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Addition of Mechanical Thrombectomy Improves Odds of Good Outcome in Elderly Poststroke Patients

Following respective improvements in odds of good and poor outcomes, investigators concluded that the addition of mechanical thrombectomy should be considered over best medical management practices alone.

According to data from a recently performed systematic search, treatment with mechanical thrombectomy (MT) plus best medical management (BMM) increased the likelihood of good outcome with no increased mortality risk compared with BMM alone in patients presenting with anterior circulation stroke due to large vessel occlusion (aLVO).

The results, presented at the 2022 American Academy of Neurology (AAN) Annual Meeting, April 2-7, in Seattle, Washington, showed improved odds of good outcome (odds ratio [OR], 2.11; 95% CI, 1.11-3.99; I2 = 46%) and poor outcome (OR, 0.5; 95% CI, 0.33-0.75; I2 = 6%) that favored MT. Lead author Aisha Ali, MD, neurology resident, University of Illinois College of Medicine, and colleagues concluded that in this group, MT should be considered over BMM alone.

Six randomized studies that reported on functional outcomes at 90 days for elderly patients were included in the analysis. Using modified Rankin scale (mRS), outcomes were defined as excellent (mRS ≤1), good (mRS ≤2), or poor (mRS ≥5), with effect sizes calculated using random effect meta-analysis and results expressed by ORs and 95% confidence intervals. Among RESILIENT, DAWN, DEFUSE 3, ESCAPE, SWIFT PRIME, and REVASCAT, the 6 included trials, investigators compared outcomes of 1315 patients, 442 of which were considered elderly (>70 or >80 years).

While the addition of MT did show improvement on good and poor outcomes, it did not improve the odds for excellent outcome (OR, 2.24; 95% CI, 0.93-5.38; I2 = 55%) and mortality (OR, 0.6; 95% CI, 0.29-1.22; I2 = 34%). In the nonelderly group, the odds of excellent outcome (OR, 2.86; 95% CI, 2.05-3.99; I2 = 0%) good outcome (OR, 3.52; 95% CI, 2.63-4.70; I2 = 0%), poor outcome (OR, 0.5; 95% CI, 0.36-0.70; I2 = 0%), and mortality (OR, 0.53; 95% CI, 0.31-0.90; I2 = 0%) favored MT over BMM.

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Considering elders typically present with more baseline disability, researchers have tried to understand more about the risk vs reward benefit MT might bring to this patient group. In a 2018 study of patients at least 80 years old (n = 96) who underwent MT for ischemic stroke, slightly over one-third of the cohort (34%) had a good outcome. Investigators found that the Alberta Stroke Program Early CT Score (ASPECTS) and National Institutes of Health Stroke Scale (NIHSS) predicted good outcome regardless of baseline disability (P <.001 and P = .009, respectively).2

Elders aged at least 90 years, a patient group typically underrepresented in thrombectomy trials, have also shown benefit from MT. Despite high mortality and less frequent favorable outcome, findings from Meyer et al indicated that MT is still effective and safe for nonagenarians. In a cohort of 203 patients with anterior circulation stroke and prestroke mRS scores of less than 3, good functional outcome was observed in 21.6% (41 of 193) at 90 days. In-hospital mortality was 27.1% (55 of 203) and increased significantly at 90 days to 48.9% (93 of 190; P <.001). Similarly, investigators concluded that decision making for thrombectomy should be based with regard to initial NIHSS and ASPECTS score.3

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REFERENCES
1. Ali A, Trifan G, Testai F. Efficacy and safety of mechanical thrombectomy in elderly patients. Presented at: 2022 AAN Annual Meeting; April 2-7; Seattle, Washington. Abstract 2768
2. Slawski DE, Salahuddin H, Shawver J, et al. Mechanical thrombectomy in elderly stroke patients with mild-to-moderate baseline disability. Intervent Neurol. 2018;7:246-255. doi:10.1159/000487333
3. Meyer L, Alexandrou M, Flottman F, et al. Endovascular treatment of very elderly patients aged ≥90 with acute ischemic stroke. J Am Heart Assoc. 2020;9:e014447. doi:10.1161/JAHA.119.014447