Endovascular Treatment of Very Elderly Patients Aged ≥90 With Acute Ischemic Stroke

Abstract

Background Patients aged ≥90 were excluded or under‐represented in past thrombectomy trials; thus, uncertainty remains whether treatment benefits can be expected regardless of age. This study investigates outcome and safety of thrombectomy in nonagenarians to improve decision making in a real‐world setting. Methods and Results All currently available data of patients aged ≥90 enrolled in the GSR‐ET (German Stroke Registry–Endovascular Treatment) were combined with a smaller cohort from 3 tertiary stroke centers. Baseline characteristics, procedural (Thrombolysis in Cerebral Infarction scale) and functional outcomes (modified Rankin Scale; mRS ), as well as complications (symptomatic intracranial hemorrhage, serious adverse events; SAEs) were analyzed. Good functional outcome was defined as mRS ≤3 at 90‐days. 203 patients with anterior circulation stroke and prestroke mRS ≤3 were included. The rate of successful recanalization (Thrombolysis in Cerebral Infarction scale ≥2b) was 75.9% (154/203). Good functional outcome ( mRS ≤3) was observed in 21.6% (41 of 193) at 90‐days. In‐hospital mortality was 27.1% (55 of 203) and increased significantly at 90 days to 48.9% (93 of 190; P <0.001). Symptomatic intracranial hemorrhage occurred in 3% (6 of 203) of patients. Logistic regression analysis identified Alberta Stroke Program Early CT Score (adjusted odds ratio, 1.93; 95% CI , 1.01–3.70; P =0.046) and initial National Institute of Health Stroke Scale (adjusted odds ratio, 0.85; 95% CI , 0.76–0.97; P =0.014) as independent predictors for good outcome. Patients with successful recanalization had a significant ( P =0.001) shift of mRS distribution with higher rates of good functional outcomes (23.8% [34 of 143] versus 14.9% [7 of 47]) and lower mortality at 90‐days (46.8% [67 of 143] versus 55.3% [26 of 47]). Conclusions Despite high mortality and less frequent favorable outcome, our data suggest that thrombectomy is still effective and safe for nonagenarians. Decision making for thrombectomy in patients aged ≥90 should be based on a case‐by‐case basis with regard to initial National Institute of Health Stroke Scale and Alberta Stroke Program Early CT Score.

Predicting mortality in acute ischaemic stroke treated with mechanical thrombectomy: analysis of a multicentre prospective registry

“…Very recently, an analysis of German Stroke Registry-Endovascular Treatment showed that patients aged ≥90 years have higher mortality for thrombectomy. 25 Decision-making for thrombectomy in patients aged ≥90 years should be premised on a case-by-case basis with regard to admission NIHSS and ASPECT scores.…”

Direct versus Bridging Mechanical Thrombectomy in Elderly Patients with Acute Large Vessel Occlusion: A Multicenter Cohort Study

“…The median patient age was 73 years (IQR, 69-78 years), and the median baseline NIHSS score was 17 (IQR, [13][14][15][16][17][18][19][20][21][22]. Of the 482 enrolled patients, 259 (53.73%) were men and 392 (81.33%) had anterior circulation stroke.…”

“…15 In contrast, some studies have revealed no association of IVT pre-treatment prior to MT with prognosis in elderly patients. [16][17][18] It is important to note that those studies were not designed to compare the effects of direct MT and bridging MT. Furthermore, some of those studies were not multicenter studies.…”

Expanding indications for endovascular thrombectomy-how to leave no patient behind

“… 1 Even for nonagenarians multiple studies evaluating thrombectomy have shown promising results. 27 , 28 In a recent analysis including 124 nonagenarians from the ETIS Registry, patients with successful reperfusion had lower 90-day mRS compared to non-recanalized patients. Moreover, patients with successful reperfusion after one pass had reduced 90-day mortality and increased odds of good outcome (mRS score ⩽3).…”