Elderly Patients Are at Higher Risk for Poor Outcomes After Intra-Arterial Therapy

Is endovascular treatment still good for acute ischemic stroke in the elderly? A meta-analysis of observational studies in the last decade

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.

Efficacy and safety of reperfusion treatments in middle-old and oldest-old stroke patients

Introduction

Intravenous thrombolysis (IT) and mechanical thrombectomy (MT) have significantly changed the clinical outcome of acute ischaemic stroke (AIS). Concerns about possible complications often reduce the use of these treatment options for older patients, preferentially managed with antiplatelet therapy (AT). Aim of this study was to evaluate, in a population of middle-old (75–84 years) and oldest-old (≥ 85 years) subjects, the efficacy and safety of different treatments for AIS (IT, IT + MT, MT or AT), mortality and incidence of serious complications.

Patients and methods

All patients aged over 75 years admitted for AIS in two Stroke Units were enrolled. The physician in each case considered all treatment options and chose the best approach. NIHSS and modified Rankin Scale (mRS) were obtained and differences between admission and discharge scores, defined as delta(NIHSS) and delta(mRS), were calculated. The relationship between delta(NIHSS), delta(mRS) and type of procedure was analysed with a GLM/Multivariate model. Differences in mortality and incidence of serious complications were analysed with the chi-square test.

Results

A total of 273 patients, mean age 84.07 (± 5.47) years, were included. The Delta(NIHSS) was significantly lower in patients treated with AT than in those treated with IT and MT (p < 0.009 and p < 0.005, respectively). Haemorrhagic infarction occurrence was significantly lower (p < 0.0001) among patients treated with AT (10.6%) or IT (16.7%) compared to MT (34.9%) or MT + IT (37.0%). No significant difference was observed for in-hospital mortality. Age did not influence the outcome.

Conclusions

Our results suggest that IT and AT are effective and relatively safe approaches in middle-aged and older patients.

Pre-treatment lesional volume in older stroke patients treated with endovascular treatment

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.

Large-Scale Multivariate Analysis to Interrogate an Animal Model of Stroke: Novel Insights Into Poststroke Pathology

[Figure: see text].

Acute Recanalization of Large Vessel Occlusion in the Anterior Circulation Stroke: Is Mechanical Thrombectomy Alone Better in Patients over 80 Years of Age? Findings from a Retrospective Observational Study

Real-world data report worse 3-month clinical outcomes in elderly patients with acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT). The aim was to identify factors influencing clinical outcome in elderly patients with anterior circulation AIS treated with MT (±intravenous thrombolysis (IVT)). In a retrospective, monocentric study, analysis of prospectively collected data of 138 patients (≥80 years) was performed. IVT was an independent negative predictor (OR 0.356; 95% CI: 0.134–0.942) and female sex an independent positive predictor (OR 4.179, 95% CI: 1.300–13.438) of 3-month good clinical outcome (modified Rankin scale 0–2). Female sex was also an independent negative predictor of 3-month mortality (OR 0.244, 95% CI: 0.100–0.599). Other independent negative predictors of 3-month good clinical outcome were older age, lower pre-stroke self-sufficiency, more severe neurological deficit and longer procedural intervals. Mortality was also independently predicted by longer procedural interval and by the occurrence of symptomatic intracerebral hemorrhage (p < 0.05 in all cases). Our results demonstrated, that in patients aged ≥80 years with anterior circulation AIS undergoing MT (±IVT), IVT reduced the chance of 3-month good clinical outcome and female sex was associated with a greater likelihood of 3-month good clinical outcome and lower probability of 3-month mortality.

Reperfusion therapy for acute ischemic stroke in older people: An observational real-life study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Neurologic Emergencies at the Extremes of Age

The diagnosis and management of neurologic conditions are more complex at the extremes of age than in the average adult. In the pediatric population, neurologic emergencies are somewhat rare and some may require emergent consultation. In older adults, geriatric physiologic changes with increased comorbidities leads to atypical presentations and worsened outcomes. The unique considerations regarding emergency department presentation and management of stroke and altered mental status in both age groups is discussed, in addition to seizures and intracranial hemorrhage in pediatrics, and Parkinson's disease and meningitis in the geriatric population.

National Trends in Utilization and Outcome of Endovascular Thrombectomy for Acute Ischemic Stroke in Elderly

OBJECTIVE

Octogenarians were excluded and/or underrepresented in the major endovascular thrombectomy (EVT) randomized controlled trials, but continue to make up a growing proportion of stroke patients. To evaluate real-world trends in utilization and outcome of EVT in patients ≥80 years in a large nationally representative database.

METHODS

Using the Nationwide Inpatient Sample (2014-2016), we identified patients admitted to United States hospitals with acute ischemic stroke (AIS) who also underwent EVT. The primary endpoint was good outcome (discharge to home/acute rehabilitation center). Poor outcome (discharge to skilled nursing facility or hospice and in-hospital mortality), intracerebral hemorrhage and in-hospital mortality were secondary outcome measures.

RESULTS

In 376,956 patients with AIS, 6,230(1.54%) underwent EVT. 1,547(24.83%) were ≥80. The rate of EVT in AIS patients ≥80 more than doubled from 0.83%(n = 317) in 2014 to 1.83%(n = 695) in 2016. The rate of good outcome in patients ≥80 was 9%, significantly lower than younger patients (26%, p<0.001). In-hospital mortality was 19% in patients ≥80 compared to 13% in the younger cohort (p < 0.001). There was no difference in the rate of hemorrhagic transformation between octogenarians and younger patients (18.52% vs 17.01%, p=0.19). In patients ≥80 years of age, decreasing baseline comorbidity burden independently predicted good outcome (OR 0.258, 95% CI [0.674- 0.935]).

CONCLUSIONS

A two-fold increase in the utilization of EVT in patients ≥80 years of age was seen from 2014 to 2016. While the comparative rate of good outcome is significantly lower in this age group, elderly patients with fewer comorbidities demonstrated better outcomes after EVT.

