Intracranial angioplasty and/or stent placement in octogenarians is associated with a threefold greater risk of periprocedural stroke or death

Ischemic Conditioning Is Safe and Effective for Octo- and Nonagenarians in Stroke Prevention and Treatment

Symptomatic intracranial arterial stenosis (SIAS) is very common in octo- and nonagenarians, especially in the Chinese population, and is likely the most common cause of stroke recurrence worldwide. Clinical trials demonstrate that endovascular treatment, such as stenting, may not be suitable for octogenarians with systemic diseases. Hence, less invasive methods for the octogenarian patients are urgently needed. Our previous study (unique identifier: NCT01321749) showed that repetitive bilateral arm ischemic preconditioning (BAIPC) reduced the incidence of stroke recurrence by improving cerebral perfusion (confirmed by single photon emission computed tomography and transcranial Doppler sonography) in patients younger than 80 years of age; however, the safety and effectiveness of BAIPC on stroke prevention in octo- and nonagenarians with SIAS are still unclear. The objective of this study was to evaluate the safety and effectiveness of BAIPC in reducing stroke recurrence in octo- and nonagenarian patients with SIAS. Fifty-eight patients with SIAS were enrolled in this randomized controlled prospective study for 180 consecutive days. All patients enrolled in the study received standard medical management. Patients in the BAIPC group (n = 30) underwent 5 cycles consisting of bilateral arm ischemia followed by reperfusion for 5 min each twice daily. Those in the control group (n = 28) underwent sham-BAIPC twice daily. Blood pressure, heart rate, local skin status, plasma myoglobin, and plasma levels of thrombotic and inflammatory markers were documented in both groups before beginning the study and for the first 30 days. Finally, the incidences of stroke recurrence and magnetic resonance imaging during the 180 days of treatment were compared. Compared with the control, BAIPC had no adverse effects on blood pressure, heart rate, local skin integrity, or plasma myoglobin, and did not induce cerebral hemorrhage in the studied cohort. BAIPC reduced plasma high sensitive C-reactive protein, interleukin-6, plasminogen activator inhibitor-1, leukocyte count, and platelet aggregation rate and elevated plasma tissue plasminogen activator (all p < 0.01). In 180 days, 2 infarctions and 7 transient ischemic attacks were observed in the BAIPC group compared with 8 infarctions and 11 transient ischemic attacks in the sham BAIPC group (p < 0.05). BAIPC may safely inhibit stroke recurrence, protect against brain ischemia, and ameliorate plasma biomarkers of inflammation and coagulation in octo- and nonagenarians with SIAS. A multicenter trial is ongoing.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov, unique identifier: NCT01570231.

Comparison of acute nonthrombolytic and thrombolytic treatments in ischemic stroke patients 80 years or older

OBJECTIVES

The aim of this study was to compare the clinical outcomes of acute ischemic stroke patients 80 years or older treated with intravenous recombinant tissue plasminogen activator (i.v. rt-PA), or endovascular intervention with or without i.v. rt-PA, or nonthrombolytic medical treatment.

METHODS

This study was a retrospective, nonrandomized, observational study of patients, admitted within 9 hours of symptom onset, at 3 academic, university-affiliated hospitals. The main outcome measures were neurologic improvement, defined by improvement in National Institutes of Health Stroke Scale score at 7 days or discharge of 4 or more, or achieving a score of 0; symptomatic and asymptomatic intracerebral hemorrhage; favorable outcome (discharge modified Rankin score 0-2); and in-hospital mortality.

RESULTS

A total of 44 patients received i.v. rt-PA, 46 received endovascular intervention with or without i.v. rt-PA, and 66 received nonthrombolytic medical treatment. I.v. rt-PA-treated patients had a significantly clinically higher chance of favorable outcome (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.8-17.5), when compared with nonthrombolytic medical treatment. A significantly higher rate of neurologic improvement was observed among the i.v. rt-PA (7.2; 95% CI, 2.7-19.5) and endovascularly treated patients (5.8; 95% CI, 2-16.8) when compared with nonthrombolytic medical treatment.

CONCLUSIONS

A prominently higher rate of neurologic improvement and favorable clinical outcome was observed among acute ischemic stroke patients 80 years or older treated with i.v. rt-PA or endovascular intervention when compared with nonthrombolytic medical treatment, supporting the use of acute thrombolytic therapies in this patient population when contraindications are not present.