Final Infarct Volume of <10 cm3 is a Strong Predictor of Return to Home in Nonagenarians Undergoing Mechanical Thrombectomy

Utility of Thrombectomy in Nonagenarians: A Scoping Review

BACKGROUND

Mechanical thrombectomy represents a mainstay of management for acute ischemic stroke in the setting of large vessel occlusion. However, there are no clinical practice guidelines defining the role of thrombectomy at the extremes of age. In this scoping review, we aimed to summarize the existing medical and neurosurgical literature pertaining to mechanical thrombectomy in nonagenarians. The PubMed database was queried using the following terms and relevant citations assessed: "thrombectomy nonagenarian," "thrombectomy age 90," "stroke nonagenarian," and "ischemic stroke thrombectomy." Common measurable outcomes, including mortality, modified Rankin scale (mRS) score, and thrombolysis in cerebral infarction (TICI) scale score, were utilized to compare results.

SUMMARY

Thrombectomy was shown to improve functional outcomes in all eight of the studies included in the analysis. Mortality was assessed in only two reported studies, and thrombectomy was shown to provide a mortality benefit in 1 study among patients for whom first-pass reperfusion was achieved. Other outcomes of reported interest included greater early neurologic recovery at discharge and improved functional outcomes at 90 days among nonagenarians who underwent thrombectomy as compared to those who received thrombolytic therapy alone. Nonagenarians with good functional status at baseline were the most likely to have favorable outcomes.

KEY MESSAGES

Mechanical thrombectomy improves outcomes among nonagenarians presenting with acute ischemic stroke due to large vessel occlusion. Further large-scale prospective studies are warranted to optimize patient selection and develop clinical practice guidelines specific to this important patient demographic.

Good collaterals and better outcomes after EVT for basilar artery occlusion: A systematic review and meta-analysis

BACKGROUND

Stroke caused by acute basilar artery occlusion (BAO) is devastating with high dependency and mortality. Recent trials have demonstrated the efficacy of endovascular treatment (EVT) for acute BAO, while pretreatment collaterals may be a valuable prognostic indicator for post-EVT outcomes.

AIMS

To systematically review and synthesize evidence on the associations between pretreatment collateral status and outcomes after EVT in acute BAO.

METHODS

We retrieved relevant full-text articles published in English since 1 January 2010, reporting associations between pretreatment collateral status and outcomes after EVT for BAO, by searching MEDLINE and Embase. The primary outcome was favorable or good 90-day functional outcome (modified Rankin Scale [mRS] 0-2 or 0-3); secondary outcomes included successful recanalization, symptomatic intracranial hemorrhage, final infarct volume, and 90-day mortality. Risk ratios (RRs) with 95% confidence intervals (CIs) for good versus poor collaterals on the outcomes were synthesized using random-effects models. Subgroup and sensitivity analyses were conducted for the primary outcome.

RESULTS

Overall, 29 primary studies (2995 participants) were included in qualitative review, among which 16 studies (1447 participants) were meta-analyzed. With different imaging modalities and methods to grade the collateral status, good collaterals were found in 33-85% of patients in the individual primary studies (I2 = 95.2%, p < 0.001), with a pooled proportion of 51% (95% CI: 40-62%) across all studies. Good pretreatment collaterals were associated with a doubled rate of favorable/good 90-day functional outcome (RR = 2.03, 95% CI: 1.63-2.51, p < 0.001), a higher rate of successful recanalization (RR = 1.23, 95% CI: 1.04-1.45, p = 0.015), and reduced 90-day mortality (RR = 0.59, 95% CI: 0.43-0.81, p = 0.001) after EVT for BAO. None of the primary studies reported the associations of good collaterals with the other secondary outcomes. Subgroup analyses revealed possibly more prominent protective effect of good pretreatment collaterals over the primary outcome, in studies with longer time windows in patient eligibility criteria for EVT (p = 0.028 for between-subgroup heterogeneity).

CONCLUSIONS

In patients with BAO receiving EVT, good pretreatment collateral status was associated with a higher chance of favorable 90-day functional outcome, despite the various methods in grading the collateral circulation. Efforts are needed for more standardized collateral assessment in BAO, for more reliable and generalizable investigations of its clinical implications.

