Intravenous Thrombolysis for Acute Ischemic Stroke in the Elderly: An Italian Cohort Study in a “Real World” Setting

Abstract

Thrombolysis in the elderly is still a matter of debate. Recently, the Third International Stroke Trial (IST-3) suggested that recombinant tissue plasminogen activator (rt-PA) improves functional outcome, without a substantial absolute increase in symptomatic intracranial hemorrhage, even in older patients. The aim of the current prospective study is to describe safety and functional outcome in a cohort of patients treated by intravenous rt-PA in an Italian stroke unit “real world setting”. All the consecutive patients treated with rt-PA between 2006 and 2010 in an Italian province with 290,000 inhabitants were enrolled. Total and symptomatic (associated with a 4-point worsening on the National Institutes of Health Stroke Scale [NIHSS] score) hemorrhages were evaluated, as safety measures, along with disability (at 3-month modified Rankin scale) as effectiveness measure. One hundred and eighty-seven patients were treated with rt-PA; 90 males (48.1%); average age 75.1 (±11.9) years; 79 (42.2%) patients aged ≥80 years. Patients aged ≥80 years had a higher NIHSS score at stroke onset (13.5 vs. 10.9). No significant difference was found between patients aged <80 years and ≥80 years in mortality rate ( p = 0.1), total or symptomatic intracranial hemorrhage ( p = 0.52 and p = 0.085, respectively), whereas the 3-month disability was higher in octogenarians ( p = 0.004). Thrombolysis in patients aged ≥80 years was not associated with significantly increased intracranial hemorrhage. The higher 3-month disability rate observed in octogenarians may be explained by the more severe stroke and higher poststroke disability. Based on the current, “real world setting” study, we advocate the need for a randomized clinical trial to better clarify the efficacy and safety of intravenous thrombolysis for acute ischemic stroke in the elderly.