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Mehta A, Fifi JT, Shoirah H, Singh IP, Shigematsu T, Kellner CP, De Leacy R, Mocco J, Majidi S. National Trends in Utilization and Outcome of Endovascular Thrombectomy for Acute Ischemic Stroke in Elderly. J Stroke Cerebrovasc Dis 2020; 30:105505. [PMID: 33271488 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105505] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/07/2020] [Accepted: 11/22/2020] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Amol Mehta
- Department of Neurology, Columbia University, New York, NY, USA.
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Hazem Shoirah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - I Paul Singh
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tomoyoshi Shigematsu
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Shahram Majidi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Baek JH, Kim BM, Heo JH, Nam HS, Kim YD, Park H, Bang OY, Yoo J, Kim DJ, Jeon P, Baik SK, Suh SH, Lee KY, Kwak HS, Roh HG, Lee YJ, Kim SH, Ryu CW, Ihn YK, Kim B, Jeon HJ, Kim JW, Byun JS, Suh S, Park JJ, Lee WJ, Roh J, Shin BS. Number of Stent Retriever Passes Associated With Futile Recanalization in Acute Stroke. Stroke 2019; 49:2088-2095. [PMID: 30354993 DOI: 10.1161/strokeaha.118.021320] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background and Purpose- Stent retriever (SR) thrombectomy has become the mainstay of treatment of acute intracranial large artery occlusion. However, it is still not much known about the optimal limit of SR attempts for favorable outcome. We evaluated whether a specific number of SR passes for futile recanalization can be determined. Methods- Patients who were treated with a SR as the first endovascular modality for their intracranial large artery occlusion in anterior circulation were retrospectively reviewed. The recanalization rate for each SR pass was calculated. The association between the number of SR passes and a patient's functional outcome was analyzed. Results- A total of 467 patients were included. Successful recanalization by SR alone was achieved in 82.2% of patients. Recanalization rates got sequentially lower as the number of passes increased, and the recanalization rate achievable by ≥5 passes of the SR was 5.5%. In a multivariable analysis, functional outcomes were more favorable in patients with 1 to 4 passes of the SR than in patients without recanalization (odds ratio [OR] was 8.06 for 1 pass; OR 7.78 for 2 passes; OR 6.10 for 3 passes; OR 6.57 for 4 passes; all P<0.001). However, the functional outcomes of patients with ≥5 passes were not significantly more favorable than found among patients without recanalization (OR 1.70 with 95% CI, 0.42-6.90 for 5 passes, P=0.455; OR 0.33 with 0.02-5.70, P=0.445 for ≥6 passes). Conclusions- The likelihood of successful recanalization got sequentially lower as the number of SR passes increased. Five or more passes of the SR became futile in terms of the recanalization rate and functional outcomes.
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Affiliation(s)
- Jang-Hyun Baek
- From the Department of Neurology, National Medical Center, Seoul, Korea (J.-H.B.)
- Department of Neurology, Severance Hospital Stroke Center (J.-H.B., J.H.H., H.S.N., Y.D.K., H.P.)
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital Stroke Center (B.M.K., D.J.K.)
| | - Ji Hoe Heo
- Department of Neurology, Severance Hospital Stroke Center (J.-H.B., J.H.H., H.S.N., Y.D.K., H.P.)
| | - Hyo Suk Nam
- Department of Neurology, Severance Hospital Stroke Center (J.-H.B., J.H.H., H.S.N., Y.D.K., H.P.)
| | - Young Dae Kim
- Department of Neurology, Severance Hospital Stroke Center (J.-H.B., J.H.H., H.S.N., Y.D.K., H.P.)
| | - Hyungjong Park
- Department of Neurology, Severance Hospital Stroke Center (J.-H.B., J.H.H., H.S.N., Y.D.K., H.P.)
| | - Oh Young Bang
- Yonsei University College of Medicine, Seoul, Korea; Departments of Neurology (O.Y.B.)
| | - Joonsang Yoo
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea (J.Y.)
| | - Dong Joon Kim
- Department of Radiology, Severance Hospital Stroke Center (B.M.K., D.J.K.)
| | | | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Korea (S.K.B., J.R.)
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital (S.H.S.)
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital (K.-Y.L.)
| | | | - Hong Gee Roh
- Chonbuk National University Medical School and Hospital, Jeonju, Korea; Departments of Radiology (H.G.R.)
| | - Young-Jun Lee
- Konkuk University Hospital, Seoul, Korea; Department of Radiology, Hanyang University Hospital, Seoul, Korea (Y.-J.L.)
| | - Sang Heum Kim
- Department of Radiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea (S.H.K.)
| | - Chang Woo Ryu
- Department of Radiology, Kyung Hee University Gangdong Hospital, Seoul, Korea (C.W.R.)
| | - Yon-Kwon Ihn
- Department of Radiology, St. Vincent's Hospital, Catholic University School of Medicine, Suwon, Korea (Y.K.I.)
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul (B.K.)
| | - Hong-Jun Jeon
- Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea (H.J.-J.)
| | - Jin Woo Kim
- Department of Radiology, Inje University Ilsan Paik Hospital, Korea (J.W.K.)
| | - Jun Soo Byun
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (J.S.B., W.J.L.)
| | - Sangil Suh
- Department of Radiology, Korea University Guro Hospital, Seoul (S.S.)
| | | | - Woong Jae Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (J.S.B., W.J.L.)
| | - Jieun Roh
- Department of Radiology, Pusan National University Yangsan Hospital, Korea (S.K.B., J.R.)
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Jayaraman MV, McTaggart RA. Endovascular Treatment of Anterior Circulation Large Vessel Occlusion in the Elderly. Front Neurol 2018; 8:713. [PMID: 29403421 PMCID: PMC5780400 DOI: 10.3389/fneur.2017.00713] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 12/11/2017] [Indexed: 11/13/2022] Open
Abstract
Endovascular treatment of anterior circulation large vessel occlusion in the elderly population presents special challenges and opportunities. In this review, we discuss the published literature regarding thrombectomy in elderly patients and also discuss specific issues related to treatment in this patient population. In summary, while the overall outcomes following thrombectomy in elderly patients are worse than following thrombectomy in younger patients, there appears to be a similar benefit as in young patients. While there are challenges with successfully delivering thrombectomy in older patients, age alone should not be an independent exclusion from thrombectomy.
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Affiliation(s)
- Mahesh V Jayaraman
- Department of Diagnostic Imaging, Warren Alpert School of Medicine at Brown University, Providence, RI, United States.,Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, RI, United States.,Department of Neurosurgery, Warren Alpert School of Medicine at Brown University, Providence, RI, United States.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI, United States
| | - Ryan A McTaggart
- Department of Diagnostic Imaging, Warren Alpert School of Medicine at Brown University, Providence, RI, United States.,Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, RI, United States.,Department of Neurosurgery, Warren Alpert School of Medicine at Brown University, Providence, RI, United States.,The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI, United States
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