Endovascular treatment in older adults with acute ischemic stroke in the MR CLEAN Registry

Abstract

ObjectiveTo explore clinical outcomes in older adults with acute ischemic stroke treated with endovascular thrombectomy (EVT).MethodsWe included consecutive patients (2014–2016) with an anterior circulation occlusion undergoing EVT from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry. We assessed the effect of age (dichotomized at ≥80 years and as continuous variable) on the modified Rankin Scale (mRS) score at 90 days, symptomatic intracranial hemorrhage (sICH), and reperfusion rate. The association between age and mRS was assessed with multivariable ordinal logistic regression, and a multiplicative interaction term was added to the model to assess modification of reperfusion by age on outcome.ResultsOf the 1,526 patients, 380 (25%) were ≥80 years of age (referred to here as older adults). Older adults had a worse functional outcome than younger patients (adjusted common odds ratio [acOR] for an mRS score shift toward better outcome 0.31, 95% confidence interval [CI] 0.24–0.39). Mortality was also higher in older adults (51% vs 22%, adjusted odds ratio 3.12, 95% CI 2.33–4.19). There were no differences in proportion of patients with mRS scores of 4 to 5, sICH, or reperfusion rates. Successful reperfusion was more strongly associated with a shift toward good functional outcome in older adults than in younger patients (acOR 3.22, 95% CI 2.04–5.10 vs 2.00, 95% CI 1.56–2.57, pinteraction = 0.026).ConclusionOlder age is associated with an increased absolute risk of poor clinical outcome, while the relative benefit of successful reperfusion seems to be higher in these patients. These results should be taken into consideration in the selection of older adults for EVT.

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

“…Recanalisation rates for older cohorts show a high variability due to smaller sample sizes and differences in study design (selection of patients, selection of occluded vessels to be analysed, etc.). For patients aged 80 years or older, successful recanalisation is reported for 96% [ 19 ], 78.5% [ 8 ] and 54.2% [ 20 ]. For nonagenarians, successful recanalisation is reported for 79.3% [ 8 ] and 66.6% [ 21 ].…”

Effectiveness of Thrombectomy in Stroke According to Baseline Prognostic Factors: Inverse Probability of Treatment Weighting Analysis of a Population-Based Registry

“…This is in line with recent observations describing few complications and potential benefits of thrombectomy in groups of patients with large infarctions, 7,10 or other poor prognostic factors such as poor collateral circulation 8 and older age. 23 At the same time, these results support the use of broad inclusion criteria in RCTs testing MT in stroke, as excluding patients with certain poor prognostic factors may paradoxically reduce the treatment's effect size. 24 Nevertheless, the overall clinical outcome is still poor in about two out of three patients of this subgroup of patients, meaning that they may benefit from better revascularization techniques, additional neuroprotectant strategies, or even improved imaging selection to identify extensive irreversible damage better.…”

Reperfusion therapy for acute ischemic stroke in older people: An observational real‐life study

“…29 Moreover, even though they were treated the same way with thrombolysis and/or EVT and within the same timeframe, the older group who underwent EVT had less successful reperfusion therapy (successful reperfusion after EVT was achieved in 75.1% of these patients vs. in 86.0% of patients in the younger group, p < 0.001, probably because of vessels tortuosity, elongation, and/or proximal atherosclerosis in the oldest) associated with higher mortality and disability at 3 months. 29,30,32 Finally, most AIS in older patients were embolic in origin (62.2% vs. 37.6% in the younger group, p < 0.001) and associated with anticoagulant therapy, which is a predictor of worse outcomes at 3 months in older survivors, 34 as are severe Fazekas grade 3 periventricular white matter lesions. 35 Even though the outcome was poorer for the older patients in our study, thrombolysis and/or EVT improved their mean NIHSS at discharge by 5.5 points.…”