Original Paper Received: June 13, 2013 Accepted: September 30, 2013 Published online: November 23, 2013
Cerebrovasc Dis 2013;36:430–436 DOI: 10.1159/000356186
Predictors of Outcome after Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion in Patients Aged ≥80 Years Wiebke Kurre a Marta Aguilar-Pérez a Ludwig Niehaus c Sebastian Fischer a Elisabeth Schmid b Hansjörg Bäzner b Hans Henkes a
Departments of a Neuroradiology and b Neurology, Klinikum Stuttgart, Stuttgart, and c Department of Neurology, Klinikum Schloss Winnenden, Winnenden, Germany
Key Words Old age · Mechanical thrombectomy · Predictors of outcome · Stroke
Abstract Background: There is uncertainty about the role of endovascular recanalization procedures for the treatment of acute ischemic stroke in patients aged ≥80 years. Therefore, careful patient selection is mandatory. Our aim was to find valid predictors of clinical outcome after mechanical thrombectomy (mTE) based on the sparse information available in the emergency setting. Methods: We included consecutive patients aged ≥80 years treated by mTE for anterior circulation thromboembolic vessel occlusion in our department between January 2008 and January 2013. Successful recanalization was defined as a thrombolysis in cerebral infarction (TICI) score of 2b or 3. The rates of parenchymal hemorrhage types I (PHI) and II (PHII) according to the ECASS definition and the rate of focal and diffuse subarachnoid hemorrhage (SAH) were reported. A modified Ranking scale (mRS) score of 0–2 at 90 days was defined as a favorable outcome. We evaluated the influence of gender, smoking habits, atrial fibrillation, diabetes, hypertension, hyperlipidemia, coronary artery and peripheral artery disease, National Institutes of Health Stroke Scale (NIHSS) score, Totaled Health Risks in Vascular Events (THRIVE) score, Alberta Stroke Program Early CT Score (ASPECTS), and duration of symptoms on favorable outcome. Significant pre-
© 2013 S. Karger AG, Basel 1015–9770/13/0366–0430$38.00/0 E-Mail [email protected] www.karger.com/ced
dictors were then included in a stepwise logistic regression analysis. Odds ratios (OR), 95% confidence intervals (CI), and receiver operating characteristics (ROC) curves were calculated. p < 0.05 was considered statistically significant. Results: In the defined period, we treated 109 patients aged ≥80 years with 116 occluded anterior circulation target vessels. Successful recanalization was achieved in 87.9% of the targets. The rates of PHI, PHII, and focal and diffuse SAH were 6.4, 5.5, 12.8, and 7.3%, with an overlap between PH and SAH. The combined rate of PHII and/or diffuse SAH was 9.2%. Despite good recanalization rates and reasonable rates of hemorrhage, only 19 patients (17.4%) were functionally independent at 90 days. An additional 12 patients (11.0%) suffered from moderate disability (mRS score 3), 26 (23.9%) were severely disabled (mRS score 4–5) and 52 (47.7%) were deceased. NIHSS, ASPECTS, and THRIVE scores significantly predicted a favorable outcome. Stepwise logistic regression identified NIHSS (OR 0.89; 95% CI 0.82–0.96; p = 0.009) and ASPECTS (OR 2.27; 95% CI 1.28–4.02; p = 0.005) as independent predictors. The ROC area was 0.81. Conclusion: ASPECTS and NIHSS were independent predictors of a favorable outcome in patients aged ≥80 years after mTE for anterior circulation large vessel occlusion and may support decision making with regard to the treatment modality. Since the chances of gaining functional independence are limited, careful consideration of each individual case is mandatory. Further studies comparing endovascular and standard treatment in octogenarians are warranted. © 2013 S. Karger AG, Basel
Wiebke Kurre Department of Neuroradiology, Klinikum Stuttgart Kriegsbergstrasse 60 DE–70174 Stuttgart (Germany) E-Mail wiebke.kurre @ gmx.de
Downloaded by: John Rylands Library 130.88.90.140 - 5/21/2015 7:07:48 PM
Management of acute ischemic stroke in elderly patients will be one of the future challenges in health care. Stroke is the second leading cause of mortality and the third leading cause of ‘disability-adjusted life years’, indicating the overall disease burden [1, 2]. Stroke rates double with every decade of life after the age of 55, reaching an incidence of 20.78 first-ever strokes per 1,000 patient years beyond the age of 80 years [3, 4]. Projections of demographic data predict that the absolute number of octogenarians will be more than double in 2060 compared to 2008 [5]. Poor clinical outcomes in terms of functional dependency or death are more frequent in the elderly, resulting in an increasing demand for nursing care. Demographic and clinical data underline the importance of effective treatment strategies for acute stroke in elderly patients. The Third International Stroke Trial (IST-3) proved the benefit of intravenous thrombolysis (IVT) in elderly patients and represents an important step towards a more active management of stroke in the elderly [6]. Nowadays, an increasing proportion of patients with major vessel occlusion are treated by mechanical thrombectomy (mTE). Randomized trials mainly based on intra-arterial thrombolysis have not proven the superiority of the endovascular approach compared to IVT, but cohort studies with new-generation stent retrievers have yielded promising results [7–9]. Experience with endovascular stroke treatment in elderly patients is sparse and the clinical benefit is not yet clear. Therefore, careful patient selection is mandatory. The aim of our study was to analyze the overall clinical outcome of patients aged ≥80 years after mTE for anterior circulation ischemic stroke and to find valid predictors of clinical outcome to facilitate decision making in the emergency situation.
