Intravenous Thrombolysis for Acute Ischemic Stroke After the 80 Years of Age
DOI:
https://doi.org/10.24950/rspmi/original/189/3/2018Keywords:
Aged, 80 and over, Stroke, Thrombolytic Therapy, Tissue Plasminogen ActivatorAbstract
Introduction: The incidence of stroke increases exponentially with age, representing the leading cause of death after the 80 years of age. Intravenous thrombolysis with recombinant tissue plasminogen activator (IV-rtPA) represents an advance in the treatment of ischemic stroke and its use in the elderly > 80 years old was a recent target of discussion.
Material and Methods: A retrospective study was performed in the 2010-2015 period that included patients >80 years old with ischemic stroke who underwent IV-rtPA. The study evaluated demographic and clinical variables, occurrence of hemorrhagic transformation and prognosis. Statistical analysis was performed using SPSS software.
Results: We included 45 patients, mean age 84.4 years old and female predominance (62.2%). The main risk factors were arterial hypertension (68.9%) and cardioembolism (62.2%). In most cases, IV-rtPA was performed until 3 hours (82.2%). hemorrhagic transformation occurred in 22.2%, with worse prognosis at 3 months (p = 0.000). Lower severity of stroke and length of hospital stay were associated with better prognosis at 3 months (p = 0.025 and p = 0.005, respectively).
Discussion: Some of these results are in agreement with data from other studies. The increase in age is associated with a worse prognosis. hemorrhagic transformation is one of IV-rtPA concerns. The incidence of arterial hypertension and atrial fibrillation increases with age, both associated with an increased risk of stroke.
Conclusion: The safety of IV-rtPA has been demonstrated in several studies. Age should not be an exclusion criterion, since properly selected patients may benefit from such therapy.
Downloads
References
Asdaghi N, Butcher KS, Hill MD. Risks and benefits of thrombolysis in the elderly. Int J Stroke. 2012;7:142-9. doi: 10.1111/j.1747 4949.2011.00744.x.
IST-3 collaborative group, Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. 2012;379:2352-63. doi: 10.1016/S0140-6736(12)60768-5.
Pego PM, Nunes AP, Ferreira P, Sousa C, Amaral-Silva A. Thrombolysis in patients aged over 80 years is equally effective and safe. J Stroke Cerebrovasc Dis. 2016;25:1532-8. doi: 10.1016/j.jstrokecerebrovasdis.2016.03.007.
Pundik S, McWilliams-Dunnigan L, Blackham KL, Kirchner HL, Sundararajan S, Sunshine JL, et al. Older age does not increase risk of hemorrhagic complications after intravenous and/or intra-arterial thrombolysis for acute stroke. J Stroke Cerebrovasc Dis. 2008;17:266-72. doi: 10.1016/j. jstrokecerebrovasdis.2008.03.003.
Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2016;47:581-641. doi: 10.1161/ STR.0000000000000086.
Toni D, Lorenzano S, Agnelli G, Guidetti D, Orlandi G, Semplicini A, et al. Intravenous thrombolysis with rt-PA in acute ischemic stroke patients aged older than 80 years in Italy. Cerebrovasc Dis. 2008;25:129-35. doi: 10.1159/000112323.
Alshekhlee A, Mohammadi A, Mehta S, Edgell RC, Vora N, Feen E, et al. Is thrombolysis safe in the elderly? Analysis of a national database. Stroke. 2010;41:2259-64. doi: 10.1161/STROKEAHA.110.588632.
Chen Y, Li CH, Wang YX, Zhang CH, Dong Z, Zhang FF, et al. Safety and effectiveness of intravenous thrombolysis with recombinant tissue plasminogen activator in eighty years and older acute ischemic stroke patients. Eur Rev Med Pharmacol Sci. 2015;19:1852-8.
Mione G, Ducrocq X, Thilly N, Lacour JC, Vespignani H, Richard S. Outcome of intravenous recombinant tissue plasminogen activator for acute ischemic stroke in patients aged over 80 years. Geriatr Gerontol Int. 2016;16:843-9. doi: 10.1111/ggi.12565.
Sagnier S, Galli P, Poli M, Debruxelles S, Renou P, Olindo S, et al. The impact of intravenous thrombolysis on outcome of patients with acute ischemic stroke after 90 years old. BMC Geriatr. 2016;16:156. doi: 10.1186/ s12877-016-0331-1.
