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Reperfusion for Nonagenarians Treated by Mechanical Thrombectomy
Study Questions:
Do nonagenarians with ischemic stroke caused by large vessel occlusion (LVO) who are treated with mechanical thrombectomy do better if successful reperfusion is achieved?
Methods:
This is a retrospective analysis of 124 patients aged >90 years with anterior or posterior circulation ischemic stroke caused by LVO treated with endovascular therapy at one of seven different stroke centers between October 2013 and April 2018. Successful reperfusion was defined as thrombolysis in cerebral infarction (TICI) ≥2b flow after the endovascular procedure, and patients were divided into two groups according to whether or not successful reperfusion was achieved. The primary outcome was a favorable functional outcome at 90 days, as defined by a modified Rankin scale (mRS) score of 0-2 or a score equal to the prestroke mRS. Secondary outcomes included a good 90-day outcome (mRS 0-3 or equal to the prestroke mRS) and 90-day all-cause mortality.
Results:
At 90 days, 28/124 (22.6%) patients had a favorable outcome, 39/124 (31.5%) had a good outcome, and 41/124 (33.1%) had died. Patients with successful reperfusion had lower 90-day mRS scores than patients without successful reperfusion (odds ratio [OR], 3.26; 95% confidence interval [CI], 1.03-10.25). Of those with successful reperfusion, 52.6% (50/95) received intravenous (IV) tissue plasminogen activator (tPA), whereas of those without successful reperfusion, 33.3% (9/27) received IV tPA. In the group of patients who had successful reperfusion compared to those without successful reperfusion, only those with successful reperfusion after the first pass (53/97 or 55.6%) had decreased odds of 90-day mortality (adjusted OR [aOR], 0.16; 95% CI, 0.04–0.42) and increased odds of a good outcome (aOR, 7.06; 95% CI, 1.87–26.63). Increased odds of a favorable outcome were not observed (aOR, 2.69; 95% CI, 0.74-9.77).
Conclusions:
At 90 days, about one-third of nonagenarians with ischemic stroke caused by LVO treated with mechanical thrombectomy had a good outcome (mRS 0-3) and about one-third were dead. Outcomes were better if successful reperfusion was achieved.
Perspective:
These results are not surprising given that successful (as compared to unsuccessful) reperfusion is associated with better outcomes in non-nonagenarians. Of note, this study did not “answer the question of the benefit-risk ratio of endovascular therapy in very elderly patients” because it did not compare the outcomes of patients who underwent mechanical thrombectomy to those who did not undergo mechanical thrombectomy.
Keywords: Aged, 80 and over, Brain Ischemia, Cerebral Infarction, Endovascular Procedures, Geriatrics, Reperfusion, Secondary Prevention, Stroke, Thrombectomy, Tissue Plasminogen Activator, Treatment Outcome
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