Effect of age and baseline ASPECTS on outcomes in large-vessel occlusion stroke: results from the HERMES collaboration

BACKGROUND

Patient age and baseline Alberta Stroke Program Early CT score (ASPECTS) are both independent predictors of outcome in acute ischemic stroke patients treated with endovascular therapy (EVT). We assessed the combined effect of age and ASEPCTS on clinical outcome in acute ischemic stroke patients with LVO with and without EVT, and EVT treatment effect in different age/ASPECTS subgroups.

METHODS

The HERMES collaboration pooled data of seven randomized controlled trials that tested the efficacy of EVT. Adjusted logistic regression was performed to test for multiplicative interaction of age and ASPECTS with the primary outcome (ordinal mRS) and secondary outcomes (mRS 0-2/0-1/0-3) in the EVT and control arms. Patients were then stratified by age (<75 vs ≥ 75 years) and ASPECTS (0-5/6-7/8-10), and adjusted effect-size estimates for the association of EVT were derived for the six age/ASPECTS subgroups.

RESULTS

1735 patients were included in the analysis. There was no multiplicative interaction between age and ASPECTS on clinical outcomes. In the exploratory subgroup analysis, we found a nominally negative point estimate for the association of EVT with clinical outcome in the ASPECTS 0-5/age ≥75, subgroup (acOR 0.36, 95% CI 0.07 to 1.89). The point estimate for moderate outcome (mRS0-3) nominally favored EVT (aOR 1.24, 95% CI 0.16 to 9.84). In all other subgroups, effect size-estimates consistently favored EVT.

CONCLUSION

There was no multiplicative interaction of age and ASPECTS on clinical outcomes in EVT or control arm patients. Outcomes in patients ≥75 years with ASPECTS 0-5 were poor, irrespective of treatment. Further investigation to define the role of EVT and range of acceptable outcomes in this subgroup is warranted.

Endovascular treatment in older adults with acute ischemic stroke in the MR CLEAN Registry

Objective

To explore clinical outcomes in older adults with acute ischemic stroke treated with endovascular thrombectomy (EVT).

Methods

We 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.

Results

Of 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).

Conclusion

Older 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.

Brain Atrophy and the Risk of Futile Endovascular Reperfusion in Acute Ischemic Stroke

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.

Effect of Age on Arterial Recanalization and Clinical Outcome in Thrombolyzed Acute Ischemic Stroke in CLOTBUST Cohort

Background and Aims:

Despite the evidence from randomized clinical trials, the effectiveness of intravenous tissue recombinant plasminogen activator (IV-tPA) for elderly patients (≥80 yrs) with acute ischemic stroke (AIS) is often an important consideration in clinical practice. We evaluated the effect of older age on arterial recanalization, timing of recanalization and outcome in thrombolysed AIS patients.

Methods:

Consecutive AIS patients treated with IV-tPA and transcranial Doppler (TCD) examination within 3 hours of symptom-onset were included. Thrombolysis in Brain Ischemia (TIBI) flow-grading system was used to interpret TCD findings of persistent occlusion, re-occlusion and complete recanalization within 2 hours of IV-tPA bolus. Poor functional outcome was defined by modified Rankin score of 3 or more. Univariate and multiple logistic regression analyses were performed to assess the effect of age on clinical and TCD outcome measures.

Results:

The study included 361 patients (elderly = 85, <80 yrs = 276). Median age was 68 years (range 18-91 years). Compared to the elderly, younger patients (<80 years) were more females (63.5% versus 41.3%), had higher baseline National Institute of Health Stroke Scale score (17.5 versus 16.0 points) and shorter time from symptom-onset to IV-tPA bolus (median 136.6 versus 139.7 minutes). No significant differences were noted between the site of arterial occlusion, TCD outcome measures or time of complete recanalization between the 2 groups. More patients aged < 80 years achieved good functional outcome (51.9% versus 31.8% in the older age group; P = 0.004). IV-tPA induced recanalization and symptomatic intracranial hemorrhage were similar in the 2 groups. Multivariate logistic regression showed elderly age as an independent predictor of poor outcome (adjusted OR 2.5, 95%CI 1.26-4.95; P = 0.008).

Conclusion:

Elderly AIS patients achieve relatively poor functional outcome after IV-tPA despite similar rates of arterial recanalization. However, there is no increase in the hemorrhagic risk. Perhaps, decision for IV thrombolysis in elderly patients should be made cautiously.

Mechanical Thrombectomy for Acute Ischemic Stroke in Octogenarians: A Systematic Review and Meta-Analysis

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.

Comparative Effectiveness of Endovascular Thrombectomy in Elderly Stroke Patients

Background and Purpose- Strokes in patients aged ≥80 years are common, and advanced age is associated with relatively poor poststroke functional outcome. The current guidelines do not recommend an upper age limit for endovascular thrombectomy (EVT). The purpose of this study is to evaluate the effectiveness of EVT in acute stroke because of large vessel occlusion for elderly patients >age 80 years. Methods- A Markov decision analytic model was constructed from a societal perspective to evaluate health outcomes in terms of quality-adjusted life years (QALYs) after EVT for acute ischemic stroke because of large vessel occlusion in patients above age 80 years. Age-specific input parameters were obtained from the most recent/comprehensive literature. Good outcome was defined as a modified Rankin Scale score ≤2. Probabilistic, 1-way, and 2-way sensitivity analyses were performed for both healthy patients and patients with disability at baseline. Results- Base case calculation showed in functionally independent patients at baseline, intravenous thrombolysis (IVT) with tPA (tissue-type plasminogen activator) only to be the better strategy with 3.76 QALYs compared to 2.93 QALYs for patients undergoing EVT. The difference in outcome is 0.83 QALY (equivalent to 303 days of life in perfect health). For patients with baseline disability, IVT only yields a utility of 1.92 QALYs and EVT yields a utility of 1.65 QALYs. The difference is 0.27 QALYs (equivalent to 99 days of life in perfect health). Multiple sensitivity analyses showed that the effectiveness of EVT is significantly determined by the morbidity and mortality after both IVT and EVT strategies, respectively. Conclusions- Our study demonstrates the impact of relevant factors on the effectiveness of EVT in patients above 80 years of age. Morbidity and mortality after both IVT and EVT strategies significantly influence the outcomes in both healthy and disabled patients at baseline. Better identification of patients not benefiting from IVT would optimize the selective use of EVT thereby improving its effectiveness.

