Hostname: page-component-78c5997874-s2hrs Total loading time: 0 Render date: 2024-11-10T17:44:53.408Z Has data issue: false hasContentIssue false
  • English
  • Français

Stroke thrombolysis in the very elderly

Part of: Bespoke shallow archive Weizmann

Published online by Cambridge University Press:  20 September 2010

Cora McGreevy ,
Alan Moore ,
Ciaran Donegan  and
David JP Williams
Cora McGreevy*
Affiliation:
Department of Geriatric Medicine, Beaumont Hospital and Royal College of Surgeons, Dublin, Ireland
Alan Moore
Affiliation:
Department of Geriatric Medicine, Beaumont Hospital and Royal College of Surgeons, Dublin, Ireland
Ciaran Donegan
Affiliation:
Department of Geriatric Medicine, Beaumont Hospital and Royal College of Surgeons, Dublin, Ireland
David JP Williams
Affiliation:
Department of Geriatric Medicine, Beaumont Hospital and Royal College of Surgeons, Dublin, Ireland
*
Address for correspondence: Dr Cora McGreevy, c/o Department of Geriatric Medicine, Beaumont Hospital, Dublin, Ireland. E-mail: coramcgreevy@eircom.net
Get access Rights & Permissions [Opens in a new window]

Summary

Acute ischaemic stroke is common in older people and is associated with a higher morbidity and mortality compared with younger patients. Intravenous thrombolysis with recombinant tissue plasminogen activator (r-tPA) has become the mainstay of treatment and is the only evidence-based specific treatment for acute ischaemic stroke. However, little data are available on the safety of thrombolysis in the over-80 years age group due to under-representation of this group in trials and the upper age limit for licensing of the drug. In this review, we look at the pathophysiology of stroke and recent advances in neuroimaging techniques. We also look at the evidence base for use of thrombolysis in stroke and in particular analyse the trials that include the very elderly as subjects. Finally, issues around ongoing trials and future research are discussed.

