dont mix up mechanical thrombectomy and chemical thrombolysis

1:28 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

kellert et al have published a very important article...which is seen in day to day practice....and which I have kept telling to anyone I meet and cares to listen to me....which is "DO ONLY MECH THROMBECTOMY AND DONT MIX UP DIFFERENT TECHNIQUES OF RECANALISATION"

 
if a vessel gets recanalised by the aspiration and the solitaire device, its well and good, but pushing in antiplatelet drugs or even rTPA in case of failure or for recanalising distal branches, is not a very good idea, as it results in haemorrhage a lot of times.
 
The reason is not clear but the observation is.. however some hypotheses can definitely be made.
1. GOD does not want this patient to improve !
2. there is distal vessel occlusion and insitu thrombus formation apart from the large vessel occlusion,
3. 'no-reflow' phenomenon
4. poor collateral
5. the parenchymal territory is already damaged irreversibly
6. the mech device has opened the larger proximal artery resulting in hyperperfusion, and the drug directly is toxic to cells, thus resulting in enhanced bleeding ....
 
most likely a combination of all these is happening....
What I am getting to in acute stroke intervention in my short career is that if a patient comes with acute stroke---
1. be aggressive with intravenous thrombolysis.
2. if CT/MRI/CTA/MRA/CTP show large vessel occlusion with favourable ASPECT score (plus good leptomeningeal score or large mismatch, as per availability of data), the go straight for aspiration and mechanical thrombectomy.... and forget about chemical intravenous or intraarterial thrombolysis
3. however, if the interventionist is not comfortable with mech devices then combined IVT+IAT should be done wherever possible.
 
the link and the abstract are given underneath
 
Kellert et al. Tirofiban Is Associated With Risk of Fatal Intracerebral Hemorrhage and Poor Outcome. Stroke. 44: 1453-1455 Published online before print March 5, 2013, doi: 10.1161/​STROKEAHA.111.000502
 

Abstract

Background and Purpose—To investigate the relationship between severe bleeding complications and outcome after mechanical thrombectomy with or without glycoprotein-IIb/IIIa inhibitor tirofiban treatment.
Methods—The study included prospectively collected data of consecutive patients with acute ischemic stroke in whom mechanical thrombectomy was perfomed in the years 2006 to 2011.
Results—Of 162 patients, 128 patients had anterior circulation stroke, and 34 patients had posterior circulation stroke. Additional treatment with tirofiban was given to 30 of 128 patients with anterior circulation stroke and to 20 of 34 patients with posterior circulation stroke. Treatment with tirofiban did not influence recanalization rates. Fatal intracerebral hemorrhage occurred more frequently in tirofiban-treated patients in the entire cohort (12.0% vs 2.7%; P=0.03) and in tirofiban-treated patients with anterior circulation stroke (13.3% vs 3.1%; P=0.05). Logistic regression found age (odds ratio, 1.17; 95% confidence interval, 1.00–1.37; P=0.05) and tirofiban treatment (odds ratio, 3.03; 95% confidence interval, 1.50–4.05; P=0.04) to be independent predictors for fatal intracerebral hemorrhage. Tirofiban treatment was also an independent predictor for poor outcome (odds ratio, 6.60; 95% confidence interval, 1.06–41.52; P=0.04) in addition to National Institute of Health Stroke Scale (odds ratio, 1.08; 95% confidence interval, 1.00–1.17; P=0.05).
Conclusions—In endovascular stroke therapy, additional treatment with the glycoprotein-IIb/IIIa inhibitor tirofiban is associated with increased risk of fatal intracerebral hemorrhage and poor outcome.
 
 
 
 


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How to determine suitability of thrombolysis in acute stroke

6:28 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Disclaimer: This is a difficult topic and you may find the points given above varying from the standard 'GUIDELINES'. I would like to say that this is what we "PRACTICE' with the patients/attendants consent which is mandatory.


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The hyperdense vessel sign on CT predicts successful recanalization with the...

