Mechanical Thrombectomy in Elderly Stroke Patients with Mild-to-Moderate Baseline Disability

Abstract

Background: The number of elderly patients suffering from ischemic stroke is rising. Randomized trials of mechanical thrombectomy (MT) generally exclude patients over the age of 80 years with baseline disability. The aim of this study was to understand the efficacy and safety of MT in elderly patients, many of whom may have baseline impairment. Methods: Between January 2015 and April 2017, 96 patients ≥80 years old who underwent MT for stroke were selected for a chart review. The data included baseline characteristics, time to treatment, the rate of revascularization, procedural complications, mortality, and 90-day good outcome defined as a modified Rankin Scale (mRS) score of 0–2 or return to baseline. Results: Of the 96 patients, 50 had mild baseline disability (mRS score 0–1) and 46 had moderate disability (mRS score 2–4). Recanalization was achieved in 84% of the patients, and the rate of symptomatic hemorrhage was 6%. At 90 days, 34% of the patients had a good outcome. There were no significant differences in good outcome between those with mild and those with moderate baseline disability (43 vs. 24%, p = 0.08), between those aged ≤85 and those aged > 85 years (40.8 vs. 26.1%, p = 0.19), and between those treated within and those treated beyond 8 h (39 vs. 20%, p = 0.1). The mortality rate was 38.5% at 90 days. The Alberta Stroke Program Early CT Score (ASPECTS) and the National Institutes of Health Stroke Scale (NIHSS) predicted good outcome regardless of baseline disability (p < 0.001 and p = 0.009, respectively). Conclusion: Advanced age, baseline disability, and delayed treatment are associated with sub­optimal outcomes after MT. However, redefining good outcome to include return to baseline functioning demonstrates that one-third of this patient population benefits from MT, suggesting the real-life utility of this treatment.

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

“…In the present series, patients with a prestroke mRS 1 had similar odds as patients with a prestroke mRS 0 of having a good outcome at 90 days while a prestroke mRS 2 was associated with poor functional outcome irrespective of age (multilevel OR: 0.31, 95% CI: 0.16–0.60, p = 0.001). Other authors have found a similar tendency of good outcomes at 90 days in patients with mild to moderate disability irrespective of age [22]. Nevertheless, even an mRS of 3 in elderly patients may allow them to live at home with some assistance, not needing nursing home care and thus reducing the need for rehabilitation and costs for society [23, 24].…”

“…The mRS score was assigned as follows: 0, no symptoms; 1, no clinically relevant disability; 2, slight disability (able to look after own affairs without assistance but not to a full extent); 3, moderate disability (requires some help but able to walk unassisted); 4, moderately severe disability (unable to attend to own bodily needs or to walk without assistance); 5, severe disability (requires constant nursing care); and 6, dead. We defined stroke etiology according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification [22].…”

Evolution of the stroke paradigm: A review of delayed recanalization

“…23 Similarly, others have shown that the mortality rate in patients greater than 80 treated with mechanical thrombectomy beyond 8 h of symptom onset was not significantly higher than patients treated within 8 h of symptom onset (56% versus 32.4%, p = 0.055); although not statistically significant, the mortality number was certainly higher among the group with an initial moderate disability compared to the group with mild disability. 33 Because of the small sample size, the lack of significance in mortality rates may be attributed to a statistical type-2 error, and additional studies are needed with a higher power to establish if mortality rates are significantly increased due to recanalization outside of 8 h from stroke onset.…”

Mechanical thrombectomy for acute stroke in pregnancy

“…8,[13][14][15][16][17][18][19][20][21][22][23][24][25] Older patients, however, have shown to have a suboptimal benefit from mechanical thrombectomy, often due to reduced recanalisation success secondary to tortuous atherosclerotic vasculature. 26,27 When looking at patients of a younger population, Mocco et al first brought together a study comprising seven patients under 35 years of age who all underwent endovascular stroke intervention. 28 Five out of seven regained independent function at time of discharge, whilst the remaining two were found to have regained functional independence by the time of follow-up at 25 months.…”

“…Older patients, however, have shown to have a suboptimal benefit from mechanical thrombectomy, often due to reduced recanalisation success secondary to tortuous atherosclerotic vasculature. 26,27…”