Author: Michele Romoli Male Doctor looking at Brain MRI Scan

X: @MicheleRomoli

With the global aging population, strokes among elderly individuals represent a growing challenge. Historically, age-related comorbidities and frailty often excluded patients over 80 from stroke trials, leading to uncertainty about treatment benefits in this population. However, recent evidence indicates that endovascular thrombectomy (EVT) can still yield meaningful benefits for elderly patients, including improved survival and functional outcomes, albeit with some limitations (Romoli et al., 2024; McDonough et al., 2022).

Insights from Randomized Trials – The HERMES collaboration provided robust evidence supporting EVT’s efficacy across age groups, including patients ≥85 years. Older patients had worse baseline prognoses and higher mortality but derived significant benefits from EVT compared to medical management alone. McDonough et al. (2022) highlighted that, despite worse functional outcomes, the treatment effect for EVT in patients ≥85 was comparable to younger cohorts, reinforcing the importance of offering EVT to elderly patients with appropriate clinical profiles. However, the HERMES sub-analysis faced certain limitations. The study included a small sample of patients aged ≥85 years (4.4% of the cohort), limiting the generalizability of its findings. Furthermore, the highly selective nature of trial participants may not represent the broader elderly population, many of whom have significant comorbidities. The controlled trial environment also differs from real-world clinical settings, where variability in operator experience and resources can influence outcomes.

Real-World Data on EVT in the Elderly – A 2018 meta-analysis by Hilditch et al. revealed that in the real-world setting approximately 27% of octogenarians undergoing EVT achieved functional independence (mRS ≤2) at 90 days, with successful recanalization rates of 78%. Although mortality was higher at 34%, these results underscore that EVT offers a substantial chance of recovery even in very elderly patients. Notably, symptomatic intracranial hemorrhage was reported in only 8% of cases, and procedural complications occurred in 11%, highlighting the safety of modern thrombectomy techniques for this population (Hilditch et al., 2018). Recently, the nationwide Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) also provided insights into EVT outcomes for patients aged 80 and above. While elderly patients generally exhibit lower rates of good functional outcomes (modified Rankin Scale 0–2) compared to younger cohorts, the net benefit of EVT was evident. Indeed, 34.1% of patients aged ≥80 achieved good outcomes. Despite an increased procedural difficulty and a slightly higher rate of complications, successful reperfusion was consistent across age groups, emphasizing that age alone should not be a contraindication for EVT.

Critical Considerations for EVT in the Elderly – Careful selection is essential, focusing on patients with favorable baseline characteristics, such as independent pre-stroke function and limited infarct core (Broussalis et al., 2015).There are also technical challenges: age-related anatomical changes can complicate vascular access, potentially increasing the risk of aborted procedures. However, advanced devices and techniques have mitigated these challenges.

It should in any case be noted that approximately 28–30% of patients ≥80 achieve mRS 0–2, significantly better than historical outcomes without EVT (Sharobeam et al., 2019), therefore supporting intervention also in this age group.

Conclusion – While EVT outcomes in the elderly may not match those of younger patients, the procedure remains beneficial, offering improved survival and reduced disability compared to conservative treatments. As the elderly population grows, expanding access to EVT through careful selection and procedural advancements is imperative. Future research should focus on optimizing strategies to enhance functional recovery and minimize complications in this vulnerable group.

References

  • Romoli M., Migliaccio L., Saia V., et al. Stroke thrombectomy in the elderly: A propensity score-matched study on a nationwide real-world registry. European Stroke Journal, 2024.
  • McDonough R.V., Ospel J.M., Campbell B.C.V., et al. Functional outcomes of patients ≥85 years with acute ischemic stroke following EVT: A HERMES substudy. Stroke, 2022.
  • Broussalis E., Weymayr F., Hitzl W., et al. Endovascular mechanical recanalization of acute ischaemic stroke in octogenarians. European Radiology, 2015.
  • Sharobeam A., Cordato D.J., Manning N., et al. Functional outcomes at 90 days in octogenarians undergoing thrombectomy for acute ischemic stroke: A prospective cohort study and meta-analysis. Frontiers in Neurology, 2019.
  • Hilditch C.A., Nicholson P., Murad M.H., et al. Endovascular management of acute stroke in the elderly: A systematic review and meta-analysis. American Journal of Neuroradiology, 2018

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