Functional Outcomes at 90 Days in Octogenarians Undergoing Thrombectomy for Acute Ischemic Stroke: A Prospective Cohort Study and Meta-Analysis
Angelos Sharobeam, Dennis John Cordato, Nathan Manning, Andrew Cheung, Jason Wenderoth, Cecilia Cappelen-Smith, Angelos Sharobeam, Dennis John Cordato, Nathan Manning, Andrew Cheung, Jason Wenderoth, Cecilia Cappelen-Smith
Abstract
Background: Elderly patients account for 30% of acute ischemic stroke (AIS) but are under-represented in randomized controlled trials of endovascular thrombectomy (EVT). Meta-analysis of "real world" studies evaluating 90-day outcomes in elderly patients ≥80 years have been limited to small numbers undergoing EVT with older generation devices. Methods: A retrospective analysis of 181 prospectively collected patients who received EVT for anterior circulation AIS at an Australian center over 2.5-years. The study aims to determine (i) 90-day functional outcomes (modified Rankin Scale mRS 0-2) in patients ≥80 vs. <80 years, (ii) the interaction of prognostic factors and age and (iii) compare our data to those previously reported using a meta-analysis of outcomes in observational studies using second generation thrombectomy devices. Results: We analyzed 2,387 patients (≥80 years, n = 649; <80 years, n = 1,738) from 14 studies including our study (≥80 years, n = 71; <80 years, n = 110). Twenty-eight percent of our and 30% of the meta-analysis elderly cohort achieved good 90-day mRS compared to 55 and 52%, respectively of younger patients (p < 0.001). Twenty-seven percent of our and 26% of the meta-analysis elderly cohort died compared to 16% (p = 0.07) and 15% (p < 0.0001), respectively of younger patients. Baseline NIHSS≥16 correlated with poor prognosis in elderly (OR 16.4; 95% CI 4.49-59.91, p < 0.001) and younger (OR 8.73;95% CI 3.35-22.80, p < 0.001) patients. Prior rt-PA was associated with favorable outcome in younger (OR 2.90; 95%CI 1.29-6.52, p = 0.01) patients only. Conclusion: EVT has less favorable outcomes in elderly patients. However, results are better than outcomes in historical controls not treated with thrombectomy providing further support for EVT in the elderly.
Keywords: elderly; endovascular; outcome; stroke; thrombectomy.
Figures
References
- Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous rt-PA vs. rt-PA alone in stroke. N Engl J Med. (2015) 372:2285–95. 10.1056/NEJMoa1415061
- Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. . Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. (2015) 372:1019–30. 10.1056/NEJMoa1414905
- Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. . Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. (2015) 372:2296–306. 10.1056/NEJMoa1503780
- Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. . Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. (2015) 372:1009–18. 10.1056/NEJMoa1414792
- Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. . A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. (2015) 372:11–20. 10.1056/NEJMoa1411587
- Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. (2016) 387:1723–31. 10.1016/S0140-6736(16)00163-X
- Jovin TG, Saver JL, Ribo M, Pereira V, Furlan A, Bonafe A, et al. . Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods. Int J Stroke. (2017) 12:641–52. 10.1177/1747493017710341
- Albers GW, Lansberg MG, Kemp S, Tsai JP, Lavori P, Christensen S, et al. . A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3). Int J Stroke. (2017) 12:896–905. 10.1177/1747493017701147
- Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. . 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke. (2018) 49:e46–110. 10.1161/STR.0000000000000158
- Sacco RL. Risk factors and outcomes for ischemic stroke. Neurology. (1995) 45(2 Suppl. 1):S10–4.
- To CY, Rajamand S, Mehra R, Falatko S, Badr Y, Richards B, et al. . Outcome of mechanical thrombectomy in the very elderly for the treatment of acute ischemic stroke: the real world experience. Acta Radiol Open. (2015) 4:2058460115599423. 10.1177/2058460115599423
- Tajima Y, Hayasaka M, Ebihara K, Kawauchi D, Suda S. Thrombectomy in octogenarians in the era of stent retriever: is an age limit necessary? J Neuroendovasc Ther. (2017) 11:563–9. 10.5797/jnet.oa.2017-0031
- Fonarow GC, Reeves MJ, Zhao X, Olson DM, Smith EE, Saver JL, et al. . Age-related differences in characteristics, performance measures, treatment trends, and outcomes in patients with ischemic stroke. Circulation. (2010) 121:879–91. 10.1161/CIRCULATIONAHA.109.892497
- Jeon JP, Kim SE, Kim CH. Endovascular treatment of acute ischemic stroke in octogenarians: a meta-analysis of observational studies. Clin Neurol Neurosurg. (2017) 161:70–7. 10.1016/j.clineuro.2017.08.015