Endovascular Treatment Decision Making in Octogenarians and Nonagenarians : Insights from UNMASK EVT an International Multidisciplinary Study

BACKGROUND

Evidence for efficacy and safety in stroke patients ≥80 years is limited, since they were underrepresented in randomized thrombectomy trials. This study sought to explore how physicians approach endovascular therapy (EVT) decision making in octogenarians and nonagenarians under their current local resources under assumed ideal conditions, i.e. without external (monetary or infrastructural) limitations.

METHODS

In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 out of a pool of 22 case scenarios with different evidence levels for EVT, 4 of which involved octogenarians and 2 nonagenarians, and asked how they would treat the patient in the given scenario A) under their current local resources and B) under assumed ideal conditions, i.e. with no external restraints. Decision rates were calculated and clustered multivariable regression analysis performed to determine adjusted measures of effect size for patient age.

RESULTS

In octogenarians, physicians decided in favor of EVT in 76.7% (all of which were level 2B evidence scenarios) under current local resources and in 80.2% under assumed ideal conditions. In nonagenarians, 74.0% decided in favor of EVT under current local resources (level 1A scenarios: 87.7%, level 2B scenarios: 60.3%) and 79.2% would offer EVT under assumed ideal conditions (level 1A scenarios: 91.3%, level 2B scenarios: 67.2%). Age was not a significant predictor for treatment decision under current local resources (adjusted odds ratio, OR: 0.99, confidence interval, CI: 0.96-1.02 per decile increase) and under assumed ideal conditions (adjusted OR: 1.00, CI 0.97-1.03 per decile increase).

CONCLUSION

The vast majority of physicians participating in this survey would offer EVT to acute ischemic stroke patients above 80 years.

White matter hyperintensity burden in patients with ischemic stroke treated with thrombectomy

INTRODUCTION

To determine the influence of white matter hyperintensity (WMH) burden on functional outcome, rate of symptomatic intracerebral hemorrhage (sICH), and procedural success in patients with acute ischemic stroke (AIS) treated by mechanical thrombectomy (MT) with current stentriever/aspiration devices.

METHODS

Patients with AIS due to large vessel occlusion (LVO) from the Thrombectomie des Artères Cérébrales (THRACE) trial and prospective cohorts from 2 academic comprehensive stroke centers treated with MT were pooled and retrospectively analyzed. WMH volumes were obtained by semiautomated planimetric segmentation and tested in association with the rate of favorable outcome (90-day functional independence), substantial recanalization after MT, and sICH.

RESULTS

A total of 496 participants were included between 2015 and 2018 (50% female, mean age 68.1 ± 15.0 years). Overall, 434 (88%) patients presented with detectable WMH (mean ± SD 4.93 ± 7.7). Patients demonstrated increasingly worse outcomes with increasing WMH volumes (odds ratio [aOR]1.05 per 1-cm3 increase for unfavorable outcome, 95% confidence interval [CI] 1.01-1.06, p = 0.014). Fifty-seven percent of patients in the first quartile of WMH volume vs 28% in the fourth quartile demonstrated favorable outcome (p < 0.001). WMH severity was not associated with sICH rate (aOR 0.99, 95% CI 0.93-1.04, p = 0.66), nor did it influence recanalization success (aOR 0.99, 95% CI 0.96-1.02, p = 0.84).

CONCLUSION

Our study provides evidence that in patients with AIS due to LVO and high burden of WMH as assessed by pretreatment MRI, the safety and efficacy profiles of MT are similar to those in patients with lower WMH burden and confirms that they are at higher risk of unfavorable outcome. Because more than a quarter of patients in the highest WMH quartile experienced favorable 3 months outcome, WMH burden may not be a good argument to deny MT.

CLINICALTRIALSGOV IDENTIFIER

NCT01062698.

Endovascular treatment of acute ischaemic stroke in octogenarians and nonagenarians compared with younger patients

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.

Functional Outcomes at 90 Days in Octogenarians Undergoing Thrombectomy for Acute Ischemic Stroke: A Prospective Cohort Study and Meta-Analysis

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.

Outcomes of endovascular thrombectomy in the elderly: a ‘real-world’ multicenter study

Background

The efficacy of endovascular thrombectomy (ET) for acute ischemic stroke (AIS) in octogenarians is still controversial.

Objective

To evaluate, using a large multicenter cohort of patients, outcomes after ET in octogenarians compared with younger patients.

Methods

Data from prospectively maintained databases of patients undergoing ET for AIS at seven US-based comprehensive stroke centers between January 2013 and January 2018 were reviewed. Demographic, procedural, and outcome variables were collected. Outcomes included 90-day modified Rankin Scale (mRS) score, postprocedural National Institutes of Health Stroke Scale score, postprocedural hemorrhage, and mortality. Univariate and multivariate analyses were performed to assess the independent effect of age ≥80 on outcome measures. Subgroup analyses were also performed based on location of stroke, success of recanalization, or ET technique used.

Results

Rates of functional independence (mRS score 0–2) after ET in elderly patients were significantly lower than for younger counterparts. Age ≥80 was independently associated with increased mortality and poor outcome. Age ≥80 showed an independent negative prognostic effect on outcome even when patients were divided according to thrombectomy technique, location of stroke, or success of recanalization. Age ≥80 independently predicted higher rate of postprocedural hemorrhage, but not success of recanalization. Baseline deficit and number of reperfusion attempts, but not Thrombolysis in Cerebral Infarction score were associated with lower odds of good outcome.

Conclusion

The large effect size of ET on AIS outcomes is significantly diminished in the elderly population when using comparable selection criteria to those used in younger counterparts. This raises concerns about the risk–benefit ratio and the cost-effectiveness of performing this procedure in the elderly before optimizing patient selection.

