title: Impact of a combined intravenous/intra-arterial approach in octogenarians.
abstract: BACKGROUND
  Intravenous (IV) alteplase is not currently recommended in octogenarian patients, and the benefit/risk ratio of endovascular (intra-arterial, IA) therapy remains to be determined. The aim of this study was to determine the impact of a combined IV-IA approach in octogenarians.
  
  
  METHODS
  From a single-centre interventional study, we report age-specific outcomes of patients treated by a combined IV-IA thrombolytic approach. Patients ≥80 years with documented arterial occlusion treated by conventional IV thrombolysis constituted the control group.
  
  
  RESULTS
  Among 84 patients treated by the IV-IA approach, those ≥80 years (n = 25) had a similar rate of early neurological improvement to that of patients <80 years, whereas the 90-day favourable outcome rate was lower in octogenarians (adjusted odds ratio, OR, 0.21; 95% confidence interval, CI, 0.06-0.75). No difference in symptomatic intracranial haemorrhage was observed whereas a higher rate of 90-day mortality (adjusted OR, 3.27; 95% CI, 0.76-14.14) and asymptomatic intracranial haemorrhage (adjusted OR, 6.39; 95% CI, 1.54-26.63) were found in patients ≥80 years old. Among octogenarians, and compared to IV-thrombolysis-treated patients (n = 24), patients treated by the IV-IA approach had a higher rate of recanalization (76 vs. 33%, p = 0.003) associated with increased early neurological improvement (32 vs. 8%, p = 0.07). Although there was a higher rate of asymptomatic intracranial haemorrhage (44 vs. 8%, p = 0.005) observed in the IV-IA group, no difference existed in symptomatic intracranial haemorrhage rates and 90-day favourable outcome.
  
  
  CONCLUSIONS
  The IV-IA approach in octogenarians was associated with lower efficacy at 3 months and higher mortality and asymptomatic haemorrhagic complications than in patients <80 years old. Definite recommendations cannot be given, but an endovascular approach may cause more harm than positive effects in patients over 80 years and should not be considered outside an approved protocol.
authors.affiliation: Department of Neurology and Stroke Centre, Bichat University Hospital, Paris, France.
authors.forename: Mikael
authors.initials: M
authors.lastname: Mazighi
authors.forename: Julien
authors.initials: J
authors.lastname: Labreuche
authors.forename: Elena
authors.initials: E
authors.lastname: Meseguer
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Serfaty
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Laissy
authors.forename: Philippa C
authors.initials: PC
authors.lastname: Lavallée
authors.forename: Lucie
authors.initials: L
authors.lastname: Cabrejo
authors.forename: Céline
authors.initials: C
authors.lastname: Guidoux
authors.forename: Bertrand
authors.initials: B
authors.lastname: Lapergue
authors.forename: Isabelle F
authors.initials: IF
authors.lastname: Klein
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Olivot
authors.forename: Halim
authors.initials: H
authors.lastname: Abboud
authors.forename: Olivier
authors.initials: O
authors.lastname: Simon
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Schouman-Claeys
authors.forename: Pierre
authors.initials: P
authors.lastname: Amarenco
mesh_terms: D000208:Acute Disease; D000328:Adult; D000367:Age Factors; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy* / Q000401:mortality; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D007269:Injections, Intra-Arterial; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D012042:Registries / Q000706:statistics & numerical data; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy* / Q000401:mortality; D015912:Thrombolytic Therapy / Q000379:methods* / Q000706:statistics & numerical data; D010959:Tissue Plasminogen Activator / Q000600:supply & distribution*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator