Ischaemic Stroke in the Very Elderly Patients

1. Ischaemic Stroke in The Very Elderly
Ade Wijaya, MD – January 2022

2. Introduction
• Life expectancy ↑
• Increasing age is a non modifiable risk factor of stroke
• Elderly patients present unique challenges, fragilities and specific
needs, both in the acute and in the chronic phase after stroke
Kontis V, Bennett JE, Mathers CD, et al. Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble. Lancet 2017;389:1323-1335.
Gur AY, Tanne D, Bornstein NM, et al. Stroke in the very elderly: characteristics and outcome in patients aged 85 years with a first-ever ischemic stroke. Neuroepidemiology 2012;39:57-62.
Sharrief A, Grotta JC. Stroke in the elderly. Handbook of clinical neurology. Elsevier; 2019. p. 393-418
Smithard DG. Stroke in frail older people. Geriatrics 2017;2:24

3. Risk Factors & Outcomes
• Atrial fibrillation and hypertension ↑
• More severe stroke by NIHSS
• Poorer prognosis: mortality rate of 17% between 81 and 90 years of
age and up to 28% over 90 years
• IV rt-PA increase prognosis in 81-90 years of age but not increase
prognosis in > 90 years of age
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly: the Framingham Study. Arch Intern Med 1987;147:1561-1564
Bray BD, Campbell J, Hoffman A, et al. Stroke thrombolysis in England: an age stratified analysis of practice and outcome. Age Ageing 2013;42:240-245.
Sagnier S, Galli P, Poli M, et al. The impact of intravenous thrombolysis on outcome of patients with acute ischemic stroke after 90 years old. BMC Geriatr 2016;16:156.
Mione G, Ducrocq X, Thilly N, et al. Outcome of intravenous recombinant tissue plasminogen activator for acute ischemic stroke in patients aged over 80 years. Geriatr Gerontol Int 2016;16:843-849.

4. Endovascular Management
• Good functional recovery can be achieved in a high proportion of
patients despite the higher incidence of comorbidity
• Outcomes are inferior to those reported for younger patients;
however, endovascular therapy can allow at least 1 in 4 patients older
than 80 years of age to regain independent function at 3 month
• More research is required to improve patient selection in the elderly,
but age should not be a discriminator when deciding to offer
endovascular therapy for patients with acute stroke
Hilditch, C. A., Nicholson, P., Murad, M. H., Rabinstein, A., Schaafsma, J., Pikula, A., ... & Brinjikji, W. (2018). Endovascular management of acute stroke in the elderly: a systematic review and meta-analysis. American Journal of
Neuroradiology, 39(5), 887-891.

5. Secondary Prevention
• Guidelines support a policy of oral anticoagulant therapy for the very
elderly patients with AF
• Direct oral anticoagulants are recommended with better efficacy and
safety profile in nonvalvular AF patients
• Direct oral anticoagulants should not be used in ESUS
• Restarting of direct oral anticoagulants after ICH : 4-8 weeks
Sandrine Deltour, Eric Pautas. Anticoagulation decisions in elderly patients with stroke. Revue Neurologique, Elsevier Masson, 2020, 176 (9), pp.692-700. ff10.1016/j.neurol.2020.04.015ff. ffhal-03046643f

6. Summary
• Stroke is common in very elderly population
• Poorer prognosis
• Treatment similar to general population with more careful assestment

7. THANK YOU