Intravenous thrombolysis for acute cerebral ischaemia in old stroke patients ≥80 years of age

Abstract

Despite increasing life expectancy, few data exist on the outcome of elderly stroke patients treated with IV thrombolysis. We analyzed the prospectively collected data from the Lille University Hospital stroke unit on patients treated with IV rt-PA within 4.5 h, comparing patients ≥80 years to younger ones. We considered the following outcomes: neurological improvement at the acute phase (NIHSS 0 or 1 at 24 h, or if the difference between NIHSS at 24 h and at baseline was ≥4), occurrence of intracerebral haemorrhage, mortality and functional outcome in survivors (favourable if mRS ≤2 or equal to pre-stroke score) at 3 months. Predictors of vital and functional outcome were determined using logistic regression analysis. Four hundred patients were treated with IV rt-PA, 98 (25%) being ≥80 years. The proportion of patients with neurological improvement at the acute phase (31 vs. 40%, OR 0.7, 95%CI 0.4-1.2), and with ICH (19 vs. 21%, OR 0.9, 95%CI 0.5-1.7) was similar among older and younger patients. At 3 months, 35% of patients ≥80 years had died; 52% of survivors had favourable functional outcome. Using multivariate analysis, age ≥80 years was an independent predictor of death (3.4; 95%CI 1.6-7.3), and of reduced likelihood of favourable functional outcome in survivors (OR 0.3; 95%CI 0.2-0.7) at 3 months. Although outcome at 3 months is worse for older patients than for their younger counterparts, our results are encouraging with a similar proportion of patients with early neurological improvement and with ICH in old and young patients and about half of the survivors having a favourable functional outcome in patients ≥80 years.

Thrombolysis in Patients Aged over 80 Years Is Equally Effective and Safe

“…Many other studies had previously reported similar rates of symptomatic and asymptomatic intracranial hemorrhages between younger and older patients. 7,9,11,[14][15][16]19,20,23,24 In contrast to our study, most previous studies revealed an increased 30-day mortality. 7,[9][10][11][13][14][15][16]24 So, according to our results, older patients seem to also be likely to benefit in the short and long term from IVrtPA and do not seem to be in increased risk of mortality or hemorrhagic transformation.…”

“…Most previous studies had shown lower rates of favorable and independent outcomes at day 90 in patient aged over 80 years old. 7,12,15,16 However, a recent randomized controlled trial including 1617 patients over 80 years suggested that benefit does not seem to be diminished in the elderly. 26 Also, in a study by Zeevi et al, 19 older patients treated with IV-rtPA presented with a 12-month modified Barthel Index score comparable to that of younger patients.…”

“…Most studies seem to show worse outcome and increased mortality in patients aged over 80 years old with acute ischemic stroke treated with IV-rtPA when compared with younger counterparts. [7][8][9][10][11][12][13][14][15][16][17] Nevertheless, patients from this age group still seem to benefit from this treatment and do not seem to have an increased risk of symptomatic intracranial hemorrhage after IV-rtPA, as demonstrated in several observational studies [7][8][9][11][12][13][14]16,[18][19][20][21][22][23][24][25] and also in a randomized controlled trial. 26 Thus, there is increasing evidence supporting the finding that old age, by itself, should not be a reason to exclude patients from treatment with IV-rtPA.…”

Estudio observacional sobre tratamiento trombolítico del infarto cerebral agudo en pacientes mayores y menores de 80 años: experiencia de un hospital en Bogotá, Colombia, 2007-2014

“…A good functional prognosis, defined as a mRS between zero and two, among subjects ≥ 80 years who were treated with rt-PA in the first six hours was also found in 27.2% of the treatment group and in 23.4% of the allocated placebo group (p=0.07) 26 in the meta -analysis that included the Third International Stroke Trial (IST-3) results. Our results showed that 25% of the older group treated with rt-PA had an good functional prognosis at day seven, compared with 53.7% in the younger population indicating a benefit in both age groups however, clearly larger in the patients <80 years [27][28][29][30][31][32][33][34][35][36][37][38] .…”

“…Thereby we decided to compare our results with similar non-randomized controlled studies as shown [27][28][29][30][31][32][33][34][35][36][37] . They compared treated patients older and younger than 80 years, with better disability outcomes measured by mRS in the youngest population, with no striking difference in symptomatic intracerebral hemorrhage, but with a remarkable intra-hospital mortality and at three months (See Table 6).…”