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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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2
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Laugesen NG, Brandt AH, Stavngaard T, Højgaard J, Hansen K, Truelsen T. Mechanical thrombectomy in stroke patients of advanced age with score-based prediction of outcome. Interv Neuroradiol 2022:15910199221149073. [PMID: 36579806 DOI: 10.1177/15910199221149073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Stroke patients ≥80 years constituted only 15% in randomised trials on mechanical thrombectomy (MT), but is a considerable higher proportion in clinical practice. Association of clinical variables collected before MT with functional outcome has not been independently described in these patients, while being important in the decision of patient eligibility for MT. METHODS We included patients consecutively at a single centre (2017-2021) categorised as octogenarians (age: 80-89 years) or nonagenarians (age: 90-99 years). Functional outcome at 90 days was defined as fair (modified Rankin Scale (mRS) 0-3) or poor (mRS 4-6). Clinical variables collected before MT were analysed for association with shift of mRS in a poor direction. Significant predictors were used to produce a risk score of fair outcome. Significance was set at the p < 0.05 level. RESULTS Nonagenarians (n = 43, 15.5%) compared to octogenarians (n = 235, 84.5%) less likely achieved fair outcome (20.9% vs. 46.0%, p < 0.01) with higher mortality (65.1% vs. 31.9%, p < 0.01). Significant predictors of outcome were: age, adjusted odds ratio (aOR) = 0.91 (95% confidence interval (CI): 0.86-0.97); pre-stroke mRS, aOR = 0.57 (95% CI: 0.44-0.73); National Institute of Health Stroke Scale at admission, aOR = 0.91 (95% CI: 0.87-0.95); Alberta Stroke Program Early Computed Tomography, aOR = 1.23 (95% CI: 1.05-1.45). After bootstrap validation, the area under the curve of the risk score was 0.74 and the optimal cut-off for fair outcome was a score of >7 points. CONCLUSIONS One in two octogenarians achieved fair outcome, however, only one in five nonagenarians had fair outcome. The clinical risk score could be considered as guidance when deciding patient eligibility for MT.
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Affiliation(s)
| | - Andreas Hjelm Brandt
- Neurovascular Section, Department of Radiology, 53146Rigshospitalet, Copenhagen, Denmark
| | - Trine Stavngaard
- Neurovascular Section, Department of Radiology, 53146Rigshospitalet, Copenhagen, Denmark
| | - Joan Højgaard
- Stroke Center Rigshospitalet, Department of Neurology, 53146Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Stroke Center Rigshospitalet, Department of Neurology, 53146Rigshospitalet, Copenhagen, Denmark
- 53139Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Truelsen
- Stroke Center Rigshospitalet, Department of Neurology, 53146Rigshospitalet, Copenhagen, Denmark
- 53139Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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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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4
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Adcock AK, Schwamm LH, Smith EE, Fonarow GC, Reeves MJ, Xu H, Matsouaka RA, Xian Y, Saver JL. Trends in Use, Outcomes, and Disparities in Endovascular Thrombectomy in US Patients With Stroke Aged 80 Years and Older Compared With Younger Patients. JAMA Netw Open 2022; 5:e2215869. [PMID: 35671055 PMCID: PMC9175073 DOI: 10.1001/jamanetworkopen.2022.15869] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE Patients aged 80 years and older were often excluded or underrepresented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis. OBJECTIVE To delineate temporal trends in EVT use, outcomes, and disparities among patients with acute ischemic stroke aged 80 years and older vs those younger than 80 years. DESIGN, SETTING, AND PARTICIPANTS A US nationwide retrospective cohort study using prospectively collected data was conducted in patients admitted with a primary diagnosis of acute ischemic stroke between April 1, 2012, and June 30, 2019. Data were obtained from hospitals participating in the Get With the Guidelines-Stroke (GWTG-Stroke) program, which is a stroke quality improvement registry, with data collected prospectively, sponsored by the American Heart Association/American Stroke Association. Data analysis was conducted from November 2, 2020, to June 25, 2021. EXPOSURES Potentially eligible for EVT based on arrival within 6 hours and National Institutes of Health Stroke Scale score greater than or equal to 6. MAIN OUTCOMES AND MEASURES Efficacy outcomes included discharge to home, independent ambulation at discharge, and functional independence (modified Rankin Scale score 0-2) at discharge. Safety outcomes included in-hospital mortality, combined in-hospital mortality or discharge to hospice, and symptomatic intracranial hemorrhage. RESULTS Among 302 965 patients with ischemic stroke meeting study criteria as potentially eligible for EVT admitted to 614 GWTG-Stroke hospitals, 14.0% (42 422) received EVT (21 634 women [51.0%]), including 10.7% (12 768 of 119 453) of patients aged 80 years and older (median [IQR] age, 85 [82-89] years) and 16.2% (29 654 of 183 512) of patients younger than 80 years (median [IQR] age, 65 [56-73] years). Among patients aged 80 years and older, EVT rates increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. By study end, the relative rate of EVT among eligible patients aged 80 years and older compared with those younger than 80 years increased from 0.49 (3.3% vs 6.7%) to 0.76 (20.8% vs 27.3%). Older patients had worse outcomes at discharge compared with younger patients, including discharge to home: 12.5% vs 31.1% (adjusted odds ratio [aOR], 0.43; 95% CI, 0.40-0.46), functional independence (modified Rankin Scale score 0-2): 10.9% vs 26.6% (aOR, 0.45; 95% CI, 0.41-0.49), and inpatient death or discharge to hospice, 34.5% vs 16.1% (aOR, 2.22; 95% CI, 2.09-2.36). Symptomatic intracranial hemorrhage rates did not differ significantly (6.9% vs 6.5%; aOR, 1.04; 95% CI, 0.94-1.14). CONCLUSIONS AND RELEVANCE In this cohort study, use of EVT among individuals aged 80 years and older increased substantially from 2012 to 2019, although the rate remained lower than in younger patients. Although favorable functional outcomes at discharge were lower and combined mortality or discharge to hospice was higher in the older patients, the risk of symptomatic intracranial hemorrhage was not increased.
