Mechanical Thrombectomy of Large Artery Occlusion Is Beneficial in Octogenarians

Acute Reperfusion Therapies and Prognosis in Nonagenarian Stroke Patients

INTRODUCTION

Thrombolysis and endovascular thrombectomy (EVT) are standard treatments after stroke. We previously reported that these therapies benefit stroke patients over 80 years old. Now, we aimed to study reperfusion therapies specifically in nonagenarians, hypothesizing a poorer prognosis in this group.

METHODS

Nonagenarian stroke patients were identified from our prospective monocentric cohort, which included consecutive patients ≥80 years old treated with thrombolysis and/or EVT from 2015 to 2019. Baseline characteristics, treatments, and outcomes, as well as complications and mortality were analyzed.

RESULTS

Ninety-six nonagenarians were treated with thrombolysis (69.8%) and/or EVT (81.1%). A total of 51% had a pre-stroke modified Rankin score (mRS) ≤2. Cardioembolism was the most common etiology (67.7%). Age was associated with a higher mRS after stroke with a turning point at 90 years old: (90-99 years old: odds ratio [OR] = 0.33, 95% confidence interval [95% CI]: 0.13-0.83, p = 0.02) versus (85-89 years old: OR = 0.72, 95% CI: 0.34-1.50, p = 0.38), with 80- to 84-year-old patients as the reference. In nonagenarians, previous coronary artery disease (OR = 8.02, 95% CI: 1.66-38.68, p = 0.01), initial National Institute of Health Stroke Score (NIHSS) (OR = 1.11, 95% CI: 1.03-1.19, p = 0.01), pre stroke independence (OR = 0.25, 95% CI: 0.08-0.71, p = 0.01), and "drip-and-ship" status (OR = 3.35, 95% CI: 1.22-9.16, p = 0.02) were associated with 3-month mortality. Nonagenarians had more baseline comorbidities (p = 0.003) and lower levels of pre-stroke independence (p = 0.002) than octogenarians (n = 261). Despite no difference in the use of acute treatments, timelines, and rates of successful reperfusion, a good functional status at 3 months was less common in nonagenarians than octogenarians (14.3% vs. 34.0%, p < 0.001) with a higher mortality (60.2% vs. 16.4%, p < 0.001). A total of 9.5% of nonagenarians experienced a symptomatic intracranial hemorrhage.

CONCLUSIONS

Age is a crucial factor affecting prognosis after stroke with a turning point at 90 years old. However, age alone should not be a limiting factor for treatment decision. Despite higher mortality and poorer functional prognosis overall, some nonagenarians may benefit from reperfusion therapies.

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.

Anterior circulation large vessel occlusion outcomes in patients transferred from a peripheral primary stroke centre

OBJECTIVES

To identify predictors of functional outcome in patients with an anterior circulation large-vessel occlusion (LVO) in a setting of long transfer distances.

METHODS

Outcomes of LVO patients transferred for an endovascular thrombectomy (EVT) from North Karelia Central Hospital to Kuopio University Hospital between January 2018 and October 2019 were analysed using retrospective patient chart review.

RESULTS

Three months after the stroke, modified Rankin Scale (mRS) was 0-2 in 20 of the 41 transferred patients. They were younger (66.7 vs. 74.2 years, p = 0.032) and had less severe stroke symptoms (National Institutes of Health Stroke Scale, NIHSS, 11.5 vs. 16.5, p = 0.029) than those with mRS 3-6. They also had the occlusion less often in M1 and more often in M2. EVT was performed in 32 patients (no differences between those treated with EVT and those not treated with EVT). Their median age was 73.0 years (interquartile range 65.5, 79.8; range 32-86; 25% over 80), mean NIHSS score 14.0 (standard deviation 5.9) and mRS eventually 0-2 in 44%. Only NIHSS was associated with mRS (OR = 1.16; p = 0.016) in the EVT-treated patients. mRS was 0 in 38% of all EVT-treated octogenarians but 4-6 in 83% of those with an internal carotid artery and/or M1 occlusion.

DISCUSSION

Outcomes depended on stroke severity, age and vessel of occlusion. Prognosis was worse if the occlusion included M1, especially in octogenarians. Mothership and Drip-n-ship strategies should be compared in patients from remote locations stratified by stroke severity and patient age.

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.

Mechanical thrombectomy in stroke in nonagenarians: useful or futile?

BACKGROUND

Mechanical thrombectomy is the standard treatment in acute ischemic stroke due to large vessel occlusion, but there is limited evidence about its efficacy in very old patients. We sought to analyse safety and effectiveness of mechanical thrombectomy in nonagenarian versus octagenarian patients.

METHODS

We included consecutive patients with acute ischemic stroke due to large vessel occlusion subjected to mechanical thrombectomy, during 29 months in a tertiary center. Patients were divided into two sub-groups, according to age: 80-89 and >90 years old. Recanalization, complications, functional outcome and mortality at discharge and at 3 months were compared. Multivariable analysis was performed to identify independent predictors of functional outcome at 3 months of follow-up, assessed by the modified Rankin Scale.

RESULTS

A total of 128 octogenarians (88.9%) and 16 nonagenarians (11.1%) met the inclusion criteria. Successful revascularization was achieved in 87.5% of octagenarians and in 81.3% of nonagenarians (p = 0.486). Symptomatic hemorrhage occurred in 3.1% and 6.3% of younger and older patients, respectively (p = 0.520). Cerebral edema occured in 35.2% of octagenarians versus 25.0% of nonagenarians (p = 0.419). Functional independence (mRS ≤ 2) at 3 months was achieved in 28 (22.6%) and 5 (31.3%) of octagenarians and nonagenarians, respectively (p = 0.445). Mortality at 3 months was not significantly higher in nonagenarians (37.5%) versus octagenarians (33.9%, p = 0.773).

CONCLUSIONS

No significant diferences were found in functional outcome, mortality, recanalization and complication rates between octagenarians and nonagenarians submitted to mechanical thrombectomy, underlining that patients should not be excluded from mechanical thrombectomy based on age alone.

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.

Large Vessel Occlusion in Acute Ischemic Stroke Patients: A Dual-Center Estimate Based on a Broad Definition of Occlusion Site

BACKGROUND

Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery.

METHODS

We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported.

RESULTS

Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02).

CONCLUSIONS

The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.

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.