Follow-Up Infarct Volume Prediction by CTP-Based Hypoperfusion Index, and the Discrepancy between Small Follow-Up Infarct Volume and Poor Functional Outcome-A Multicenter Study

(1) Background: Follow-up infarct volume (FIV) may have implications for prognostication in acute ischemic stroke patients. Factors predicting the discrepancy between FIV and 90-day outcomes are poorly understood. We aimed to develop a comprehensive predictive model of FIV and explore factors associated with the discrepancy. (2) Methods: Patients with acute anterior circulation large vessel occlusion were included. Baseline clinical and CT features were extracted and analyzed, including the CTP-based hypoperfusion index (HI) and the NCCT-based e-ASPECT, measured by automated software. FIV was assessed on follow-up NCCT at 3−7 days. Multiple linear regression was used to construct the predictive model. Subgroup analysis was performed to explore factors associated with poor outcomes (90-mRS scores 3−6) in small FIV (<70 mL). (3) Results: There were 170 patients included. Baseline e-ASPECT, infarct core volume, hypoperfusion volume, HI, baseline international normalized ratio, and successful recanalization were associated with FIV and included in constructing the predictive model. Baseline NIHSS, baseline hypertension, stroke history, and current tobacco use were associated with poor outcomes in small FIV. (4) Conclusions: A comprehensive predictive model (including HI) of FIV was constructed. We also emphasized the importance of hypertension and smoking status at baseline for the functional outcomes in patients with a small FIV.

An Initial High National Institutes of Health Stroke Scale Score and Any Intracranial Hemorrhage Are Independent Factors for a Poor Outcome in Nonagenarians Treated with Thrombectomy for Acute Large Vessel Occlusion: The Tokyo/Tama-REgistry of Acute Endovascular Thrombectomy (TREAT) Study

BACKGROUND

Mechanical thrombectomy (MT) is effective in acute ischemic stroke patients ≥80 years old with large vessel occlusion (LVO). However, data for patients ≥90 years old remain very limited, and factors influencing functional outcomes are unclear. This study aimed to investigate factors influencing functional outcomes in patients ≥90 years old treated with MT for acute LVO.

METHODS

This retrospective observational study used prospectively collected data from the Tokyo/tama-REgistry of Acute endovascular Thrombectomy (TREAT) study. Inclusion criteria were as follows: 1) patients ≥90 years old treated with MT for LVO and 2) prestroke modified Rankin Scale (mRS) score, 0-3. The functional outcome was defined based on the mRS score at 90 days after the procedure: good functional outcome, mRS score 0-3 and poor functional outcome, mRS score 4-6.

RESULTS

Data were analyzed for 104 patients ≥90 years old. The good functional outcome was observed in 25 patients (24.0%), and the poor functional outcome was observed in the remaining 79 patients. Significant differences were identified in initial National Institutes of Health Stroke Scale (NIHSS) score, modified Thrombolysis in Cerebral Infarction grade 2b-3, modified Thrombolysis in Cerebral Infarction grade 3, and any intracranial hemorrhage and hemorrhagic infarction in univariate analyses. Multivariable analysis confirmed the initial NIHSS score (odds ratio, 1.08; 95% confidence interval, 1.01-1.17; P = 0.045) and any intracranial hemorrhage (odds ratio, 11.6; 95% confidence interval, 1.43-95.0; P = 0.022) as independent factors for the functional outcome.

CONCLUSIONS

An initial high NIHSS score and any intracranial hemorrhage are independent factors for the poor functional outcome in acute ischemic stroke patients ≥90 years old treated with MT.

Outcomes of endovascular thrombectomy in patients selected by computed tomography perfusion imaging - a matched cohort study comparing nonagenarians to younger patients

BACKGROUND

Endovascular thrombectomy (EVT) is efficacious for appropriately selected patients with large vessel occlusions (LVO) up to 24 hours from symptom onset. There is limited information on outcomes of nonagenarians, selected with computed tomography perfusion (CTP) imaging.

