Introduction Although endovascular thrombectomy (ET) is currently a standard of care in managing acute ischemic stroke, the design of major trials on ET either excluded or under-represented patients older than 80 years old. However, several centers in the US and internationally have expanded the use of ET in the elderly patients often using similar selection criteria to younger patients. In this work, we evaluated functional outcomes, complications, and predictors of outcome after ET in the elderly compared to younger patients.
Methods Records of patient undergoing ET for acute ischemic stroke at seven major centers in the United States between January 2013 and December 2017 were retrospectively reviewed for patient characteristics, procedural variables, complications, incidence of post-procedural hemorrhage and functional outcomes measured by 90 day mRS scores. Univariate and multivariate regression analysis were used to compare elderly patients (80 years and older) to younger adults and to determine whether advanced age (≥80 years) is an independent predictor of outcomes of stroke patients undergoing ET.
Results A total of 1406 patients (367 patients ≥80 years old) were included in analysis of which 1270 had completed follow-up. Octogenarians had significantly higher percentage of females (65.9% vs 46.3% p<0.05), higher baseline NIHSS (17.4 vs 16.05, p<0.05), and higher ASPECT scores (9 vs 8, p<0.05) compared to younger adults. There were no significant differences in pre-stroke mRS, time from onset to groin, IV-tpa use, and location of stroke (anterior vs posterior, p>0.05). The median number of comorbidities was 2 in both groups. Procedure variables including procedure time, rate IA-tpa use, final TICI flow, technique used (direct aspiration vs stent retriever), and the rate of complications were not different between the two groups (p>0.05). Elderly patients had a significantly higher median mRS at 90 day follow-up (4 vs 3, p<0.001), lower likelihood of functional independence (mRS 0–2) at 90 days (20% vs 43.5%, p<0.001), and higher mortality (37.9% vs 20.4%, p<0.001) compared to younger patients. Multi-variate analysis including patient demographics, comorbidities, procedural variables, and complications showed that age ≥80 years was an independent predictor of good outcomes (mRS 0–2) at 90 days, mortality and symptomatic ICH. Multivariate regression analysis for the elderly subset showed that older age, higher baseline NIHSS, presence of hyperlipidemia, longer procedure times and unsuccessful recanalization independently and positively correlated with mRS scores at 90 days.
Conclusion Although some randomized controlled trials have provided limited evidence of benefit for using ET in the elderly population, expanding ET to this population in the real-world requires careful refinement of patient selection. This study emphasizes that advanced age coupled to higher NIHSS on admission and an anticipated long procedure should prompt careful discussion of the risks and benefits of ET in the elderly.
Disclosures A. Alawieh: None. R. Starke: None. A. Chatterjee: None. A. Turk: None. R. De Leacy: None. A. Rai: 2; C; Stryker. K. Fargen: None. P. Kan: 2; C; Medtronics, Stryker. J. Singh: None. L. Vilella: None. F. Nascimento: None. T. Dumont: None. A. Spiotta: 1; C; Penumbra, Pulsar Vascular, Microvention, Stryker,. 2; C; Penumbra, Pulsar Vascular, Microvention, Stryker.
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