Post-stroke administration of omega-3 polyunsaturated fatty acids promotes neurovascular restoration after ischemic stroke in mice: Efficacy declines with aging

Post-stroke treatment with omega-3 polyunsaturated fatty acids (n-3 PUFAs) may be a promising therapy in young animals but this has not been tested in aged subjects, a population at most risk of ischemic stroke. Herein we examined the therapeutic efficacy of n-3 PUFAs after distal middle cerebral artery occlusion (dMCAO) in young (10-12 weeks old) and aged (18 months old) mice. Post-ischemic mice were randomly assigned to 4 groups that received: 1) regular food with low content of n-3 PUFAs, 2) intraperitoneal docosahexaenoic acid (DHA, a major component of n-3 PUFAs) injections, 3) Fish oil (FO, containing high concentration of n-3 PUFAs) dietary supplement, or 4) combined treatment with DHA and FO dietary supplement. Long-term neurorestoration induced by n-3 PUFA post-stroke administration and its underlying mechanism(s) were analyzed up to 35 days after dMCAO. Aged mice showed more severe neurological deficits than young mice after dMCAO with histological lesions extended to the striatum. Notably, post-stroke treatment with combined DHA injections and FO dietary supplementation was more effective in reducing brain injury and improving sensorimotor function in aged mice than either treatment alone, albeit to a lesser extent than in the young mice. Unlike the improvement in spatial cognitive function observed in young mice, the combined treatment regimen failed to improve cognitive function in aged mice. The reduction in stroke-induced neurological deficits with n-3 PUFA post-treatment was associated with enhanced angiogenesis, oligodendrogenesis, neuron survival and white matter restoration. Together, these results indicate that the neurological benefits of n-3 PUFA administration after stroke extend to older animals and are associated with improved neuronal survival and brain remodeling, therefore suggesting that post-stroke administration of n-3 PUFAs is a viable clinically relevant treatment option against stroke.

Thrombectomy for acute ischemic stroke in the elderly: a ‘real world’ experience

Introduction

Completed randomized trials on endovascular thrombectomy (ET) did not independently assess the efficacy of ET in the elderly (≥80 years old) who were often excluded or under-represented in trials. There were also inconsistent criteria for patient selection in this population across the different trials. This work evaluates outcomes after ET for acute ischemic stroke (AIS) in the elderly at a high volume stroke center.

Methods

We reviewed all cases of AIS that underwent a direct aspiration first pass technique (ADAPT) thrombectomy for large vessel occlusions between March 2013 and October 2017 while comparing outcomes in the elderly with younger counterparts. We also reviewed AIS cases in elderly patients undergoing medical management who were matched to the ET counterparts by demographics, comorbidities, baseline deficits, and stroke severity.

Results

Of 560 patients undergoing ET for AIS, 108 patients were in the elderly group (≥80 years of age), and had a significantly lower likelihood of functional independence (defined as a modified Rankin Scale score of 0–2) at 90 days compared with younger patients (20.5% vs 44.4%, P<0.001), and higher mortality rates (34.3% vs 20%, P<0.001). When compared with patients undergoing medical management, elderly patients did not have a significant improvement in rates of good outcomes (20.5% vs 19.5%, P>0.05), and had significantly higher rates of hemorrhage (40.7% vs 9.3%, P<0.001). We also identified baseline stroke severity and the incidence of hemorrhage as two independent predictors of outcome in the elderly patients.

Conclusions

ET in the elderly did not show a similar benefit to younger patients when compared with medical management. These findings emphasize the need for more optimal selection criteria for the elderly population to improve the risk to benefit ratio of ET.

Mechanical Thrombectomy in Elderly Stroke Patients with Mild-to-Moderate Baseline Disability

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.

Predictors of favorable outcome after mechanical thrombectomy for anterior circulation acute ischemic stroke in octogenarians

INTRODUCTION

Mechanical thrombectomy for anterior circulation large vessel occlusion (LVO) improves functional outcome at three months. This therapeutic approach is the new gold standard, with a benefit being also observed in elderly patients. However, data are limited in this heterogeneous and fragile population. The objectives of this study were, first, to describe outcome after mechanical thrombectomy in a representative group of patients over 80. Second, to evaluate factors associated with a favorable functional outcome after thrombectomy for anterior circulation LVO in elderly patients (aged≥80 years).

METHODS

A total of 169 patients with anterior circulation LVO referred for an endovascular treatment were included. Primary outcome evaluated functional outcome at three months. Multivariable analysis was performed to identify prognostic factors in elderly patients with pre-stroke mRS≤3.

RESULTS

Overall, 25.34% of patients (43/169) were functionally independent at three months (mRS≤2) and 16.57% (28/169) had a moderate functional disability (mRS=3). Mortality rate was 33.14% (56/169). At 24h, 7.1% of patients (12/169) had symptomatic hemorrhage. Male gender (P=0.033), low initial NIHSS (P=0.037), higher DWI-ASPECTS (P=0.022) and use of intravenous thrombolysis (IVT) (P=0.0193) were associated with a better functional outcome.

CONCLUSIONS

There is no reason to withhold mechanical thrombectomy on the basis of age alone. Small infarct core, low NIHSS, male gender and use of IVT are associated with a better functional outcome.

Significances and Outcomes of Mechanical Thrombectomy for Acute Infarction in Very Elderly Patients: A Single Center Experience

Objective

Mechanical thrombectomy is increasingly being used for the treatment of acute ischemic stroke. The population over 80 years of age is growing, and many of these patients have acute infarction; however, these patients are often excluded from clinical trials, so the aim of this study was to compare the functional outcomes and complication rates in very elderly patients (age ≥80 years) and aged patients (60-79 years) treated with mechanical thrombectomy.

Methods

Between January 2010 and June 2015, we retrospectively reviewed 113 senior patients (over 60 years old) treated at our institution for acute ischemic stroke with mechanical thrombectomy. They were divided into a very elderly (≥80 years) and aged (60-79 years) group, with comparisons in recanalization rates, complications, death and disability on discharge be reported.