METHODS

We retrospectively analyzed data from a large academic hospital between December 2017 and October 2019. Patients receiving EVT for anterior circulation LVO were stratified into nonagenarian (≥90 years) and younger (<90 years) groups. We performed propensity score matching on 18 covariates. In the matched cohort we compared: primary outcome of inpatient mortality and secondary outcomes of successful reperfusion (TICI ≥2B), symptomatic intracranial hemorrhage (sICH), and functional independence. Subgroup analysis compared CTP predicted core volumes in nonagenarians with outcomes.

RESULTS

Overall, 214 consecutive patients (26 nonagenarians, 188 younger) underwent EVT. Nonagenarians were aged 92.8±2.9 years and younger patients were 74.5±13.5 years. Mortality rate was significantly greater in nonagenarians compared with younger patients (43.5% vs 10.4%, OR 9.33, 95% CI 2.88 to 47.97, P<0.0001) and a greater proportion of nonagenarians developed sICH (13.0% vs 3.0%, OR 6.00, 95% CI 1.34 to 55.20, P=0.02). There were no significant differences for successful reperfusion (P=1.00) or functional independence (P=0.75). Nonagenarians selected with smaller ischemic core volumes had decreased mortality rates (P=0.045).

CONCLUSIONS

Nonagenarians were noted to have greater mortality and sICH rates following EVT compared with matched younger patients, which may be ameliorated by selecting patients with smaller CTP core volumes. Nonagenarians undergoing EVT had similar rates of successful reperfusion and functional independence compared with the younger cohort.

Indications for Mechanical Thrombectomy for Acute Ischemic Stroke: Current Guidelines and Beyond

PURPOSE OF THE REVIEW

This article reviews recent breakthroughs in the treatment of acute ischemic stroke, mainly focusing on the evolution of endovascular thrombectomy, its impact on guidelines, and the need for and implications of next-generation randomized controlled trials.

RECENT FINDINGS

Endovascular thrombectomy is a powerful tool to treat large vessel occlusion strokes and multiple trials over the past 5 years have established its safety and efficacy in the treatment of anterior circulation large vessel occlusion strokes up to 24 hours from stroke onset.

SUMMARY

In 2015, multiple landmark trials (MR CLEAN, ESCAPE, SWIFT PRIME, REVASCAT, and EXTEND IA) established the superiority of endovascular thrombectomy over medical management for the treatment of anterior circulation large vessel occlusion strokes. Endovascular thrombectomy has a strong treatment effect with a number needed to treat ranging from 3 to 10. These trials selected patients based on occlusion location (proximal anterior occlusion: internal carotid or middle cerebral artery), time from stroke onset (early window: up to 6-12 hours), and acceptable infarct burden (Alberta Stroke Program Early CT Score [ASPECTS] ≥6 or infarct volume <50 mL). In 2017, the DAWN and DEFUSE-3 trials successfully extended the time window up to 24 hours in appropriately selected patients. Societal and national thrombectomy guidelines have incorporated these findings and offer Class 1A recommendation to a subset of well-selected patients. Thrombectomy ineligible stroke subpopulations are being studied in ongoing randomized controlled trials. These trials, built on encouraging data from pooled analysis of early trials (HERMES collaboration) and emerging retrospective data, are studying large vessel occlusion strokes with mild deficits (National Institutes of Health Stroke Scale <6) and large infarct burden (core volume >70 mL).

Feasibility of Mechanical Thrombectomy for Acute Ischemic Stroke Patients Aged 90 Years or Older Compared to Younger Patients

