Acute Stroke Management in the Elderly

Abstract

Background and Purpose: Though the proportion of elderly stroke patients is increasing, patients >80 years are often excluded from clinical stroke trials. We reviewed the management of older patients presenting with acute ischemic stroke (AIS) and assessed the safety and efficacy of recombinant tissue plasminogen activator (rtPA) administration in a community-based setting. Methods: A retrospective review of patients >80 years (n = 341) admitted to a community stroke center with AIS were compared to their younger counterparts (n = 690) using the stroke center database from April 2003 to December 2005. Parameters that were measured included admission and discharge NIH Stroke Scale (NIHSS), rate of thrombolytic treatment, the frequency and etiology of thrombolytic exclusion criteria and complications from rtPA for the different aged populations. Additional data were collected for Barthel Index at 12 months. Results: A total of 166 patients underwent thrombolysis. Older patients were not delayed in reaching the hospital within 3 h of stroke onset (182/690, 26%, in the <80 cohort vs. 98/341, 29%, in the ≧80 cohort). Although the overall rates of tPA use were similar in both the young and aged cohort, older patients were less likely to be treated with rtPA because of reasons not listed as exclusion criteria (17% in the <80 cohort vs. 32% in the ≧80 cohort).The older group did not have an excess risk of intracranial hemorrhage following rtPA infusion despite equivalent NIHSS on admission (13.5 in the <80 cohort vs. 12.4 in the ≧80 cohort). Both groups showed improvement in NIHSS following thrombolytic treatment with a drop of 7.7 points in the younger age group and 5.6 points in the older group. Elderly patients treated with rtPA had a comparable 12-month modified Barthel Index score to younger cohorts. Conclusions: Early treatment with rtPA in patients >80 years appears to be both safe and efficacious. Treated patients showed improvements both acutely (a decrease in NIHSS at 72 h) and chronically, as shown by a sustained improvement in the Barthel Index. A large number of elderly patients were excluded from rtPA treatment despite arriving within the time frame of treatment for reasons not considered as traditional exclusion criteria. Older patients with AIS can be treated safely with thrombolytic therapy in a community setting. This therapy should not be withheld on the basis of age.

Thrombolysis in Patients Aged over 80 Years Is Equally Effective and Safe

“…Many other studies had previously reported similar rates of symptomatic and asymptomatic intracranial hemorrhages between younger and older patients. 7,9,11,[14][15][16]19,20,23,24 In contrast to our study, most previous studies revealed an increased 30-day mortality. 7,[9][10][11][13][14][15][16]24 So, according to our results, older patients seem to also be likely to benefit in the short and long term from IVrtPA and do not seem to be in increased risk of mortality or hemorrhagic transformation.…”

“…7,12,15,16 However, a recent randomized controlled trial including 1617 patients over 80 years suggested that benefit does not seem to be diminished in the elderly. 26 Also, in a study by Zeevi et al, 19 older patients treated with IV-rtPA presented with a 12-month modified Barthel Index score comparable to that of younger patients. Moreover, several studies revealed a similar rate of early neurological improvement in younger and older patients, 7,9 and higher rates of early neurological improvement 21 and improved functional outcome among elderly patients who underwent thrombolysis versus elderly patients who did not undergo thrombolysis.…”

“…Most studies seem to show worse outcome and increased mortality in patients aged over 80 years old with acute ischemic stroke treated with IV-rtPA when compared with younger counterparts. [7][8][9][10][11][12][13][14][15][16][17] Nevertheless, patients from this age group still seem to benefit from this treatment and do not seem to have an increased risk of symptomatic intracranial hemorrhage after IV-rtPA, as demonstrated in several observational studies [7][8][9][11][12][13][14]16,[18][19][20][21][22][23][24][25] and also in a randomized controlled trial. 26 Thus, there is increasing evidence supporting the finding that old age, by itself, should not be a reason to exclude patients from treatment with IV-rtPA.…”

Interventional Stroke Therapies in the Elderly: Are We Helping?

“…Several studies evaluating the use of IV tPA in the elderly have found it to be safe and effective. [4][5][6][7] However, less information is available regarding the safety and efficacy of endovascular recanalization therapies for the acute management of AIS. Therapies including IA tPA, clot retrieval devices, and combination therapies with IV tPA have been shown to improve revascularization rates and stroke outcomes up to 6 hours after the onset of stroke in younger patients.…”

Effectiveness and Safety of Thrombolysis in Ischemic Stroke Patients Aged 80 Years or Older

“…[4][5][6][7][8][9] Observational studies comparing patients aged with respect to the effect of intravenous (IV) or intra-arterial (IA) thrombolysis. [10][11][12][13][14][15] Most of studies showed that the elderly treated with thrombolysis have higher mortality than the younger, and they tend to have worse outcome. The risk of symptomatic hemorrhagic transformation (sHT) is not different between the elderly and younger patients, although there are persistent concerns that advanced age increases the risk of sHT related to thrombolysis, 11,12,16,17 By including only the patients received thrombolysis, most of previous studies made a comparison between the old, thrombolysis-treated patients and the young, also thrombolysis-treated ones.…”