IV thrombolysis may be safe in patients with ischemic stroke aged 90 years or older
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The odds of 3-month symptomatic intracranial hemorrhage following IV thrombolysis for ischemic stroke among patients aged 90 years or older were not greater compared with younger patients, researchers reported.
“Higher probability of death and poor functional outcome during follow-up in the very elderly seems not to be related to IV thrombolysis (IVT) treatment. Very high age itself should not be a reason to withhold IVT,” Valerian L. Altersberger, MD, of the Stroke Centre and department of neurology at the University Hospital Basel and University of Basel, Switzerland, and colleagues wrote.
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“Current IVT guidelines recommend IVT for patients with ischemic stroke who are > 80 years old. However, this recommendation is not based on evidence from any studies focusing on IVT in very elderly patients,” the researchers wrote.
The TRISP registry
Researchers used data from the Thrombolysis in Ischemic Stroke Patients (TRISP) registry to evaluate the 3-month safety of IVT in patients aged 90 years or older. Patients were compared with a younger cohort (< 90 years) for outcomes including intracranial hemorrhage, death and poor functional outcome at 3 months.
Poor functional outcome was defined as 3-month modified Rankin Scale score of 3 to 5 among patients with a before-stroke score of 2 or less, or a 3-month score of 4 to 5 in patients with before-stroke score of 3 or more.
Among 16,974 patients included in the analysis, 5.7% were aged 90 years or older.
Those aged 90 years or older were more often women, were more likely to have a before-stroke modified Rankin Scale score of 3 or more, and had higher NIH Stroke Scale score, BP, glucose and creatinine levels at hospital admission for stroke compared with the younger group.
Researchers reported that the likelihood of intracranial hemorrhage at 3 months was not significantly greater between the older and younger groups (older, 5.7%; younger, 4.4%; adjusted OR = 1.14; 95% CI, 0.83-1.57). However, the odds of death (aOR = 3.77; 95% CI, 3.14-4.53) and poor functional outcome at 3 months (aOR = 2.63; 95% CI, 2.13-3.25) were greater among patients aged 90 years or older compared with younger patients.
After adjustment for confounders, the probability of functional improvement after 24 hours did not differ among patients aged 90 years or older compared with younger patients (aOR = 0.85; 95% CI, 0.7-1.04), according to the study.
Plateau after 79 years
In a post hoc analysis in which patients were stratified by age, researchers observed the rate of symptomatic intracranial hemorrhage increased with every 10 years until patients were aged 70 to 79 years, after which point the rate of symptomatic intracranial hemorrhage remained stable.
“As expected, patients 90 years had more severe strokes, more often relevant prestroke disability and were more likely to have cardiovascular risk factors compared with patients < 90 years,” the researchers wrote. “Consequently, patients 90 years died more often during follow-up and had poorer functional outcomes even after adjustment for potential confounders.
“[A]lthough widely accepted risk factors for symptomatic intracranial hemorrhage were more frequent in the very elderly ... the probability of symptomatic intracranial hemorrhage after IVT did not differ significantly between patients 90 and < 90 years in our study. However, when analyzing the age-dependent probability for symptomatic intracranial hemorrhage by decade, the probability increased up to 70 to 79 years and plateaued for higher age, which might reflect a ceiling effect of symptomatic intracranial hemorrhage after the age of 70 in our cohort.”
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