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By Dr Nicolas Martinez-Majander, Department of Neurology, Helsinki University Hospital, Finland

An 83-year-old woman was admitted to our hospital with right hemiparesis, dysphasia and left-sided gaze deviation (NIHSS 19) 40 minutes after symptom onset. She was an ex-smoker with paroxysmal atrial fibrillation, hypertension and dyslipidemia. The patient was on warfarin. Pre-stroke mRS was considered 0. Initial non-contrast CT showed only mild leukoaraiosis, but no signs of acute ischemia or intracranial hemorrhage. For unknown reasons the point-of-care INR was only 1.3 and the patient received thrombolysis 16 minutes after admission. Furthermore, CT angiography showed a left-sided M1 occlusion with moderate collaterals.

In addition, mechanical thrombectomy (MT) was successfully performed, with a complete recanalization (TICI 3) 154 minutes after symptom onset. There were no acute complications and patient was transferred to our Stroke Unit. However, 24 hours control CT demonstrated a medium-sized ischemic lesion in the left MCA area, with parenchymal hemorrhage (1,3 x 2,1 x 1,1 cm, with ECASS2 classification PH2) located in the infarcted area. At this point, she still had severe hemiparesis and she was mute, NIHSS 24.

Control CTs during the following weeks showed hematoma resorption, but after 90 days she was still bedridden, and was admitted to a long-term nursing home (mRS 5). Anticoagulation was not considered safe to restart and she was not fit enough for left atrial appendage closure.

As we all know, management of acute ischemic stroke caused by a large vessel occlusion with MT has been proven efficient and safe. However, real-world data on outcomes of MT in the elderly is scarce. A recent MR Clean registry-based study by Groot and colleagues showed that older age was associated with an increased absolute risk of poor outcome compared to younger patients (adjusted OR for a mRS score shift toward better outcome 0.31, 95% CI 0.24-0.39).1 Elderly patients had also higher mortality, 51% vs 22%, aOR  3.12, 95% CI 2.04-5.10). However, with successful reperfusion, these patients still seemed to have a relative benefit from MT. This topic was further discussed by doctors Sposato and Lorenzano in their editorial.2 As they mention, the age distribution of population is getting older in developed countries and individuals older than 80 years are the ones with the highest risk of ischemic stroke. However, these patients are underrepresented in trials and their outcome in real world practice may be worse than in trials, despite the similar rates of reperfusion and symptomatic ICH1,2

In 2018, a systematic review and meta-analysis including 17 studies on 860 elderly patients treated with MT showed that up to 27% of these patients had a good functional outcome at 3 months, defined as mRS 2 or less.3 The incidence of symptomatic ICH was 8% (vs incidence of any ICH 24%) and 34% of patients were dead at 3 months. After this analysis, similar results have been reported elsewhere. Sharobeam and colleagues analyzed 649 patients aged ≥80 years and showed good recovery also in 30% patients, with mortality rate of 26% at 3 months.4 Even more recent study focusing on patients older than 90 years of age also reported good functional outcome (here defined as mRS ≤3) in 22%, symptomatic ICH in 3%, and mortality in 49% of all 203 included patients at 3 months5.

In conclusion, although elderly patients may have higher mortality and less frequently favorable outcome compared to younger patients, age is not a contraindication for MT. More data on octogenarians are still needed to verify these findings.

References

  1. Groot AE, Treurniet KM, Jansen IGH, et al. Endovascular treatment in older adults with acute ischemic stroke in the MR CLEAN Registry. Neurology. 2020;95(2):e131-e139.
  2. Sposato LA, Lorenzano S. Real-world data for mechanical thrombectomy in the elderly population: A red flag? Neurology. 2020;95(2):57-58.
  3. Hilditch CA, Nicholson P, Murad MH, et al. Endovascular Management of Acute Stroke in the Elderly: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2018;39(5):887-891.
  4. Sharobeam A, Cordato DJ, Manning N, Cheung A, Wenderoth J, Cappelen-Smith C. Functional Outcomes at 90 Days in Octogenarians Undergoing Thrombectomy for Acute Ischemic Stroke: A Prospective Cohort Study and Meta-Analysis. Front Neurol. 2019;10:254. Published 2019 Mar 20.
  5. Meyer L, Alexandrou M, Flottmann F, et al. Endovascular Treatment of Very Elderly Patients Aged ≥90 With Acute Ischemic Stroke. J Am Heart Assoc. 2020;9(5):e014447.