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

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
• endovascular treatment
• intravenous thrombolysis
• elderly patients

Acknowledgments

We thank all the ANGEL-ACT study groups for providing the data: Zhongrong Miao, MD; Liqiang Gui, MD; Cunfeng Song, MD; Ya Peng, MD; Jin Wu, MD; Shijun Zhao, MD; Junfeng Zhao, MD; Zhiming Zhou, MD; Yongli Li, MD; Ping Jing, MD; Lei Yang, MD; Yajie Liu, MD; Qingshi Zhao, MD; Yan Liu, MD; Xiaoxiang Peng, MD; Qingchun Gao, MD; Zaiyu Guo, MD; Wenhuo Chen, MD; Weirong Li, MD; Xiaojiang Cheng, MD; Yun Xu, MD; Yongqiang Zhang, MD; Guilian Zhang, MD; Yijiu Lu, MD; Xinyu Lu, MD; Dengxiang Wang, MD; Yan Wang, MD; Hao Li, MD; Yang Hua, MD; Deqin Geng, MD; Haicheng Yuan, MD; Hongwei Wang, MD; Haihua Yang, MD; Zengwu Wang, MD; Liping Wei, MD; Xuancong Liufu, MD; Xiangqun Shi, MD; Juntao Li, MD; Wenwu Yang, MD; Wenji Jing, MD; Xiang Yong, MD; Leyuan Wang, MD; Chunlei Li, MD; Yibin Cao, MD; Qingfeng Zhu, MD; Peng Zhang, MD; Xiang Luo, MD; Shengli Chen, MD; WenWu Peng, MD; Lixin Wang, MD; Xue Wen, MD; Shugui Shi, MD; Wanming Wang, MD; Wang Bo, MD; Pu Yuan, MD; Dong Wang, MD; Haitao Guan, MD; Wenbao Liang, MD; Daliang Ma, MD; Long Chen, MD; Yan Xiao, MD; Xiangdong Xie, MD; Zhonghua Shi, MD; Xiangjun Zeng, MD; Fanfan Su, MD; MingZe Chang, MD; Jijun Yin, MD; Hongxia Sun, MD; Chong Li, MD; Yong Bi, MD; Gang Xie, MD; Yuwu Zhao, MD; Chao Wang, MD; Peng Zhang, MD; Xianjun Wang, MD; Dongqun Li, MD; Hui Liang, MD; Zhonglun Chen, MD; Yan Wang, MD; Yu Xin, Wang, MD; Lin Yin, MD; HongKai Qiu, MD; Jun Wei, MD; Yaxuan Sun, MD; Xiaoya Feng, MD; Weihua Wu, MD; Lianbo Gao, MD; Zhibing Ai, MD; Tan Lan, MD; Li Ding, MD; Qilong Liang, MD; Zhimin Wang, MD; Jianwen Yang, MD; Ping Xu, MD; Wei Dong, MD; Quanle Zheng, MD; Zhenyun Zhu, MD; Liyue Zhao, MD; Qingbo Meng, MD; Yuqing Wei, MD; Xianglin Chen, MD; Wei Wang, MD; Dong Sun, MD; Yongxing Yan, MD; Guangxiong Yuan, MD; Yadong Yang, MD; Jianfeng Zhou, MD; Zhi Yang, MD; Zhenzhong Zhang, MD; Ning Guan, MD; Huihong Wang, MD.

We thank Justin Dean and Angela Morben from Liwen Bianji, Edanz Group China (www.liwenbianji.cn/ac), for editing the English text of a draft of the manuscript.

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author Zhongrong Miao ([email protected]) upon reasonable request.

Disclosure

The authors report no conflicts of interest in this work.