Intra-Arterial Recanalization Techniques for Patients 80 Years or Older with Acute Ischemic Stroke: Pooled Analysis from 4 Prospective Studies

Abstract

BACKGROUND AND PURPOSE Previous studies have demonstrated limited benefit with endovascular procedures such as stent placement in octogenarians. We evaluated the safety and effectiveness of intra-arterial recanalization techniques to treat ischemic stroke in patients 80 years or older presenting within 6 hours of symptom onset. MATERIALS AND METHODS We pooled the data from 4 prospective studies by evaluating intra-arterial recanalization techniques for treatment of ischemic stroke. Clinical and radiologic evaluations were performed before treatment and at 24 hours, 7 to 10 days, and 1 to 3 months after treatment. We performed multivariate analyses to evaluate the effect of ages 80 years and older on angiographic recanalization, favorable outcome (modified Rankin scale of 0–2), and mortality rate at 1 to 3 months. RESULTS A total of 101 patients were treated in the 4 protocols. Of these, 24 were 80 years or older. There was no significant difference between the 2 age groups in sex, initial stroke severity, time to treatment, site of vascular occlusion, and rate of symptomatic and asymptomatic intracranial hemorrhage (ICH). In logistic regression analysis, age 80 years or older was associated with a lower likelihood of a favorable outcome (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.13–1.2; P = .11) and recanalization (OR, 0.36; 95% CI, 0.12–1.1; P = .07) and with higher mortality rate (OR, 3.17; 95% CI, 1.05–9.55; P = .04) after adjusting for study protocol. After adjusting for recanalization in addition to study protocol, the older age group still had a lower likelihood of favorable outcomes (OR, 0.34; 95% CI, 0.1–1.1; P = .07) and higher mortality rates (OR, 3.62; 95% CI, 1.15–11.36; P = .027). CONCLUSIONS Our study demonstrates that patients 80 years and older are at higher risk for poor outcome at 1 to 3 months following intra-arterial recanalization techniques. This relationship is independent of recanalization rate and symptomatic ICH supporting the role of other mechanisms.

Improving patient selection for endovascular treatment of acute cerebral ischemia: a review of the literature and an external validation of the Houston IAT and THRIVE predictive scoring systems

“…47 The 90-day outcomes among the elderly showed lower rates of excellent functional outcome (mRS score < 1, 26% of elderly patients vs 40% of younger patients) and survival (57% vs 80%, respectively), regardless of recanalization status. The authors ultimately report that patients 80 years and older had a higher risk for poor outcome at 1-3 months following IAT, even after adjusting for recanalization status.…”

“…It is posited that diminished neural plasticity in the elderly may lower the chances of recovery following cerebral injury. 12,47,56 Patients 80 years of age or older were reported to have more frequent comorbidities, more extensive coronary disease, and a 2-to 4-fold increase in risk for complications following IAT, including death, Q wave myocardial infarction, renal failure, stroke and vascular complications. 7,47 Studies also show that elderly patients have a reduced capacity for developing collateral blood flow and that increased age predicts the absence of collateral circulation to the ischemic region.…”

“…12,47,56 Patients 80 years of age or older were reported to have more frequent comorbidities, more extensive coronary disease, and a 2-to 4-fold increase in risk for complications following IAT, including death, Q wave myocardial infarction, renal failure, stroke and vascular complications. 7,47 Studies also show that elderly patients have a reduced capacity for developing collateral blood flow and that increased age predicts the absence of collateral circulation to the ischemic region. 35,47 The presence of collateral flow is correlated with better outcomes, most likely due to its ability to provide at-risk areas of brain tissue with some blood flow; the independent predictive values of the presence of comorbidities and the presence of collateral flow are discussed later in this paper.…”

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] …”

“…Age has also been shown to be an important factor in recovery after treatment for ischaemic stroke, with age groups ≥70-80 years associated with a significant reduction in recanalization rates [19]. Even when adjusted for recanalization, this age group displayed poorer clinical outcomes, with a trend of better outcomes with decreasing patient age [20,21].…”