Optimal Angiographic Goal and Number of Passes for Octogenarians Undergoing Endovascular Stroke Thrombectomy

Huanwen Chen; Marco Colasurdo; Chad Schrier; Jose Marino; Michael S Phipps; Marcella A Wozniak; Carolyn A Cronin; Prachi Mehndiratta; John W Cole; Timothy R Miller; Jacob Cherian; Dheeraj Gandhi; Seemant Chaturvedi; Gaurav Jindal

doi:10.1016/j.wneu.2024.03.123

Optimal Angiographic Goal and Number of Passes for Octogenarians Undergoing Endovascular Stroke Thrombectomy

World Neurosurg. 2024 Mar 28:S1878-8750(24)00508-4. doi: 10.1016/j.wneu.2024.03.123. Online ahead of print.

Affiliations

¹ Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA; National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA; Department of Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA.
² Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA; Department of Interventional Radiology, Oregon Health and Sciences University, Portland, Oregon, USA.
³ Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA.
⁴ Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA.
⁵ Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA.
⁶ Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA; Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA; Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA.
⁷ Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA. Electronic address: drjindal@gmail.com.

PMID: 38552786
DOI: 10.1016/j.wneu.2024.03.123

Abstract

Background: The optimal recanalization goal and number of endovascular thrombectomy (EVT) passes for elderly patients with large vessel occlusion strokes is unclear.

Methods: Consecutive patients 80 years or older undergoing EVT were identified from 2016 to 2022 at a single center. Clinical information, procedural details, and modified treatment in cerebral ischemia (mTICI) scores were collected. Primary outcome was modified Rankin scale (mRS) at 90 days. Bivariate and multivariable analyses were conducted to assess associations between mTICI scores, EVT passes, and 90-day outcomes.

Results: One hundred twenty-six patients were identified. At 90 days, mTICI 2b recanalization resulted in high rates of poor outcomes (8.7% functional independence and 60.9% mortality) not significantly different from mTICI 0, 1 or 2a (median mRS 6 vs. 6, P = 0.61). Complete recanalization (mTICI 2c or 3) led to significantly better mRS outcomes at 90 days compared to mTICI 2b (median mRS 4 vs. 6, adjusted P = 0.038), with 26.8% functional independence and 37.8% mortality. In multivariable analysis, complete recanalization was significantly associated with better 90-day outcomes than mTICI 2b or lower recanalization (odds ratio 4.24 [95% Confidence interval 1.46-12.3]; P = 0.002), while the number of passes was not independently associated with worse outcomes (P = 0.98).

Conclusions: For octogenarians, mTICI 2b recanalization yields limited clinical benefit and results in poor 90-day outcomes. In contrast, complete recanalization is independently associated with significantly better outcomes. Thus, once the decision is made to pursue EVT in the elderly, mTICI 2c or better recanalization should be the angiographic goal. Providers should not withhold thrombectomy passes based on age alone.

Keywords: Elderly; Endovascular; Passes; Recanalization; Stroke; Thrombectomy.