- Wahlgren N, Ahmed N, Davalos A, Ford GA, Grond M, Hacke W, et al. Thrombolysis with alteplase for acute ischemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. (2007) 369:275–82. 10.1016/S0140-6736(07)60149-4
- Duffis EJ, He W, Prestigiacomo CJ, Gandhi CD. Endovascular treatment for acute ischemic stroke in octogenarians compared with younger patients: a meta-analysis. Int J Stroke. (2014) 9:308–12. 10.1111/ijs.12098
- Hilditch CA, Nicholson P, Murad MH, Rabinstein A, Schaafsma J, Pikula A, et al. . Endovascular management of acute stroke in the elderly: a systematic review and meta-analysis. Am J Neuroradiol. (2018) 39:887–91. 10.3174/ajnr.A5598
- Alawieh A, Starke RM, Chatterjee AR, Turk A, De Leacy R, Rai AT, et al. Outcomes of endovascular thrombectomy in the elderly: a ‘real-world’ multicenter study. J Neurointerv Surg. (2018) 10:1209–17. 10.1136/neurintsurg-2018-014289
- Azkune Calle I, Bocos Portillo J, Anton-Ladislao A, Gil Garcia A, Gonzalez Diaz E, Gomez-Beldarrain M, et al. . Clinical outcome of mechanical thrombectomy for stroke in the elderly. J Stroke Cerebrovasc Dis. (2017) 26:582–8. 10.1016/j.jstrokecerebrovasdis.2016.11.117
- Broussalis E, Weymayr F, Hitzl W, Unterrainer AF, Trinka E, Killer M. Endovascular mechanical recanalization of acute ischemic stroke in octogenarians. Eur Radiol. (2016) 26:1742–50. 10.1007/s00330-015-3969-8
- Castonguay AC, Zaidat OO, Novakovic R, Nguyen TN, Taqi MA, Gupta R, et al. . Influence of age on clinical and revascularization outcomes in the North American Solitaire Stent-Retriever Acute Stroke Registry. Stroke. (2014) 45:3631–6. 10.1161/STROKEAHA.114.006487
- Cohen JE, Gomori JM, Leker RR. Stent retriever-based thrombectomy in octogenarians. Interv Neurol. (2016) 5:111–7. 10.1159/000446795
- Figueiredo S, Carvalho A, Rodrigues M, Cunha A, Paredes L, Costa H, et al. . Endovascular stroke treatment of patients over 80 years old: cumulative evidence from the “real world”. J Stroke Cerebrovasc Dis. (2017) 26:2949–53. 10.1016/j.jstrokecerebrovasdis.2017.07.020
- Imahori T, Tanaka K, Arai A, Shiomi R, Fujiwara D, Mori T, et al. Mechanical thrombectomy for acute ischemic stroke patients aged 80 years or older. J Stroke Cerebrovasc Dis. (2017) 26:2793–9. 10.1016/j.jstrokecerebrovasdis.2017.06.060
- Karhi S, Nerg O, Miettinen T, Makipaakkanen E, Taina M, Manninen H, et al. . Mechanical thrombectomy of large artery occlusion is beneficial in octogenarians. In Vivo. (2018) 32:1223–30. 10.21873/invivo.11368
- Kleine JF, Boeckh-Behrens T, Prothmann S, Zimmer C, Liebig T. Discrepancy between early neurological course and mid-term outcome in older stroke patients after mechanical thrombectomy. J Neurointerv Surg. (2016) 8:671–6. 10.1136/neurintsurg-2015-011702
- Koizumi S, Ota T, Shigeta K, Amano T, Ueda M, Matsumaru Y, et al. Onset to reperfusion time was not important in mechanical thrombectomy for elderly patients: a retrospective multicenter study in Tama area, Tokyo. Cerebrovasc Dis. (2018) 46:89–96. 10.1159/000492867
- Parrilla G, Carreon E, Zamarro J, Espinosa de Rueda M, Garcia-Villalba B, Marin F, et al. . Recanalization and mortality rates of thrombectomy with stent-retrievers in octogenarian patients with acute ischemic stroke. Cardiovasc Intervent Radiol. (2015) 38:288–94. 10.1007/s00270-014-0920-3
- Son S, Kang DH, Hwang YH, Kim YS, Kim YW. Efficacy, safety, and clinical outcome of modern mechanical thrombectomy in elderly patients with acute ischemic stroke. Acta Neurochir. (2017) 159:1663–9. 10.1007/s00701-017-3269-y
- Zhu W, Xiao L, Lin M, Liu X, Yan B. Large-vessel occlusion is associated with poor outcome in stroke patients aged 80 years or older who underwent intravenous thrombolysis. J Stroke Cerebrovasc Dis. (2016) 25:2712–6. 10.1016/j.jstrokecerebrovasdis.2016.07.021
- Russo T, Felzani G, Marini C. Stroke in the very old: a systematic review of studies on incidence, outcome, and resource use. J Aging Res. (2011) 2011:108785. 10.4061/2011/108785
- Chandra RV, Leslie-Mazwi TM, Oh DC, Chaudhry ZA, Mehta BP, Rost NS, et al. . Elderly patients are at higher risk for poor outcomes after intra-arterial therapy. Stroke. (2012) 43:2356–61. 10.1161/STROKEAHA.112.650713
- National Institute of Neurological Disorders and Stroke rt-PA SSG Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. (1995) 333:1581–7. 10.1056/NEJM199512143332401
- Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, et al. . Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. (2008) 359:1317–36. 10.1056/NEJMoa0804656
- Rao NM, Levine SR, Gornbein J, Saver JL. Defining clinically relevant cerebral hemorrhage after thrombolytic therapy for stroke: analysis of the National Institute of Neurological Disorders and Stroke tissue-type plasminogen activator trials. Stroke. (2014) 45:2728–33. 10.1161/STROKEAHA.114.005135
Source: PubMed