Mechanical thrombectomy in elderly stroke patients with low ASPECTS: insights from STAR

Conor Cunningham^#¹, Zachary Hubbard^#¹, Rahim Abo Kasem^#¹, Sameh Samir Elawady², Mohammad-Mahdi Sowlat¹, Hidetoshi Matsukawa³, Ilko Maier⁴, Pascal Jabbour⁵, Joon-Tae Kim⁶, Stacey Q Wolfe⁷, Ansaar T Rai⁸, Robert M Starke⁹, Marios-Nikos Psychogios¹⁰, Edgar A Samaniego¹¹, Nitin Goyal¹², Shinichi Yoshimura³, Hugo Cuellar¹³, Brian M Howard^{14

15}, Ali Alawieh¹⁴, Ali Alaraj¹⁶, Mohamad Ezzeldin^{17

18}, Daniele G Romano¹⁹, Omar Tanweer²⁰, Justin R Mascitelli²¹, Isabel Fragata²², Adam J Polifka²³, Fazeel Siddiqui²⁴, Joshua W Osbun²⁵, Ramesh Grandhi²⁶, Roberto Javier Crosa²⁷, Charles Matouk²⁸, Min S Park²⁹, Michael R Levitt³⁰, Waleed Brinjikji³¹, Mark Moss³², Ergun Daglioglu³³, Richard Williamson³⁴, Pedro Navia³⁵, Peter Kan³⁶, Reade Andrew De Leacy³⁷, Shakeel A Chowdhry³⁸, David Altschul³⁹, Sami Al Kasab⁴⁰, Alejandro M Spiotta⁴¹

Affiliations

¹ Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
² Neurology, Houston Methodist Hospital, Houston, Texas, USA.
³ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
⁴ Neurology, University Medicine Goettingen, Goettingen, Germany.
⁵ Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁶ Neurology, Chonnam National University Medical School, Gwangju, Korea (the Republic of).
⁷ Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.
⁸ Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA.
⁹ Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
¹⁰ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹¹ Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
¹² Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
¹³ Neurosurgery, LSUHSC, Shreveport, Louisiana, USA.
¹⁴ Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁵ Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁶ Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
¹⁷ Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas, USA.
¹⁸ Neuroendovascular surgery, HCA Houston, Houston, Texas, USA.
¹⁹ Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy.
²⁰ Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
²¹ Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
²² Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
²³ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
²⁴ Department of Neuroscience, University of Michigan Health-West, Wyoming, Michigan, USA.
²⁵ Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
²⁶ Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA.
²⁷ Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay.
²⁸ Neurosurgery, Yale University, New Haven, Connecticut, USA.
²⁹ Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
³⁰ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
³¹ Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA.
³² Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, Arkansas, USA.
³³ Neurosurgery, Ankara Bilkent City Hospital, Ankara, Turkey.
³⁴ Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
³⁵ Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
³⁶ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
³⁷ Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
³⁸ Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA.
³⁹ Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, USA.
⁴⁰ Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.
⁴¹ Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA spiotta@musc.edu.

^# Contributed equally.

PMID: 39855673
DOI: 10.1136/jnis-2024-022677

Multicenter Study

Mechanical thrombectomy in elderly stroke patients with low ASPECTS: insights from STAR

Conor Cunningham et al. J Neurointerv Surg. 2025.

. 2025 Jun 1;17(e2):e206-e215.

doi: 10.1136/jnis-2024-022677.

Authors

Affiliations

¹ Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
² Neurology, Houston Methodist Hospital, Houston, Texas, USA.
³ Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
⁴ Neurology, University Medicine Goettingen, Goettingen, Germany.
⁵ Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁶ Neurology, Chonnam National University Medical School, Gwangju, Korea (the Republic of).
⁷ Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.
⁸ Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA.
⁹ Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
¹⁰ Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
¹¹ Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
¹² Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.
¹³ Neurosurgery, LSUHSC, Shreveport, Louisiana, USA.
¹⁴ Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁵ Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁶ Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
¹⁷ Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas, USA.
¹⁸ Neuroendovascular surgery, HCA Houston, Houston, Texas, USA.
¹⁹ Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy.
²⁰ Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
²¹ Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
²² Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
²³ Department of Neurosurgery, University of Florida, Gainesville, Florida, USA.
²⁴ Department of Neuroscience, University of Michigan Health-West, Wyoming, Michigan, USA.
²⁵ Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA.
²⁶ Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA.
²⁷ Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay.
²⁸ Neurosurgery, Yale University, New Haven, Connecticut, USA.
²⁹ Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
³⁰ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
³¹ Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA.
³² Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, Arkansas, USA.
³³ Neurosurgery, Ankara Bilkent City Hospital, Ankara, Turkey.
³⁴ Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
³⁵ Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain.
³⁶ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
³⁷ Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
³⁸ Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA.
³⁹ Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, USA.
⁴⁰ Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.
⁴¹ Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA spiotta@musc.edu.

^# Contributed equally.

PMID: 39855673
DOI: 10.1136/jnis-2024-022677

Abstract

Background: The elderly population (≥80 years) were underrepresented in recent trials of endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion acute ischemic stroke (LVO-AIS) with low Alberta Stroke Program Early CT Score (ASPECTS) (≤5).

Methods: This study analyzed data from a prospectively maintained database of 37 thrombectomy centers. The primary cohort of the study comprised patients with LVO-AIS aged ≥80 who underwent EVT with ASPECTS≤5 from 2013 to 2023. The primary outcome was favorable modified Rankin Scale (mRS) score of 0-3. Propensity score matching (PSM) and multivariate regression were applied.

