Acute stroke treatment and outcome in the oldest old (90 years and older) at a tertiary care medical centre in Germany-a retrospective study showing safety and efficacy in this particular patient population

Abstract

Background Stroke is among the most common causes of death and disability worldwide. Despite the relevance of stroke-related disease burden, which is constantly increasing due to the demographic change in industrialized countries with an ageing population and consecutively an increase in age-associated diseases, there is sparse evidence concerning acute stroke treatment and treatment-related outcome in the elderly patient group. This retrospective study aimed at analysing patient characteristics, therapy-related complications and functional outcome in stroke patients aged 90 years or older who underwent acute stroke treatment (i.e. intravenous thrombolysis, mechanical thrombectomy, or both). Methods We identified files of all inpatient stays at the Department of Neurology at Saarland University Medical Center (tertiary care level with a comprehensive stroke unit) between June 2011 and December 2018 and filtered for subjects aged 90 years or older at the time of admission. We reviewed patient files for demographic data, symptoms upon admission, (main) diagnoses, comorbidities, and administered therapies. For patients admitted due to acute stroke we reviewed files for therapy-related complications and functional outcome. We compared the modified Rankin scale (mRS) scores upon admission and at discharge for these patients. Results We identified 566 inpatient stays of subjects aged 90 years or older. Three hundred sixty-seven of the 566 patients (64.8%) were admitted and discharged due to symptoms indicative of stroke. Two hundred eleven patients received a diagnosis of ischaemic stroke. These 211 patients were analysed subsequently. Sixty-four patients qualified for acute stroke treatment (intravenous thrombolysis n = 22, mechanical thrombectomy n = 26, intravenous thrombolysis followed by mechanical thrombectomy n = 16) and showed a significant improvement in their functional status as measured by change in mRS score (admission vs. discharge, p 0.001) with 7 (10.9%) observed potentially therapy-related complications (relevant drop in haemoglobin n = 2, subarachnoidal haemorrhage n = 1, cerebral haemorrhage n = 3, extracranial bleeding n = 1). One intravenous thrombolysis was stopped because of an uncontrollable hypertensive crisis. Patients who did not qualify for these treatments (including those declining acute treatment) did not show a change of their functional status between admission and discharge (p 0.064). Conclusion Our data indicate that acute stroke treatment is effective and safe in the oldest old. Age alone is no criterion to withhold an acute intervention even in oldest old stroke patients.

Efficacy of Endovascular Thrombectomy in the Oldest Old (Stroke 90+ Study): A Community Center Experience

“…This report has documented safety and benefit of EVT in patients who are 90 years and older in a community hospital setting, further supporting EVT in eligible advanced aged patients. Our outcomes were equivalent to, although there are few, other published studies [10].…”

“…The landmark HERMES collaborative trial (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials), and its sub-study suggest not withholding EVT on the basis of age alone [7,8] although surveyed clinicians state that age still plays a key role when making individual thrombectomy decisions [9]. In addition, the most recent guidelines from the American Stroke Association/American Heart Association suggest more studies are needed for patients >=90 years especially in the “real-world setting” [10].…”

Intravenous Thrombolysis in Patients 90 Years or Older with Moderate to Severe Acute Ischemic Stroke Increases Ambulation at Discharge and Is Safe: A Prospective Cohort Study from a Single Center in Santiago, Chile

“…Death rates have been demonstrated to be similar between groups in other studies [ 6 – 8 , 12 , 13 ], according to randomized evidence [ 2 ]. Our study has several limitations and possible biases.…”

“…However, in numerous countries, guidelines tend to view age as a relative exclusion criterion for patients aged 80 and above within the 3–4.5-h treatment window [ 3 – 5 ]. Despite comparable bleeding risk to younger groups and observed higher probabilities of improved functional outcomes compared to non-thrombolyzed patients of the same age, some guidelines continue to emphasize age-related considerations [ 6 – 8 ]. The aim of this study was to investigate the safety and efficacy of rtPA treatment in previously ambulatory patients aged 90 years or older with moderate or severe AIS admitted to our institution.…”

Risk factors for stroke outcomes in adults: Stroke in China

“…[45,46] Another acute stroke treatment and outcomes in the oldest old (90 years and older) at a tertiary care medical center in Germany found that acute stroke treatment is effective and safe in the oldest old. [47] A higher NHISS score was an independent risk factor for stroke recurrence in patients with a history of stroke. [29] Lai et al [48] found that NIHSS can be used as a risk factor for 90-day prognosis in patients undergoing thrombectomy (EVT), and the 7-day NIHSS score is more accurate.…”