SIR—Treatment with intravenous tissue plasminogen activator (t-PA) in acute ischaemic stroke has been shown to improve outcome [1]. Little is known regarding the safety and efficacy of this treatment in patients aged 80 years and older, because this age group was underrepresented in clinical trials [1–4]. The NINDS trial [1] was the only trial without age limit and only 7% (n = 42) of the included patients were older than 80 years. However, about 30% of admitted ischaemic stroke patients are older than 80 years [5]. A number of previous observational studies compared the outcome of t-PA treatment in patients older than 80 years with their younger counterparts [6–12], and a recent systemic review suggested that t-PA is safe in older patients, despite a higher 3-month mortality and a less favourable functional outcome [13]. In this study, we compared the safety and outcome of t-PA treatment in patients aged 80 years and older with their younger counterparts in a prospective cohort from the University Medical Center Groningen (UMCG). In contrast to most previous studies, we not only investigated the 3month mortality but we also compared the early in-hospital mortality at 7 days between the two groups.

Routine thrombolysis with intravenous tissue plasminogen activator in acute ischaemic stroke patients aged 80 years or older: a single centre experience

Despite increasing life expectancy, few data exist on the outcome of elderly stroke patients treated with IV thrombolysis. We analyzed the prospectively collected data from the Lille University Hospital stroke unit on patients treated with IV rt-PA within 4.5 h, comparing patients ≥80 years to younger ones. We considered the following outcomes: neurological improvement at the acute phase (NIHSS 0 or 1 at 24 h, or if the difference between NIHSS at 24 h and at baseline was ≥4), occurrence of intracerebral haemorrhage, mortality and functional outcome in survivors (favourable if mRS ≤2 or equal to pre-stroke score) at 3 months. Predictors of vital and functional outcome were determined using logistic regression analysis. Four hundred patients were treated with IV rt-PA, 98 (25%) being ≥80 years. The proportion of patients with neurological improvement at the acute phase (31 vs. 40%, OR 0.7, 95%CI 0.4–1.2), and with ICH (19 vs. 21%, OR 0.9, 95%CI 0.5–1.7) was similar among older and younger patients. At 3 months, 35% of patients ≥80 years had died; 52% of survivors had favourable functional outcome. Using multivariate analysis, age ≥80 years was an independent predictor of death (3.4; 95%CI 1.6–7.3), and of reduced likelihood of favourable functional outcome in survivors (OR 0.3; 95%CI 0.2–0.7) at 3 months. Although outcome at 3 months is worse for older patients than for their younger counterparts, our results are encouraging with a similar proportion of patients with early neurological improvement and with ICH in old and young patients and about half of the survivors having a favourable functional outcome in patients ≥80 years.

Intravenous thrombolysis for acute cerebral ischaemia in old stroke patients ≥80 years of age

Multiple studies have shown a clinical benefit of thrombectomy in acute ischaemic stroke, but most of them excluded octogenarians. The purpose of this study was to compare the outcomes between octogenarians and younger patients after thrombectomy. One hundred and sixty-six patients with large cerebral artery occlusion and consecutive thrombectomy were evaluated and divided into two patient age groups: younger than 80 years and older than 80 years. We compared recanalization rates, complications experienced, disability, death after discharge and at a 90-day follow-up between these age groups. Sixty-eight percent of octogenarians and 72 % of younger patients were registered with successful recanalization (p = 1.0). There was no significant difference in symptomatic intracerebral haemorrhage between the groups (p = 0.32). However, octogenarians had a significantly lower rate of good clinical outcome (24 % vs. 48 %; p = 0.008) and a higher mortality rate (36 % vs. 12 %; p = 0.0013). Octogenarians have a lower chance of good clinical outcome and a higher mortality rate despite successful recanalization. Nevertheless, 24 % of octogenarians were documented with mRS ≤2. As this age group of octogenarians will grow prospectively, careful patient selection should be mandatory when considering octogenarians for thrombectomy. • Careful patient selection for thrombectomy should be mandatory in octogenarians. • Octogenarians have a higher mortality rate despite successful recanalization. • Nearly one-third of octogenarians were documented with a good clinical outcome.

