Better outcomes with mechanical thrombectomy in elderly stroke patients

Results of a meta-analysis suggest that a favourable outcome is more likely if mechanical thrombectomy is added to best medical management (BMM) in elderly patients with anterior circulation stroke due to large vessel occlusion (aLVO). Compared with BMM alone, adding mechanical thrombectomy did not increase mortality.

Mechanical thrombectomy is considered standard treatment for aLVO, but controversy still exists about the risk-benefit ratio and cost-effectiveness of performing this procedure in the elderly. Researchers therefore performed a systematic search to identify randomised trials up to October 2021 comparing treatment of aLVO patients with mechanical thrombectomy or BMM and reporting functional outcome. For this meta-analysis, patients were categorised as either elderly (>70 years) or non-elderly. Outcomes were evaluated based on the modified Rankin Scale score: a score ≤1 was considered excellent, ≤2 good, and ≥5 poor. Dr Aisha Ali (University of Illinois, IL, USA) presented the results [1].

The inclusion criteria were met by 6 trials: RESILIENT, DAWN, DEFUSE 3, ESCAPE, SWIFT PRIME, and REVASCAT. A total of 1,315 participants were included in the analysis, of whom 873 were non-elderly and 442 were elderly patients. In both age groups, mechanical thrombectomy yielded more favourable outcomes, especially in the non-elderly group. In the non-elderly group, the odds of all outcomes favoured mechanical thrombectomy over BMM:

• excellent outcome (OR 2.86; 95% CI 2.05–3.99; I²=0%);
• good outcome (OR 3.52; 95% CI 2.63–4.70; I²=0%);
• poor outcome (OR 0.5; 95% CI 0.36-0.70; I²=0%);
• mortality (OR 0.53; 95% CI 0.31-0.90; I²=0).

In the elderly group, the odds of all outcomes were also more favourable for mechanical thrombectomy, except for the excellent outcome and mortality:

• excellent outcome (OR 2.24; 95% CI 0.93-5.38; I²=55%), no difference;
• good outcome (OR 2.11; 95% CI 1.11-3.99; I²=46%);
• poor outcome (OR 0.5; 95% CI 0.33-0.75; I²=6%);
• mortality (OR 0.6; 95% CI 0.29-1.22; I²=34%), no difference.

So, even in elderly patients, it appears mechanical thrombectomy should be considered over BMM alone.

1. Ali A, et al. Efficacy and safety of mechanical thrombectomy in elderly patients. S17.008, AAN 2022, 02–07 April.

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Posted on 2 June 2022