Age Dependency of Successful Recanalization in Anterior Circulation Stroke: The ENDOSTROKE Study

Abstract

Background: Clinical outcome after endovascular stroke therapy (EVT) for proximal anterior circulation stroke is often disappointing despite high recanalization rates. The ENDOSTROKE study aims to determine predictors of clinical outcome in patients undergoing EVT. Here we focus on the impact of age and recanalization on proximal middle cerebral artery (M1-MCA) or carotid T occlusion. Methods: ENDOSTROKE is an investigator-initiated, industrially independent multicenter registry launched in January, 2011, for consecutive patients undergoing EVT for large-vessel stroke. This analysis focuses on patients treated in 11 academic and nonacademic stroke centers with angiographically proven M1-MCA (n = 259) or carotid T occlusion (n = 103). Recanalization was defined as Thrombolysis in Myocardial Infarction (TIMI) score 2 or 3, and in patients with available Thrombolysis in Cerebral Ischemia (TICI) data (n = 309) as TICI scores 2b-3. Good outcome was defined as modified Rankin Scale (mRS) score of 0-2 assessed after 3 months or later. Results: The median age was 68 years (25th and 75th percentiles: 56, 76 years), and the median National Institutes of Health Stroke Scale (NIHSS) score at admission was 16 (13, 19); 41% of the patients had a favorable (mRS scores 0-2), and 59% had an unfavorable (mRS scores 3-6) outcome; 83% reached TIMI 2-3 flow. Independent predictors of good outcome were younger age, lower initial NIHSS scores, TIMI 2/3 recanalization and lower serum glucose levels. Outcome was highly dependent on patients' age: 60% of the patients within the lowest age quartile (range: 18-56 years) experienced good clinical outcome, decreasing stepwise over 47% (57-68 years) and 37% (69-76 years) to 17% in the highest age quartile (77-94 years). The proportion of patients with poor clinical outcome despite TIMI 2/3 recanalization (‘futile recanalization') increased dramatically from only 29% in the lowest age quartile over 34% and 40% (2nd and 3rd age quartiles) up to 53% in the highest age quartile. Results were similar in patients with available TICI scores, with ‘futile recanalization' rates increasing from 24% to 46% (lowest to highest age quartile). Conclusions: This study emphasizes the dramatic impact of patients' age on outcome in EVT for M1-MCA or carotid T occlusion, even in the presence of recanalization. Reasons for this age-related decrease in clinically successful recanalization rates urgently need clarification and may comprise patient-related factors (age-related increase in cardioembolic strokes, collateral status, comorbidities) as well as periprocedural issues (tortuous vessel anatomy in the elderly, age-dependent negative impact of general anesthesia in EVT).

TICI and Age: What's the Score?

“…Additionally, in our study, there was no difference in intracranial hemorrhage rates of all types in the younger age group (19% versus 14%, P ϭ .410); moreover, hemorrhage did not have a significant impact on differences in clinical outcome or mortality rates between the 2 groups and is in keeping with previously published results. 12 Singer et al 22 demonstrated the highest rates of good clinical outcome (mRS Յ2) in the youngest quartile (60%) and the lowest in the oldest quartile (17%). They then dichotomized the entire patient cohort into good and poor clinical outcomes and determined the proportion of patients within each group in whom successful reperfusion was achieved.…”

“…21 Intracranial hemorrhage was reported with the European Cooperative Acute Stroke Study classification. 22 For the current study, we excluded patients from both studies for whom no TICI score or 90-day mRS was available.…”

Recanalization and Mortality Rates of Thrombectomy With Stent-Retrievers in Octogenarian Patients with Acute Ischemic Stroke

“…Previous studies with stent retrievers in patients older than 80 years include Gratz et al [7], who studied 50 octogenarian patients with anterior circulation strokes treated exclusively with Solitaire FR, with a recanalization rate of 74 %, mRS C 3 at 3 months of 89 %, and mortality of 44 %. Other articles analyzed the general impact of age in the clinical response to mechanical thrombectomy [20][21][22], but these papers did not focus on the subgroup of octogenarians and included other mechanical therapies different to stent-retrievers. Our series differ from Gratz's in that both patients with anterior and posterior circulation strokes have been included and up to four different stent-retrievers (not only Solitaire FR) could be chosen for treatment by the neurointerventionist in charge.…”

Differences in Factors Predicting Outcome and Mortality after Mechanical Thrombectomy for Acute Large Vessel Stroke Between Patients over and Under 70 Years of Age: A Five Year Retrospective Study

“…Several studies show increasing age correlation with unfavourable outcomes [21,26,27] with lower rates of recanalization [19] and higher mortality and haemorrhage [28] …”

“…Even when adjusted for recanalization, this age group displayed poorer clinical outcomes, with a trend of better outcomes with decreasing patient age [20,21].…”