10:54 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 
 

Sent to you by subbu via Google Reader:

 
 

via Journal of NeuroInterventional Surgery Online First by Froehler, M. T., Tateshima, S., Duckwiler, G., Jahan, R., Gonzalez, N., Vinuela, F., Liebeskind, D., Saver, J. L., Villablanca, J. P., For the UCLA Stroke Investigators on 5/22/12

Background

The success of mechanical clot retrieval for acute ischemic stroke may be influenced by the characteristics of the occlusive thrombus. The thrombus can be partly characterized by CT, as the hyperdense vessel sign (HVS) suggests erythrocyte-rich clot whereas fibrin-rich clot may be isodense. We hypothesized that the physical clot characteristics that determine CT density may also determine likelihood of retrieval with the Merci device.

Methods

We reviewed all acute stroke cases initially imaged with non-contrast CT before attempted Merci clot retrieval at a single center between 2004 and 2010. Each CT was blindly assessed for the presence or absence of the HVS, and post-retrieval angiograms were blindly assessed for reperfusion using the TICI scale.

Results

Of 67 patients analyzed (mean age 69; median NIHSS 19; 61% female), the HVS was seen in 42, and no HVS was present in 25. Successful recanalization was achieved in 79% of patients with the HVS (33/42), but in only 36% (9/25) of patients without HVS (p=0.001). The HVS was the only significant predictor of recanalization while accounting for age, treatment with IV-tPA, clot location, stroke etiology, time to treatment, and number of retrieval attempts.

Conclusion

The HVS in acute ischemic stroke was strongly predictive of successful recanalization using the Merci device. The HVS may indicate thrombi that are less adhesive compared with isodense clots that are more resistant to mechanical retrieval. The absence of HVS on pre-treatment CT may thus suggest the need for a more aggressive or alternative therapeutic approach.


 
 

Things you can do from here:

 
 


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Eligibility for Intravenous Recombinant Tissue-Type Plasminogen Activator Wi...

10:28 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 
 

Sent to you by subbu via Google Reader:

 
 

via Stroke current issue by de los Rios la Rosa, F., Khoury, J., Kissela, B. M., Flaherty, M. L., Alwell, K., Moomaw, C. J., Khatri, P., Adeoye, O., Woo, D., Ferioli, S., Kleindorfer, D. O. on 5/25/12

Background and Purpose—

The publication of the European Cooperative Acute Stroke Study (ECASS III) expanded the treatment time to thrombolysis for acute ischemic stroke from 3 to 4.5 hours from symptom onset. The impact of the expanded time window on treatment rates has not been comprehensively evaluated in a population-based study.

Methods—

All patients with an ischemic stroke presenting to an emergency department during calendar year 2005 in the 17 hospitals that compromise the large 1.3 million Greater Cincinnati/Northern Kentucky population were included in the analysis. Criteria for exclusion from thrombolytic therapy are analyzed retrospectively for both the standard and expanded timeframes with varying door-to-needle times.

Results—

During the study period, 1838 ischemic strokes presenting to an emergency department were identified. A small proportion of them arrived in the expanded time window (3.4%) compared with the standard time window (22%). Only 0.5% of those who arrived in this timeframe met eligibility criteria for thrombolysis compared with 5.9% using standard eligibility criteria in the standard timeframe. These results did not vary significantly by repeated analysis varying the door-to-needle time or the expanded time window's exclusion criteria.

Conclusions—

In reality, the expanded time window for thrombolysis in acute ischemic stroke benefits few patients. If we are to improve recombinant tissue-type plasminogen activator administration rates, our focus should be on improving stroke awareness, transport to facilities with ability to administer thrombolysis, and familiarity of physicians with acute stroke treatment guidelines.