Results: In a study of 14 233 patients undergoing EVT, 1741 patients were 80 or older, with 122 presenting with low ASPECTS. While successful recanalization rates were similar between age groups, patients aged ≥80 had significantly lower favorable 90-day mRS scores and higher mortality before propensity score matching (PSM). After PSM, differences in mortality and symptomatic intracranial hemorrhage (sICH) were no longer significant. Among all elderly patients, higher ASPECTS was an independent predictor of a 90-day favorable outcome but was not associated with 90-day mortality. For patients aged ≥80 years with low ASPECTS, favorable outcomes were associated only with lower rates of atrial fibrillation, baseline functioning (mRS 0-1), fewer thrombectomy passes, and higher likelihood of first-pass reperfusion within 30 min of puncture.

Conclusion: While age ≥80 increases mortality and disability in patients with AIS and low ASPECTS, select elderly patients may still benefit from EVT when clinical factors are considered, supporting individualized treatment and better patient selection for future trials.

Keywords: Artery; Catheter; Stroke; Thrombectomy.

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Conflict of interest statement

Competing interests: HM received a lecture fee from Daiichi-Sankyo and Stryker and consulting services fee from B. Braun. IM: speakers’ honoraria from Pfizer and Bristol-Myers Squibb. RMS: research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, Department of Health Biomedical Research Grant (21K02AWD-007000) and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities, unrestricted research grant from Medtronic and Balt and has consulting and teaching agreements with Penumbra, Abbott, Medtronic, Balt, InNeuroCo, Cerenovus, Naglreiter, Tonbridge, Von Medical, and Optimize Vascular. M-NP: Grants from the Swiss National Science Foundation (SNF) for the DISTAL trial (33IC30_198783) and TECNO trial (32003B_204977), Grant from Bangerter-Rhyner Stiftung for the DISTAL trial. Unrestricted Grants for the DISTAL trial from Stryker Neurovascular Inc., Phenox GmbH, Penumbra Inc. and Rapid Medical Inc., Sponsor-PI SPINNERS trial (Funded by a Siemens Healthineers AG Grant), Research agreement with Siemens Healthineers AG, Local PI for the ASSIST, EXCELLENT, TENSION, COATING, SURF and ESCAPE-NEXT trials. Speaker fees: Stryker Neurovascular Inc., Medtronic Inc., Penumbra Inc., Acandis GmbH, Phenox GmbH, Siemens Healthineers AG. ES: consults for Medtronic, microvention, Rapid Medical. SY: received lecture fee from Stryker, Medtronic, Johnson & Johnson, Kaneka Medics. HC: Consultant for Medtronic and Microvention. JAG: Georgia Research Alliance, Emory Medical Care Foundation, Neurosurgery Catalyst, Consultant: Cognition, Imperative Care. DGR: Consultant for Penumbra, Balt, Microvention, Phenox. OT: Consulting Agreements: Viz.AI, Inc, Penumbra, Inc, Balt, Inc, Stryker Inc, Imperative Inc. Proctor: Microvention Inc, Medtronic Inc. Educational/Research Grants: Q’apel Inc, Steinberg Foundation. CM: Consultant for Stryker, Medtronic, Microvention, Penumbra, and Silk Road Medical. Speaker for Penumbra and Silk Road Medical. Contact PI for NIH Grant R21NS128641. MSP: Consultant for Medtronic. MRL: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Medtronic, Aeaean Advisers, Metis Innovative, and Genomadix; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. WB: Holds equity in Nested Knowledge, Superior Medical Editors, Piraeus Medical, Sonoris Medical, and MIVI Neurovascular. He receives royalties from Medtronic and Balloon Guide Catheter Technology. He receives consulting fees from Medtronic, Stryker, Imperative Care, Microvention, MIVI Neurovascular, Cerenovus, Asahi, and Balt. He serves in a leadership or fiduciary role for MIVI Neurovascular, Marblehead Medical LLC, Interventional Neuroradiology (Editor in Chief), Piraeus Medical, and WFITN. RW: Consultant for Medtronic, Stryker, and Synaptive Medical. PN: Consultant for Penumbra, Medtronic, Stryker, Cerenovus and Balt. PK: Grants from the NIH (1U18EB029353-01) and unrestricted educational grants from Medtronic and Siemens. Consultant for Imperative Care and Stryker Neurovascular. Stock ownership in Vena Medical. RADL: PI for Imperative Trial; Research grants from Siemens Healthineers and Kaneka medical. Consultant for Cerenovus, Stryker Neurovascular and Sim & Cure. Minor equity interest Vastrax, Borvo medical, Synchron, Endostream, Von Vascular, Radical catheters and Precision Recovery Inc. SAC: Consultant and proctor for Medtronic and Microvention. ME: Consultant for Viz.ai and Imperative care. Investments in Galaxy Therapeutics. DA: Consultant for MicroVention, Stryker, and Cerenovus. RG: Consultant for Balt Neurovascular, Cerenovus, Medtronic Neurovascular, Rapid Medical, and Stryker Neurovascular. AMS: Consultant for Penumbra, Terumo, RapidAI, Cerenovus. AAlaraj: Consultant for Cerenovus. SAK: received general payments from AstraZeneca Pharmaceuticals, MicroVention, and Stryker.

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Mechanical thrombectomy in elderly stroke patients with low ASPECTS: insights from STAR

Affiliations

Mechanical thrombectomy in elderly stroke patients with low ASPECTS: insights from STAR

Authors

Affiliations

Abstract

Conflict of interest statement

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LinkOut - more resources

Full Text Sources

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