Age over 80 years predicts poorer functional outcome and higher mortality in patients with acute ischemic stroke treated using a stent-retriever device, according to a registry study published online October 30, 2014, ahead of print in Stroke. Mechanical thrombectomy with stent retrievers has shown promise, but data in older patients have been limited, the authors say.

At 90 days, older patients had higher mortality and were less likely to have a favorable functional outcome than younger patients, although no difference was seen between the groups in symptomatic intracranial hemorrhage (table 1).

In addition, the mean National Institutes of Health Stroke Scale (NIHSS) score was 20.9 in the younger group and 28.4 in the older group (P = .02). More of the older patients received intraarterial tissue plasminogen activator during the procedure (38.5% vs. 25.4%; P = .02). Use of rescue therapy was similar between the groups, as were other procedural characteristics and all angiographic outcomes including TIMI flow and the rates of distal embolization and embolization into new territory.

On multivariate analysis, older age and use of general anesthesia were independent predictors of clinical outcome and mortality in the overall study population. Independent predictors of mortality in patients older than 80 years were initial NIHSS score, lack of revascularization success, rescue therapy use, and symptomatic intracranial hemorrhage.

Elderly Patients Should Not Be Denied Stent Retriever

In an email interview with TCTMD, Dr. Zaidat cautioned against interpreting the findings to mean that older patients are not candidates for this treatment. “The elderly may not do as well as the young but may still do better than those who were not treated with thrombectomy,” he said.

He also noted that the age cutoff of 80 years is derived from a subgroup analysis showing trends based on age. Dividing the group every 10 years reveals a sharper change of outcomes at 80 years than at earlier age deciles, Dr. Zaidat said.

The lack of comparison with medical therapy limits interpretation of the study, said Jan Gralla, MD, MSc, of the University of Bern (Bern, Switzerland), who has participated in other research on the Solitaire FR device. Though in an email interview with TCTMD, Dr. Gralla agreed that the results do not suggest older patients should be excluded from receiving the treatment. “From what we know so far, the outcome in general in the elderly patients is worse compared to younger patients,” he said. “Nevertheless, studies do show a benefit from treatment, and some patients have a very good recovery due to treatment.”

Dr. Gralla said an individualized approach to treatment should be taken in patients over 80, with comorbidities, amount of salvageable brain tissue, and other factors playing big roles in decision making. “This group has to be taken seriously and be addressed in further studies,” he asserted, adding, “Due to the dramatic increase in age in our countries, this will be a large fraction of stroke patients, and if a treatment can reduce morbidities after stroke among them, this is highly cost-effective.”

Dr. Zaidat said clinicians should carefully assess several variables before making treatment decisions in elderly patients. He suggested qualifications for thrombectomy in those over 80 may include a clean CT scan with a good Alberta Stroke Program Early CT score, a time to groin puncture within 6 hours of symptom onset, and a favorable penumbral imaging pattern.

Source: 
Castonguay AC, Zaidat OO, Novakovic R, et al. Influence of age on clinical and revascularization outcomes in the North American Solitaire: Stent-Retriever Acute Stroke registry. Stroke. 2014;Epub ahead of print.

Related Stories:

• Stent Retriever Leads to Procedural Success, Poorer Outcomes in Nonstandard Acute Stroke Patients
• Stent Retriever Device Shows Promise in Acute Ischemic Stroke
• Novel Clot Retrieval System Superior to Older Device in Acute Stroke Patients