Despite a having a higher risk of poor outcomes and death compared with younger patients, the very elderly should not be barred from the therapy, the study authors say.
In patients aged 90 years and older who experience an anterior circulation stroke, mechanical thrombectomy can be safe and beneficial, data from a retrospective review suggest.
Most of the pivotal randomized trials demonstrating the benefits of mechanical thrombectomy for large-vessel occlusion (LVO) stroke excluded patients older than 80 or 85 years of age. “Those studies without an upper age limit enrolled only a small number of octogenarians, and even fewer nonagenarians,” write the study authors, who were led by Lukas Meyer, MD (University Medical Center Hamburg-Eppendorf and Klinikum Bremen-Mitte GmbH, Germany).
As a result, while mechanical thrombectomy is not contraindicated in those aged 90 years and older, available data in this group are “limited and inconsistent,” the investigators point out. What the existing evidence does suggest is that thrombectomy in elderly patients tends to carry a higher mortality risk and lower likelihood of good outcome than in younger patients, the researchers point out.
In their review, published online recently ahead of print in the Journal of NeuroInterventional Surgery, Meyer et al looked at 79 patients aged ≥ 90 years from three neurointerventional centers who underwent mechanical thrombectomy for anterior circulation stroke between 2013 and 2017.
Median time from groin puncture to recanalization was 39 minutes (IQR 25-57 minutes). The rate of successful recanalization, defined as TICI ≥ 2b, was 69.6%. Good functional outcome, defined as 90-day mRS ≤ 2, was observed in 16% of patients.
In-hospital mortality was 29.1%, and this increased significantly at 90 days to 46.7% (P < 0.001). Symptomatic intracranial hemorrhage occurred in 5.1% of patients.
The investigators did not identify any independent predictors of 90-day good functional outcome and speculate that factors such as low NIHSS score on admission and successful recanalization, which are favorable predictors in younger patients, may not apply to the very elderly.
Best Available Option
Mechanical thrombectomy in nonagenarians, although technically challenging, can be considered feasible and comparatively safe, Meyers and colleagues conclude. However, preexisting comorbidities, as well as hospitalization and rehabilitation, represent risk factors potentially leading to poor clinical outcomes and death in older patients regardless of the initial result of the procedure.
Despite the high mortality risk and given the lack of effective noninterventional therapies, the study authors say they do not recommend excluding nonagenarians from receiving mechanical thrombectomy.
“Instead, patients should be evaluated on a case-by-case basis, with specific consideration of the patient’s baseline medical condition and the severity of the stroke,” they suggest.
Meyer L, Alexandrou M, Leischner H, et al. J NeuroIntervent Surg. 2019;Epub ahead of print.
Meyer reports no relevant conflicts of interest.