But many patients still have poor outcomes, highlighting the need for additional research.
Routine use of endovascular therapy among patients ages 80 and older with strokes caused by large-vessel occlusions results in better outcomes than IV thrombolysis alone, but poor outcomes are still common in these older patients, according to an analysis published online March 16, 2018, ahead of print in the Journal of NeuroInterventional Surgery.
The investigators, led by Andreas Kastrup, MD (Klinikum Bremen-Mitte, Bremen, Germany), write that several landmark trials have demonstrated the benefits of endovascular therapy over IV thrombolysis for the treatment of proximal intracranial occlusions of the anterior circulation across all age groups, including patients in their 80s.
“However,” they write, “advanced age was an exclusion criterion in two trials and the number of older patients included in the other trials was rather small, likely reflecting a selection bias.” They note that only 16% of patients in the MR CLEAN trial were ages 80 and older.
“In addition, several case series and registries have clearly shown that older patients have a poorer clinical outcome after [endovascular therapy] than younger patients, even despite adequate recanalization rates,” they write. Outcomes of endovascular therapy have yet to be directly compared to IV thrombolysis in octogenarians, they point out.
The investigators retrospectively analyzed prospectively-collected clinical and imaging data on patients ages 80 and older with distal intracranial carotid artery and/or M1/M2 occlusions treated between January 2008 and October 2017 at their institution. They compared outcomes between 217 patients treated with IV thrombolysis between January 2008 and October 2012 and 209 patients treated with endovascular therapy (with or without IV thrombolysis) between November 2012 and October 2017.
A greater proportion of patients in the endovascular therapy group had a good outcome, defined as a modified Rankin Scale (mRS) score ≤ 2, and an excellent outcome, defined as an mRS score 0-1. In addition, a significantly smaller proportion of patients treated with endovascular therapy died, had a poor outcome (mRS 5-6), or experienced symptomatic intracranial hemorrhage (ICH). Median ASPECTS at follow-up was higher in patients treated endovascularly compared with those treated using IV thrombolysis alone.
Outcomes: Endovascular Therapy vs IV Thrombolysis Alone
|
|
Endovascular Therapy (n = 209) |
IV Thrombolysis Alone (n = 217) |
P Value |
|
mRS 0-1 |
12% |
4% |
< 0.01 |
|
mRS ≤ 2 |
25% |
16% |
< 0.05 |
|
mRS 5-6 |
35% |
52% |
< 0.001 |
|
Mortality |
14% |
22% |
< 0.05 |
|
Symptomatic ICH |
1% |
6% |
< 0.01 |
|
Median Follow-Up ASPECTS |
7 |
6 |
< 0.05 |
Although routine use of endovascular therapy versus IV thrombolysis improved early clinical and radiological outcomes in these patients, every second patient after IV thrombolysis and every third patient after endovascular therapy had a very poor early clinical outcome, the authors report. “Irrespective of the treatment modality, the prognosis was even poorer in the subgroup of nonagenarians,” they add.
Since overall outcomes were relatively poor with the use of endovascular thrombectomy in older patients, the investigators conclude that further research is needed to clarify the role of this intervention in this patient population.
Source:
Kastrup A, Brunner F, Hildebrandt H, et al. Endovascular therapy versus thrombolysis in patients with large vessel occlusions within the anterior circulation aged ≥ 80 years. J Neurointerv Surg. 2018;Epub ahead of print.
Disclosures:
Kastrup reports no relevant conflicts of interest.