Results

The mean age was 70.3 years in the aged group and 83.4 years in the very elderly group. Elderly patients had higher rates of mechanical thrombectomy failure than the younger group (40% vs. 14%; odds ratio [OR] 4.1; 95% confidence interval [CI] 1.4-11.9; p=0.012). Results from thrombolysis in cerebral ischemia and modified Rankin scale at discharge were worse in the older group (p=0.005 and 0.023 respectively). There were no differences in mortality rate or other complications, but infarction progression rates were significantly higher in the very elderly group. (15% vs. 2.2%; OR 8.0; 95% CI 1.2-51.7; p=0.038). The majority (92.3%) of the patients who failed in aged group were not successful after several trials. However, in half (4 of 8) of the very elderly group, the occlusion site could not be accessed.

Conclusion

Patients older than 80 years of age undergoing mechanical thrombectomy for acute infarction were more difficult to recanalize due to inaccessible occlusion sites and had a higher rate of infarction progression, However, mortality and other complications were similar to those in younger patients.

Endovascular Stroke Treatment of Patients Over 80 Years Old: Cumulative Evidence from the "Real World"

BACKGROUND

Evidence on stent retriever-based thrombectomy (SRT) efficacy in elderly patients is controversial. This study aimed to analyze safety and efficacy outcomes in octogenarians submitted to SRT.

METHODS

Analysis was based on a prospective observational registry of patients with stroke because of anterior circulation large-vessel occlusion treated with SRT at our center between January 2015 and September 2016. Patients were dichotomized into 2 age groups: ≤80 and >80 years old. Outcomes at 90 days were assessed: "excellent outcome" (a modified Rankin scale [mRs] score of 0-1) and "good outcome" (a mRs score of 0-2).

RESULTS

A total of 141 patients were included: 35 (24.8%) >80 years old and 106 (71.2%) ≤80 years old; 43.4% of patients in the younger group and 25.7% of patients in the older group achieved an "excellent outcome." A "good outcome" was achieved in 65.1% of patients in the younger group, and 60% of patients in the older group; crude odds ratio (OR) for "excellent outcome" was 0.452 (P = .067). Crude OR for "good outcome" was 0.804 (P = .587). After adjusting for gender, National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program Early CT Score, and thrombolysis, the OR was 0.450 (P = .100) and 1.217 (P =  .686) for "excellent" and "good" outcomes, respectively.

CONCLUSIONS

In this cohort, 60% of elderly patients regained functional independence at 3 months after SRT. Although age may be a prognostic factor, patients should not be excluded from SRT based on age criteria.

LAA occluder device for stroke prevention: Data on WATCHMAN and other LAA occluders

NOAC therapy has become the standard for stroke prevention in patients with atrial fibrillation. Yet some patients suffer extracranial bleeding events or have other reasons to seek non-pharmacologic stroke protection. LAA occlusion with the WATCHMAN device has been proven safe and effective for such patients and is now recommended in current guidelines for this patient group; other devices also seek approval.

Impact of Baseline Ischemia on Outcome in Older Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

The outcome for older stroke patients who undergo endovascular revascularization remains unsatisfactory. We aimed to determine the effect of the extent of baseline ischemia on outcome according to age, testing the hypothesis that the restorative capacity for recovery is only marginal in older patients.

METHODS

Two hundred and thirteen patients who underwent endovascular revascularization due to occlusion in the M1 segment of the middle cerebral artery (with or without internal carotid artery occlusions) were selected for analysis. Patients were categorized into three age groups: group A (<66 years), group B (66-75 years), and group C (>75 years). Using pretreatment diffusion-weighted imaging (DWI), the Alberta Stroke Program Early CT Score (ASPECTS) and lesion volume were independently measured and analyzed in relation to a favorable outcome.

RESULTS

A favorable outcome was achieved in 111 of 213 patients overall: in 60 of the 94 (63.8%) patients in group A, in 36 of the 70 (51.4%) patients in group B, and in 15 of the 49 (30.6%) patients in group C (p=0.001). In older stroke patients (group C), a DWI ASPECTS ≥9 and lesion volume ≤5 mL were found to predict a favorable outcome, which was more restrictive than the cutoffs for their younger counterparts (groups A and B; DWI ASPECTS ≥8 and lesion volume ≤20 mL).

CONCLUSIONS

The age-adjusted pretreatment DWI lesion volume and ASPECTS may represent useful surrogate markers for functional outcome according to age. The use of more-restrictive inclusion criteria for older stroke patients could be warranted, although larger studies are necessary to confirm these findings.

Endovascular Stroke Treatment of Nonagenarians

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.

Functional disability and associated factors in elderly stroke survivors in Vitória, Brazil

Abstract Objective: The aim of the present study was to estimate the prevalence of disability and associated factors in elderly stroke survivors. Methods: A cross-sectional study of 230 elderly persons was conducted in the 22 territories of the Estratégia de Saúde da Família (the Family Health Strategy) of Vitória, in the state of Espirito Santo. Patients were assessed using the modified Rankin Scale. Poisson regression with robust variance in crude and adjusted analyses was employed. Results: The majority of subjects were men (52.1%) aged between 60 to 98 years, with a mean age of 75.8 (sd±9.2). The prevalence of disability was 66%. Age ≥80 years, self-perceived limitations in bodily function, considering the physical structure of the street to be a barrier to leaving home and believing street lighting to be insufficient were positively associated with functional disability. Possessing 12 or more years of schooling was inversely associated with the outcome. Conclusions: The high prevalence of disability and associated factors in elderly stroke survivors reinforce the need for a health system that operates continuously and proactively, promoting active aging.

Endovascular mechanical recanalization of acute ischaemic stroke in octogenarians

BACKGROUND

Multiple studies have shown a clinical benefit of thrombectomy in acute ischaemic stroke, but most of them excluded octogenarians. The purpose of this study was to compare the outcomes between octogenarians and younger patients after thrombectomy.

MATERIALS AND METHODS

One hundred and sixty-six patients with large cerebral artery occlusion and consecutive thrombectomy were evaluated and divided into two patient age groups: younger than 80 years and older than 80 years. We compared recanalization rates, complications experienced, disability, death after discharge and at a 90-day follow-up between these age groups.

