SAN ANTONIO — Octogenarians with acute stroke underwent intracerebral clot retrieval as safely and effectively as did younger patients in a retrospective review of 186 patients aged 80 or older.
Results from a prior study identified advanced age as a strong predictor of bad outcomes in patients with acute ischemic stroke treated with thrombectomy, but this new study showed that “the risk of symptomatic intracerebral hemorrhage did not appear significantly increased in the elderly,” Dr. Raul G. Nogueira said at the International Stroke Conference.
“Age is an imperfect surrogate for functional status. Treatment individualization is therefore required,” said Dr. Nogueira, a neurologist and radiologist at Massachusetts General Hospital, Boston.
His study combined data from three separate series of acute stroke patients who underwent endovascular clot removal using the Merci retriever: the MERCI trial, with 141 patients, the Multi MERCI trial, with 164 patients, and the first 814 patients in the MERCI registry. Of these 1,119 patients, 186 were aged 80 or older and had a modified Rankin scale score of 0 or 1 before their stroke.
The average age of the 80 and older subgroup was 85, with a range of 80-96. Their average NIH Stroke Scale score before treatment was 19; two-thirds were women. They were treated an average of 5 hours after stroke onset, with a range of 2-21 hours. Treatment involved an average of three passes of the Merci device. It began with an intravenous infusion of tissue plasminogen activator (TPA) in 21% of patients, and 47% received intra-arterial TPA.
In the 73 elderly patients culled from the MERCI and Multi MERCI trials, the incidence of symptomatic intracranial hemorrhage following treatment was 10%, with a 3% rate of parenchymal hematoma type II (data on these outcomes were not available from the MERCI registry). These adverse event rates were similar to those reported for the entire MERCI and Multi MERCI studies, Dr. Nogueira said at the conference, sponsored by the American Heart Association.
Recanalization of the blocked artery occurred in 69% of the 186 elderly patients, compared with 65% for all patients in the MERCI and Multi MERCI studies, showing that clot retrieval was as effective in the elderly as it was in all patients.
Of the 305 patients in the combined MERCI and Multi MERCI studies, 63 were aged 80 or older, which meant that this analysis in part compared the same octogenarian patients to themselves. But most of the octogenarian patients in the analysis came from the MERCI registry, and nearly 80% of patients in the combined MERCI and Multi MERCI group were younger than 80.
At 90 days after treatment in the 128 elderly patients successfully recanalized by clot retrieval and TPA treatment, the modified Rankin scale score reached 0-2 in 24%, and 48% of the patients had died. In contrast, among the 58 elderly patients who failed to achieve recanalization with treatment, 2% had a modified Rankin scale score of 0-2, and 75% died.
In a multivariate analysis, achievement of good blood flow through the previously occluded cerebral artery was a major determinant of a good 90-day outcome and 90-day survival. The findings show the key role of recanalization in producing a good outcome in elderly patients, Dr. Nogueira said.
“This is not a controlled study, but it is good as you can get,” he said in an interview. “It seems like the elderly can benefit. An 80- or 90-year-old with good [pre-stroke] function can do better than a 70-year-old with bad function.”