Impact of Reperfusion for Nonagenarians Treated by Mechanical Thrombectomy

Abstract

Background and Purpose— Nonagenarians represent a growing stroke population characterized by a higher frailty. Although endovascular therapy (ET) is a cornerstone of the management of acute ischemic stroke related to large vessel occlusion, the benefit of reperfusion among nonagenarians is poorly documented. We aimed to assess the impact of ET-related reperfusion on the functional outcome of reperfusion in this elderly population. Methods— A retrospective analysis of clinical and imaging data from all patients aged over 90 included in the ETIS (Endovascular Treatment in Ischemic Stroke) registry between October 2013 and April 2018 was performed. Association between post-ET reperfusion and favorable (modified Rankin Scale [0–2] or equal to prestroke value) and good (modified Rankin Scale [0–3] or equal to prestroke value) outcome were evaluated. Demographic and procedural predictors of functional outcome, including the first-pass effect, were evaluated. Results were adjusted for center, admission National Institutes of Health Stroke Scale, and use of intravenous thrombolysis. Results— Among the 124 nonagenarians treated with ET, those with successful reperfusion had the lowest 90-day modified Rankin Scale (odds ratio, 3.26; 95% CI, 1.04–10.25). Only patients with successful reperfusion after the first pass (n=53, 56.7%) had a reduced 90-day mortality (odds ratio, 0.15; 95% CI, 0.05–0.45) and an increased rate of good outcome (odds ratio, 4.55; 95% CI, 1.38–15.03). No increase in the rate of intracranial hemorrhage was observed among patients successfully reperfused. Conclusions— Successful reperfusion improves the functional outcome of nonagenarians who should not be excluded from ET. The first-pass effect should be considered in the procedural management of this frail population.

Successful Bridging Therapy in a 103-Year-Old Woman with Acute Terminal Internal Carotid Artery Occlusion

“…Indeed, these very elderly patients represent a highly vulnerable population, with more frailty, multiple comorbidities, and poorer functional outcomes. Arterial tortuosity is also more prevalent in the elderly than in younger patients, which could potentially preclude the benefit MT due to difficulty in accessing the occlusion site or increased complication rate [9]. The incidence of atrial fibrillation also increases with age, and it constitutes the most frequent cause of acute large vessel occlusion in elderly stroke patients [9].…”

“…Arterial tortuosity is also more prevalent in the elderly than in younger patients, which could potentially preclude the benefit MT due to difficulty in accessing the occlusion site or increased complication rate [9]. The incidence of atrial fibrillation also increases with age, and it constitutes the most frequent cause of acute large vessel occlusion in elderly stroke patients [9]. Our patient presented to the hospital within 1 h of stroke onset secondary to ICA-T occlusion, with an admission NIHSS score of 30.…”

“…We decided to undertake MT only in left ICA-T as her severe neurological deficits were more likely attributed to left ICA-T occlusion rather than PCA stenosis. A retrospective analysis of nonagenarians in the ETIS registry showed that MT could improve functional outcome when successful reperfusion was achieved after the first pass [9].…”

“…It remains controversial whether endovascular reperfusion therapy is beneficial for nonagenarians. A recent study by Ikeuchi et al [8] reported poor outcomes in patients aged 90 years and older after MT, while Drouard-de Rousiers et al [9] showed that successful reperfusion improved the functional outcomes of nonagenarians, particularly when first-pass recanalization could be achieved. We present a case of successful bridging therapy in a 103-year-old woman, the second oldest case with favorable outcome documented [10].…”

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

“…However, this subgroup was relatively small and represented only 15.5% of the overall patients (198 vs. 2,160 patients). HERMES and other large prospective studies found that compared to relatively younger age groups, older patients have lower probability to achieve a good functional outcome (90-day modified Rankin Scale [mRS] 0–2) with increased mortality [9-11]. Some studies have even questioned the utility of EVT in older patients, specifically older than 90 years, because of the low rate of favorable outcome and high rates of intracerebral hemorrhage and mortality [12, 13].…”