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Thrombolytic therapy for acute ischaemic stroke in octogenarians: selection by magnetic resonance imaging improves safety but does not improve outcome

P A Ringleb, Ch Schwark, M Köhrmann, S Külkens, E Jüttler, W Hacke and P D Schellinger

Neurologische Klinik der Ruprecht Karls-Universität Heidelberg, Heidelberg, Germany

Correspondence to:
Correspondence to:
Dr P A Ringleb
Neurologische Klinik der Ruprecht-Karls-Universität Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; peter.ringleb{at}med.uni-heidelberg.de

Background: Owing to the fear of an increased bleeding risk, thrombolytic therapy is withheld from many patients with acute stroke >80 years of age.

Objective: To analyse the risk for symptomatic intracranial haemorrhage (sICH), morbidity and mortality after thrombolytic therapy in octogenarians focusing, in particular, on whether patients selected using magnetic resonance imaging (MRI) had a better risk:benefit ratio.

Methods: The prospectively collected single-centre data of all patients treated with systemic thrombolytic therapy for acute ischaemic stroke since 1998 (n = 468) were reviewed, and patients 80 years (n = 90) were compared with those aged <80 years (n = 378). In addition, the group of octogenarians was analysed with respect to initial imaging modality.

Results: The overall rate of sICH in the octogenarians was 6.9%, compared with 5.3% in younger patients (p = 0.61). In older patients selected by computed tomography, the rate of sICH was 9.4%; no patient selected by MRI had sICH (p = 0.10). Mortality in the octogenarians selected by computed tomography was 29.7% after 3 months as compared with 26.9% in the patients selected by MRI (p = 1.0). 20.3% of the octogenarians selected by computed tomography and 15.4% of those selected by MRI had a favourable outcome (modified Rankin scale 1) after 3 months (p = 0.77).

Conclusion: Compared with younger patients, octogenarians do not have an increased risk of sICH. The use of MRI to select octogenarians for thrombolytic therapy seemed to decrease the risk of sICH, but did not influence the overall outcome after 3 months.

Abbreviations: DWI, diffusion-weighted imaging; EMEA, European Medicines Evaluation Agency; IQR, interquartile range; mRS, modified Rankin Scale; MRI, magnetic resonance imaging; NIHSSS, National Institution of Health Stroke Scale Score; NINDS, National Institute of Neurological Disorders and Stroke; rt-PA, recombinant tissue-type plasminogen activator; sICH, symptomatic intracranial haemorrhage

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