Efficacy of Thrombolytic (rt-PA) Therapy in Old Stroke Patients: The Perugia Stroke Unit Experience

Abstract

The use of intravenous recombinant tissue plasminogen activator (rt-PA) administered within 3 hrs from symptom onset is beneficial in selected patients independent of age; although oldest patients (> or = 80 years) are excluded a priori. We report an experience relative to rt-PA treatment in the oldest patients including outcome at 3 months. Data were from the hospital-based Perugia Stroke Registry. Seventy-two consecutive acute stroke patients, fulfilling NINDS and EUSI-criteria were treated with rt-PA of these 23 patients (30.5%) were > or = 80 years. The median and mean age were, respectively, 72.5 and 71.1 +/- 12.7 years (range 35-94). The proportion of favorable outcome at 3-months did not differ between groups (55% elderly versus 51.1% of younger patients). Proportions of unfavorable outcome and death from baseline were similar in both groups of patients. Age did not influence prognosis in patients treated with rt-PA. The oldest stroke patients should not be excluded from rt-PA treatment on the basis of age per se.

Intravenous thrombolysis in acute ischaemic stroke: a systematic review and meta-analysis to aid decision making in patients over 80 years of age

“…The individual characteristics of the studies are tabulated in table 1 and details of each study, including results, are mentioned in table 2. Uyttenboogaart17 performed multivariate analysis to adjust for possible confounders and eight other studies10–12 14–16 18 19 21 performed logistic regression analysis to adjust for the differences in important baseline characteristics and to identify predictors of favourable and/or poor outcomes. Our analysis showed that there was little evidence to suggest publication bias in funnel plots for the three outcomes (figure 1).…”

“…Five studies10 13 16 17 20 used the definition as utilised by the National Institute of Neurological Diseases and Stroke (NINDS) study group22 where a haemorrhage was considered symptomatic if it was not seen on a previous CT scan and there had subsequently been a decline in neurological status. Eight9 11 12 14 15 18 19 21 used the definition as utilised by the European Cooperative Acute Stroke Study III (ECASS III) trial23 where SICH was defined as an intracranial bleed on CT scan with a decrease in the National Institutes of Health Stroke Scale score of 4 or more points.…”

“…If those in the <80 year age group are followed-up less rigorously for example, and if loss to follow-up is mainly caused by greater health or mobility, then the proportion of patients in the <80 year age group associated with SICH or mortality will be biased upwards and this could contribute to a non-significant result. Unfortunately, only Parnetti21 and Meseguer19 described and compared losses to follow-up.…”

Outcome of Acute Ischemic Stroke in Very Elderly Patients: Is Intravenous Thrombolysis Beneficial?

“…Recent observational studies have reported on this issue and yield inconsistent results [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21]. Several clinical experiences found outcome is not different between the elderly and younger subjects [7,10,13,18,19,20]. Possible explanations for this may be the selection of more healthy subjects without contraindication of tPA treatment.…”

“…Many recent reports investigated tPA effects on very old patients [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22]. Several observational studies [7,8,10,11,12,13,14,15,16,18,19,20,21] compared the elderly with younger counterparts, but the inherent differences in the comparator group were major determinants for the outcome. The majority of studies demonstrate that tPA is safe without increasing symptomatic intracranial hemorrhage (SICH) in the very old group, but outcome is less favorable in patients ≥80 years as compared with younger patients [8,11,12,14,15,16,21,22], as was known before the introduction of IV tPA.…”