Réza Behrouz1, Jaime Masjuán-Vallejo2, Rocío Vera2, Joshua Z Willey3, Mickael Zedet4, Solène Moulin4, Charlotte Cordonnier4, Catharina J M Klijn5, Karin Kanselaar5, Maaike Dirks6, Brian Silver7, Muhib Khan8, Mahmoud R Azarpazhooh9, Daniel A Godoy10, Christine Roffe11, Lizz Paley12, Benjamin D Bray13, Craig J Smith14, Mario Di Napoli15. 1. Department of Neurology, School of Medicine, University of Texas Health Science Center, San Antonio, Texas. Electronic address: behrouz@uthscsa.edu. 2. Department of Neurology, Ramón y Cajal University Hospital, Universidad de Alcala, Madrid, Spain. 3. Department of Neurology, Columbia University College of Physician and Surgeons, New York, New York. 4. Université de Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU de Lille, Department of Neurology, Lille, France. 5. Centre for Cognitive Neuroscience, Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands. 6. Department of Neurology, University Medical Centre Utrecht, Utrecht, The Netherlands. 7. Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts. 8. Neuroscience Institute, Spectrum Health, Grand Rapids, Michigan. 9. Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. 10. Neurosciences Intensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina. 11. Stroke Research Group, Institute for Applied Sciences, Keele University, Stoke-on-Trent, United Kingdom. 12. Farr Institute of Health Informatics, University College London, London, United Kingdom. 13. Royal College of Physicians, Centre for Stroke and Vascular Research, King's College London, London, United Kingdom. 14. Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, United Kingdom; Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom. 15. Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy; The Neurological Section, Neuro-epidemiology Unit, SMDN, Centre for Cardiovascular Medicine and Cerebrovascular Disease Prevention, L'Aquila, Italy.
Abstract
BACKGROUND: Nonagenarians are under-represented in thrombolytic trials for acute ischemic stroke (AIS). The effectiveness of intravenous thrombolytics in nonagenarians in terms of safety and outcome is not well established. MATERIALS AND METHODS: We used a multinational registry to identify patients aged 90 years or older with good baseline functional status who presented with AIS. Differences in outcomes-disability level at 90 days, frequency of symptomatic intracerebral hemorrhage (sICH), and mortality-between patients who did and did not receive thrombolytics were assessed using multivariable logistic regression, adjusted for prespecified prognostic factors. Coarsened exact matching (CEM) was utilized before evaluating outcome by balancing both groups in the sensitivity analysis. RESULTS: We identified 227 previously independent nonagenarians with AIS; 122 received intravenous thrombolytics and 105 did not. In the unmatched cohort, ordinal analysis showed a significant treatment effect (adjusted common odds ratio [OR]: .61, 95% confidence interval [CI]: .39-.96). There was an absolute difference of 8.1% in the rate of excellent outcome in favor of thrombolysis (17.4% versus 9.3%; adjusted ratio: .30, 95% CI: .12-.77). Rates of sICH and in-hospital mortality were not different. Similarly, in the matched cohort, CEM analysis showed a shift in the primary outcome distribution in favor of thrombolysis (adjusted common OR: .45, 95% CI: .26-.76). CONCLUSIONS: Nonagenarians treated with thrombolytics showed lower stroke-related disability at 90 days than those not treated, without significant difference in sICH and in-hospital mortality rates. These observations cannot exclude a residual confounding effect, but provide evidence that thrombolytics should not be withheld from nonagenarians because of age alone.
BACKGROUND: Nonagenarians are under-represented in thrombolytic trials for acute ischemic stroke (AIS). The effectiveness of intravenous thrombolytics in nonagenarians in terms of safety and outcome is not well established. MATERIALS AND METHODS: We used a multinational registry to identify patients aged 90 years or older with good baseline functional status who presented with AIS. Differences in outcomes-disability level at 90 days, frequency of symptomatic intracerebral hemorrhage (sICH), and mortality-between patients who did and did not receive thrombolytics were assessed using multivariable logistic regression, adjusted for prespecified prognostic factors. Coarsened exact matching (CEM) was utilized before evaluating outcome by balancing both groups in the sensitivity analysis. RESULTS: We identified 227 previously independent nonagenarians with AIS; 122 received intravenous thrombolytics and 105 did not. In the unmatched cohort, ordinal analysis showed a significant treatment effect (adjusted common odds ratio [OR]: .61, 95% confidence interval [CI]: .39-.96). There was an absolute difference of 8.1% in the rate of excellent outcome in favor of thrombolysis (17.4% versus 9.3%; adjusted ratio: .30, 95% CI: .12-.77). Rates of sICH and in-hospital mortality were not different. Similarly, in the matched cohort, CEM analysis showed a shift in the primary outcome distribution in favor of thrombolysis (adjusted common OR: .45, 95% CI: .26-.76). CONCLUSIONS: Nonagenarians treated with thrombolytics showed lower stroke-related disability at 90 days than those not treated, without significant difference in sICH and in-hospital mortality rates. These observations cannot exclude a residual confounding effect, but provide evidence that thrombolytics should not be withheld from nonagenarians because of age alone.
Authors: B Baena Álvarez; S García-Madrona; R Sainz Amo; F Rodríguez Jorge; J Gómez Corral; R Vera Lechuga; M C Matute Lozano; A Sánchez Sánchez; A De Felipe Mimbrera; A Cruz Culebras; J Masjuan Vallejo Journal: Eur Geriatr Med Date: 2021-04-28 Impact factor: 1.710