TY - JOUR
T1 - Functional Outcomes of Patients ≥85 Years With Acute Ischemic Stroke Following EVT
T2 - A HERMES Substudy
AU - McDonough, Rosalie V.
AU - Ospel, Johanna M.
AU - Campbell, Bruce C. V.
AU - Hill, Michael D.
AU - Saver, Jeffrey L.
AU - Dippel, Diederik W. J.
AU - Demchuk, Andrew M.
AU - Majoie, Charles B. L. M.
AU - Brown, Scott B.
AU - Mitchell, Peter J.
AU - Bracard, Serge
AU - Guillemin, Francis
AU - Jovin, Tudor G.
AU - Muir, Keith W.
AU - HERMES collaborators
AU - White, Philip
AU - Goyal, Mayank
N1 - Funding Information: No authors received any payments for work on the submitted manuscript. Dr Ospel reports support from the University of Basel Research Foundation, Julia Bangerter Rhyner Foundation, and Freiwillige Akademische Gesellschaft Basel. Dr Saver reports being an employee of the University of California; serving as an unpaid site investigator in multicenter trials run by Medtronic and Stryker for which the University of California (UC) Regents received payments on the basis of clinical trial contracts for the number of subjects enrolled; receiving funding for services as a scientific consultant regarding trial design and conduct to Medtronic, Stryker, Cerenovus and Rapid Medical. The UC Regents have patent rights in endovascular retrievers. Dr Dippel reports that his institution has received honoraria for his speaking from Stryker and grant funding from the Dutch Heart Foundation, AngioCare BV, Medtronic/EV3, MEDAC Gmbh/ LAMEPRO, Penumbra, Stryker, and Top Medical/ Concentric. Dr Majoie reports grants paid to the institution from the Netherlands Cardiovascular Research Committee (CVON)/Dutch Heart Foundation, the European commission, Stichting Toegepast Wetenschappelijk Instituut voor Neuromodulatie (TWIN) foundation, and Stryker. Dr Majoie is shareholder of Nicolab, a company that focuses on the use of artificial intelligence for medical image analysis. Dr Jovin reports receiving grants from Stryker Neurovascular and consultant fees for Anaconda, VizAI, FreeOx Biotech, Corindus, Cerenovus, Route92, Blockade Medical, and Medtronic. Dr Bracard reports grants from the French Ministry of Health during the conduct of the THRACE study (Trial and Cost Effectiveness Evaluation of Intra-Arterial Thrombectomy in Acute Ischemic Stroke), and personal fees from General Electric Medical Systems and nonfinancial support from Microvention Europe outside the submitted work. Dr Guillemin reports grants from the French Ministry of Health during the conduct of the THRACE study. Dr Campbell reports that his institution received a grant to support the EXTEND-IA trial (Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial) from Covidien/Medtronic. Dr Campbell reports grant funding from the National Health and Medical Research Council of Australia and Medtronic and fellowships from the National Heart Foundation of Australia, National Stroke Foundation of Australia, and Royal Australasian College of Physicians. Dr Mitchell reports that his institution received grants from Medtronic and Stryker; he received consultant fees from Stryker and Microvention. Dr White reports grants from UK National Institutes for Health Research, Microvention Terumo, Stryker, Medtronic, and Penumbra; received consultation fees from Microvention Terumo. Dr Muir has received consultant fees from Boehringer Ingelheim, Bayer and Daiichi-Sankyo. Dr Brown reports receiving consulting fees from Medtronic/Covidien and personal fees from the University of Calgary. Dr Demchuk reports receiving grant support and personal fees from Medtronic and has a patent with Circle Cardiovascular Imaging on stroke imaging software. Dr Hill reports unrestricted grant funding for the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times) to University of Calgary from Covidien/Medtronic, and active/in-kind support consortium of public/charitable sources (Heart and Stroke Foundation, Alberta Innovates Health Solutions, Alberta Health Services) and the University of Calgary (Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, and Calgary Stroke Program); grant funding from Boehringer Ingelheim, NoNo, Inc, and Stryker. Personal fees from Merck, nonfinancial support from Hoffmann-La Roche Canada. In addition, Dr Hill has a submitted patent for triaging systems in ischemic stroke and owns stock in Calgary Scientific, a company that focuses on medical imaging software. Dr Goyal reports receiving an unrestricted institutional grant from Medtronic; he received a grant from Stryker and consulting fees from Stryker, Microvention, Mentice; he holds patent rights in systems and methods for acute stroke diagnosis with GE Healthcare. The other author reports no conflicts. Funding Information: The HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) is supported by an unrestricted grant from Medtronic to the University of Calgary. The company was not involved in the design, analysis, or writing of this study. Publisher Copyright: © 2022 Lippincott Williams and Wilkins. All rights reserved.