Mechanical thrombectomy (MT) is a proven treatment for acute ischemic stroke (AIS). However, the efficacy of this treatment is uncertain for very elderly patients. This study aimed to investigate the safety and effectiveness of MT in 90 years or older patients compared with younger patients. We retrospectively reviewed AIS patients treated with MT between October 2018 and June 2020 in our institution. Patients were divided into two groups: aged ≥90 and <90 years. We compared the following factors: functional outcome at discharge, in-hospital death, successful recanalization, and complications. Multivariate logistic regression analysis for the good functional outcome was performed. In consideration of pre-stroke basic activities of very elderly patients, we defined the good functional outcome as modified Rankin Scale (mRS) 0–3. In all, 66 patients were included, and 19 patients (28%) were ≥90 years old. Pre-stoke mRS was higher in ≥90-year-old patients (p = 0.01). In ≥90-year-old patients, we achieved successful recanalization in 17 patients (90%), and only one patient experienced hemorrhagic complication related with the procedure. The good functional outcome (mRS: 0–3) at discharge were six patients (32%) in ≥90 years old versus 19 patients (40%) in <90 years old (p = 0.6). Three patients died in hospital in each group (16% versus 6%) (p = 0.3). Only the stroke severity was negatively related with the good functional outcome in a multivariate analysis. In conclusion, for ≥90-year-old patients compared with younger patients, MT is an equally feasible therapy. Patients should not be excluded from MT based on age alone.

Impact of endovascular reperfusion therapy in nonagenarians with anterior circulation large-vessel ischaemic stroke

BACKGROUND AND PURPOSE

The benefit of endovascular thrombectomy (EVT) among nonagenarians (90 years or older) is poorly documented. We aimed to investigate the clinical and imaging factors associated with good outcomes and mortality at 90 days in nonagenarians undergoing EVT for acute ischemic stroke (AIS).

METHODS

Data from a prospectively maintained institutional registry of consecutive AIS patients treated with EVT from January 2012 to December 2018 were retrospectively analysed. Comorbid conditions were classified with a modified version of the Charlson Comorbidity Index (CCI). The degree of disability was assessed by the modified Rankin Scale (mRS). Outcomes included good functional outcome (mRS scores of 0-3) and mortality at 90 days.

RESULTS

Among 110 patients (age, 92.3 ± 2.5 years; men, 28.2%) treated with EVT, good outcome was achieved in 39 (35.5%) patients, successful reperfusion (modified Thrombolysis in Cerebral Infarction grades of 2b-3) was achieved in 78 (70.9%) patients and 38 (34.5%) patients died at 90 days. The functional outcome at 3 months was associated with pre-stroke status (CCI and pre-stroke mRS score). Successful reperfusion (adjusted odds ratio [OR], 11.6; 95% CI, 1.3-104.2; P = 0.03) and early neurologic improvement at 24 h (adjusted OR, 16.4; 95% CI, 5.2-51.5; P < 0.001) were independent predictors of a good outcome. Early neurological improvement (adjusted OR, 0.06; 95% CI, 0.02-0.23; P < 0.001) was an independent predictor of 90-day mortality.

CONCLUSIONS

Successful reperfusion therapy improves the functional outcome of nonagenarians who should not be excluded from EVT. The presence and severity of comorbidities should be considered in the procedural management of this vulnerable population.

Outcomes of Large Vessel Occlusion Stroke in Patients Aged ≥90 Years

BACKGROUND AND PURPOSE

Outcomes in patients ≥90 years of age with stroke due to large vessel occlusion were compared between endovascular therapy (EVT) and medical management.

METHODS

Of 2420 acute ischemic stroke patients with large vessel occlusion in a prospective, multicenter, nationwide registry in Japan, patients aged ≥90 years with occlusion of the internal carotid artery or M1 segment of the middle cerebral artery were included. The primary effectiveness outcome was a favorable outcome at 3 months, defined as achieving a modified Rankin Scale score of 0 to 2 or return to at least the prestroke modified Rankin Scale score at 3 months. Safety outcomes included symptomatic intracranial hemorrhage within 72 hours after onset. Intergroup biases were adjusted by multivariable adjustment with inverse probability of treatment weighting.

RESULTS

A total of 150 patients (median age, 92 [interquartile range, 90-94] years; median prestroke modified Rankin Scale score, 2 [interquartile range, 0-4]) were analyzed. EVT was performed in 49 patients (32.7%; mechanical thrombectomy, n=43). The EVT group showed shorter time from onset to hospital arrival (P=0.03), higher Alberta Stroke Program Early CT Score (P<0.01), and a higher rate of treatment with intravenous thrombolysis (P<0.01) than the medical management group. The favorable outcome was seen in 28.6% of the EVT group and 6.9% of the medical management group (P<0.01). EVT was associated with the favorable outcome (adjusted odds ratio, 8.44 [95% CI, 1.88-37.97]). Rates of symptomatic intracranial hemorrhage were similar between the EVT group (0.0%) and the medical management group (3.9%; P=0.30).

