Endovascular thrombectomy in octogenarians and nonagenarians with large vessel occlusion: Technical aspects and clinical outcome

Outcomes of different anesthesia techniques in nonagenarians treated with mechanical thrombectomy for anterior circulation large vessel occlusion: An inverse probability weighting analysis

INTRODUCTION

There is a lack of evidence for the optimal type of anesthesia technique in patients ⩾ 90 years with acute ischemic stroke undergoing mechanical thrombectomy (MT) as this subgroup of patients was often excluded or under-represented in previous trials. We aimed to compare outcomes between general anesthesia (GA) and non-GA techniques in patients ⩾ 90 years with large vessel occlusion (LVO) undergoing MT.

PATIENTS AND METHODS

Our study included patients ⩾ 90 years with anterior circulation LVO, NIHSS ⩾ 6, ASPECTS ⩾ 5 consecutively treated with MT within 6 h after stroke onset in three thrombectomy capable centers between January 1st, 2016 and March 30th, 2023. Inverse probability weighting (IPW) was used to reduce bias by indication of the anesthesia type on study outcomes. We used a weighted ordinal robust logistic regression analysis to explore the primary outcome of modified Rankin Scale (mRS) shift at 90 days in GA versus non-GA treated patients. Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (sICH) and TICI score of 2b, 2c, or 3.ResultsWe included 139 patients ⩾ 90 years treated with MT, 62 were in GA group and 77 in non-GA group. There was a significant shift for worse mRS scores at 90-day in non-GA treated patients (cOR 3.65, 95% CI 1.77-7.77, p = 0.001). The weighted logistic regression showed that non-GA technique was an independent predictor of 90-day mortality (OR 7.49, 95% CI 2.00-28.09; p = 0.003).

CONCLUSION

Our study indicated that nonagenarians with acute ischemic stroke treated with MT without GA have a worse prognosis than their counterparts undergoing MT with GA. Further studies in larger cohorts are warranted to evaluate the optimal type of anesthesia in this patient population.

Association of Brain Atrophy With Functional Outcome and Recovery Trajectories After Thrombectomy: Post Hoc Analysis of the ESCAPE-NA1 Trial

BACKGROUND AND OBJECTIVES

Brain frailty may impair the ability of acute stroke patients to cope with the injury, irrespective of their chronologic age, resulting in impaired recovery. We aim to investigate the impact of brain atrophy on functional outcome assessed at different time points after endovascular thrombectomy (EVT).

METHODS

In this retrospective post hoc analysis of the ESCAPE-NA1 trial, we analyzed CT imaging data for cortical atrophy by using the GCA scale, including region-specific scales, and subcortical atrophy by using the intercaudate distance to inner table width (CC/IT) ratio. The primary outcome was 90-day mRS (ordinal shift analysis), and the secondary outcome was the mRS score over time. Adjustments were made for age, sex, baseline NIHSS, final infarct volume, stroke laterality, total Fazekas score, and nerinetide-alteplase interaction. Sensitivity analyses were additionally performed in only those patients for whom MRI data were available.

RESULTS

Of 1,102 participants (mean age of 69.5 ± 13.7 years; 554 men), 818 (74%) had GCA = 0, 220 (20%) had GCA = 1, and 64 (6%) had GCA = 2/3. The median CC/IT ratio was 0.12 (IQR0.10-0.15). Cortical atrophy (GCA ≥ 1 vs GCA 0) was associated with worse 90-day mRS (acOR = 1.62 [95% CI 1.22-2.16]; p = 0.001), lower rates of 90-day mRS0-2 (aOR = 0.65 [95% CI 0.45-0.94]; p = 0.022), and higher mortality (aOR = 2.12 [95% CI 1.28-3.5]; p = 0.003), regardless of the region assessed. Subcortical atrophy was associated with worse 90-day mRS (acOR [per 0.01 increase in CC/IT ratio] = 1.07 [95% CI 1.04-1.11]; p < 0.001) and lower rates of 90-day mRS0-2 (aOR = 0.92 [95% CI 0.88-0.97]; p = 0.001). Furthermore, with various degrees of atrophy, we observed heterogeneity in mRS measurements during follow-up: worse mRS scores for higher atrophy grades (p < 0.001). Compared with participants with GCA = 0, the mRS for participants with GCA = 1 was higher at 30 days (adjusted difference = 0.41 [95% CI 0.18-0.65]) and remained worse at 90 days (adjusted difference = 0.72 [95% CI 0.49-0.95]). Similar effects were seen for participants with worse cortical atrophy, regardless of the region assessed, and worse subcortical atrophy. Furthermore, 26/63(41%) and 124/274(45%) patients with severe cortical/subcortical atrophy (GCA 2/3 and highest CC/IT ratio quartile, respectively) achieved good functional outcome (mRS0-2), compared with 539/812(66.4%) with no cortical atrophy and 209/274(76%) in the lowest CC/IT ratio quartile.

DISCUSSION

In this large RCT-derived population, participants with brain atrophy, as visually assessed on acute noncontrast computed tomography imaging, showed less favorable stroke recovery after EVT and worse 90-day functional outcomes compared with participants without brain atrophy. This may support physicians with recovery expectations when planning post-EVT care with patients and their families.

