Introduction Patients over 80 years old account for one third ischemic strokes in the developed world, with an overall poor outcome. Although current guidelines do not recommend an upper age limit for endovascular approach, the benefit in the elderly population is still uncertain. In spite of efforts to identify criteria associated with good outcomes in this age range, literature has not found any yet. We aimed to use novel tools being reported in stroke literature, such as First Pass Effect (FPE) and Hypoperfusion Intensity Ratio (HIR), to optimize elderly patient selection for thrombectomy.
Methods A single-center retrospective analysis of a prospectively maintained large vessel occlusion database (2014–2019) was conducted. We included patients ≥80 years old with acute ischemic stroke that underwent endovascular thrombectomy. First pass thrombectomy was defined as single attempt obtaining TICI 2b or higher without distal embolization, as previously stated in literature. Collaterals were assessed based on HIR (good collaterals <0.4; poor collaterals ≥0.4). Baseline characteristics, procedural data, and outcomes were evaluated. The association between clinical and procedural variables and outcomes at 90 days was assessed.
Results A total 146 patients were included in the study. Mean age was 87.8±4.12 (range 80–100) and 65.75% were female. Pre-stroke functional independence (baseline mRS 0–2) was seen in 64.1%. Median time of onset to groin puncture was 261.5 minutes and mean time from groin puncture to recanalization was 37.15 minutes. Good collaterals were seen in 50.9% of patients. Successful reperfusion (TICI 2b or higher) was achieved in 87.1%. The rates of good outcome (mRS 0–2), acceptable outcome (mRS 0–3) and poor outcome (mRS 4–6) at 90 days were 18.5%, 38.1% and 43.4%, respectively. Multivariate logistic regression indicated that pre-stroke functional independence (p=0.0008), good collaterals (p=0.0009), use of stent retriever (Solitaire, p=0.035; Trevo, p=0.032) and balloon guide catheter (p=0.028) were associated with good outcome.
Conclusions In our retrospective cohort of elderly patients treated with thrombectomy, the baseline characteristics that appear to influence in the rate of good outcome were the pre-stroke functional independence and the presence of good collaterals. Although previous studies with younger populations showed promising use of First Pass Effect measure to predict good outcome in patients who underwent thrombectomy, we did not find any significant association in patients ≥80-year-old. Preference for the use of stent-retriever and balloon guide-catheter may shorten the time to reperfusion and therefore, provide better outcomes. We emphasize the need of further studies to improve selection criteria for endovascular thrombectomy in this population.
Disclosures A. Monteiro: None. G. Cortez: None. Y. Murtaza: None. A. Aghaebrahim: None. E. Sauvageau: None. R. Hanel: 2; C; Microvention, Codman, Stryker, Medtronic.
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