CONCLUSIONS

Patients who underwent EVT showed better functional outcomes than those with medical management without increased symptomatic intracranial hemorrhages. Given proper patient selection, withholding EVT solely on the basis of the age of patients may not offer the best chance of good outcome. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02419794.

Mechanical Thrombectomy in Nonagenarians: a Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to summarize the current literature on mechanical thrombectomy (MT) in nonagenarians and to provide updated clinical evidence of its feasibility, effectiveness, and safety in nonagenarians. PubMed, EMBASE, the Cochrane Library, and Web of Science were searched for relevant randomized controlled trials and observational studies that reported the clinical outcomes of nonagenarians with acute ischemic stroke after undergoing mechanical thrombectomy. Risk of bias was assessed using different scales. I² statistic was used to evaluate the heterogeneity of the results, while meta-regression and sensitivity analyses were performed to investigate the source of heterogeneity. Thirteen studies and 657 patients were included. The estimated rate of successful revascularization was 80.82% (95% confidence interval [CI]: 77.48-83.97%), and the rate of favorable outcome (modified Rankin score [mRS] 0-2) was 21.60% (95% CI: 13.81-30.41%). The rate of good outcome (mRS score 0-3) was 23.08% (95% CI: 18.88-27.55%). The estimated risk of death during hospitalization was 20.55% (95% CI: 15.93-25.55%), while the mortality rate at 3 months was 44.38% (95% CI: 33.66-55.36%). The rate of intracranial hemorrhage (ICH) occurrence was 12.84% (95% CI: 5.27-22.68%), while the rate of symptomatic intracranial hemorrhage (sICH) was 3.52% (95% CI: 1.67-5.85%). The rate of hospital-related complications was 26.93% (95% CI: 10.53-47.03%). MT in nonagenarians demonstrated a high rate of successful revascularization. Conversely, the rate of futile revascularization is high with a low functional independence proportion. Therefore, MT should not be indiscriminately advocated in nonagenarians. Satisfactory results require careful selection of patients. Further high-quality studies are needed to clarify the selection algorithm.

Age and Outcome after Endovascular Treatment in Anterior Circulation Large-Vessel Occlusion Stroke: ETIS Registry Results

BACKGROUND

Increasing patient age has been identified in clinical trials as a poor prognostic factor for functional independence after endovascular treatment (EVT) for acute ischemic stroke. These findings may not be fully generalizable to clinical practice due to strict inclusion and exclusion criteria in these trials. We aim to assess and quantify the association of patient age, especially in patients >80 and >90 years old, with functional outcome after EVT in current, everyday clinical practice.

METHODS

The ETIS (Endovascular Treatment in Ischemic Stroke) Registry is an ongoing, prospective, observational study of 6 comprehensive stroke centers in France. We analyzed 1,708 patients treated between January 2017 and December 2018 and assessed the association of patient age with functional outcome adjusting for demographic and procedural predictors of functional outcome.

RESULTS

The positive effect of mechanical thrombectomy diminished significantly with increasing age: compared to the 18-80 years age group, the odds for achieving a good functional outcome at 90 days after the procedure decreased in the 80-90 and >90 years groups (multilevel OR: 0.38, 95% CI: 0.28-0.51 and OR: 0.2, 95% CI: 0.09-0.45, respectively, p < 0.001). Increasing age was associated with increased mortality (multilevel OR: 2.46, 95% CI: 1.72-3.54 for the 80-90 years group and multilevel OR: 5.49, 95% CI: 2.97-10.16 for the >90 years group).

CONCLUSION

Patient age is strongly associated with functional outcome after EVT for acute ischemic stroke. The positive effect of thrombectomy persists in older age groups, even after adjustment for prognostic factors related to poor functional outcome. Stroke physicians should provide EVT irrespective of the patient's age.