RESULTS

Sixty-eight percent of octogenarians and 72 % of younger patients were registered with successful recanalization (p = 1.0). There was no significant difference in symptomatic intracerebral haemorrhage between the groups (p = 0.32). However, octogenarians had a significantly lower rate of good clinical outcome (24 % vs. 48 %; p = 0.008) and a higher mortality rate (36 % vs. 12 %; p = 0.0013).

CONCLUSION

Octogenarians have a lower chance of good clinical outcome and a higher mortality rate despite successful recanalization. Nevertheless, 24 % of octogenarians were documented with mRS ≤2. As this age group of octogenarians will grow prospectively, careful patient selection should be mandatory when considering octogenarians for thrombectomy.

KEY POINTS

• Careful patient selection for thrombectomy should be mandatory in octogenarians. • Octogenarians have a higher mortality rate despite successful recanalization. • Nearly one-third of octogenarians were documented with a good clinical outcome.

[Angiographically documented hemorrhagic transformation of embolic stroke: A case report]

A 81-year-old man with rheumatoid vasculitis presented with total aphasia followed by right hemiplegia. The NIHSS score was 24. Diffusion weighted magnetic resonance imaging (DWI) demonstrated an acute infarct in the left middle cerebral artery (MCA) territory, and magnetic resonance angiogram (MRA) revealed left MCA M1 occlusion. We administrated recombinant tissue plasminogen activator (rt-PA) at 132 min after symptom onset, but symptom was not improved. Emergency neuroendovascular recanalization was conducted with Penumbra(®) system. After MCA was recanalized partially, extravasations appeared on left lenticulostriate arteries territory at 376 min from symptom onset. Multiple extravasations spread over perforating branches, and ventricular rupture recognized angiographically. After the procedure, head CT demonstrated hematoma on left basal ganglia territory with intraventricular bleeding. Rheumatoid vasculitis might affect hemorrhagic infarction in emergency neuroendovascular recanalization procedure, and careful choice of treatment would be required.

Influence of age on clinical and revascularization outcomes in the North American Solitaire Stent-Retriever Acute Stroke Registry

BACKGROUND AND PURPOSE

The Solitaire With the Intention for Thrombectomy (SWIFT) and thrombectomy revascularization of large vessel occlusions in acute ischemic stroke (TREVO 2) trial results demonstrated improved recanalization rates with mechanical thrombectomy; however, outcomes in the elderly population remain poorly understood. Here, we report the effect of age on clinical and angiographic outcome within the North American Solitaire-FR Stent-Retriever Acute Stroke (NASA) Registry.

METHODS

The NASA Registry recruited sites to submit data on consecutive patients treated with Solitaire-FR. Influence of age on clinical and angiographic outcomes was assessed by dichotomizing the cohort into ≤80 and >80 years of age.

RESULTS

Three hundred fifty-four patients underwent treatment in 24 centers; 276 patients were ≤80 years and 78 were >80 years of age. Mean age in the ≤80 and >80 cohorts was 62.2±13.2 and 85.2±3.8 years, respectively. Of patients >80 years, 27.3% had a 90-day modified Rankin Score ≤2 versus 45.4% ≤80 years (P=0.02). Mortality was 43.9% and 27.3% in the >80 and ≤80 years cohorts, respectively (P=0.01). There was no significant difference in time to revascularization, revascularization success, or symptomatic intracranial hemorrhage between the groups. Multivariate analysis showed age >80 years as an independent predictor of poor clinical outcome and mortality. Within the >80 cohort, National Institutes of Health Stroke Scale (NIHSS), revascularization rate, rescue therapy use, and symptomatic intracranial hemorrhage were independent predictors of mortality.

CONCLUSION

Greater than 80 years of age is predictive of poor clinical outcome and increased mortality compared with younger patients in the NASA registry. However, intravenous tissue-type plasminogen activator use, lower NIHSS, and shorter revascularization time are associated with better outcomes. Further studies are needed to understand the endovascular therapy role in this cohort compared with medical therapy.

Determinants of early outcomes in patients with acute ischemic stroke and proximal artery occlusion

BACKGROUND

Proximal artery occlusions (PAO) recanalize in only a small percentage of acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (IV tPA) alone, yet the benefits of adjunctive or substitutive intra-arterial therapy (IAT) in this patient subgroup are not well established. We evaluated early poststroke outcomes in a cohort of AIS patients with PAO categorized as "likely to benefit" (LTB) from IAT using prespecified criteria.

METHODS

Using a prespecified protocol, 193 patients from our institutional stroke database admitted between January 1, 2007, and December 31, 2011, were prospectively deemed LTB from IAT. Logistic regression was used to determine independent predictors of favorable (discharge to home or acute rehabilitation) versus unfavorable (discharge to skilled nursing facility, hospice, or in-hospital mortality) outcome.

RESULTS

Of the patients included, 29.5% received IV tPA only, 11.4% underwent IAT only, and 37.8% had both. Overall in-hospital mortality was 19.2%. In a univariate analysis, age (odds ratio [OR], .95; 95% confidence interval [CI], .93-.98), IV tPA (OR, 2.3; 95% CI, 1.2-4.3), and history of atrial fibrillation (OR, .5; 95% CI, .28-.97) were associated with outcome. Effect of IAT was not statistically significant (OR, 1.3; 95% CI, .7-2.3; P = .4). In multivariate analysis, the only independent predictor of favorable outcome was IV tPA administration (OR, 2.4; 95% CI, 1.2-5.0). The odds of favorable poststroke outcome were significantly lowered (OR, .3; 95% CI, .1-.6; P = .0006) in those receiving neither IV tPA nor IAT.

CONCLUSIONS

In AIS patients with PAO thought most likely to benefit from IAT, IV tPA independently predicted favorable outcomes. These data reinforce the recommendation to provide early IV tPA to all eligible patients.

Endovascular stroke therapy

BACKGROUND

Following the development of intravenous thrombolysis as a successful treatment for ischaemic stroke, advances in neurointerventional radiology have facilitated endovascular approaches to treatment. This article reviews the available endovascular therapeutic options and their evidence-base.