 
 

Things you can do from here:

 
 


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CLOTBUST sonothrombolysis of acute stroke

3:29 PM Posted by Dr Subhash Kumar, MBBS, MD, DM


CLOTBUST sonothrombolysis in acute stroke is a new addition in the armamentarium of physicians traeting these particularly challenging patients. It uses the simple premise of continuous transfer of ultrasonic wanes to the site of the clot in the blood vessel, which in a way soften ups the clot, such that intravenously given thrombolytic agents can work more effectively, resulting in better recanalisation rates, hence translating into better patient outcome.
We recently performed it on a patient with 3.5 hours of acute stroke onset, patient presenting with right sided weakness and Wernicke's aphasia, MRI showing acute left MCA territory diffusion restriction. As the DWI volume was not much and ASPECTS score was good, thrombolysis was performed along with continuous transcranial Doppler using a 2MHz probe, for two hours. After about 45 minutes, the patient responded, sat up himself and the weakness improved. Over the next 48 hours he continued to improve and had 4+/5 power with some aphasia; the aphasis improved over next two weeks and the patient is independent for ADL.
The TCD frame with the doppler probe in place

MRI showing diffusion restriction in left MCA territory


I started the doppler
The TCD wave at the end of the procedure ( 2 hours)
The patient sat up on his own









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Incidence and outcome of procedural distal emboli using the Penumbra thrombectomy for acute stroke

3:23 PM Posted by Dr Subhash Kumar, MBBS, MD, DM



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Pre-intervention triage incorporating perfusion imaging improves outcomes in patients undergoing endovascular stroke therapy: a comparison with the device trials

3:18 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

http://jnis.bmj.com/content/early/2012/02/17/neurintsurg-2011-010189.short

Pre-intervention triage incorporating perfusion imaging improves outcomes in patients undergoing endovascular stroke therapy: a comparison with the device trials

  1. Jeffrey Carpenter
 

Abstract

Objectives Endovascular therapy of acute ischemic stroke is evolving towards thrombectomy devices for vessel recanalization. High rates of revascularization have been reported in stroke device trials. However, the discrepancy between recanalization and outcomes raises the question whether patients with irreversible ischemic injury are being exposed to these interventions. This study evaluated a triage methodology that incorporates perfusion imaging against previous device trials that treated all patients within a certain time frame.
Methods 99 consecutive patients were identified with anterior circulation strokes who had undergone endovascular therapy. All patients had a baseline NIHSS score ≥8 and had undergone pre-intervention CT perfusion. Rates of recanalization and functional outcomes were compared with the MERCI, Multi-MERCI and Penumbra trials.
Results This study's recanalization rate of 55.6% is not significantly different from the 46% for MERCI (p=0.15) and 68% for Multi-MERCI (p=0.08) but was significantly lower than the 82% for the Penumbra trial (p<0.0001). Successfully recanalized patients had a significantly higher good outcome of 67% in this cohort versus 46% in MERCI, 49% in Multi-MERCI and 29% in Penumbra. The rate of futile recanalization was 33% compared with 54% for MERCI, 51% for Multi-MERCI and 71% for Penumbra. A small cerebral blood volume (CBV) abnormality (p<0.0001) and large mean transit time–CBV mismatch (p<0.0001) were strong predictors of a good outcome.
Conclusion Despite similar or lower recanalization rates, there was a significantly higher rate of good outcomes in the recanalized population and thus a significantly lower rate of futile recanalization in this study versus the device trials, suggesting a role for pre-intervention perfusion imaging for patient selection.
 
 


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Dont use a lot of contrast!