Ford GA, Ahmed N, Azevedo E, Grond M, Larrue V, Lindsberg PJ, et al. Intravenous alteplase for stroke in those older than 80 years old. Stroke. 2010;41:2568-74. doi: 10.1161/STROKEAHA.110.581884.
Liu Y, Zhao H, Zhou J, Wang Q, Chen Z, Luo N. Mild stroke and advanced age are the major reasons for exclusion from thrombolysis in stroke patients admitted within 4.5 hours. J Stroke Cerebrovasc Dis. 2014;23:1571- 6. doi: 10.1016/j.jstrokecerebrovasdis.2013.12.041.
Sylaja PN, Cote R, Buchan AM, Hill MD; Canadian Alteplase for Stroke Effectiveness Study (CASES) Investigators. Thrombolysis in patients older than 80 years with acute ischaemic stroke: Canadian Alteplase for Stroke Effectiveness Study. J Neurol Neurosurg Psychiatry. 2006;77:826-9. doi: 10.1136/jnnp.2005.086595.
European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis. 2008;25:457-507. doi: 10.1159/000131083.
Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute
ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947. doi: 10.1161/STR.0b013e318284056a.
Molina CA, Alvarez-Sabín J, Montaner J, Abilleira S, Arenillas JF, Coscojuela P, et al. Thrombolysis-related hemorrhagic infarction: a marker of early reperfusion, reduced infarct size, and improved outcome in patients with proximal middle cerebral artery occlusion. Stroke. 2002;33:1551-6.
Larrue V, von Kummer R, del Zoppo G, Bluhmki E. Hemorrhagic transformation in acute ischemic stroke. Potential contributing factors in the European Cooperative Acute Stroke Study. Stroke. 1997;28:957-60.
Miller DJ, Simpson JR, Silver B. Safety of thrombolysis in acute ischemic stroke: a review of complications, risk factors, and newer technologies. Neurohospitalist. 2011;1:138-47. doi: 10.1177/1941875211408731.
Zhang J, Yang Y, Sun H, Xing Y. Hemorrhagic transformation after cerebral infarction: current concepts and challenges. Ann Transl Med. 2014;2:81. doi: 10.3978/j.issn.2305-5839.2014.08.08.
Mazya M, Egido JA, Ford GA, Lees KR, Mikulik R, Toni D, et al. Predicting the risk of symptomatic intracerebral hemorrhage in ischemic stroke treated with intravenous alteplase: safe Implementation of Treatments in Stroke (SITS) symptomatic intracerebral hemorrhage risk score. Stroke. 2012;43:1524-31. doi: 10.1161/STROKEAHA.111.644815.
Rao NM, Levine SR, Gornbein JA, Saver JL. Defining clinically relevant cerebral hemorrhage after thrombolytic therapy for stroke: analysis of the National Institute of Neurological Disorders and Stroke tissue-type plasminogen activator trials. Stroke. 2014;45:2728-33. doi: 10.1161/ STROKEAHA.114.005135.
Zhu W, Xiao L, Lin M, Liu X, Yan B. Large-vessel occlusion is associated with poor outcome in stroke patients aged 80 years or older who underwent intravenous thrombolysis. J Stroke Cerebrovasc Dis. 2016;25:2712-6. doi: 10.1016/j.jstrokecerebrovasdis.2016.07.021.
Sobolewski P, Brola W, Stoiński J, Szczuchniak W, Fudala M, Hatalska-Żerebiec R, et al. Intravenous thrombolysis in patients aged more than 80 years in the three rural hospitals in southeast Poland: an observational study. Geriatr Gerontol Int. 2014;14:689-94. doi: 10.1111/ggi.12135.
Boulouis G, Dumont F, Cordonnier C, Bodenant M, Leys D, Hénon H. Intravenous thrombolysis for acute cerebral ischaemia in old stroke patients ≥ 80 years of age. J Neurol. 2012;259:1461-7. doi: 10.1007/s00415-011- 6359-4.
Uyttenboogaart M, Schrijvers EM, Vroomen PC, De Keyser J, Luijckx GJ. Routine thrombolysis with intravenous tissue plasminogen activator in acute ischaemic stroke patients aged 80 years or older: a single centre experience. Age Ageing. 2007;36:577-9. doi: 10.1093/ageing/afm022.
Perren F, Eriksson A, Jönsson AC, Kremer C. Older women benefit from thrombolysis as much as older men. J Stroke Cerebrovasc Dis. 2016;25:1882-6. doi: 10.1016/j.jstrokecerebrovasdis.2016.03.001.
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright (c) 2023 Medicina Interna
Open Access
