Direct versus Bridging Mechanical Thrombectomy in Elderly Patients with Acute Large Vessel Occlusion: A Multicenter Cohort Study

Clin Interv Aging. 2021 Jul 5:16:1265-1274. doi: 10.2147/CIA.S313171. eCollection 2021.

Abstract

Purpose: Elderly people represent a growing stroke population with different pathophysiological states than younger. Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is beneficial for elderly patients remains unclear. This study compared the efficacy and safety between elderly patients treated with MT alone and those treated with both IVT and MT.

Patients and methods: Patients aged ≥65 years who were eligible for IVT within 4.5 h from symptom onset were selected from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke) registry, a prospective registry program for patients with endovascular treatment from 111 Chinese stroke centers. The primary efficacy outcome was the 90-day modified Rankin Scale score. We compared efficacy and safety outcomes using ordinal or binary logistic regression or a generalized linear model.

Results: In total, 482 elderly patients were included: 187 (38.8%) received IVT and MT (bridging MT) and 295 (61.2%) received MT alone (direct MT). There was no significant difference in the 90-day modified Rankin Scale score between the two groups (median: 4 vs 4 points, respectively; adjusted β=-0.048, P=0.822). The direct MT group had a shorter onset-to-puncture time (225 vs 255 min, respectively; adjusted β=-55.074, P=0.002) and a lower rate of parenchymal hemorrhage type 2 within 24 h (2.80% vs 6.63%, respectively; adjusted odds ratio [OR]=0.287, 95% confidence interval [CI]=0.096-0.856, P=0.025). In addition, the direct MT group showed a trend toward a lower incidence of sICH (5.67% vs 10.06%, adjusted OR=0.453, P=0.061), procedure-related complications (7.12% vs 12.30%, adjusted OR=0.499, P=0.052) and distal or new territorial embolization (4.07% vs 6.95%, adjusted OR=0.450, P=0.093).

Conclusion: Direct MT had similar efficacy to bridging MT in terms of the 90-day functional outcome in elderly patients, whereas bridging MT had a longer onset-to-puncture time and increased risk of hemorrhagic transformation and procedure-related complications.

Keywords: acute ischemic stroke; elderly patients; endovascular treatment; intravenous thrombolysis.

Publication types

  • Multicenter Study

MeSH terms

  • Administration, Intravenous
  • Aged
  • Cerebral Hemorrhage* / diagnosis
  • Cerebral Hemorrhage* / etiology
  • Cerebrovascular Disorders* / complications
  • Cerebrovascular Disorders* / diagnosis
  • Cerebrovascular Disorders* / therapy
  • China / epidemiology
  • Cohort Studies
  • Female
  • Humans
  • Ischemic Stroke* / drug therapy
  • Ischemic Stroke* / etiology
  • Ischemic Stroke* / surgery
  • Male
  • Outcome and Process Assessment, Health Care
  • Quality Improvement
  • Thrombectomy* / adverse effects
  • Thrombectomy* / methods
  • Thrombolytic Therapy / methods
  • Workflow

Grants and funding

This study is supported by grants from the National Key Research and Development Program of China (2016YFC1301500, 2018YFC1312801), the National Natural Science Foundation of China (81971116), the Shaanxi Provicial Key Research and Development Project of China (2019ZDLSF01–04), and a Postdoctoral Science Foundation (2019M650773).