SUMMARY

Initial studies demonstrated that endovascular treatment of ischaemic stroke with intra-arterial thrombolysis and/or the use of clot-retrieval, thrombus aspiration and stent-retriever devices produced early recanalisation and reperfusion and improved neurological outcome. More recent randomised trials, however, have failed to show translation of recanalisation into successful clinical outcome with 'time to treatment' proving crucial. In this rapidly evolving field, combined therapy incorporating intravenous and intra-arterial thrombolysis in combination with endovascular clot-retrieval has been developed and further studies are expected to yield better evidence to guide the optimal treatment of acute cerebral ischaemia.

Recanalization and mortality rates of thrombectomy with stent-retrievers in octogenarian patients with acute ischemic stroke

BACKGROUND

Our objective was to evaluate the effect of treatment with stent-retrievers in octogenarians suffering an acute ischemic stroke.

METHODS

A total of 150 consecutive patients with acute stroke who were treated with stent-retrievers between April 2010 and June 2012 were retrospectively reviewed. Patients were divided into those <80 years old (n = 116) and those ≥80 (n = 34). Baseline characteristics, procedure data, and endpoints (postprocedural NIHSS, death, and mRS at 3 months) were compared.

RESULTS

High blood pressure, atrial fibrillation, and anticoagulation were more frequent in octogenarians (p = 0.01, 0.003, and 0.04 respectively). There were no differences between both groups regarding previous intravenous thrombolysis (32.4 vs. 48.3 %, p = 0.1), preprocedural NIHSS (18.1 vs. 16.8, p = 0.3), procedure time (74.5 (40-114) min vs. 63 (38-92) min, p = 0.2), revascularization time (380.5 (298-526.3) min vs. 350 (296.3-452.8), p = 0.3), TICI ≥ 2B (88.2 vs. 93.9 %, p = 0.1), and symptomatic haemorrhage (5.9 vs. 2.6 %, p = 0.3). Discharge NIHSS was higher in octogenarians (9.7 vs. 6.5, p = 0.03). Death and 3-month mRS ≥3 were more frequent in octogenarians (35.3 vs. 17.2 %, p = 0.02 and 73.5 vs. 37.1 %, p = 0.02). ICA-involvement and prolonged revascularization involved higher mortality (66.7 vs. 27.6 %, p = 0.03) and worse mRS (50 vs. 24.4 %, p = 0.06) in octogenarians.

CONCLUSIONS

In our series, treatment with stent-retrievers in octogenarians with acute ischemic stroke achieved good rates of recanalization but with a high mortality rate. ICA involvement and revascularization times beyond 6 hours associated to a worse prognosis. These data might be of value in the design of prospective studies evaluating the clinical efficacy of the endovascular treatments in octogenarians.

Age dependency of safety and outcome of endovascular therapy for acute stroke

Elderly patients generally experience less favorable outcomes and higher mortality after acute stroke than younger patients. The aim of this study was to analyze the influence of age on outcome and safety after endovascular therapy in a large cohort of patients aged between 20 and 90 years. We prospectively acquired data of 1,000 stroke patients treated with endovascular therapy at a single center. Logistic regression analysis was performed to determine predictors of outcome and linear regression analysis to evaluate the association of age and outcome after 3 months. Younger age was an independent predictor of favorable outcome (OR 0.954, p < 0.001) and survival (OR 0.947, p < 0.001) in multivariate regression analysis. There was a linear relationship between age and outcome. Ever increase in 26 years of age was associated with an increase in the modified Rankin Scale of 1 point (p < 0.001). However, increasing age was not a risk factor for symptomatic (p = 0.086) or asymptomatic (p = 0.674) intracerebral hemorrhage and did not influence recanalization success (p = 0.674). Advancing age was associated with a decline of favorable outcomes and survival after endovascular therapy. This decline was linear from age 20 to 90 years, but was not related to lower recanalization rates or higher bleeding risk in the elderly. The efficacy of endovascular stroke therapy seems to be preserved also in the elderly and other factors than efficacy of endovascular therapy such as decreased plasticity are likely to explain the worse outcome with advancing age.

Clinical Outcome after Intra-Arterial Stroke Therapy in the Very Elderly: Why is it so Heterogeneous?

Very elderly patients (i.e., ≥80 years) are disproportionally affected by acute ischemic stroke. They account for a third of hospital stroke admissions, but two-thirds of overall stroke-related morbidity and mortality. There is some evidence of clinical benefit in treating selected very elderly patients with intravenous thrombolysis (IVT). For very elderly patients ineligible or non-responsive to IVT, intra-arterial therapy (IAT) may have promise in improving clinical outcome. However, its unequivocal efficacy in the general population remains to be proven in randomized trials. Small cohort studies reveal that the rate of good clinical outcome for very elderly patients after IAT is highly variable, ranging from 0 to 28%. In addition, they experience higher rates of futile reperfusion than younger patients. Thus, it is imperative to understand the factors that impact on clinical outcome in very elderly patients after IAT. The aim of this review is to examine the factors that may be responsible for the heterogeneous clinical response of the very elderly to IAT. This will allow the reader to integrate the current available evidence to individualize intra-arterial stroke therapy in very elderly patients. Placing emphasis on pre-stroke independent living, smaller infarct core size, short procedure times, and avoiding general anesthesia where feasible, will help improve rates of good clinical outcome.

Predictors of outcome after mechanical thrombectomy for anterior circulation large vessel occlusion in patients aged ≥80 years

BACKGROUND

There is uncertainty about the role of endovascular recanalization procedures for the treatment of acute ischemic stroke in patients aged ≥80 years. Therefore, careful patient selection is mandatory. Our aim was to find valid predictors of clinical outcome after mechanical thrombectomy (mTE) based on the sparse information available in the emergency setting.