Keywords

elderlystrokethrombolytic therapy
Type
Clinical geriatrics
Information
Reviews in Clinical Gerontology , Volume 20 , Issue 4 , November 2010 , pp. 261 - 267
Copyright
Copyright © Cambridge University Press 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1Sivenius, J, Riekkinen, PJ Sr, Laakso, M. Antiplatelet treatment in elderly people with transient ischaemic attacks or ischaemic strokes. BMJ 1995; 310: 25–26.CrossRefGoogle ScholarPubMed
2The NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischaemic stroke. N Engl J Med 1995; 333: 1581–87.CrossRefGoogle Scholar
3Wardlaw, JM, Del Zoppo, G, Yamaguchi, T et al. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2003; (3) CD 000213.CrossRefGoogle Scholar
4Nedeltchev, K, der Maur, TA, Georgiadis, D, Arnold, M, Caso, V, Mattle, HP, Schroth, G, Remonda, L, Sturzenegger, M, Fischer, U, Baumgartner, RW. Ischaemic stroke in young adults: predictors of outcome and recurrence. J Neurol Neurosurg Psychiatry 2005; 76: 191–95.CrossRefGoogle ScholarPubMed
5Abdel Latif, A, Messinger-Rapport, BJ. Should nursing home residents with atrial fibrillation be anticoagulated? Cleve Clin J Med 2004; 71: 40–44.CrossRefGoogle ScholarPubMed
6Endemann, DH, Schiffrin, EL. Endothelial dysfunction. J Am Soc Nephrol 2004; 15: 1983–92.CrossRefGoogle ScholarPubMed
7Soiza, RL, Davie, MM, Willams, DJP. Use of the augmentation index to predict short term outcome after acute ischaemic stroke. Am J Hypertens 2010; 23: 737–42.CrossRefGoogle Scholar
8Barber, PA, Demchuk, AM, Zhang, J et al. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000; 355: 1670–74.CrossRefGoogle Scholar
9Donnan, GA, Davis, SM. Neuroimaging, the ischaemic penumbra, and selection of patients for acute stroke therapy. Lancet Neurol 2002; 1: 417–25.CrossRefGoogle ScholarPubMed
10Muir, KW, Santosh, C. Imaging of acute stroke and transient ischaemic attack. Neurol Neurosurg Psychiatry 2005; 76: 19–28.CrossRefGoogle ScholarPubMed
11Ringleb, PA, Schwark, Ch, Köhrmann, M, Külkens, S, Jüttler, E, Hacke, W, Schellinger, PD. Thrombolytic therapy for acute ischaemic stroke in octogenarians: selection by magnetic resonance imaging improves safety but does not improve outcome. J Neurol Neurosurg Psychiat 2007; 78: 690–93.CrossRefGoogle Scholar
12Ovbiagele, B, Saver, JL, Sanossian, N, Salamon, N, Villablanca, P, Alger, JR, Razinia, T, Kim, D, Liebeskind, DS. Predictors of cerebral microbleeds in acute ischaemic stroke and TIA patients. Cerebrovasc Dis 2006; 22: 378–83.CrossRefGoogle ScholarPubMed
13Neumann-Haefelin, T, Hoelig, S, Berkefeld, J, Fiehler, J, Gass, A, Humpich, M, Kastrup, A, Kucinski, T, Lecei, O, Liebeskind, DS, Rother, J, Rosso, C, Samson, Y, Saver, JL, Yan, B; MR Stroke Group, . Leukoariosis is a risk factor for intracerebral haemorrhage after thrombolysis for acute stroke. Stroke 2006; 37: 2463–66.CrossRefGoogle Scholar
14Thomalla, G, Kohrmann, M, Rother, J, Schellinger, PD. [Effective acute stroke treatment beyond approval limitations:intravenous thrombolysis within an extended time window (3–6 h) and in old patients (aged 80 and over).] Fortschr Neurol Psychiatr 2007; 75: 343–50.CrossRefGoogle ScholarPubMed
15Wardlaw, JM, Murray, V, Berge, E, Del Zoppo, GJ. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2009; (4): CD000213.CrossRefGoogle Scholar
16Wahlgren, N, Ahmed, N, Dávalos, A, Ford, GA, Grond, M, Hacke, W, Hennerici, MG, Kaste, M, Kuelkens, S, Larrue, V, Lees, KR, Roine, RO, Soinne, L, Toni, D, Vanhooren, G; SITS-MOST investigators, . Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Survey (SITS-MOST): an observational study. Lancet 2007; 369: 275–82.CrossRefGoogle Scholar
17Hacke, W, Kaste, M, Bluhmki, E, Brozman, M, Dávalos, A, Guidetti, D, Larrue, V, Lees, KR, Medeghri, Z, Machnig, T, Schneider, D, von Kummer, R, Wahlgren, N, Toni, D; ECASS Investigators, . Thrombolysis with alteplase 3 to 4.5 hours after ischaemic stroke. N Engl J Med 2008; 359: 1317–29.CrossRefGoogle Scholar
18Van Oostenbrugge, RJ, Hupperts, RMM, Lodder, J. Thrombolysis for acute stroke with special emphasis on the very old: experience from a single Dutch centre. J Neurol Neurosurg Psychiat 2006; 77: 375–77.CrossRefGoogle ScholarPubMed
19Engelter, ST, Reichhart, M, Sekoranja, L, Georgiadis, D, Baumann, A, Weder, B, Müller, F, Lüthy, R, Arnold, M, Michel, P, Mattle, HP, Tettenborn, B, Hungerbühler, HJ, Baumgartner, RW, Sztajzel, R, Bogousslavsky, J, Lyrer, PA. Thrombolysis in stroke patients aged 80 years and older: Swiss survey of IV thrombolysis. Neurology 2005; 65: 1795–98.CrossRefGoogle ScholarPubMed
20Pundik, S, McWilliams-Dunnigan, L, Blackham, KL, Kirchner, HL, Sundararajan, S, Sunshine, JL, Tarr, RW, Selman, WR, Landis, DM, Suarez, JI. Older age does not increase risk of haemorrhagic complications after intravenous and/or intra-arterial thrombolysis for acute stroke. J Stroke Cerebrovasc Dis 2008; 17: 266–72.CrossRefGoogle ScholarPubMed
21Vatankhah, B, Dittmar, MS, Fehm, NP, Erban, P, Ickenstein, GW, Jakob, W, Bogdahn, U, Horn, M. Thrombolysis for stroke in the elderly. J Thromb Thrombolysis 2005; 20: 5–10.CrossRefGoogle ScholarPubMed
22Engelter, ST, Bonati, LH, Lyrer, PA. Intravenous thrombolysis in stroke patients of > or = 80 versus < 80 years of age – a systematic review across cohort studies. Age Ageing 2006; 35: 572–80.CrossRefGoogle ScholarPubMed
23Zeevi, N, Chhabra, J, Silverman, IE, Lee, NS, McCullough, LD. Acute stroke management in the elderly. Cerebrovasc Dis 2007; 23: 304–8.CrossRefGoogle ScholarPubMed
24Kim, D, Ford, GA, Kidwell, CS. Intra-arterial thrombolysis for acute stroke in patients 80 and older. Am J Neuroradiol 2007; 28: 159–63.Google ScholarPubMed
25Smith, WS, Sung, G, Starkman, S, Saver, JL, Kidwell, CS, Gobin, YP, Lutsep, HL, Nesbit, GM, Grobelny, T, Rymer, MM, Silverman, IE, Higashida, RT, Budzik, RF, Marks, MP; MERCI Trial Investigators, . Safety and efficacy of mechanical embolectomy in acute ischemic stroke results of the MERCI trial. Stroke 2005; 36: 1432–38.CrossRefGoogle ScholarPubMed
26Smith, WS. Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol 2006; 27: 1177–82.Google ScholarPubMed
27Sandercock, P, Berge, E, Dennis, M, Forbes, J, Hand, P, Kwan, J, Lewis, S, Lindley, R, Neilson, A, Wardlaw, J. Cost effectiveness of intravenous thrombolysis with recombinant tissue plasminogen activator for acute ischaemic stroke assessed by a model based on UK NHS costs. Stroke 2004; 35: 1490–97.CrossRefGoogle Scholar
28Ford, GA, Larrue, V, Ahmed, N et al. Thrombolysis for acute ischaemic stroke in patients older than 80 years: results from the SITS (Safe Implementation of Thrombolysis in Stroke) Register. 15th European Stroke Conference. Cerebrovasc Dis 2006; 21 (suppl 4): 1–162.Google Scholar
29Sandercock, P, Lindley, R, Wardlaw, J, Dennis, M, Lewis, S, Venables, G, Kobayashi, A, Czlonkowska, A, Berge, E, Slot, KB, Murray, V, Peeters, A, Hankey, G, Matz, K, Brainin, M, Ricci, S, Celani, MG, Righetti, E, Cantisani, T, Gubitz, G, Phillips, S, Arauz, A, Prasad, K, Correia, M, Lyrer, P; IST-3 Collaborative Group. The third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke. Trials 2008; 9: 37.CrossRefGoogle ScholarPubMed
30Toni, D. Thrombolysis in Elderly Stroke Patients in Italy (TESPI). Stroke Trials Registry. Available at: www.strokecenter.org/trials/TrialDetail.asspx?tid=1081 (accessed 2 June 2010).Google Scholar