Sudhir Datar1, Christopher McLouth2, Patrick Reynolds3. 1. Department of Neurology, Section of Neurocritical Care, Wake Forest Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC, 27157, USA. sdatar@wakehealth.edu. 2. Department of Biostatistics, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA. 3. Department of Neurology, Section of Stroke and Cerebrovascular Diseases, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.
Abstract
BACKGROUND: Large ischemic stroke in the very elderly population is presumed to invariably carry a poor prognosis and clinicians may refrain from continuing intensive care. Many elderly patients are not surgical candidates, and there is a paucity of data outlining the real-world outcomes of continued medical management. Our objective is to identify the factors associated with the outcome of very elderly patients with large hemispheric infarction (LHI) treated with medical management alone. METHODS: We performed a retrospective review of all consecutive adults ≥ 70 years of age with LHI identified from a single center stroke registry between 2012 and 2016. Mean volume of infarction was calculated using the ABC/2 method. RESULTS: Of a total of 2335 patients, 71 (mean age 81 ± 7 years,) met inclusion criteria. Forty-one were women (58%). Mean admission National Institute of Health Stroke Score (NIHSS) was 21 ± 6. Intravenous tPA was administered in 30 (42%) and 9 (13%) patients underwent thrombectomy. Mean infarct volume was 175 ± 75 cc. Twenty-seven patients (38%) survived to hospital discharge; 6 (9%) eventually went home (albeit with mRS 4) and one (1%) went to assisted living. Multivariate logistic regression analysis found that admission NIHSS ≥ 20 (p = 0.0007) and mechanical ventilation within 48 h of admission (p = 0.0396) were independently associated with poor outcome. CONCLUSION: Ten percent of medically managed patients (≥ 70 years of age) with LHI can go home or to assisted living, but with a mRS of 4. Whether this is an acceptable outcome must be individualized on a case-by-case basis; however, poor prognosis should not be automatically presumed solely based on the combination of older age and a large stroke.
BACKGROUND: Large ischemic stroke in the very elderly population is presumed to invariably carry a poor prognosis and clinicians may refrain from continuing intensive care. Many elderly patients are not surgical candidates, and there is a paucity of data outlining the real-world outcomes of continued medical management. Our objective is to identify the factors associated with the outcome of very elderly patients with large hemispheric infarction (LHI) treated with medical management alone. METHODS: We performed a retrospective review of all consecutive adults ≥ 70 years of age with LHI identified from a single center stroke registry between 2012 and 2016. Mean volume of infarction was calculated using the ABC/2 method. RESULTS: Of a total of 2335 patients, 71 (mean age 81 ± 7 years,) met inclusion criteria. Forty-one were women (58%). Mean admission National Institute of Health Stroke Score (NIHSS) was 21 ± 6. Intravenous tPA was administered in 30 (42%) and 9 (13%) patients underwent thrombectomy. Mean infarct volume was 175 ± 75 cc. Twenty-seven patients (38%) survived to hospital discharge; 6 (9%) eventually went home (albeit with mRS 4) and one (1%) went to assisted living. Multivariate logistic regression analysis found that admission NIHSS ≥ 20 (p = 0.0007) and mechanical ventilation within 48 h of admission (p = 0.0396) were independently associated with poor outcome. CONCLUSION: Ten percent of medically managed patients (≥ 70 years of age) with LHI can go home or to assisted living, but with a mRS of 4. Whether this is an acceptable outcome must be individualized on a case-by-case basis; however, poor prognosis should not be automatically presumed solely based on the combination of older age and a large stroke.
Authors: N G Smedira; B H Evans; L S Grais; N H Cohen; B Lo; M Cooke; W P Schecter; C Fink; E Epstein-Jaffe; C May Journal: N Engl J Med Date: 1990-02-01 Impact factor: 91.245
Authors: Michel T Torbey; Julian Bösel; Denise H Rhoney; Fred Rincon; Dimitre Staykov; Arun P Amar; Panayiotis N Varelas; Eric Jüttler; DaiWai Olson; Hagen B Huttner; Klaus Zweckberger; Kevin N Sheth; Christian Dohmen; Ansgar M Brambrink; Stephan A Mayer; Osama O Zaidat; Werner Hacke; Stefan Schwab Journal: Neurocrit Care Date: 2015-02 Impact factor: 3.210
Authors: M R Frankel; L B Morgenstern; T Kwiatkowski; M Lu; B C Tilley; J P Broderick; R Libman; S R Levine; T Brott Journal: Neurology Date: 2000-10-10 Impact factor: 9.910
Authors: Hermann Neugebauer; Claire J Creutzfeldt; J Claude Hemphill; Peter U Heuschmann; Eric Jüttler Journal: Neurocrit Care Date: 2014-08 Impact factor: 3.210
Authors: Jeannette Hofmeijer; L Jaap Kappelle; Ale Algra; G Johan Amelink; Jan van Gijn; H Bart van der Worp Journal: Lancet Neurol Date: 2009-03-05 Impact factor: 44.182
Authors: Eric Jüttler; Stefan Schwab; Peter Schmiedek; Andreas Unterberg; Michael Hennerici; Johannes Woitzik; Steffen Witte; Ekkehart Jenetzky; Werner Hacke Journal: Stroke Date: 2007-08-09 Impact factor: 7.914