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Multicenter Study
. 2024 Aug 1;7(8):e2426007.
doi: 10.1001/jamanetworkopen.2024.26007.

Age and Functional Outcomes in Patients With Large Ischemic Stroke Receiving Endovascular Thrombectomy

Laurens Winkelmeier  1 , Helge Kniep  1 , Tobias Faizy  2 , Christian Heitkamp  1 , Ludovic Holtz  1 , Lukas Meyer  1 , Fabian Flottmann  1 , Alexander Heitkamp  1 , Maximilian Schell  3 , Götz Thomalla  3 , Jens Fiehler  1 , Gabriel Broocks  1   4 ; German Stroke Registry–Endovascular Treatment (GSR-ET)
Collaborators, Affiliations
Multicenter Study

Age and Functional Outcomes in Patients With Large Ischemic Stroke Receiving Endovascular Thrombectomy

Laurens Winkelmeier et al. JAMA Netw Open. .

Abstract

Importance: Randomized clinical trials have demonstrated the efficacy and safety of endovascular thrombectomy for acute ischemic stroke with large infarct. Patients older than 80 years with large infarct are commonly encountered in clinical practice but underrepresented in randomized clinical trials.

Objective: To provide an age-based analysis of functional outcomes in endovascular thrombectomy for acute ischemic strokes with large infarct.

Design, setting, and participants: This retrospective multicenter cohort study included patients from the German Stroke Registry who received endovascular thrombectomy for acute ischemic stroke with large infarct at 1 of 25 German stroke centers between May 2015 and December 2021. Patients with acute ischemic stroke due to anterior circulation large vessel occlusion and large infarct were included. Large infarct was defined as an Alberta Stroke Program Early Computed Tomography Score of 0 to 5. Patients were subdivided by age to evaluate its association with functional outcomes.

Exposure: Age.

Main outcomes and measures: Primary outcomes were independent ambulation (90-day modified Rankin Scale score of 0-3) and mortality (90-day modified Rankin Scale score of 6).

Results: A total of 408 patients with large infarct were included (217 women [53.2%]; median [IQR] age, 75 [64-83] years). The rate of independent ambulation decreased from 56.4% in patients aged 60 years and younger (44 of 78 patients) to 15.1% in patients older than 80 years (19 of 126 patients) (P < .001), while mortality increased from 15.4% (12 patients) to 64.3% (81 patients) (P < .001). Being older than 80 years was associated with lower rates of independent ambulation (adjusted odds ratio [aOR], 0.44; 95% CI, 0.23-0.82; P = .01) and higher mortality (aOR, 2.75; 95% CI, 1.61-4.72; P < .001). A final modified Thrombolysis in Cerebral Infarction grade of 2b or 3 was associated with higher rates of independent ambulation (aOR, 4.95; 95% CI, 2.14-11.43; P < .001), independent of age and without significant interaction (aOR, 0.69; 95% CI, 0.35-1.34; P = .27).

Conclusions and relevance: In this cohort study of patients with acute ischemic stroke and large infarct, age was associated with functional outcomes. Patients older than 80 years had poor prognosis with high mortality but with sizeable differences depending on additional baseline and treatment characteristics. While it does not seem justified to apply a fixed upper age limit for endovascular thrombectomy, these results could assist clinicians in making informed treatment decisions in older patients with large ischemic stroke.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kniep reported receiving personal fees from and having an ownership stake in Eppdata GmbH and receiving speaker fees from Asklepios Kliniken outside the submitted work. Dr Faizy reported receiving grants from the German Research Foundation outside the submitted work. Dr Meyer reported receiving speaker fees from Balt and personal fees from Eppdata GmbH outside the submitted work. Dr Flottmann reported receiving personal fees from Eppdata GmbH outside the submitted work. Dr Thomalla reported receiving grants from the German Research Foundation, the German Innovations Fund, and European Union Horizon 2020 and personal fees from Acandis, Alexion, Amarin, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb/Pfizer, Daiichi Sankyo, Portola, and Stryker outside the submitted work. Dr Fiehler reported receiving personal fees from Acandis, Cerenovus, Medtronic, MicroVention, Medtronic, Penumbra, Phenox, Stryker, Tonbride, and Roche and having stocks or stock options in Tegus Medical, Eppdata, and Vastrax outside the submitted work. Dr Broocks reported receiving personal fees from Eppdata GmbH and speaker fees from Balt. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Distribution of Scores on the Modified Rankin Scale (mRS), Independent Ambulation, and Mortality at 90 Days, Stratified by Age in Patients With Acute Ischemic Stroke and Large Infarct
A, The dashed line marks mRS score of 6 (death), and the solid line marks mRS scores of 0, indicating no symptoms; 1, no clinically significant disability; 2, slight disability; and 3, moderate disability (the patient can walk unassisted). mRS score of 4 indicates moderately severe disability and 5, severe disability.
Figure 2.
Figure 2.. Predicted Probabilities for Independent Ambulation and Death Following Endovascular Thrombectomy Among Patients With Acute Ischemic Stroke With Large Infarct
The predicted probabilities for independent ambulation at 90 days (A) and death within 90 days (B) are shown for given patient and treatment characteristics (age ≤80 years vs >80 years; prestroke modified Rankin Scale [mRS] score; admission National Institutes of Health Stroke Scale [NIHSS] score; and final modified Thrombolysis in Cerebral Infarction [mTICI] grade). The predicted probabilities are derived from the regression model in eTable 2 in Supplement 1.
Figure 3.
Figure 3.. Age and Clinical Benefit of Successful Reperfusion
Predicted probabilities with 95% CIs for independent ambulation at 90 days (A) and death within 90 days (B), stratified by age and reperfusion status. Results were adjusted for prestroke modified Rankin Scale score and admission National Institutes of Health Stroke Scale score. mTICI indicates modified Thrombolysis in Cerebral Infarction.
See this image and copyright information in PMC

Comment in

  • doi: 10.1001/jamanetworkopen.2024.25958

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