; 7:246-255. [PMID: 29765394 DOI: 10.1159/000487333] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/31/2018] [Indexed: 11/19/2022]
Abstract
Background The number of elderly patients suffering from ischemic stroke is rising. Randomized trials of mechanical thrombectomy (MT) generally exclude patients over the age of 80 years with baseline disability. The aim of this study was to understand the efficacy and safety of MT in elderly patients, many of whom may have baseline impairment. Methods Between January 2015 and April 2017, 96 patients ≥80 years old who underwent MT for stroke were selected for a chart review. The data included baseline characteristics, time to treatment, the rate of revascularization, procedural complications, mortality, and 90-day good outcome defined as a modified Rankin Scale (mRS) score of 0-2 or return to baseline. Results Of the 96 patients, 50 had mild baseline disability (mRS score 0-1) and 46 had moderate disability (mRS score 2-4). Recanalization was achieved in 84% of the patients, and the rate of symptomatic hemorrhage was 6%. At 90 days, 34% of the patients had a good outcome. There were no significant differences in good outcome between those with mild and those with moderate baseline disability (43 vs. 24%, p = 0.08), between those aged ≤85 and those aged > 85 years (40.8 vs. 26.1%, p = 0.19), and between those treated within and those treated beyond 8 h (39 vs. 20%, p = 0.1). The mortality rate was 38.5% at 90 days. The Alberta Stroke Program Early CT Score (ASPECTS) and the National Institutes of Health Stroke Scale (NIHSS) predicted good outcome regardless of baseline disability (p < 0.001 and p = 0.009, respectively). Conclusion Advanced age, baseline disability, and delayed treatment are associated with sub-optimal outcomes after MT. However, redefining good outcome to include return to baseline functioning demonstrates that one-third of this patient population benefits from MT, suggesting the real-life utility of this treatment.
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Affiliation(s)
- Diana E Slawski
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | | | | | - Cynthia L Kenmuir
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Syed F Zaidi
- University of Toledo Medical Center, Toledo, Ohio, USA
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20
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Jeon JP, Kim SE, Kim CH. Endovascular treatment of acute ischemic stroke in octogenarians: A meta-analysis of observational studies. Clin Neurol Neurosurg 2017; 161:70-77. [PMID: 28863285 DOI: 10.1016/j.clineuro.2017.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 08/23/2017] [Accepted: 08/27/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, South Korea; Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Sung-Eun Kim
- Department of Emergency Medicine, Seoul Emergency Operations Center, Seoul, South Korea
| | - Chul Ho Kim
- Department of Neurology, Hallym University College of Medicine, Chuncheon, South Korea.
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21
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Clinical Outcome of Mechanical Thrombectomy for Stroke in the Elderly. J Stroke Cerebrovasc Dis 2017; 26:582-588. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.117] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/10/2016] [Accepted: 11/24/2016] [Indexed: 11/19/2022] Open
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22
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Möhlenbruch M, Pfaff J, Schönenberger S, Nagel S, Bösel J, Herweh C, Ringleb P, Bendszus M, Stampfl S. Endovascular Stroke Treatment of Nonagenarians. AJNR Am J Neuroradiol 2016; 38:299-303. [PMID: 27789451 DOI: 10.3174/ajnr.a4976] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/19/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Although endovascular treatment has become a standard therapy in patients with acute stroke, the benefit for very old patients remains uncertain. The purpose of this study was the evaluation of procedural and outcome data of patients ≥90 years undergoing endovascular stroke treatment. MATERIALS AND METHODS We retrospectively analyzed prospectively collected data of patients ≥90 years in whom endovascular stroke treatment was performed between January 2011 and January 2016. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS, prestroke mRS), at discharge (NIHSS), and after 3 months (mRS). RESULTS Twenty-nine patients met the inclusion criteria for this analysis. The median prestroke mRS was 2. Successful recanalization (TICI ≥ 2b) was achieved in 22 patients (75.9%). In 9 patients, an NIHSS improvement ≥ 10 points was noted between admission and discharge. After 3 months, 17.2% of the patients had an mRS of 0-2 or exhibited prestroke mRS, and 24.1% achieved mRS 0-3. Mortality rate was 44.8%. There was only 1 minor procedure-related complication (small SAH without clinical sequelae). CONCLUSIONS Despite high mortality rates and only moderate overall outcome, 17.2% of the patients achieved mRS 0-2 or prestroke mRS, and no serious procedure-related complications occurred. Therefore, very high age should not per se be an exclusion criterion for endovascular stroke treatment.
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Affiliation(s)
- M Möhlenbruch
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - J Pfaff
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - S Schönenberger
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - S Nagel
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - J Bösel
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - C Herweh
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - P Ringleb
- Neurology (S. Schönenberger, S.N., J.B., P.R.), University Hospital Heidelberg, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
| | - S Stampfl
- From the Departments of Neuroradiology (M.M., J.P., C.H., M.B., S. Stampfl)
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