3:14 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

 

It has been known that contrast is neurotoxic and my teachers have always told me to use less as far as possible

A recent article nicely shows the same....

http://stroke.ahajournals.org/content/39/12/3283.full

Microcatheter Contrast Injections During Intra-Arterial Thrombolysis May Increase Intracranial Hemorrhage Risk

 Pooja Khari et al

Abstract

Background and Purpose— During intra-arterial revascularization, either guide catheter injections of contrast in the neck or microcatheter contrast injections (MCIs) at or beyond the site of an occlusion, can be used to visualize intracranial vasculature. Neurointerventionalists vary widely in their use of MCIs for a given circumstance. We tested the hypothesis that MCIs are a risk factor for intracranial hemorrhage (ICH) in the Interventional Management of Stroke (IMS) I and II trials of combined intravenous/IA recombinant tissue plasminogen activator therapy.
Methods— All arteriograms with M1, M2, and ICA terminus occlusions were reanalyzed (n=98). The number of MCIs within or distal to the target occlusion was assigned. Postprocedure CTs were reviewed for contrast extravasation and ICH. Contrast extravasation was defined as a hyperdensity suggestive of contrast (Hounsfield unit >90) seen at 24 hours or present before 24 hours and persisting or replaced by ICH at 24 hours.
Results— In this IMS subset, the rate of any ICH was 58% (57 of 98). More MCIs were seen in the ICH group (median=2 versus 1; P=0.04). Increased MCIs were associated with higher ICH rates (P=0.03). MCIs remained associated with ICH in multivariable analysis (P=0.01) as did baseline CT edema/mass effect, atrial fibrillation, time to intravenous recombinant tissue plasminogen activator initiation, and Thrombolysis in Cerebral Infarction reperfusion score. MCIs were also associated with contrast extravasation in unadjusted and adjusted analyses.
Conclusions— MCIs may risk ICH in the setting of combined intravenous/intra-arterial recombinant tissue plasminogen activator therapy, possibly due to contrast toxicity or pressure transmission by injections. MCIs should be minimized whenever possible. These findings will be tested prospectively in the IMS III trial.

 



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Hemorrhagic Risk of Recent Silent Cerebral Infarct on Prethrombolysis MR Imaging in Acute Stroke

2:49 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Hemorrhagic Risk of Recent Silent Cerebral Infarct on Prethrombolysis MR Imaging in Acute Stroke

by Gaillard, N., Schmidt, C., Costalat, V., Bousquet, J. P., Heroum, C., Milhaud, D., Bonafe, A., Arquizan, C.
 
BACKGROUND AND PURPOSE: EIH is a rare complication after thrombolysis in patients with acute stroke, occurring in brain regions without visible ischemic change on pretreatment imaging. RSCIs can be detected by multimodal MR imaging and might be associated with an increased risk of HT postthrombolysis, related to BBBD. We aimed to assess the incidence of RSCI on pretreatment MR imaging and the subsequent risk of HT within RSCI areas on follow-up CT performed <36 hours after rtPA administration and on additional cerebral imaging before patient discharge.
MATERIALS AND METHODS: Pretreatment MR imaging was retrospectively analyzed from consecutive patients with stroke who received intravenous or intra-arterial rtPA for 2 years. RSCI was defined on MR imaging as a parenchymal area markedly hyperintense on FLAIR, different from the hyperacute infarct, and mildly-to-markedly hyperintense on DWI or enhanced on postgadolinium T1WI imaging.
RESULTS: Eighty-six patients with a median age of 66 years and a median NIHSS score on admission of 15 were studied; 66.3% received rtPA intravenously. The presence of RSCI was identified in 10 patients (11.6%) and was associated with large-vessel-disease etiology (40% versus 5.3%, P < .001) on univariate analysis. No HT was identified within the RSCI areas on any follow-up cerebral imaging.
CONCLUSIONS: These preliminary results require validation but suggest that small RSCIs are rather frequent and might not pose a higher risk of postthrombolysis HT.

ABBREVIATIONS:

BBBD: blood-brain-barrier disruption
ECASS: European Cooperative Acute Stroke Study
EIH: extraischemic hemorrhage
FFE:fast-field echo
HI: hemorrhagic infarction
HT:hemorrhagic transformation
IQR:interquartile range
IS: ischemic stroke
PH: parenchymal hemorrhage
RSCI: recent silent cerebral infarct
SE: spin-echo
SICH: symptomatic intracerebral hemorrhage
TOAST:Trial of Org 10172 in Acute Stroke Treatment
 
http://www.ajnr.org/content/33/2/227.abstract


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Multimodal Reperfusion Therapy for Large Hemispheric Infarcts in Octogenarians: Is Good Outcome a Realistic Goal?