Predictors of outcome after mechanical thrombectomy for acute ischemic stroke in patients aged ≥90 years

BACKGROUND

Mechanical thrombectomy (MT) has established its role as a first-line treatment of acute ischemic stroke due to large vessel occlusions (LVO). However, patients older than 85 or even 80 years of age are commonly excluded from large randomized controlled stroke studies as this group was found to be associated with significantly poorer clinical outcome and increased mortality compared to younger patients. The aim of this study was to evaluate clinical and procedural factors associated with clinical outcome and mortality among nonagenarians with acute ischemic stroke treated with mechanical thrombectomy.

MATERIALS AND METHODS

This retrospective, single-center study was conducted on 38 patients with LVO treated with MT. Clinical features including baseline results, radiological imaging, procedural details and outcome results were documented and evaluated. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS) and after 3 months (mRS).

RESULTS

The rate of successful recanalization (TICI ≥2b) was 84.2 % (32/38). Symptomatic intracranial hemorrhage (sICH) was observed in 3 (7.9 %) patients. After 90 days, the mortality rate was 47.4 %. Favorable clinical outcome (mRs 0-2) was regained in 28.9 % of the patients (11/38). Poor clinical outcome (mRs<2) was observed in 9 patients (23.7 %).

CONCLUSION

Very elderly patients with LVO should not be excluded from MT even if prognosis for good clinical outcome in this age group remains low and the procedure is more challenging. Long-term outcome is predicted by stroke severity (baseline NIHSS and occluded vessel) and hospital arrival time.

Ballast and NeuronMax in stroke thrombectomy

BACKGROUND

Comparative evaluation of long sheath performance in stroke thrombectomy has not been performed.

OBJECTIVE

To review an initial experience with the new Ballast 6F long sheath compared with the NeuronMax, to evaluate comparative benchmarks in trackability, navigability, and procedural outcomes.

METHODS

A prospectively maintained thrombectomy database was evaluated over a 6-month period to compare procedural and angiographic results between a cohort of patients treated with the historical institutional standard long sheath (NeuronMax) and another with the new Ballast long sheath via a transfemoral approach.

RESULTS

Of 156 stroke thrombectomy cases, 69 were performed using NeuronMax and 40 using Ballast via a transfemoral approach; the remainder of cases employed alternative long sheaths or were performed via initial radial access. There was no significant difference in patient age, medical history, baseline National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, arch type, tissue plasminogen activator use, and clot location between the two groups. Single-pass case frequency (41% for NeuronMax vs 44% for Ballast, p=0.84), and final successful revascularization (TICI 2b or greater) were similar between the two cohorts (91% vs 98%, p=0.42). Good 90-day outcome (modified Rankin Scale score 0-2) was also similar (33% for NeuronMax, 43% for Ballast, p=0.41). Excluding tandem occlusions, mean procedural time was 31 min for NeuronMax and 25 min for Ballast (p=0.09). Puncture to long sheath access and angiography in the base target vessel was faster for Ballast than NeuronMax (6.5 min vs 9.2 min, p=0.04).

CONCLUSION

Among a cohort of practitioners with historical, preferential experience with NeuronMax for stroke thrombectomy, faster procedural times were achieved with Ballast with similar final angiographic results.

Clinical Results of Mechanical Thrombectomy in Nonagenarians with Acute Ischemic Stroke

Objective

Multiple randomized trials have demonstrated the efficacy of mechanical thrombectomy (MT), but very elderly patients aged ≥90 years were excluded. It remains uncertain whether endovascular therapy is effective for nonagenarians. The objective of this study was to investigate the effectiveness and safety of MT in nonagenarians.

Methods

Between January 2016 and March 2019, acute ischemic stroke patients aged ≥80 years who underwent MT at our hospital were retrospectively reviewed. Patients with a baseline pre-stroke modified Rankin Scale (mRS) score ≥3 were excluded from the analysis. They were divided into octogenarians (80-89 years old) and nonagenarians (90-99 years old).