PY - 2022/7/1
Y1 - 2022/7/1
N2 - Background: Observational studies have shown endovascular treatment (EVT) for acute ischemic stroke to be effective in the elderly, despite resulting in poorer outcomes and higher rates of mortality compared with younger patients. Randomized data on the effect of advanced age on outcomes following EVT are, however, lacking. Our aim was to assess the EVT effect for ischemic stroke in patients aged ≥85 years and the influence of age on outcome in a large, randomized trial dataset. Methods: Data were from the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration, a meta-analysis of 7 randomized trials published between January 1, 2010, and May 31, 2017, that tested the efficacy of EVT. A possible multiplicative interaction effect of age on the relationship between treatment and outcome was investigated. Ordinal logistic regression tested the association between EVT and 90-day functional outcome (modified Rankin Scale, primary outcome) in patients ≥85 years. Multivariable binary logistic regression was performed to compare primary and secondary outcomes (modified Rankin Scale score of 0-2/5-6) of patients ≥85 years versus those <85 years. Results: We included 1764 patients in the analysis, of whom 77 (4.4%) were ≥85 years old. A significant interaction of age and treatment on poor outcome (modified Rankin Scale score of 5-6, P=0.020) and mortality (P=0.031) was observed, with older adults having worse functional outcomes at 90 days compared with younger patients (adjusted common odds ratio, 0.20 [95% CI, 0.13-0.33]). However, a benefit of EVT was observed in the ≥85-year-old patient subgroup (common odds ratio, 4.20 [95% CI, 1.56-11.32]). Age ≥85 years was not significantly associated with differing rates of symptomatic intracerebral hemorrhage or reperfusion (adjusted odds ratio, 1.92 [95% CI, 0.71-5.15] and adjusted odds ratio, 0.91 [95% CI, 0.40-2.06], respectively). Conclusions: Patients ≥85 years old with independent premorbid function more often achieve good functional outcomes and have lower rates of mortality when treated with EVT compared with conservative management, with an observed treatment effect modification of age on outcome. EVT should therefore not be withheld in this subgroup.
AB - Background: Observational studies have shown endovascular treatment (EVT) for acute ischemic stroke to be effective in the elderly, despite resulting in poorer outcomes and higher rates of mortality compared with younger patients. Randomized data on the effect of advanced age on outcomes following EVT are, however, lacking. Our aim was to assess the EVT effect for ischemic stroke in patients aged ≥85 years and the influence of age on outcome in a large, randomized trial dataset. Methods: Data were from the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration, a meta-analysis of 7 randomized trials published between January 1, 2010, and May 31, 2017, that tested the efficacy of EVT. A possible multiplicative interaction effect of age on the relationship between treatment and outcome was investigated. Ordinal logistic regression tested the association between EVT and 90-day functional outcome (modified Rankin Scale, primary outcome) in patients ≥85 years. Multivariable binary logistic regression was performed to compare primary and secondary outcomes (modified Rankin Scale score of 0-2/5-6) of patients ≥85 years versus those <85 years. Results: We included 1764 patients in the analysis, of whom 77 (4.4%) were ≥85 years old. A significant interaction of age and treatment on poor outcome (modified Rankin Scale score of 5-6, P=0.020) and mortality (P=0.031) was observed, with older adults having worse functional outcomes at 90 days compared with younger patients (adjusted common odds ratio, 0.20 [95% CI, 0.13-0.33]). However, a benefit of EVT was observed in the ≥85-year-old patient subgroup (common odds ratio, 4.20 [95% CI, 1.56-11.32]). Age ≥85 years was not significantly associated with differing rates of symptomatic intracerebral hemorrhage or reperfusion (adjusted odds ratio, 1.92 [95% CI, 0.71-5.15] and adjusted odds ratio, 0.91 [95% CI, 0.40-2.06], respectively). Conclusions: Patients ≥85 years old with independent premorbid function more often achieve good functional outcomes and have lower rates of mortality when treated with EVT compared with conservative management, with an observed treatment effect modification of age on outcome. EVT should therefore not be withheld in this subgroup.
KW - age
KW - ischemic stroke
KW - mortality
KW - reperfusion
UR - http://www.scopus.com/inward/record.url?scp=85133102612&partnerID=8YFLogxK
U2 - https://doi.org/10.1161/STROKEAHA.121.037770
DO - https://doi.org/10.1161/STROKEAHA.121.037770
M3 - Article
C2 - 35703094
SN - 0039-2499
VL - 53
SP - 2220
EP - 2226
JO - Stroke
JF - Stroke
IS - 7
ER -