12:39 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Multimodal Reperfusion Therapy for Large Hemispheric Infarcts in Octogenarians: Is Good Outcome a Realistic Goal?

  1. D. Arkadir,
  2. R. Eichel,
  3. J.M. Gomori,
  4. T. Ben Hur,
  5. J.E. Cohen and
  6. R.R. Leker

  1. Abstract

    BACKGROUND AND PURPOSE: MMRT may be beneficial in a subset of patients with large hemispheric stroke who cannot be treated with systemic thrombolysis. Because most previous studies only included relatively young patients, the outcome of very old patients given MMRT remains unknown.

    MATERIALS AND METHODS: Consecutive patients with large hemispheric stroke treated with MMRT and admitted to intensive care were included. We compared neurologic and functional outcomes between patients younger and older than 80 years.

    RESULTS: We included 14 patients older than 80 years and compared them with 66 patients who were younger than 80. Cerebrovascular risk factor profile, admission NIHSS scores, stroke etiology and pathogenesis, and procedure-related variables did not differ between the groups except for a higher prevalence of smoking in younger patients. Excellent target vessel recanalization (Thrombolysis in Myocardial Infarction score of 3) and good outcome at 90 days (modified Rankin Score ≤2) were more common in younger patients (45% versus 14%, P = .047, and 41% versus 0%, P = .008, respectively). In contrast, mortality rates were higher in octogenarians (43% versus 17%, respectively).

    CONCLUSIONS: In this study, very old patients had higher chances of mortality and a very low probability of achieving functional independence even after MMRT. Further prospective studies are needed to examine the futility of MMRT in the very old.

    Abbreviations

    GP IIb/IIIa
    glycoprotein IIb/IIIa
    IA
    intra-arterial
    MMRT
    multimodal reperfusion therapy
    TIMI
    Thrombolysis in Myocardial Infarction
    TOAST
    Trial of ORG 10172 in Acute Stroke
    http://www.ajnr.org/content/early/2012/02/02/ajnr.A2916.abstract


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Interobserver Reliability of Baseline Noncontrast CT Alberta Stroke Program Early CT Score for Intra-Arterial Stroke Treatment Selection [BRAIN]

9:28 AM Posted by Dr Subhash Kumar, MBBS, MD, DM

Interobserver Reliability of Baseline Noncontrast CT Alberta Stroke Program Early CT Score for Intra-Arterial Stroke Treatment Selection [BRAIN]

  1. A.C. Gupta,
  2. P.W. Schaefer,
  3. Z.A. Chaudhry,
  4. T.M. Leslie-Mazwi,
  5. R.V. Chandra,
  6. R.G. González,
  7. J.A. Hirsch and
  8. A.J. Yoo
: BACKGROUND AND PURPOSE:

Early ischemic changes on pretreatment NCCT quantified using ASPECTS have been demonstrated to predict outcomes after IAT. We sought to determine the interobserver reliability of ASPECTS for patients with AIS with PAO and to determine whether pretreatment ASPECTS dichotomized at 7 would demonstrate at least substantial agreement.

MATERIALS AND METHODS:

From our prospective IAT data base, we identified consecutive patients with anterior circulation PAO who underwent IAT over a 6-year period. Only those with an evaluable pretreatment NCCT were included. ASPECTS was graded independently by 2 experienced readers. Interrater agreement was assessed for total ASPECTS, dichotomized ASPECTS (≤7 versus >7), and each ASPECTS region. Statistical analysis included determination of Cohen coefficients and concordance correlation coefficients. PABAK coefficients were also calculated.