METHODS

We included consecutive patients aged ≥80 years treated by mTE for anterior circulation thromboembolic vessel occlusion in our department between January 2008 and January 2013. Successful recanalization was defined as a thrombolysis in cerebral infarction (TICI) score of 2b or 3. The rates of parenchymal hemorrhage types I (PHI) and II (PHII) according to the ECASS definition and the rate of focal and diffuse subarachnoid hemorrhage (SAH) were reported. A modified Ranking scale (mRS) score of 0-2 at 90 days was defined as a favorable outcome. We evaluated the influence of gender, smoking habits, atrial fibrillation, diabetes, hypertension, hyperlipidemia, coronary artery and peripheral artery disease, National Institutes of Health Stroke Scale (NIHSS) score, Totaled Health Risks in Vascular Events (THRIVE) score, Alberta Stroke Program Early CT Score (ASPECTS), and duration of symptoms on favorable outcome. Significant predictors were then included in a stepwise logistic regression analysis. Odds ratios (OR), 95% confidence intervals (CI), and receiver operating characteristics (ROC) curves were calculated. p < 0.05 was considered statistically significant.

RESULTS

In the defined period, we treated 109 patients aged ≥80 years with 116 occluded anterior circulation target vessels. Successful recanalization was achieved in 87.9% of the targets. The rates of PHI, PHII, and focal and diffuse SAH were 6.4, 5.5, 12.8, and 7.3%, with an overlap between PH and SAH. The combined rate of PHII and/or diffuse SAH was 9.2%. Despite good recanalization rates and reasonable rates of hemorrhage, only 19 patients (17.4%) were functionally independent at 90 days. An additional 12 patients (11.0%) suffered from moderate disability (mRS score 3), 26 (23.9%) were severely disabled (mRS score 4-5) and 52 (47.7%) were deceased. NIHSS, ASPECTS, and THRIVE scores significantly predicted a favorable outcome. Stepwise logistic regression identified NIHSS (OR 0.89; 95% CI 0.82-0.96; p = 0.009) and ASPECTS (OR 2.27; 95% CI 1.28-4.02; p = 0.005) as independent predictors. The ROC area was 0.81.

CONCLUSION

ASPECTS and NIHSS were independent predictors of a favorable outcome in patients aged ≥80 years after mTE for anterior circulation large vessel occlusion and may support decision making with regard to the treatment modality. Since the chances of gaining functional independence are limited, careful consideration of each individual case is mandatory. Further studies comparing endovascular and standard treatment in octogenarians are warranted.

Elderly patients and intra-arterial stroke therapy

Ischemic stroke disproportionately affects the elderly, particularly those over the age of 80 years. Rates of stroke are expected to increase over the next several decades due to increasing numbers of elderly individuals, making understanding stroke treatment in this population an imperative. The only proven acute stroke therapy is early reperfusion, accomplished through intravenous or intra-arterial means. Intra-arterial stroke therapy (IAT) offers higher recanalization rates than intravenous tissue plasminogen activator, but has yet to show clear superiority over intravenous tissue plasminogen activator alone. Existing data suggest that elderly stroke patients suffer worse outcomes following IAT, despite similar rates of recanalization and symptomatic intracranial hemorrhage. This article reviews the application of IAT in the elderly population and summarizes the available studies that investigate the response of elderly patients to IAT.

Effectiveness of alteplase in the very elderly after acute ischemic stroke

Alteplase has traditionally been the only pharmacologic agent available for treating acute ischemic stroke worldwide, and is considered an effective and safe therapeutic drug for acute cerebral ischemia. However, the drug is usually indicated for use in patients aged <81 years due to insufficient literature regarding the drug’s safety in older individuals. Nevertheless, the elderly can benefit from alteplase after they experience an acute ischemic stroke. Age differences have been observed in the clinical presentation of acute ischemic stroke; however, the safety and efficacy of alteplase for patients with acute ischemic stroke do not depend on age or sex. Evidence of an increasing rate of intracerebral hemorrhage among the elderly with acute ischemic stroke, following alteplase treatment, has not been reported. Severe intracranial hemorrhage is a known side effect of alteplase but is not associated with age in patients with acute ischemic stroke. Alteplase can be used safely and effectively to treat elderly patients who suffer an acute ischemic stroke, including those over the age of 80 years.

Age-adjusted infarct volume threshold for good outcome after endovascular treatment

BACKGROUND AND PURPOSE

Infarct volume and age are strong predictors of outcome in patients with stroke. We aimed to determine the impact of infarct volume on outcome according to age.

METHODS

Consecutive patients with acute stroke with documented internal carotid artery/middle cerebral artery occlusion who underwent endovascular procedures were studied. Patients were categorized in three age groups: <70 years (G1), 70-79 years (G2), ≥80 years (G3). The Alberta Stroke Program Early CT score (ASPECTS) was graded on initial CT. Time of successful recanalization (Thrombolysis In Cerebral Infarct (TICI) ≥2b )and good outcome at 3 months (modified Rankin Scale score ≤2) were recorded. Infarct volume was measured on the 24 h control CT.

RESULTS

A total of 214 patients were studied (G1: 68; G2: 74; G3: 72). For all patients the mean infarct volume was 94.7±127 mL; 35.6% had a good outcome. We observed larger infarct volumes in patients with a bad outcome in each age group (G1: 22 vs 182 mL, p<0.01/G2: 22 vs 164 mL, p<0.01/G3: 7.6 vs 132 mL, p<0.01). However, the target cut-off infarct volume that better predicted a good outcome decreased as age increased: G1: 49 mL (sensitivity 80%, specificity 92.6%); G2: 32.5 mL (sensitivity 80%, specificity 81%); G3: 15.2 mL (sensitivity 81.3%, specificity 86.7%). Overall, after adjusting for age, occlusion location, baseline NIH Stroke Scale score and infarct volume, the only predictor of a good outcome was achieving a final infarct volume less than the age-adjusted target (OR 5.5, 95% CI 1.6 to 18.8; p<0.01). The probability of achieving an infarct volume less than the age-adjusted target decreased according to baseline ASPECTS, time and degree of recanalization.

CONCLUSIONS

Age-adjusted infarct size might represent a powerful surrogate marker of stroke outcome and further refine the predictive accuracy of infarct volume on prognosis in patients with stroke undergoing endovascular treatment. This information may be used in the design of new trials to individualize selection criteria for different age groups.