EVT outcomes poorer in ischaemic stroke patients ≥80 years old

Outcomes after endovascular thrombectomy (EVT) in patients ≥80 years old were significantly worse than those in their younger counterparts, a Hong Kong stroke centre study has found.

In this 4-year (2020 to 2024) retrospective study of electronic data of 340 patients (aged ≥80 years, n=89; aged <80 years, n=251) from Tuen Mun Hospital stroke centre’s acute ischaemic stroke registry, >80 percent of those aged ≥80 years treated with EVT required moderate functional dependence, and 25 percent died within 90 days post-EVT. [J Stroke Cerebrovasc Dis 2024;34:108130]

Timely EVT is beneficial and essential in managing acute thromboembolic cerebrovascular accidents. In the study cohort, decision for EVT in patients who presented with acute ischaemic stroke was based on mutual discussions among referring neurologists and neurointerventionists, taking into consideration the following: (1) interval from onset or last-seen-well confirmation ≤24 hours; (2) contraindication to intravenous (IV) thrombolysis with tissue plasminogen activator (tPA) or nonresponse to IV tPA with no resolution of neurological symptoms; (3) modified Rankin scale (mRS; a measure of functional independence) score of 0–2 prior to symptom onset; (4) preoperative National Institutes of Health Stroke Scale (NIHSS) score ≥6; (5) Alberta Stroke Program Early CT Score (ASPECTS) ≥6; and (6) appropriate perfusion mismatch profile based on the DEFUSE 3 study. EVT was performed after informed consent when its benefit was considered to outweigh potential harm. [N Engl J Med 2015;372:394; J Emerg Med 2018;55:151; J Emerg Med 2018;54:583-584; J Emerg Med 2018;55:151]

Compared with the younger group aged <80 years, the octogenarian group had poorer primary outcome in terms of 90-day functional independence (mRS; overall risk [OR], 0.28; 95 percent confidence interval [CI], 0.15–0.53; p<0.001) and 90-day selfcare independence (OR, 0.35; 95 percent CI, 0.21–0.64; p<0.001), as well as a slightly higher overall chance of postprocedural death (OR, 1.48; 95 percent CI, 0.85–2.60, p=0.08). Subgroup analysis with more advanced age cut-off at 90 years further demonstrated that advanced age was associated with more devastating neurological outcomes.

Significantly more octogenarians vs those aged below 80 years had dependent premorbid status (mRS >2, 4.5 vs 1.2 percent; p<0.001), possibly due to higher prevalence of cardiovascular risk factors (hypertension, 86.5 vs 75.8 percent, p<0.05; atrial fibrillation, 69.7 vs 45.2 percent, p<0.001). The authors postulated that this could be a possible explanation for the poorer post-EVT outcomes in the octogenarians compared with their younger counterparts. More complicated pre-EVT chronic medical comorbidities, which increased susceptibility to nosocomial infection, possibly explained the higher mortality in the elder group. Pretreatment NIHSS score and onset-to-groin puncture time in both groups were similar (p=0.43 and 0.18, respectively).