Objective Advanced age is a known risk factor for poorer outcomes after surgical and interventional procedures. The objective of this study is to evaluate the role of neurointerventional procedures in the treatment of acute stroke in elderly patients. The impact of neurovascular interventional therapy on patient outcomes will be compared with less invasive methods of treatment such as intravenous thrombolytic therapy and conservative management.
Methods Retrospective review of medical records of patients ≥75 years of age who were admitted to our facility with a diagnosis of acute ischemic stroke between 2006 and 2010 was performed. These patients were stratified into three categories according to management: (1) conservative management including diagnostic cerebral angiograms as part of work-up, (2) administration of intravenous t-PA with or without subsequent diagnostic cerebral angiograms, and (3) neurovascular intervention with or without prior intravenous t-PA. Types of intervention included intra-arterial t-PA and use of mechanical thrombolytic techniques. Patients who initially presented with intracranial hemorrhage and those with incomplete medical records at time of review were excluded. Outcomes measured were NIH stroke scale (NIHSS) scores at admission and at discharge, complications related to hemorrhagic conversion of ischemic stroke, survival to discharge from the hospital, and discharge disposition. Student t test was used for statistical analysis.
Results A total of 379 patients were included in this study. The conservative management group consisted of 266 patients. 66 patients were given intravenous t-PA without neurovascular intervention. 47 patients received neurovascular intervention with or without prior intravenous t-PA. In the first group, the average NIHSS score at admission was 4.71 (SD 6.69) and at discharge was 2.00 (SD 3.53). 24 patients (9.0%) in this group did not survive to discharge, and two patients (0.8%) developed intracranial hemorrhage after admission. In the second group, the average NIHSS score at admission was 11.26 (SD 7.38) and at discharge was 3.91 (SD 5.60). Eight patients (12.1%) in this group did not survive to discharge, and five patients (7.5%) developed intracranial hemorrhage. In the third group, the average NIHSS score at admission was 18.33 (SD 7.19) and at discharge was 8.48 (SD 6.38). 21 patients (44.7%) did not survive to discharge, and 11 patients (23.4%) developed intracranial hemorrhage. Three patients (6.4%) in the third group were discharged to home, with the remaining surviving patients requiring inpatient rehabilitation or a skilled nursing. 29 patients (43.9%) in the second group and 156 (58.6%) patients in the first group were discharged to home.
Conclusions Patients who were treated with neurovascular intervention had higher rates of intracranial hemorrhage and death, and greater requirement for rehabilitation or skilled nursing at discharge compared to patients who were treated conservatively. Patients receiving neurovascular intervention had significantly higher NIHSS scores on presentation, likely at least partially accounting for their poorer outcomes. Preliminary review of the data demonstrates that the current triage process is effective in reserving aggressive therapy for more severely affected patients where the benefits may outweigh the risks.
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