Intravenous tissue plasminogen activator for acute ischemic stroke in patients ≥80 years old: The London, Canada experience
Background: Although, elderly patients (≥80 years) are not excluded from receiving tPA for acute ischemic stroke (AIS), uncertainty still exists regarding the effectiveness and safety of tPA in this age group. Objective: To compare baseline characteristics, outcomes, and complications of AIS patients treated with iv tPA aged ≥80 with their younger counterparts (<80). Methods: Patients ≥80 were compared to the younger group aged <80 in the prospective London Canada registry of iv tPA use for AIS. Patients presenting with AIS within three hours of symptom onset were treated according to the 1995 National Institute of Neurological Disorders and Stroke (NINDS) guidelines but excluded if >1/3 middle cerebral artery territory was involved. Findings: To date 62 patients have been treated. Median ages of the young group (n=46) are 68 years (range of 37–79) and of the older group (n=16) are 85 years (range of 80–93). Thirty-one of 46 younger patients and eleven of 16 older patients have reached the 3 month follow-up mark. The elderly group had a statistically significant higher mean pre-stroke Modified Rankin Score (mRS) of 1.5 compared to 0.6 for the younger group (p=0.01). The mean initial National Institutes of Health Stroke Scale Scores (NIHSSS), and mean time to tPA from stroke onset do not differ significantly: 14 (young) and 17 (old) (p=0.07), and 151 minutes (young) and 155 minutes (old) (p=0.67). Percent of patients achieving ≥4 point improvement in NIHSS 24 hours post tPA, a 3 month NIHSS of 0–1, and a 3 month MRS of 0–1 are 63 V.S. 44 (p=0.29), 35 V.S. 36 (p=0.80)and 41 V.S. 9 (p=0.12) for the young and old groups respectively. Only one patient (age 81) had a fatal intracranial hemorrhage (ICH). No other patients in the registry suffered a symptomatic ICH. Of the younger group, 11% and of the elderly group, 19% had an asymptomatic ICH (p=0.71). Conclusions: Despite the elderly patients having greater pre-stroke disability, iv tPA for AIS in this group does not significantly differ in effectiveness and complications compared to the same treatment in patients under age 80. TPA should not be withheld from AIS patients on the basis of age alone.