Mechanical Thrombectomy in Nonagenarians: A Propensity Score Matched Analysis

Agarwal, Shashank; Huang, Jeffrey; Scher, Erica; Farkas, Jeffrey; Arcot, Karthikeyan; Gordon, David; Turkel‐Parrella, David; Tiwari, Ambooj; Liff, Jeremy; Yaghi, Shadi; Dehkharghani, Seena; Ishida, Koto; Riina, Howard A.; Frontera, Jennifer A.

doi:10.1016/j.jstrokecerebrovasdis.2020.104870

Cited by 10 publications

(4 citation statements)

References 26 publications

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“…When comparing outcomes to other retrospective studies, Agarwal et al note only 44% of nonagenarian patients in their study were discharged to rehab, which is even lower than seen in our cohort. [5] A lack of delayed outcome data, such as 90-day mRS and disposition, is a notable limitation of this study. The source data is also lacking on baseline comorbidities, however, low sample size makes it difficult to control for these regardless, as it is for other interventional variables that were available such as time from onset to thrombolysis/revascularization.…”

Section: Discussionmentioning

confidence: 95%

Resource Considerations for Acute Ischemic Stroke Intervention in Nonagenarians

Gandhi,

Hollender,

Chukwuneke

et al. 2024

Preprint

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Background: While there is evidence to support the viability of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) as treatments for acute ischemic stroke (AIS) even in the very elderly, there are practical considerations to be made regarding triage and resource allocation, particularly in a hub-and-spoke system of stroke intervention. Methods: This is a cross-sectional study using stroke quality registry data from 2017-2021 at a comprehensive stroke center serving as the primary hub for an associated healthcare system. We identified patients aged 90 or above who received acute stroke treatment with IVT and/or MT. NIHSS, modified Rankin Score (mRS), transfer status, length of stay (LOS), and discharge disposition were examined. Results: Out of 268 total nonagenarians admitted for AIS, 60 received an acute intervention (37 IVT, 14 MT, 9 both). All MT attempts resulted in successful reperfusion (>TICI2b). Median initial and discharge mRS were 2 and 5 respectively; only 3.3% were discharged home, with 46.7% of patients either deceased or discharged to hospice. Median LOS was 5 days (range 0-77), but prolonged LOS was common, with 11 patients having LOS >14 days. Comparing the groups who received MT vs. IVT alone, the median initial NIHSS was 17 vs. 15 (p=0.23); the MT group had better baseline mRS (1 vs 3, p=0.005), but despite this, there were no significant differences in mortality (57% vs 41%) or discharge mRS (5 vs. 5). Median LOS was not significantly different (6 vs. 5 days). Mortality in MT was 75% for transfers vs. 53% for local arrivals (p=0.36). Conclusion: Despite safe and technically successful treatment, outcomes were poor overall in the nonagenarian population after both MT +/- IVT, with very high morbidity and mortality.

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Section: Discussionmentioning

confidence: 95%

Resource Considerations for Acute Ischemic Stroke Intervention in Nonagenarians

Gandhi,

Hollender,

Chukwuneke

et al. 2024

Preprint

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“…41 Some data from single centers show no difference between octogenarians and nonagenarians 42 or younger patients, 43 and no difference in discharge disposition between younger patients (<69 years) and nonangenarians. 44 There has been one meta-analysis for this topic showing high revascularization rates in nonagenarians with low rates of good clinical outcomes. 45…”

Section: Standardsmentioning

confidence: 99%

Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

Al‐Mufti

Schirmer

Starke

et al. 2021

J NeuroIntervent Surg

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BackgroundThe purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis.MethodsWe performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged <18 years and >80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence.ResultsMT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.

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“…11 Similarly, a recent study comparing EVT outcomes in nonagenarians to adults ≤69 years old showed similar rates of favorable disposition and of in-hospital deaths between the 2 groups. 14 Patients with baseline disability are also often excluded from clinical trials of EVT and in clinical practice. A recent study challenged this construct, suggesting that patients with premorbid disability (mRS score 2-4) undergoing EVT achieve benefit in terms of accumulated disability.…”

Section: See Related Article P 2746mentioning

confidence: 99%

Treat or Retreat: Reasons for Deferral of Endovascular Therapy for Large Vessel Occlusion Stroke

Camargo

Jadhav

2021

Stroke

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ndovascular therapy (EVT) has revolutionized the care of patients with acute ischemic stroke (AIS) and is now recognized as one of the most effective interventions to improve clinical outcomes, with a number needed to treat as low as 2 to 3. [1][2][3][4][5] Despite its benefits, EVT has been mainly applied to baseline functionally independent patients with severe clinical symptoms in the setting of a proximal large vessel occlusion of the anterior circulation with small core volume. Furthermore, access to EVT-capable centers may be limited. Hence, the percentage of patients that currently receive EVT for AIS has been reported as low as 1.9% to 20.6% in industrialized nations. 6,7 EDITORIAL

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Mechanical Thrombectomy in Nonagenarians: A Propensity Score Matched Analysis

Cited by 10 publications

References 26 publications

Resource Considerations for Acute Ischemic Stroke Intervention in Nonagenarians

Resource Considerations for Acute Ischemic Stroke Intervention in Nonagenarians

Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

Treat or Retreat: Reasons for Deferral of Endovascular Therapy for Large Vessel Occlusion Stroke

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