Intravenous thrombolysis in acute ischaemic stroke: a systematic review and meta-analysis to aid decision making in patients over 80 years of age

Abstract

Introduction Patients ≥ 80 years of age are increasingly receiving intravenous thrombolysis for acute ischaemic stroke (AIS) despite lack of firm evidence. This systematic review assesses the safety and efficacy of intravenous thrombolysis with alteplase in ≥ 80 versus < 80 year old patients with AIS. Methods The existing literature was systematically analysed for outcome measures of mortality, functional recovery by modified Rankin scale and symptomatic intracranial haemorrhage (SICH) at 3 months following intravenous thrombolysis with alteplase in <80 and ≥ 80 year old patients with AIS. Statistical tests were performed for heterogeneity and publication bias. A detailed sensitivity analysis was performed and Forest plot was constructed for each of the outcome measures. Results 13 studies were identified. The overall OR was 2.77 (95% CI 2.25 to 3.40) for death, 0.49 (95% CI 0.40 to 0.61) for achieving a favourable outcome and 1.31 (95% CI 0.93 to 1.84) for SICH in ≥ 80 year old patients compared with those < 80 years old. The total number of events contributing to the estimates of effect for each outcome was: death 199, favourable outcome 141 and SICH 49. Conclusion Patients ≥ 80 years of age appear to have a lower probability of gaining a favourable outcome and a higher mortality rate compared with patients < 80 years old; however, the rate of SICH was not significantly increased. This supports recruitment of patients aged ≥ 80 years into ongoing trials comparing thrombolysis with controls. For patients who refuse or cannot be randomised, it provides information on risks and benefits of using alteplase off-licence.