Efficacy and Safety of Endovascular Thrombectomy for Ischemic Stroke in Nonagenarians

Abstract

Introduction: Increased life expectancy results in a rapid increase of nonagenarian patients presenting with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). We conducted this study to assess the efficacy and safety of endovascular thrombectomy (ET) in this age group with use of imaging-based selection. Methods: We retrospectively analyzed clinical and imaging data from 2 different comprehensive stroke centers and compared the outcomes of ET versus intravenous thrombolysis (IVT) alone among eligible nonagenarians with LVO in anterior circulation and evidence of salvageable tissue on brain magnetic resonance imaging (MRI). Results: A total of 617 patients of AIS had been treated with IVT or ET, including 23 eligible nonagenarians. Among these, 9 patients were treated with IVT alone (IVT group) and 14 patients received ET group. Notably, the symptomatic intracranial hemorrhage rates were significantly lower after ET than after IVT (European-Australasian Acute Stroke Study II criteria, 0 vs. 33.3%; p = 0.047; National Institute of Neurological Disorders and Stroke criteria, 7.1 vs. 66.7%; p = 0.005). Moreover, although there were no statistically significant differences between the 2 groups on efficacy, ET tended to lead to greater early neurologic recovery at discharge (71.4 vs. 33.3%, p = 0.102) and improve functional outcome at 90 days (71.4 vs. 44.4%, p = 0.383), respectively. Conclusion: By using MRI-based selection, ET in nonagenarians with AIS caused by LVO within anterior circulation was safe and may lead to improve early neurologic recovery and functional independence at 90 days, as compared with IVT alone. Randomized trial in larger sample size testing efficacy of ET using diffusion-weighted imaging-fluid attenuated inversion recovery mismatch selection in this age group appears feasible.

Mechanical Thrombectomy for Acute Ischemic Stroke in Nonagenarian Patients: A Case Report from dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

“…Although advanced age was reported to be associated with an increased tortuosity of the cerebral vasculature that increase technical difficulty of mechanical thrombecomy and resulting less complete recanalization, the use of latest generation of device can result in less complication. 9 The first-line mechanical thrombectomy device strategy either stent retriever, contact aspiration, or either combination of both did not give significance in achieving successful reperfusion. 7…”

“…Intracranial hemorrhage within 24 hours occurred in 24-28% patients but only 4-8% considered as symptomatic, and there was no difference rates between patients with and without successful reperfusion. 6,7, 9 When compared with thrombolysis alone, nonagenarian patients who got endovascular treatment have lower NIHSS score at discharge, better mRS score at 90 days after procedure, and less symptomatic ICH. Although advanced age was reported to be associated with an increased tortuosity of the cerebral vasculature that increase technical difficulty of mechanical thrombecomy and resulting less complete recanalization, the use of latest generation of device can result in less complication.…”

Temporal trends in results of endovascular treatment of anterior intracranial large cerebral vessel occlusion: A 7-year study

“…However, it is important to integrate the expanding indications since 2015, with EVT progressively being considered for increasingly older patients, more extensive ischemic cores and later time-windows. [34][35][36] The evidence of a preserved therapeutic benefit in these subgroups, usually associated with an a priori poorer prognosis, is likely to have influenced the clinical outcome over the study period. Furthermore, IVT rates have decreased markedly over the years in the observed population of EVT treated patients.…”

Age and Outcome after Endovascular Treatment in Anterior Circulation Large-Vessel Occlusion Stroke: ETIS Registry Results

“…ASPECTS is a strong predictor of good functional outcome irrespective of age (multilevel OR: 1.18, 95% CI: 1.11–1.26, p < 0.001). By using FLAIR-DWI mismatch selection criteria, Wu et al [25]achieved a 71.4% rate of good outcome in nonagenarians. Kaeshmacher found that in patients <80 years old presenting with ASPECTS 0-5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage [26].…”

“…In our series, only 12.7% of nonagenarians achieved a good functional outcome at 90 days after the procedure with a mortality of 46.5%. Based on small retrospective cohorts, other studies have reported good functional outcomes ranging from 13 to 71.4% and mortality rates ranging from 7.7 to 71.6% [9, 13, 25, 33-38] with the best results occurring in series with highly selected patients [37] and strict inclusion criteria based on advanced imaging [36, 38]. Despite the relatively poor outcomes in very elderly patients in this series, these results should be interpreted in the context of the dismal natural history of acute ischemic stroke in this patient population.…”