Methods Our hospital is a tertiary referral center providing endovascular service for 13 regional stroke units. All endovascular stroke treatments were registered retrospectively since January 2008 and prospectively since October 2011. The local ethics committee approved the data collection and analysis. For this study, we selected consecutive patients aged ≥80 years treated by mTE for anterior circulation thromboembolic stroke between January 2008 and January 2013. The following comorbidities were registered: atrial fibrillation, diabetes, hyperlipidemia, active smoking, hypertension, coronary artery disease, and peripheral artery disease. Pre- and poststroke disability was assessed using the modified Ranking scale (mRS). Stroke severity at presentation was described using the National Institutes of Health
Clinical Outcome after mTE in Elderly Patients
Stroke Scale (NIHSS). The Totaled Health Risks in Vascular Events (THRIVE) score was calculated for each patient [10]. CT or MRI ruled out intracranial hemorrhage. Infarct size was estimated with the Alberta Stroke Program Early CT Score (ASPECTS) or diffusion-weighted imaging ASPECTS (DWI-ASPECTS). CT or MRI angiography confirmed major vessel occlusion. Patients with an NIHSS score ≥4 and major vessel occlusion were considered for endovascular treatment. In case of fluctuating or progressive neurologic deficits, we also treated patients with minor symptoms (NIHSS score
Cerebrovasc Dis 2013;36:430–436 DOI: 10.1159/000356186
Predictors of Outcome after Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion in Patients Aged ≥80 Years Wiebke Kurre a Marta Aguilar-Pérez a Ludwig Niehaus c Sebastian Fischer a Elisabeth Schmid b Hansjörg Bäzner b Hans Henkes a
Departments of a Neuroradiology and b Neurology, Klinikum Stuttgart, Stuttgart, and c Department of Neurology, Klinikum Schloss Winnenden, Winnenden, Germany
Key Words Old age · Mechanical thrombectomy · Predictors of outcome · Stroke
Abstract Background: There is uncertainty about the role of endovascular recanalization procedures for the treatment of acute ischemic stroke in patients aged ≥80 years. Therefore, careful patient selection is mandatory. Our aim was to find valid predictors of clinical outcome after mechanical thrombectomy (mTE) based on the sparse information available in the emergency setting. Methods: We included consecutive patients aged ≥80 years treated by mTE for anterior circulation thromboembolic vessel occlusion in our department between January 2008 and January 2013. Successful recanalization was defined as a thrombolysis in cerebral infarction (TICI) score of 2b or 3. The rates of parenchymal hemorrhage types I (PHI) and II (PHII) according to the ECASS definition and the rate of focal and diffuse subarachnoid hemorrhage (SAH) were reported. A modified Ranking scale (mRS) score of 0–2 at 90 days was defined as a favorable outcome. We evaluated the influence of gender, smoking habits, atrial fibrillation, diabetes, hypertension, hyperlipidemia, coronary artery and peripheral artery disease, National Institutes of Health Stroke Scale (NIHSS) score, Totaled Health Risks in Vascular Events (THRIVE) score, Alberta Stroke Program Early CT Score (ASPECTS), and duration of symptoms on favorable outcome. Significant pre-
© 2013 S. Karger AG, Basel 1015–9770/13/0366–0430$38.00/0 E-Mail [email protected] www.karger.com/ced
dictors were then included in a stepwise logistic regression analysis. Odds ratios (OR), 95% confidence intervals (CI), and receiver operating characteristics (ROC) curves were calculated. p < 0.05 was considered statistically significant. Results: In the defined period, we treated 109 patients aged ≥80 years with 116 occluded anterior circulation target vessels. Successful recanalization was achieved in 87.9% of the targets. The rates of PHI, PHII, and focal and diffuse SAH were 6.4, 5.5, 12.8, and 7.3%, with an overlap between PH and SAH. The combined rate of PHII and/or diffuse SAH was 9.2%. Despite good recanalization rates and reasonable rates of hemorrhage, only 19 patients (17.4%) were functionally independent at 90 days. An additional 12 patients (11.0%) suffered from moderate disability (mRS score 3), 26 (23.9%) were severely disabled (mRS score 4–5) and 52 (47.7%) were deceased. NIHSS, ASPECTS, and THRIVE scores significantly predicted a favorable outcome. Stepwise logistic regression identified NIHSS (OR 0.89; 95% CI 0.82–0.96; p = 0.009) and ASPECTS (OR 2.27; 95% CI 1.28–4.02; p = 0.005) as independent predictors. The ROC area was 0.81. Conclusion: ASPECTS and NIHSS were independent predictors of a favorable outcome in patients aged ≥80 years after mTE for anterior circulation large vessel occlusion and may support decision making with regard to the treatment modality. Since the chances of gaining functional independence are limited, careful consideration of each individual case is mandatory. Further studies comparing endovascular and standard treatment in octogenarians are warranted. © 2013 S. Karger AG, Basel
Wiebke Kurre Department of Neuroradiology, Klinikum Stuttgart Kriegsbergstrasse 60 DE–70174 Stuttgart (Germany) E-Mail wiebke.kurre @ gmx.de
Downloaded by: John Rylands Library 130.88.90.140 - 5/21/2015 7:07:48 PM
Management of acute ischemic stroke in elderly patients will be one of the future challenges in health care. Stroke is the second leading cause of mortality and the third leading cause of ‘disability-adjusted life years’, indicating the overall disease burden [1, 2]. Stroke rates double with every decade of life after the age of 55, reaching an incidence of 20.78 first-ever strokes per 1,000 patient years beyond the age of 80 years [3, 4]. Projections of demographic data predict that the absolute number of octogenarians will be more than double in 2060 compared to 2008 [5]. Poor clinical outcomes in terms of functional dependency or death are more frequent in the elderly, resulting in an increasing demand for nursing care. Demographic and clinical data underline the importance of effective treatment strategies for acute stroke in elderly patients. The Third International Stroke Trial (IST-3) proved the benefit of intravenous thrombolysis (IVT) in elderly patients and represents an important step towards a more active management of stroke in the elderly [6]. Nowadays, an increasing proportion of patients with major vessel occlusion are treated by mechanical thrombectomy (mTE). Randomized trials mainly based on intra-arterial thrombolysis have not proven the superiority of the endovascular approach compared to IVT, but cohort studies with new-generation stent retrievers have yielded promising results [7–9]. Experience with endovascular stroke treatment in elderly patients is sparse and the clinical benefit is not yet clear. Therefore, careful patient selection is mandatory. The aim of our study was to analyze the overall clinical outcome of patients aged ≥80 years after mTE for anterior circulation ischemic stroke and to find valid predictors of clinical outcome to facilitate decision making in the emergency situation.
Methods Our hospital is a tertiary referral center providing endovascular service for 13 regional stroke units. All endovascular stroke treatments were registered retrospectively since January 2008 and prospectively since October 2011. The local ethics committee approved the data collection and analysis. For this study, we selected consecutive patients aged ≥80 years treated by mTE for anterior circulation thromboembolic stroke between January 2008 and January 2013. The following comorbidities were registered: atrial fibrillation, diabetes, hyperlipidemia, active smoking, hypertension, coronary artery disease, and peripheral artery disease. Pre- and poststroke disability was assessed using the modified Ranking scale (mRS). Stroke severity at presentation was described using the National Institutes of Health
Clinical Outcome after mTE in Elderly Patients
Stroke Scale (NIHSS). The Totaled Health Risks in Vascular Events (THRIVE) score was calculated for each patient [10]. CT or MRI ruled out intracranial hemorrhage. Infarct size was estimated with the Alberta Stroke Program Early CT Score (ASPECTS) or diffusion-weighted imaging ASPECTS (DWI-ASPECTS). CT or MRI angiography confirmed major vessel occlusion. Patients with an NIHSS score ≥4 and major vessel occlusion were considered for endovascular treatment. In case of fluctuating or progressive neurologic deficits, we also treated patients with minor symptoms (NIHSS score