Outcomes of young patients following mechanical thrombectomy for stroke: A systematic review and meta-analysis

BACKGROUND

Young patients experience acute ischemic stroke (AIS) at much lower rates than their older counterparts. We performed a systematic review and meta-analysis to assess the question regarding outcomes and clinical characteristics of young stroke patients who underwent mechanical thrombectomy for AIS.

METHODS

Following PRISMA guidelines, a systematic review of the literature was conducted using the databases PubMed, MEDLINE, and Embase. The primary outcome of interest was 90-day modified Rankin Scale (mRS) 0-2. Secondary outcome variables included rate of successful reperfusion (TICI 2b/3), symptomatic intracerebral hemorrhage (sICH), and mortality. Using R software version 4.1.2, we calculated pooled event rates and their corresponding 95% confidence intervals (CI) for all outcomes.

RESULTS

Our analysis included eight studies with a total of 1903 patients. Definitions of young patients included age ranges of 18-49/50 years, 18-54/55 years, and 18-64/65 years. Functional independence was achieved in 62.0% of the patients, with an overall mortality of 9.0%. Moreover, successful reperfusion was achieved in 82.0% of the patients with sICH rates of 5.7%. There was significant heterogeneity among different analyses, which could not be attributed to the differences of the definition of young patients.

CONCLUSIONS

Following mechanical thrombectomy for AIS, patients aged 18-65 years achieved relatively high rates of functional independence and successful reperfusion and low rates of mortality and sICH.Clinical Perspective In this systematic review and meta-analysis of eight studies, we examined outcomes in young stroke patients, aged 18-65 years old, following mechanical thrombectomy for acute ischemic stroke. We found that young patients achieved high rates of functional independence, high rates of successful reperfusion, and low rates of mortality and symptomatic intracerebral hemorrhage.While there have been several papers examining outcomes following mechanical thrombectomy for acute ischemic stroke in young patients, the results of these studies have yet to be pooled together in a meta-analysis. Our results indicate that young patients have good outcomes following mechanical thrombectomy. Further studies that examine these outcomes are warranted so that a higher-powered analysis can be performed to better informed clinicians regarding outcomes in this patient age-group cohort.

Trends in Use, Outcomes, and Disparities in Endovascular Thrombectomy in US Patients With Stroke Aged 80 Years and Older Compared With Younger Patients

IMPORTANCE

Patients aged 80 years and older were often excluded or underrepresented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis.

OBJECTIVE

To delineate temporal trends in EVT use, outcomes, and disparities among patients with acute ischemic stroke aged 80 years and older vs those younger than 80 years.

DESIGN, SETTING, AND PARTICIPANTS

A US nationwide retrospective cohort study using prospectively collected data was conducted in patients admitted with a primary diagnosis of acute ischemic stroke between April 1, 2012, and June 30, 2019. Data were obtained from hospitals participating in the Get With the Guidelines-Stroke (GWTG-Stroke) program, which is a stroke quality improvement registry, with data collected prospectively, sponsored by the American Heart Association/American Stroke Association. Data analysis was conducted from November 2, 2020, to June 25, 2021.

EXPOSURES

Potentially eligible for EVT based on arrival within 6 hours and National Institutes of Health Stroke Scale score greater than or equal to 6.

MAIN OUTCOMES AND MEASURES

Efficacy outcomes included discharge to home, independent ambulation at discharge, and functional independence (modified Rankin Scale score 0-2) at discharge. Safety outcomes included in-hospital mortality, combined in-hospital mortality or discharge to hospice, and symptomatic intracranial hemorrhage.

RESULTS

Among 302 965 patients with ischemic stroke meeting study criteria as potentially eligible for EVT admitted to 614 GWTG-Stroke hospitals, 14.0% (42 422) received EVT (21 634 women [51.0%]), including 10.7% (12 768 of 119 453) of patients aged 80 years and older (median [IQR] age, 85 [82-89] years) and 16.2% (29 654 of 183 512) of patients younger than 80 years (median [IQR] age, 65 [56-73] years). Among patients aged 80 years and older, EVT rates increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. By study end, the relative rate of EVT among eligible patients aged 80 years and older compared with those younger than 80 years increased from 0.49 (3.3% vs 6.7%) to 0.76 (20.8% vs 27.3%). Older patients had worse outcomes at discharge compared with younger patients, including discharge to home: 12.5% vs 31.1% (adjusted odds ratio [aOR], 0.43; 95% CI, 0.40-0.46), functional independence (modified Rankin Scale score 0-2): 10.9% vs 26.6% (aOR, 0.45; 95% CI, 0.41-0.49), and inpatient death or discharge to hospice, 34.5% vs 16.1% (aOR, 2.22; 95% CI, 2.09-2.36). Symptomatic intracranial hemorrhage rates did not differ significantly (6.9% vs 6.5%; aOR, 1.04; 95% CI, 0.94-1.14).

CONCLUSIONS AND RELEVANCE

In this cohort study, use of EVT among individuals aged 80 years and older increased substantially from 2012 to 2019, although the rate remained lower than in younger patients. Although favorable functional outcomes at discharge were lower and combined mortality or discharge to hospice was higher in the older patients, the risk of symptomatic intracranial hemorrhage was not increased.

Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

BACKGROUND

The purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis.

METHODS

We performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged <18 years and >80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence.

RESULTS

MT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.