RESULTS:

One hundred fifty-five patients met our study criteria. Median pretreatment ASPECTS was 8 (interquartile range 7–9). Interrater agreement for total ASPECTS was substantial (concordance correlation coefficient = 0.77). The mean ASPECTS difference between readers was 0.2 (95% confidence interval, –2.8 to 2.4). For dichotomized ASPECTS, there was a 76.8% (119/155) observed rate of agreement, with a moderate = 0.53 (PABAK = 0.54). By region, agreement was worst in the internal capsule and the cortical areas, ranging from fair to moderate. After adjusting for prevalence and bias, agreement improved to substantial or near perfect in most regions.

CONCLUSIONS:

Interobserver reliability is substantial for total ASPECTS but is only moderate for ASPECTS dichotomized at 7. This may limit the utility of dichotomized ASPECTS for IAT selection.


http://www.ajnr.org/content/early/2012/02/09/ajnr.A2942.abstract


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Recanalization with Wingspan Stent for Acute Middle Cerebral Artery Occlusion in Failure or Contraindication to Intravenous Thrombolysis: A Feasibility Study [INTERVENTIONAL]

9:27 AM Posted by Dr Subhash Kumar, MBBS, MD, DM

Recanalization with Wingspan Stent for Acute Middle Cerebral Artery Occlusion in Failure or Contraindication to Intravenous Thrombolysis: A Feasibility Study [INTERVENTIONAL

  1. S.M. Sung,
  2. T.H. Lee,
  3. H.J. Cho,
  4. Y.L. Sol,
  5. K.H. Park,
  6. D.S. Jung and
  7. C.W. Kim
: BACKGROUND AND PURPOSE:

Recanalization with the Wingspan stent, which can be deployed rapidly and safely, is an option for treating acute ischemic stroke when intravenous thrombolysis has failed or is contraindicated. This study was performed to evaluate feasibility, efficacy, and safety of recanalization for acute middle cerebral artery occlusion using the Wingspan stent.

MATERIALS AND METHODS:

We collected 10 patients with acute MCA occlusion in whom recanalization was not achieved with a standard intravenous thrombolysis, or who were ineligible for intravenous thrombolysis, or who presented after 3 hours of symptom onset and in whom the stent placement could be completed within 8 hours from symptom onset. We analyzed angiographic and clinical results.

RESULTS:

Successful recanalization with the Wingspan stent was achieved in all patients. The mean NIHSS score on admission was 12.7 points (range 4–21). The occlusion sites were located in the 1st segment (n = 7; 2 left, 5 right) and 2nd segment (n = 3, all right) of the MCA. The mean time interval from stroke symptom onset to stent placement was 344.8 ± 76.3 minutes. No intracranial hemorrhage, vessel perforations, or dissections occurred in any patient. Nine patients improved on the NIHSS at 7 days. One patient did not have a change in the NIHSS score, even though the occluded artery was completely recanalized. At 7 days, the NIHSS score of all patients was 4.4 ± 4.7 (median 4, range 0–13). At discharge, an mRS of ≤3 was achieved in all patients and an mRS of ≤2 was achieved in 7 patients (70%).

CONCLUSIONS:

This small case series demonstrates the feasibility of using the Wingspan stent safely and effectively for MCA occlusions when standard treatments are ineffective or not available.

http://www.ajnr.org/content/early/2012/02/09/ajnr.A2996.abstract


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Incomplete mechanical recanalization of middle cerebral artery occlusions facilitates endogenous recanalization within 5 h

9:21 AM Posted by Dr Subhash Kumar, MBBS, MD, DM

Incomplete mechanical recanalization of middle cerebral artery occlusions facilitates endogenous recanalization within 5 h
Loh, Y., Shi, Z., Liebeskind, D., Jahan, R., Gonzalez, N., Vespa, P. M., Starkman, S., Saver, J. L., Tateshima, S., Vinuela, F., Duckwiler, G.

Background and purpose

Successful revascularization can often improve functional outcome after large intracranial arterial occlusions. However, incomplete or unsuccessful recanalization is often the end result after attempted mechanical thrombectomy. A study was undertaken to determine whether partial recanalization of proximal isolated middle cerebral artery (MCA) occlusions facilitates endogenous thrombolysis and spontaneous recanalization.

