Outcomes of Nonagenarians with Acute Ischemic Stroke Treated with Intravenous Thrombolytics

Behrouz, Réza; Masjuán-Vallejo, Jaime; Vera, Rocío; Willey, Joshua Z.; Zedet, Mickael; Moulin, Solène; Cordonnier, Charlotte; Klijn, Catharina J.M.; Kanselaar, Karin; Dirks, Maaike; Silver, Brian; Khan, Muhib; Azarpazhooh, Mahmoud R.; Godoy, Daniel A.; Roffe, Christine; Paley, Lizz; Bray, Benjamin D.; Smith, Craig J.; Di Napoli, Mario

Abstract

Background
Nonagenarians are under-represented in thrombolytic trials for acute ischemic stroke (AIS). The effectiveness of intravenous thrombolytics in nonagenarians in terms of safety and outcome is not well established.

Materials and Methods
We used a multinational registry to identify patients aged 90 years or older with good baseline functional status who presented with AIS. Differences in outcomes—disability level at 90 days, frequency of symptomatic intracerebral hemorrhage (sICH), and mortality—between patients who did and did not receive thrombolytics were assessed using multivariable logistic regression, adjusted for prespecified prognostic factors. Coarsened exact matching (CEM) was utilized before evaluating outcome by balancing both groups in the sensitivity analysis.

Results
We identified 227 previously independent nonagenarians with AIS; 122 received intravenous thrombolytics and 105 did not. In the unmatched cohort, ordinal analysis showed a significant treatment effect (adjusted common odds ratio [OR]: .61, 95% confidence interval [CI]: .39-.96). There was an absolute difference of 8.1% in the rate of excellent outcome in favor of thrombolysis (17.4% versus 9.3%; adjusted ratio: .30, 95% CI: .12-.77). Rates of sICH and in-hospital mortality were not different. Similarly, in the matched cohort, CEM analysis showed a shift in the primary outcome distribution in favor of thrombolysis (adjusted common OR: .45, 95% CI: .26-.76).

Conclusions
Nonagenarians treated with thrombolytics showed lower stroke-related disability at 90 days than those not treated, without significant difference in sICH and in-hospital mortality rates. These observations cannot exclude a residual confounding effect, but provide evidence that thrombolytics should not be withheld from nonagenarians because of age alone.

Citation

Behrouz, R., Masjuán-Vallejo, J., Vera, R., Willey, J. Z., Zedet, M., Moulin, S., …Di Napoli, M. (2018). Outcomes of Nonagenarians with Acute Ischemic Stroke Treated with Intravenous Thrombolytics. Journal of Stroke and Cerebrovascular Diseases, 27(1), 246-256. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.08.031

• Journal Article Type: Article
• Acceptance Date: Aug 21, 2017
• Online Publication Date: Sep 19, 2017
• Publication Date: 2018-01
• Deposit Date: Nov 24, 2023
• Journal: Journal of Stroke and Cerebrovascular Diseases
• Print ISSN: 1052-3057
• Publisher: Elsevier
• Peer Reviewed: Peer Reviewed
• Volume: 27
• Issue: 1
• Pages: 246-256
• DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.08.031
• Keywords: Cardiology and Cardiovascular Medicine; Neurology (clinical); Rehabilitation; Surgery