He examined the relationship between advanced age and functional outcome after ischemic stroke treatment in a sample of 6,700 patients in the Nationwide Inpatient Sample. Of those patients, 20% were older than 80 years.
"Not surprisingly, most [68%] of these elderly old were female," said Dr. Moradiya. Those older than 80 years also had more comorbidity, leading to a higher Elixhauser comorbidity index than that in young patients (mean, 3.4 vs. 1.6).
Mortality was significantly higher in the older patients than the younger patients (31% vs. 22%), although there were no differences between the age groups in the rates of symptomatic and asymptomatic intracranial hemorrhage, mechanical ventilation, and tracheostomy.
The older patients were more likely to receive intravenous or intra-arterial thrombolysis in addition to embolectomy, probably because of an unsuccessful initial endovascular procedure. But the octogenarians did not withstand their treatment and hospitalization very well. Compared with younger patients, the older patients had significantly higher rates of heart attack (7% vs. 5%), acute kidney injury (9% vs. 6%), gastrointestinal bleeding (3% vs. 2%), urinary tract infections (22% vs. 15%), and transfusions (10% vs. 8%).
Patients older than 80 years had several comorbidities that significantly predicted mortality after ischemic stroke, including the following:
• Chronic pulmonary disease (odds ratio, 2.7).
• Acute kidney injury (OR, 3.8).
• Myocardial infarction (OR, 3.2).
• Intracranial hemorrhage (OR, 3).
• Sepsis (OR, 8).
Thrombolytic treatment lowered the risk of death by 68% in older patients, but this was not significantly different from the treatment effect in younger patients. Dr. Moradiya suggested that selecting younger or healthier patients would improve endovascular stroke treatment outcomes. "This is screening in the sense that people with this higher comorbidity profile should not undergo embolectomy, compared to the more healthy elderly."
This summation rankled some audience members, including Dr. James L. Frey, director of the stroke center at Barrow Neurological Institute, Phoenix.
"I don’t like this concept of reducing complications by screening people for these procedures," he said during the discussion. "It seems obvious that the medical complications are the problem, and not the procedure itself, so when you talk about screening, how are you going to do that?"
Very elderly stroke patients want treatment just as much as younger patients do, he said. "They don’t like what’s going wrong with their brain and they want someone to do something about it. They don’t mind so much if you try this and they die, but they do not want to live with a brain hemorrhage. It sounds like you’re saying they are better off having a clot in their middle cerebral artery than having someone try to remove it. Is this what you’re saying?"
Dr. Felipe Albuquerque, a session moderator, added his take on the issue.
"Absolutely, the brain is paramount and all other organs are secondary, so we should do all we can for the brain. But if you take the wrong person, and the procedure goes bad and they die on the table, this is not helping the brain. There are simply patients who are too high risk, and for these you might think about a different procedure."
"I don’t do these procedures with anesthesia on board," because of the extra burden it places on an elderly patient, said Dr. Albuquerque, a neurosurgeon who is also with the Barrow Neurological Institute.
"So in that sense, screening does help your approach and should perhaps obviate intervention for people who are going to die, no matter what you do."
Dr. Moradiya had no financial disclosures. Dr. Yoo said that he has received research funding from Penumbra Inc. Dr. Frey and Dr. Albuquerque said they had no relevant disclosures.