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Affiliation(s)
- Amelia K. Adcock
- Department of Neurology, West Virginia University School of Medicine, Morgantown
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eric E. Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gregg C. Fonarow
- Division of Cardiology, University of California, Los Angeles
- Section Editor, Health Care Quality and Guidelines, JAMA Cardiology
| | - Mathew J. Reeves
- Department of Epidemiology, Michigan State University, East Lansing
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Ying Xian
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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5
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Duloquin G, Ferrigno M, Hassen WB, Kyheng M, Bricout N, Boulouis G, Seners P, Labreuche J, Turc G, Naggara O, Cordonnier C, Henon H, Pasi M. Pre-treatment lesional volume in older stroke patients treated with endovascular treatment. Int J Stroke 2022; 17:1085-1092. [PMID: 35225745 DOI: 10.1177/17474930211068657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent studies in the general stroke population treated with endovascular treatment (EVT) reported that higher pre-treatment lesional volumes were independently associated with poor neurological outcome and functional dependence after stroke. However, it has been not evaluated in older patients. AIM We test the association between the pre-treatment lesional volume on diffusion-weighted magnetic resonance imaging and relevant outcome measures in older adults with stroke treated with EVT. METHODS We included consecutive older adults with stroke (⩾80 years old) treated with EVT in two academic comprehensive stroke centers. The association between pre-treatment lesional volume and relevant outcome measures (poor outcome (modified Rankin scale 4-6), 3-month mortality and symptomatic intracerebral hemorrhage (sICH)) was evaluated using univariate and multivariable models. RESULTS Five hundred seventy-nine patients were included (mean age: 85.6 ± 4.1, median lesional volume was 10 ml; interquartile range: 3-30 ml). Pre-treatment lesional volume was associated with poor functional outcome (adjusted odds ratio (aOR): 1.87, 95% confidence interval (CI): 1.60-2.20, for +1 logarithmic increase of lesional volume), 3-month mortality (aOR: 1.50, CI: 1.28-1.76), and sICH (aOR: 1.67, CI: 1.27-2.20). A threshold lesional volume >35 ml predicted 90% of patients with poor functional outcome and a cut-off >51 ml predicted 90% of patients dead at 3 months. CONCLUSIONS Pre-treatment lesional volume might contribute, in association with other relevant clinical features, to the selection of older stroke patients who will benefit from EVT.
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Affiliation(s)
- Gauthier Duloquin
- EA7460, Pathophysiology and Epidemiology of Cerebro-Cardiovascular diseases (PEC2), University Hospital of Dijon, University of Burgundy, Dijon, France
| | - Marc Ferrigno
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Wagih Ben Hassen
- Department of Neuroradiology, Paris University, Inserm U1266, GHU Paris, Saint-Anne Hospital, Paris, France
| | - Maéva Kyheng
- Département de Biostatistiques, CHU Lille, Lille, France.,University of Lille, CHU Lille, ULR 2694-METRICS: évaluation des technologies de santé et des pratiques médicales, Lille, France
| | | | - Grégoire Boulouis
- Department of Neuroradiology, Paris University, Inserm U1266, GHU Paris, Saint-Anne Hospital, Paris, France
| | - Pierre Seners
- Université de Paris, Inserm U1266, GHU Paris Psychiatrie et Neurosciences (Department of Neurology), FHU NeuroVasc, Paris, France
| | | | - Guillaume Turc
- Université de Paris, Inserm U1266, GHU Paris Psychiatrie et Neurosciences (Department of Neurology), FHU NeuroVasc, Paris, France
| | - Olivier Naggara
- Department of Neuroradiology, Paris University, Inserm U1266, GHU Paris, Saint-Anne Hospital, Paris, France
| | - Charlotte Cordonnier
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Hilde Henon
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
| | - Marco Pasi
- University of Lille, Inserm, CHU Lille, U1172-Lille Neuroscience & Cognition (LilNCog), Lille, France
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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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7
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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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8
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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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9
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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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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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Farah J, Rouchaud A, Henry T, Regen C, Mihalea C, Moret J, Spelle L. Dose reference levels and clinical determinants in stroke neuroradiology interventions. Eur Radiol 2018; 29:645-653. [DOI: 10.1007/s00330-018-5593-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/22/2018] [Accepted: 06/05/2018] [Indexed: 12/17/2022]
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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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