Effect of frailty on outcomes of endovascular treatment for acute ischaemic stroke in older patients

Abstract

Background frailty has been shown to be a better predictor of clinical outcomes than age alone across many diseases. Few studies have examined the relationship between frailty, stroke and stroke interventions such as endovascular thrombectomy (EVT). Objective we aimed to investigate the impact of frailty measured by clinical frailty scale (CFS) on clinical outcomes after EVT for acute ischemic stroke (AIS) in older patients ≥70 years. Methods in this retrospective cohort study, we included all consecutive AIS patients age ≥ 70 years receiving EVT at a single comprehensive stroke centre. Patients with CFS of 1–3 were defined as not frail, and CFS > 3 was defined as frail. The primary outcome was modified Rankin Score (mRS) at 90 days. The secondary outcomes included duration of hospitalisation, in-hospital mortality, carer requirement, successful reperfusion, symptomatic intracranial haemorrhage and haemorrhagic transformation. Results a total of 198 patients were included. The mean age was 78.1 years and 52.0% were female. Frail patients were older, more likely to be female, had more co-morbidities. CFS was significantly associated with poor functional outcome after adjustment for age, NIHSS and time to intervention (adjusted odds ratio [aOR] 1.54, 95% confidence interval [CI] 1.04–2.28, P = 0.032). There was trend towards higher mortality rate in frail patients (frail: 18.3%; non-frail: 9.6%; P = 0.080). There were no significant differences in other secondary outcomes except increased carer requirement post discharge in frail patients (frail: 91.6%; non-frail: 72.8%; P = 0.002). Conclusions frailty was associated with poorer functional outcome at 90 days post-EVT in patients ≥ 70 years.

Endovascular thrombectomy for acute ischaemic stroke improves and maintains function in the very elderly: A multicentre propensity score matched analysis

“…The increased mortality risk may also be due to unmeasured frailties. 26,27 Similar discrepancy in outcome has been observed in published cohorts of patients with pre-existing mild-moderate disability (mRS 2-3) 28,29 undergoing EVT, and a return to baseline function has been proposed as a metric to determine benefit of EVT in these patients. The rates of pre-stroke disability are expected to be higher in the elderly population and the concept of return to baseline function may also be a more appropriate endpoint in the very elderly than the conventional definition of good outcome (mRS 0-2).…”

“…The difference is likely due to unmeasured factors such as clinical frailty which is more prevalent with advancing age, and not represented by standard functional scoring system. Reports utilising clinical frailty scores have associated increased frailty with reduced likelihood of good outcome after EVT, and it is plausible that this unmeasured factor 26,27 accounts for the difference in outcome between the two groups in this study and other published cohorts (Table 3).…”

Genetic liability to frailty in relation to functional outcome after ischemic stroke

“…41 Moreover, several studies reported treatment-modifying effects of frailty upon hyperacute reperfusion therapies following stroke and consequently leading to poorer functional outcomes in frailty patients. [42][43][44] Several limitations should be considered when interpreting our findings. First, causal effect estimates were imprecise resulting from the small fraction of the phenotypic variation explained.…”

“…41 Moreover, several studies reported treatment-modifying effects of frailty upon hyperacute reperfusion therapies following stroke and consequently leading to poorer functional outcomes in frailty patients. 42–44…”

Effect of Comorbidity Burden and Polypharmacy on Poor Functional Outcome in Acute Ischemic Stroke

“…Comorbidities can furthermore be associated with frailty, a syndrome also consisting of cognitive impairment and disability [28]. Frailty has been recently identified as a predictor for poor outcome in ischemic stroke patients [29,30], and a recommendation to screen all patients over the age of 70 years for frailty has been made by an international expert consensus [28]. However, further investigations are needed, as not all comorbidities result in frailty, and a clear consensus on the best method to assess frailty in stroke patients has not been established yet.…”