Predictors of outcome after mechanical thrombectomy for acute ischemic stroke in patients aged ≥90 years

Highlights

• Mechanical thrombectomy in very elderly patients is challenging due to age-related impairment of vascular structures.

• Rate of procedural complication is not significantly higher compared to younger patients.

• Despite high mortality rate and moderate overall outcome some nonagenarians do benefit greatly from MT.

• Long-term outcome is predicted by stroke severity (baseline NIHSS, occluded vessel) and hospital arrival time.

Abstract

Background

Mechanical thrombectomy (MT) has established its role as a first-line treatment of acute ischemic stroke due to large vessel occlusions (LVO). However, patients older than 85 or even 80 years of age are commonly excluded from large randomized controlled stroke studies as this group was found to be associated with significantly poorer clinical outcome and increased mortality compared to younger patients. The aim of this study was to evaluate clinical and procedural factors associated with clinical outcome and mortality among nonagenarians with acute ischemic stroke treated with mechanical thrombectomy.

Materials and Methods

This retrospective, single-center study was conducted on 38 patients with LVO treated with MT. Clinical features including baseline results, radiological imaging, procedural details and outcome results were documented and evaluated. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS) and after 3 months (mRS).

Results

The rate of successful recanalization (TICI ≥2b) was 84.2 % (32/38). Symptomatic intracranial hemorrhage (sICH) was observed in 3 (7.9 %) patients. After 90 days, the mortality rate was 47.4 %. Favorable clinical outcome (mRs 0−2) was regained in 28.9 % of the patients (11/38). Poor clinical outcome (mRs<2) was observed in 9 patients (23.7 %).

Conclusion

Very elderly patients with LVO should not be excluded from MT even if prognosis for good clinical outcome in this age group remains low and the procedure is more challenging. Long-term outcome is predicted by stroke severity (baseline NIHSS and occluded vessel) and hospital arrival time.

Introduction

Mechanical thrombectomy (MT) has established its role as a first-line treatment of acute ischemic stroke due to large vessel occlusions (LVO) [1]. However, patients older than 85 or even 80 years of age are commonly excluded from large randomized controlled stroke studies as this group was found to be associated with significantly poorer clinical outcome and increased mortality compared to younger patients [2]. Therefore, even though the advanced age is not considered a contraindication for MT, no clear recommendations on treatment of very elderly patients (aged ≥90) with LVO have been included into recent guidelines of European Stroke Organization [3]. Nonetheless, with expected doubling of the percentage of people over 80 both in the European Union and in the United States by year 2050 and increased incidence of stroke among octogenarians and nonagenarians, it is necessary to investigate the efficacy of MT in this age group and to define predictors of favorable outcome in order to identify patients likely to benefit the most from this treatment [4,5]. Especially considering documented successful endovascular stroke management in patients over 100 years of age who recovered well [6].

The aim of this study was to evaluate clinical and procedural factors associated with clinical outcome and mortality among patients ≥90 years of age with acute ischemic stroke treated with mechanical thrombectomy.