Safety and Efficacy of Thrombolysis with Intravenous Alteplase in Older Stroke Patients

Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a subgroup analysis of the CHANCE-2 trial

OBJECTIVES

Evidence of the optimal antiplatelet therapy for elderly patients who had a stroke is limited, especially those elder than 80 years. This study aimed to explore the efficacy and safety of dual antiplatelet therapy (DAPT) in old-old patients compared with younger patients in the ticagrelor or Clopidogrel with aspirin in High-risk patients with Acute Non-disabling Cerebrovascular Events-II (CHANCE-2) trial.

METHODS

CHANCE-2 was a randomised, double-blind, placebo-controlled trial in China involving patients with high-risk transient ischaemic attack or minor stroke with CYP2C19 loss-of-function alleles. In our substudy, all enrolled patients were stratified by age: old-old (≥80 years), young-old (65-80 years) and younger (<65 years). The primary outcomes were stroke recurrence and moderate to severe bleeding within 90 days, respectively.

RESULTS

Of all the 6412 patients, 406 (6.3%) were old-old, 2755 (43.0%) were young-old and 3251 (50.7%) were younger. Old-old patients were associated with higher composite vascular events (HR 1.41, 95% CI 1.00 to 1.98, p=0.048), disabling stroke (OR 2.43, 95% CI 1.52 to 3.88, p=0.0002), severe or moderate bleeding (HR 8.40, 95% CI 1.95 to 36.21, p=0.004) and mortality (HR 7.56, 95% CI 2.23 to 25.70, p=0.001) within 90 days. Ticagrelor-aspirin group was associated with lower risks of stroke recurrence within 90 days in younger patients (HR 0.68, 95% CI 0.51 to 0.91, p=0.008), which was no differences in old-old patients.

CONCLUSION

Elderly patients aged over 80 in CHANCE-2 trial had higher risks of composite vascular events, disabling stroke, severe or moderate bleeding and mortality within 90 days. Genotype-guided DAPT might not be as effective in old-old patients as in younger ones.

TRIAL REGISTRATION NUMBER

NCT04078737.

Persistent visual perceptual disorders after stroke: Associated factors

Introduction

Visual perceptual disorders are common after stroke and often affect functional independence. Little is known about biopsychosocial variables related to these disorders. This study aimed to identify which variables best explain the persistence of visual perceptual disorders in seniors with stroke.

Method

Visual perception of 195 people aged 65 and over with stroke was assessed using the Motor-free Visual Perceptual Test – Vertical version, three weeks after returning home as well as three and six months later. Biopsychosocial and personal variables were also assessed three weeks after returning home. Correlation analyses were followed by bivariate linear regression analyses.

Results

Seventy participants still had visual perceptual disorders six months later. Many variables measured at the first test were found to be associated with visual perception at the six-month follow-up. Those best explaining the persistence of visual perceptual dysfunctions ( R2 = 49.2%) were memory (Wechsler, delayed recall) ( p < 0.001), verbal comprehension (Token Test) ( p = 0.015), stroke severity (Canadian Neurological Scale) ( p = 0.005) and sex (female) ( p = 0.02).

Conclusion

Among many variables, four (memory, verbal comprehension, stroke severity and sex) were most strongly associated with persistent visual perceptual disorders. Other studies are needed to better understand the role of memory and verbal comprehension in visual perceptual disorders after stroke.

United States trends in thrombolysis for older adults with acute ischemic stroke

OBJECTIVE

Thrombolysis for ischemic stroke has been increasing in the United States. We sought to investigate recent trends in thrombolysis use in older adults.

METHODS

A retrospective, observational analysis of hospitalization data from the Nationwide Inpatient Sample (NIS) in 2005-2010 was performed. Older adults (≥65 years) admitted with a primary diagnosis of acute ischemic stroke were included. Trends in the population-based rates of thrombolysis and outcomes from the NIS were evaluated using the Cochran-Armitage test.

RESULTS

Thrombolysis in older adult stroke patients increased from 1.7% to 5.4% (2005-2010; trend P<0.001). Large increases were observed among urban patients, urban hospitals, and high volume facilities. Individuals ≥85 years were less likely to receive thrombolysis than younger ages throughout the study period, although there was an increase from an odds ratio of 0.50 (95% CI: 0.44-0.57) to 0.75 (95% CI: 0.69-0.81) from 2005-2006 to 2009-2010 when compared to 65-74 year olds. For those receiving thrombolysis, no change was observed in intracerebral hemorrhage over time. In-hospital mortality rates did not change significantly over the study period for age subgroups and length of stay declined from 2005 to 2010 for the thrombolysis group (7.6 vs 7.0 days; trend P<0.001).

CONCLUSIONS

Rates of thrombolysis in older adults progressively increased, especially in the oldest old. Increases were largely driven by urban and high volume hospitals.

Thrombolysis and reperfusion: advanced understanding of early management strategies in acute ischemic stroke

Currently, intravenous (IV) thrombolysis within 3 hours from stroke onset is the only approved treatment in acute ischemic stroke (AIS). Although effective, the definition of therapeutic time window and appropriate patient selection still remains controversial. Notably, early endovascular treatment strategies may serve as an adjunct therapy for time window extension in AIS. In this article, we review the safety and efficacy of IV thrombolysis in AIS as it pertains to the optimal time window, the selection of eligible patients, and in combination with endovascular treatment. Combined clinical application of IV thrombolysis and endovascular therapy may improve the therapeutic outcomes for AIS patients.