Results

Forty-five patients met the inclusion criteria, including 34 octogenarians and 11 nonagenarians. Nonagenarians were more likely to be female (47.0% vs 90.9%; p <0.05). There was a significantly lower rate of a pre-stroke mRS score of 0-1 among the nonagenarians (91.1% vs 63.6%; p <0.05). Revascularization was successful in 71.0% and 81.8% (p = 0.46) of octogenarians and nonagenarians, respectively. Functional independence (mRS ≤2) at discharge was observed in 26.4% vs 27.2% (p = 0.95) of octogenarians and nonagenarians, respectively.

Conclusion

MT in nonagenarians can be considered safe without increasing hemorrhagic complications in comparison with that in octogenarians. One in four patients may have a good outcome and obtain effects equivalent to those in octogenarians if they have a good pre-stroke functional status.

Endovascular Treatment of Very Elderly Patients Aged ≥90 With Acute Ischemic Stroke

Background

Patients aged ≥90 were excluded or under‐represented in past thrombectomy trials; thus, uncertainty remains whether treatment benefits can be expected regardless of age. This study investigates outcome and safety of thrombectomy in nonagenarians to improve decision making in a real‐world setting.

Methods and Results

All currently available data of patients aged ≥90 enrolled in the GSR‐ET (German Stroke Registry–Endovascular Treatment) were combined with a smaller cohort from 3 tertiary stroke centers. Baseline characteristics, procedural (Thrombolysis in Cerebral Infarction scale) and functional outcomes (modified Rankin Scale; mRS), as well as complications (symptomatic intracranial hemorrhage, serious adverse events; SAEs) were analyzed. Good functional outcome was defined as mRS ≤3 at 90‐days. 203 patients with anterior circulation stroke and prestroke mRS ≤3 were included. The rate of successful recanalization (Thrombolysis in Cerebral Infarction scale ≥2b) was 75.9% (154/203). Good functional outcome (mRS ≤3) was observed in 21.6% (41 of 193) at 90‐days. In‐hospital mortality was 27.1% (55 of 203) and increased significantly at 90 days to 48.9% (93 of 190; P<0.001). Symptomatic intracranial hemorrhage occurred in 3% (6 of 203) of patients. Logistic regression analysis identified Alberta Stroke Program Early CT Score (adjusted odds ratio, 1.93; 95% CI, 1.01–3.70; P=0.046) and initial National Institute of Health Stroke Scale (adjusted odds ratio, 0.85; 95% CI, 0.76–0.97; P=0.014) as independent predictors for good outcome. Patients with successful recanalization had a significant (P=0.001) shift of mRS distribution with higher rates of good functional outcomes (23.8% [34 of 143] versus 14.9% [7 of 47]) and lower mortality at 90‐days (46.8% [67 of 143] versus 55.3% [26 of 47]).

Conclusions

Despite high mortality and less frequent favorable outcome, our data suggest that thrombectomy is still effective and safe for nonagenarians. Decision making for thrombectomy in patients aged ≥90 should be based on a case‐by‐case basis with regard to initial National Institute of Health Stroke Scale and Alberta Stroke Program Early CT Score.

Outcome prediction for patients with anterior circulation acute ischemic stroke following endovascular treatment: A single-center study

Previous studies have identified various factors associated with the outcomes of acute ischemic stroke (AIS) but considered only 1 or 2 predictive factors. The present study aimed to use outcome-related factors derived from biochemical, imaging and clinical data to establish a logistic regression model that can predict the outcome of patients with AIS following endovascular treatment (EVT). The data of 118 patients with anterior circulation AIS (ACAIS) who underwent EVT between October 2014 and August 2018 were retrospectively analyzed. The patients were divided into 2 groups based on the modified Rankin Scale score at three months after surgery, where 0–2 points were considered to indicate a favorable outcome and 3–6 points were considered a poor outcome. Non-conditional logistic stepwise regression was used to identify independent variables that were significantly associated with patient outcome, which were subsequently used to establish a predictive statistical model, receiver operating characteristic (ROC) curve was used to show the performance of statistical model and analyze the specific association between each factor and outcome. Among the 118 patients, 47 (39.83%) exhibited a good and 71 (60.17%) exhibited a poor outcome. Multivariate analysis revealed that the predictive model was statistically significant (χ²=78.92; P<0.001), and that the predictive accuracy of the model was 83.1%, which was higher compared with that obtained using only a single factor. ROC curve analysis shows the area under curve of the statistical model was 0.823, the analysis of diagnostic threshold for prognostic factors indicated that age, diffusion-weighted imaging lesion volume, glucose on admission, National Institutes of Health Stroke Scale score on admission and hypersensitive C-reactive protein were valuable predictive factors for the outcome of EVT (P<0.05). In conclusion, a predictive model based on non-conditional logistic stepwise regression analysis was able to predict the outcome of EVT for patients with ACAIS.