Methods

We retrospectively analyzed consecutive patients with acute ischemic stroke undergoing mechanical thrombectomy using the Merci Retriever System for occlusions involving any portion of the M1 segment of the MCA. Only those patients with a residual obstruction of the proximal MCA segments were included. The rates of facilitated endogenous recanalization (FER5) by imaging within the 5 h following intervention were compared in patients with partial proximal recanalization and those in whom recanalization was unsuccessful.

Results

Forty-two patients were included in the analysis. Twenty-six patients had good recanalization of the proximal aspect of the target lesion with an arterial occlusive lesion score of 2 or 3 but a residual partial or total occlusion of the MCA, while 16 patients failed to recanalize any portion of the target occlusion. Twelve patients (46%) in the first group and only one (5.9%) in the second group had facilitated endogenous recanalization on interval imaging 5 h after intervention (OR 12.9, 95% CI 1.5 to 112.2). Nine patients with proximal recanalization had good clinical outcomes at discharge (mRS ≤2) compared with none without recanalization (p=0.01), but FER did not have a relationship with clinical outcome.

Conclusions

Despite initially incomplete proximal mechanical thrombectomy, nearly half of all patients with residual M1 occlusions will undergo further endogenous recanalization within the subsequent 5 h.

http://jnis.bmj.com/content/early/2012/02/06/neurintsurg-2011-010207.short


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Interventional Stroke Therapies in the Elderly: Are We Helping?

10:58 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Interventional Stroke Therapies in the Elderly: Are We Helping?

  1. N. Zeevi, 
  2. G.A. Kuchel, 
  3. N.S. Lee, 
  4. I. Staff and 
  5. L.D. McCullough
    Louise D. McCullough, MD, PhD, The Stroke Clinic at Hartford Hospital, 80 Seymour St, Suite JB603, Hartford, CT 06102; e-mail:lmccullough@uchc.edu

Abstract

BACKGROUND AND PURPOSE: It is unclear whether endovascular therapies for the treatment of AIS are being offered or are safe in older adults. The use and safety of endovascular interventions in patients older than 75 years of age were assessed.

 

MATERIALS AND METHODS: A retrospective review of patients with AIS 75 years or older (n = 37/1064) was compared with a younger cohort (n = 70/1190) by using an established data base. Admission and discharge NIHSS scores, rates of endovascular treatment, SICH, in-hospital mortality, and the mBI were assessed.

 

RESULTS: Rates of endovascular treatments were significantly lower in older patients (5.9% in the younger-than-75-year versus 3.5% in the older-than-75-year cohort, P = .007). Stroke severity as measured by the NIHSS score was equivalent in the 2 age groups. The mBI at 12 months was worse in the older patients (mild or no disability in 52% of the younger-than-75-year and 22% in the 75-year-or-older cohort, P = .006). Older patients had higher rates of SICH (9% in younger-than-75-year versus 24% in the 75-year-or-older group, P = .04) and in-hospital mortality (26% in younger-than-75-year versus 46% in the 75-year-or-older group, P = .05).

 

CONCLUSIONS: Patients older than 75 years of age were less likely to receive endovascular treatments. Older patients had higher rates of SICH, disability, and mortality. Prospective randomized trials are needed to determine the criteria for selecting patients most likely to benefit from acute endovascular therapies.

 

Abbreviations

AIS 
 
acute ischemic stroke 
 
HIAT 
 
Houston intra-arterial therapy 
 
IA
 
intra-arterial
 
ICH
intracranial hemorrhage
 
INR
 
international normalized ratio
 
IQR
 
interquartile range
 
LDL
low-density lipoprotein
 
mBI
 
modified Barthel Index
 
SICH
 
symptomatic intracranial hemorrhage
 
TIMI
 
thrombolysis in myocardial infarction


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