Department of Neurology and Stroke Centre, Bichat University Hospital, Paris, France.
Cerebrovasc Dis. 2011;31(6):559-65. doi: 10.1159/000324626. Epub 2011 Apr 12.
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.
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.
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.
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.
目前不建议对 80 岁以上的患者进行静脉（IV）阿替普酶治疗，血管内（动脉内，IA）治疗的获益/风险比仍有待确定。本研究的目的是确定联合 IV-IA 方法在 80 岁以上患者中的影响。
我们从一项单中心介入研究中报告了接受联合 IV-IA 溶栓治疗的患者的年龄特异性结局。接受常规 IV 溶栓治疗的记录有动脉闭塞的 80 岁以上患者构成对照组。
在接受 IV-IA 治疗的 84 例患者中，≥80 岁的患者（n=25）与<80 岁的患者相比，早期神经改善率相似，而 90 天预后良好率较低（调整后的优势比，OR，0.21；95%置信区间，CI，0.06-0.75）。未观察到症状性颅内出血的差异，但≥80 岁的患者 90 天死亡率（调整后的 OR，3.27；95%CI，0.76-14.14）和无症状性颅内出血（调整后的 OR，6.39；95%CI，1.54-26.63）的发生率较高。在 80 岁以上的患者中，与 IV 溶栓治疗的患者（n=24）相比，接受 IV-IA 治疗的患者再通率更高（76%比 33%，p=0.003），早期神经改善率更高（32%比 8%，p=0.07）。虽然 IV-IA 组无症状性颅内出血发生率较高（44%比 8%，p=0.005），但症状性颅内出血发生率和 90 天预后良好率无差异。
与<80 岁的患者相比，80 岁以上患者采用 IV-IA 方法治疗 3 个月时疗效较低，死亡率和无症状性出血并发症较高。不能给出明确的建议，但对于 80 岁以上的患者，血管内方法可能弊大于利，不应在批准的方案之外考虑。
