Endovascular stroke therapy may prove beneficial in octogenarians

By Eleanor McDermid

Use of intra-arterial therapy (IAT) in octogenarian patients with stroke does not appear to increase their risk for dying in hospital above that seen with use of intravenous (iv) recombinant tissue plasminogen activator (rtPA), a large study suggests.

"The routine clinical use of IAT, especially in this age group, however, remains as of yet experimental," Joshua Willey (Columbia University, New York, USA) and team write in Stroke.

They also note that the risk for in-hospital death rose with increasing age, irrespective of treatment modality. This rise in risk was most noticeable between patients in their 70s and those in their 80s.

The study included 3768 patients from Specialized Program of Translational Research in Acute Stroke (SPOTRIAS) centers, of whom 1182 were aged at least 80 years. Among those treated with iv rtPA (the largest group), the risk for in-hospital mortality was increased 3.88-fold among 70-79-year olds and 6.18-fold among 80-89-year olds, relative to patients younger than 50 years. This represented a 1.54-fold difference in risk between the two older age groups, after accounting for multiple confounders.

But among octogenarians, any IAT, endovascular therapy alone, and bridging therapy were not associated with an increased risk for in-hospital mortality relative to iv rtPA therapy after accounting for confounders.

Notably, the researchers found that mortality was increased nearly fourfold among patients who arrived at hospital within 3 hours of symptom onset but underwent IAT because iv rtPA was contraindicated, relative to those eligible for iv thrombolysis, "suggesting that endovascular treatment might not benefit everyone."

This pattern was also apparent among patients aged 80 years or older, who had a 5.52-fold increased risk if they underwent IAT because of contraindications to iv therapy. Reasons for withholding iv thrombolysis included being aged 80 years or older (n=18), having a elevated international normalized ratio (n=8), and an abnormal platelet count (n=8), but often the contraindication was not listed (n=49).

Willey et al conclude: "Whether older patients should ultimately be treated with endovascular therapy with or without IV rtPA can only be answered through a clinical trial."

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