Ask your competent? doctor EXACTLY HOW THEY ARE GOING TO GET EVERY PATIENT FULLY AMBULATORY at 90 days! NO plans? You don't have a functioning stroke doctor! Why are you seeing them?
EVT on Large Core Strokes: Sobering Results for the Oldest Old
Successful reperfusion associated with good functional outcomes(Not true according to your statistics!) regardless of age
The older the patient, the worse the functional outcome tended to be after endovascular thrombectomy (EVT) for an acute ischemic stroke with a large infarct, observational data suggested.
Based on a German multicenter registry, the likelihood of independent ambulation at 90 days (modified Rankin Scale [mRS] score of 0-3) following thrombectomy dropped steadily as age increased (P<0.001):
(This is definitely a sign of doctor failure!)
- 56.4% in patients 60 years and younger
- 36.5% in those 61-70
- 20.2% ages 71-80
- 15.1% in those older than 80 years
Similarly, the risk of 90-day mortality (mRS score of 6) was increasingly unfavorable with older age (P<0.001): (This is definitely a sign of doctor failure!)
- 15.4% at age 60 and below
- 31.8% in those 61-70
- 52.1% at ages 71-80
- 64.3% for those older than 80 years
Age over 80 was confirmed to be an independent predictor of less independent ambulation (adjusted OR 0.44, 95% CI 0.23-0.82) and more mortality (adjusted OR 2.75, 95% CI 1.61-4.72) after EVT, reported a group led by Laurens Winkelmeier, MD, of University Medical Center Hamburg-Eppendorf, Germany, in JAMA Network Open.
"The association between age and functional outcomes in acute ischemic stroke [AIS] is evident. This association is mediated by higher burden of comorbidities, greater cognitive impairment, and larger frailty levels in elderly patients, among other factors," the authors wrote.
Their report adds to the scant data on stroke thrombectomy for people 80 and older, who have been underrepresented in randomized trials but are frequently encountered in real clinical practice. Current guidelines do not endorse an upper age limit to EVT.
"The question arises whether these extremely poor functional outcomes might justify the application of a fixed upper age limit for endovascular thrombectomy in acute ischemic stroke with large infarct," they suggested. "An upper age limit might simplify acute management and free up capacities of endovascular thrombectomy, but it would also underestimate the heterogeneity of aging across individuals."
The group cautioned that chronological age alone does not necessarily determine clinical outcomes. "Under specific conditions, patients older than 80 years could have a better clinical prognosis than younger patients receiving endovascular thrombectomy for large ischemic stroke," Winkelmeier and colleagues observed.
They reported that the proportion of people older than 80 with large infarcts achieving the main endpoint at 90 days ranged from 1% to 46% depending on prestroke mRS, admission NIH Stroke Scale (NIHSS) score, and final modified Thrombolysis in Cerebral Infarction (mTICI) grade.
In fact, across age groups, a predictor of independent ambulation was a final mTICI grade 2b or 3 (adjusted OR 4.95, 95% CI 2.14-11.43). Such successful reperfusion, achieved in 81.9% of people in the German registry, was also associated with lower mortality at 90 days (adjusted OR 0.23, 95% CI 0.13-0.43).
This "timely study adds to the mounting evidence indicating that swift [successful reperfusion] following EVT appears to be the strongest predictor of good clinical outcomes and improved survival in patients with large-core AIS, even in the oldest-old (>80 years) subgroup," commented Georgios Tsivgoulis, MD, of Attikon University Hospital, Athens, Greece, and Bruce Campbell, PhD, of Royal Melbourne Hospital, Australia, in an accompanying editorial.
"Given the available randomized and observational evidence, the findings ... reinforce the existing notion that EVT for AIS with large infarct should not be withheld based on an upper age limit. Nevertheless, age needs to be integrated within a multimodal prognostic approach to individualize treatment decisions in these patients with the worst prognosis in terms of AIS natural history," the duo wrote.
The retrospective cohort study was based on the German Stroke Registry that included patients with AIS due to anterior circulation large vessel occlusion and large infarct.
Winkelmeier's group identified 408 patients who received endovascular thrombectomy from 2015 to 2021 at 25 German stroke centers and met study inclusion criteria.
These patients were 53.2% women with a median age of 75 years. The median prestroke mRS was 0, indicating a group with no significant disability before admission. On admission, the median NIH Stroke Scale score was 17 points, indicating severe neurological impairment. The baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) was 5.
Study authors reported that IV thrombolysis was administered in 35.4% of the study population.
After endovascular thrombectomy, there was a 7.0% incidence of symptomatic intracranial hemorrhage within 24 hours.(So the doctors here haven't figured out how to prevent that hemorrhage. I wouldn't go to any hospital that hasn't figured that out yet. Having figured that out is a sign of competence!)
By 90 days, patients achieved mRS 0-3 in 28.9% of cases while 44.6% had died.
Tsivgoulis and Campbell warned of the lack of propensity score matching to control for between-group imbalances in this retrospective analysis. "Age and frailty are correlated, and it is likely, given the data were derived from a registry of clinical practice, that physician judgement regarding frailty in older patients was applied such that patients who received EVT may not be fully representative of their peers," they wrote.
The editorialists also pointed out the study's exclusion of patients with tandem occlusions, the underrepresentation of people with very low ASPECTS, and lack of information on baseline ischemic core volume.
Winkelmeier and colleagues acknowledged the substantial missing mRS scores in their dataset. In addition, results may not apply outside Germany or to less developed healthcare systems, they said.
![author['full_name']](https://clf1.medpagetoday.com/media/images/author/nicoleLou_188.jpg)
Disclosures
Winkelmeier, Tsivgoulis, and Campbell had no disclosures.
Study co-authors reported various ties to industry.
Primary Source
JAMA Network Open
Source Reference: Winkelmeier L, et al "Age and functional outcomes in patients with large ischemic stroke receiving endovascular thrombectomy" JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.26007.
Secondary Source
JAMA Network Open
Source Reference: Tsivgoulis G, Campbell BC "Endovascular thrombectomy for large core ischemic stroke -- age matters" JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.25958.
