Outcomes of Nonagenarians with Acute Ischemic Stroke Treated with Intravenous Thrombolytics.

BACKGROUND: Nonagenarians are under-represented in thrombolytic trials for acute ischemic stroke (AIS). The effectiveness of intravenous thrombolytics in nonagenarians in terms of safety and outcome is not well established. MATERIALS AND METHODS: We used a multinational registry to identify patients aged 90 years or older with good baseline functional status who presented with AIS. Differences in outcomes-disability level at 90 days, frequency of symptomatic intracerebral hemorrhage (sICH), and mortality-between patients who did and did not receive thrombolytics were assessed using multivariable logistic regression, adjusted for prespecified prognostic factors. Coarsened exact matching (CEM) was utilized before evaluating outcome by balancing both groups in the sensitivity analysis. RESULTS: We identified 227 previously independent nonagenarians with AIS; 122 received intravenous thrombolytics and 105 did not. In the unmatched cohort, ordinal analysis showed a significant treatment effect (adjusted common odds ratio [OR]: .61, 95% confidence interval [CI]: .39-.96). There was an absolute difference of 8.1% in the rate of excellent outcome in favor of thrombolysis (17.4% versus 9.3%; adjusted ratio: .30, 95% CI: .12-.77). Rates of sICH and in-hospital mortality were not different. Similarly, in the matched cohort, CEM analysis showed a shift in the primary outcome distribution in favor of thrombolysis (adjusted common OR: .45, 95% CI: .26-.76). CONCLUSIONS: Nonagenarians treated with thrombolytics showed lower stroke-related disability at 90 days than those not treated, without significant difference in sICH and in-hospital mortality rates. These observations cannot exclude a residual confounding effect, but provide evidence that thrombolytics should not be withheld from nonagenarians because of age alone.

Stroke occurring in patients with cognitive impairment or dementia.

OBJECTIVE: To determine how pre-stroke cognitive impairment can be detected, its mechanism, and influence on outcome and management. METHODS: Literature search. RESULTS: (i) A systematic approach with the Informant Questionnaire of Cognitive Decline in the Elderly is recommended; (ii) Pre-stroke cognitive impairment may be due to brain lesions of vascular, degenerative, or mixed origin; (iii) Patients with pre-stroke dementia, have worse outcomes, more seizures, delirium, and depression, and higher mortality rates; they often need to be institutionalised after their stroke; (iv) Although the safety profile of treatment is not as good as that of cognitively normal patients, the risk:benefit ratio is in favour of treating these patients like others. CONCLUSION: Patients with cognitive impairment who develop a stroke have worse outcomes, but should be treated like others.

Stroke occurring in patients with cognitive impairment or dementia / Comprometimento cognitivo prévio ou demência em pacientes com acidente vascular cerebral

ABSTRACT One in six patients admitted for stroke was previously demented. These patients have less access to appropriate stroke care, although little is known about their optimal management. Objective To determine how pre-stroke cognitive impairment can be detected, its mechanism, and influence on outcome and management. Methods Literature search. Results (i) A systematic approach with the Informant Questionnaire of Cognitive Decline in the Elderly is recommended; (ii) Pre-stroke cognitive impairment may be due to brain lesions of vascular, degenerative, or mixed origin; (iii) Patients with pre-stroke dementia, have worse outcomes, more seizures, delirium, and depression, and higher mortality rates; they often need to be institutionalised after their stroke; (iv) Although the safety profile of treatment is not as good as that of cognitively normal patients, the risk:benefit ratio is in favour of treating these patients like others. Conclusion Patients with cognitive impairment who develop a stroke have worse outcomes, but should be treated like others.

RESUMO Um em cada seis pacientes internados em decorrência de acidente vascular cerebral (AVC) apresenta diagnóstico prévio de demência. Estes indivíduos têm menor acesso à assistência recomendada para pacientes com AVC, mas pouco ainda se sabe em relação aos cuidados médicos ideais que devem receber. Objetivo Determinar como o comprometimento cognitivo prévio ao AVC pode ser detectado, qual o mecanismo etiológico subjacente, e as consequências para o prognóstico e para o acompanhamento clínico. Método Pesquisa bibliográfica. Resultados (i) O rastreamento sistemático com o Informant Questionnaire of Cognitive Decline in the Elderly é recomendado; (ii) O comprometimento cognitivo preexistente pode ser devido a lesões cerebrais de origem vascular, degenerativa ou mista; (iii) Pacientes com demência prévia ao AVC têm pior prognóstico, maior frequência de crises epilépticas, de delirium e depressão, além de taxas de mortalidade mais altas; eles frequentemente são institucionalizados após o AVC; (iv) Embora a tolerabilidade às medicações não seja tão boa quanto a de pacientes com AVC sem comprometimento cognitivo, a relação risco/benefício é a favor de tratamento similar àquele oferecido aos demais pacientes. Conclusão Pacientes com comprometimento cognitivo que apresentam AVC têm pior prognóstico, porém eles devem ser tratados de modo semelhante aos demais casos.

Proportion of single-chain recombinant tissue plasminogen activator and outcome after stroke.

OBJECTIVE: To determine whether the ratio single chain (sc)/(sc + 2 chain [tc]) recombinant tissue plasminogen activator (rtPA) influences outcomes in patients with cerebral ischemia. METHODS: We prospectively included consecutive patients treated with IV rtPA for cerebral ischemia in 13 stroke centers and determined the sc/(sc + tc) ratio in the treatment administered to each patient. We evaluated the outcome with the modified Rankin Scale (mRS) at 3 months (prespecified analysis) and occurrence of epileptic seizures (post hoc analysis). We registered Outcome of Patients Treated by IV Rt-PA for Cerebral Ischaemia According to the Ratio Sc-tPA/Tc-tPA (OPHELIE) under ClinicalTrials.gov identifier no. NCT01614080. RESULTS: We recruited 1,004 patients (515 men, median age 75 years, median onset-to-needle time 170 minutes, median NIH Stroke Scale score 10). We found no statistical association between sc/(sc + tc) ratios and handicap (mRS > 1), dependency (mRS > 2), or death at 3 months. Patients with symptomatic intracerebral hemorrhages had lower ratios (median 69% vs 72%, adjusted p = 0.003). The sc/(sc + tc) rtPA ratio did not differ between patients with and without seizures, but patients with early seizures were more likely to have received a sc/(sc + tc) rtPA ratio >80.5% (odds ratio 3.61; 95% confidence interval 1.26-10.34). CONCLUSIONS: The sc/(sc + tc) rtPA ratio does not influence outcomes in patients with cerebral ischemia. The capacity of rtPA to modulate NMDA receptor signaling might be associated with early seizures, but we observed this effect only in patients with a ratio of sc/(sc + tc) rtPA >80.5% in a post hoc analysis.