The findings suggest the need for further refinement and optimization of selection criteria for thrombectomy.
The benefits of endovascular therapy for acute ischemic stroke are not as great among patients aged 80 and older in comparison with younger populations, according to a multicenter database analysis. Its authors call for increased research into the appropriate selection of elderly patients for this intervention.
Now that endovascular therapy has been widely accepted as the first-line standard of care for the treatment of acute ischemic stroke, patient selection often strays outside the strict criteria put forth in the pivotal randomized controlled trials that confirmed its benefits, lead author Ali Alawieh, MD (Medical University of South Carolina, Charleston, SC), and colleagues note in their paper published online December 4, 2018, in the Journal of NeuroInterventional Surgery.
One subgroup of patients routinely left out of large clinical trials is the elderly, specifically those aged 80 and older. Even when these patients were included in trials, outcomes data remained inconclusive. Currently, the authors point out, “many conclusions about the efficacy and safety of [endovascular therapy] in the elderly have been reached based on single-arm, single-institution studies with significant heterogeneity across studies, often without comparison with optimal medical management.”
Determining the role of endovascular therapy in elderly patients is an important area of investigation, as the number of these patients presenting with acute ischemic stroke is increasing, they add.
For the study, Alawieh and colleagues reviewed a prospectively maintained database of 1,346 patients who underwent endovascular therapy for acute ischemic stroke at one of seven US-based comprehensive stroke centers between January 2013 and January 2018.
Among 1,226 patients included in multivariate analysis, age ≥ 80 was independently associated with an increased risk of mortality and poor outcome, defined as a 90-day mRS > 2. Older age remained a predictor of poor outcome when patients were divided according to thrombectomy technique, location of stroke, or success of recanalization.
Other independent predictors of outcome included prestroke health, posterior circulation stroke, and final TICI score, among others.
Predictors of Poor Outcome and Mortality on Multivariate Analysis
|
|
Good Outcome OR (95% CI) |
P Value |
Mortality OR (95% CI) |
P Value |
|
Age ≥ 80 |
0.40 (0.34-0.47) |
< 0.001 |
2.23 (1.9-2.61) |
< 0.001 |
|
Prestroke mRS |
0.75 (0.7-0.8) |
< 0.001 |
1.29 (1.22-1.36) |
< 0.001 |
|
Baseline NIHSS Score |
0.90 (0.89-0.91) |
< 0.001 |
1.09 (1.08-1.1) |
< 0.001 |
|
Posterior Circulation Stroke |
0.48 (0.38-0.59) |
0.001 |
2.14 (1.74-2.64) |
< 0.001 |
|
Number of Pass Attempts |
0.84 (0.8-0.87) |
< 0.001 |
0.88 (0.85-0.92) |
0.004 |
|
TICI Score |
1.24 (1.17-1.31) |
< 0.001 |
1.14 (1.07-1.21) |
0.038 |
In addition, age ≥ 80 independently predicted a higher rate of postprocedural hemorrhage (OR 1.59; 95% CI 1.13-2.24), but not the success of recanalization.
Findings Exist Despite Hyperselection of Elderly Patients
The authors conclude that the large effect size of endovascular therapy on acute ischemic stroke is diminished among elderly patients.
“This outcome disparity is apparent despite evidence suggesting a nonstandardized degree of ‘hyperselection’ of the elderly, as reflected in higher rates of low baseline mRS score and higher ASPECTS (smaller core infarcts) at presentation, a phenomenon that may reflect practitioners more stringent selection criteria for elderly patients,” write Alawieh et al.
“Given the US healthcare system’s emphasis on cost-effectiveness and value-based care with an increasingly aging population further emphasizing these systems of care, our findings underline the need for further refinement and optimization of selection criteria for elderly patients being considered for thrombectomy,” they conclude.
Source:
Alawieh A, Starke RM, Chatterjee AR, et al. Outcomes of endovascular thrombectomy in the elderly: a ‘real-world’ multicenter study. J NeuroIntervent Surg. 2018;Epub ahead of print.
Disclosures:
Alawieh reports no relevant conflicts of interest.