Thrombectomy for acute ischemic stroke in nonagenarians compared with octogenarians

Introduction

Multiple randomized trials have shown that endovascular thrombectomy (EVT) leads to improved outcomes in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Elderly patients were poorly represented in these trials, and the efficacy of EVT in nonagenarian patients remains uncertain.

Methods

We performed a retrospective cohort study at a single center. Inclusion criteria were: age 80–99, LVO, core infarct <70 mL, and salvageable penumbra. Patients were stratified into octogenarian (80–89) and nonagenarian (90–99) cohorts. The primary outcome was the ordinal score on the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included dichotomized functional outcome (mRS ≤2 vs mRS ≥3), successful revascularization, symptomatic intracranial hemorrhage (ICH), and mortality.

Results

108 patients met the inclusion criteria, including 79 octogenarians (73%) and 29 nonagenarians (27%). Nonagenarians were more likely to be female (86% vs 58%; p<0.01); there were no other differences between groups in terms of demographics, medical comorbidities, or treatment characteristics. Successful revascularization (TICI 2b–3) was achieved in 79% in both cohorts. Median mRS at 90 days was 5 in octogenarians and 6 in nonagenarians (p=0.09). Functional independence (mRS ≤2) at 90 days was achieved in 12.5% and 19.7% of nonagenarians and octogenarians, respectively (p=0.54). Symptomatic ICH occurred in 21.4% and 6.4% (p=0.03), and 90-day mortality rate was 63% and 40.9% (p=0.07) in nonagenarians and octogenarians, respectively.

Conclusions

Nonagenarians may be at higher risk of symptomatic ICH than octogenarians, despite similar stroke- and treatment-related factors. While there was a trend towards higher mortality and worse functional outcomes in nonagenarians, the difference was not statistically significant in this relatively small retrospective study.

Mechanical thrombectomy in nonagenarians with acute ischemic stroke

Background

Mechanical thrombectomy (MT) is a safe and effective therapy for ischemic stroke. Nevertheless, very elderly patients aged ≥90 years were either excluded or under-represented in previous trials. It remains uncertain whether MT is warranted for this population or whether there should be an upper age limit.

Methods

We retrospectively reviewed 79 patients with stroke aged ≥90 years from three neurointerventional centers who underwent MT between 2013 and 2017. Good functional outcome was defined as modified Rankin scale (mRS) ≤2 and assessed at 90-day follow-up. Successful recanalization was graded by Thrombolysis in Cerebral Infarction Scale (TICI) ≥2 b. Feasibility and safety assessments included unsuccessful recanalization attempts (TICI 0), time from groin puncture to recanalization, symptomatic intracranial hemorrhage (sICH), mortality, and intervention-related serious adverse events.

Results

Only occlusions within the anterior circulation were included. Median time from groin puncture to recanalization was 39 min (IQR 25–57 min). The rate of successful recanalization (TICI ≥2 b) was 69.6% (55/79). Good functional outcome (mRS ≤2) at 90 days was observed in 16% (12/75) of patients. In-hospital mortality was 29.1% (23/79) and increased significantly at 90 days (46.7%, 35/75; p<0.001). sICH occurred in 5.1% (4/79) of patients. No independent predictor for good functional outcome (mRS ≤2) at 90 days was identified through logistic regression analysis.

Conclusion

MT in nonagenarians leads to high mortality rates and less frequently good functional outcome compared with younger patient cohorts in previous large randomized trials. However, MT appears to be safe and beneficial for a certain number of very elderly patients and therefore should generally not be withheld from nonagenarians.