Endovascular mechanical recanalization of acute ischaemic stroke in octogenarians.

Patients with intracerebral hemorrhage frequently have indications for antithrombotic therapy. This represents a therapeutic dilemma as intracerebral hemorrhage is considered a contraindication to antithrombotic medication. Previous systematic reviews have revealed no long-term randomised studies addressing this issue. Our objective was to review observational studies describing the long-term follow-up of patients receiving antithrombotic therapy following intracerebral hemorrhage. Searches were conducted in MEDLINE and EMBASE from 1984 to 2008 for any observational studies detailing use of antithrombotic treatments in patients with intracerebral hemorrhage. Included studies must have had follow-up extending beyond discharge. The primary endpoint was recurrent intracerebral hemorrhage. Secondary endpoints were ischemic events and serious vascular events. 1,301 articles were reviewed: two epidemiological studies and six case series met the inclusion criteria. These described a total of 46 subjects receiving antiplatelet agents (from one study) and 42 patients receiving oral anticoagulants (from one study and six case-series). For patients receiving subsequent aspirin there were seven recurrent intracerebral hemorrhages and four subsequent thrombo-occulsive events. Amongst patients restarting oral anticoagulation there were four recurrent intracerebral bleeds and nine subsequent thrombo-occulsive events. There is a marked paucity of evidence to guide clinicians when planning the long-term management of patients with intracerebral hemorrhage and cogent indications for antithrombotic therapy. Published guidance addressing this issue is not evidence based. In the continued absence of randomised studies addressing antithrombotic use following intracerebral hemorrhage, there is a clear requirement for further high quality observational data on the clinical impact of antithrombotic therapy in this important patient group.

Systematic review of observational research studying the long-term use of antithrombotic medicines following intracerebral hemorrhage

Aim: The aim of the present study was to determine the demographic characteristics, localization of emboli, imaging findings, National Institutes of Health Stroke Scale (NIHSS) scores, and complications of patients who received intravenous (iv) tissue plasminogen activator (t-PA) due to early period of ischemic cerebrovascular disease (CVD) during the 6-year period in a tertiary level emergency department of a university hospital. Materials and Methods: The study was retrospectively performed in 65 patients aged ≥18 years and who underwent iv t-PA with a diagnosis of ischemic CVD. Demographic data, such as age, gender, and smoking, were obtained by examining the medical records of the patients. The baseline Glasgow Coma Scale, NIHSS, start time of the event, time of admission to the hospital, and prognosis of the patients were recorded. Results: Intracranial hemorrhage was detected in 16.9% of the patients after treatment. On examination of the patients’ outcome, a total of 32.3% (n=21) died after therapy. A significant correlation was observed between high NIHSS score and complications. Conclusion: In our study, a high NIHSS score at the time of admission has been found to increase both the risk of intracerebral hemorrhagic complication and mortality. We hypothesize that iv t-PA treatment gives successful results despite the complications, and emergency physicians should be more courageous in their application.

/pdf/evaluation-of-patients-with-ischemic-stroke-receiving-iv-t-3csns2wzt5.pdf

Evaluation of Patients with Ischemic Stroke Receiving iv t-PA in the Emergency Department

Stroke Effectiveness Study acute ischaemic stroke: Canadian Alteplase for Thrombolysis in patients older than 80 years with

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Is alteplase safe and effective in routine clinical practice for patients with ischemic stroke

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Stroke Effectiveness Study acute ischaemic stroke: Canadian Alteplase for Thrombolysis in patients older than 80 years with

Is antiplatelet therapy safe after intracerebral hemorrhage

Is alteplase safe and effective in routine clinical practice for patients with ischemic stroke