Resource Considerations for Acute Ischemic Stroke Intervention in Nonagenarians

Background: While there is evidence to support the viability of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) as treatments for acute ischemic stroke (AIS) even in the very elderly, there are practical considerations to be made regarding triage and resource allocation, particularly in a hub-and-spoke system of stroke intervention. Methods: This is a cross-sectional study using stroke quality registry data from 2017-2021 at a comprehensive stroke center serving as the primary hub for an associated healthcare system. We identified patients aged 90 or above who received acute stroke treatment with IVT and/or MT. NIHSS, modified Rankin Score (mRS), transfer status, length of stay (LOS), and discharge disposition were examined. Results: Out of 268 total nonagenarians admitted for AIS, 60 received an acute intervention (37 IVT, 14 MT, 9 both). All MT attempts resulted in successful reperfusion (>TICI2b). Median initial and discharge mRS were 2 and 5 respectively; only 3.3% were discharged home, with 46.7% of patients either deceased or discharged to hospice. Median LOS was 5 days (range 0-77), but prolonged LOS was common, with 11 patients having LOS >14 days. Comparing the groups who received MT vs. IVT alone, the median initial NIHSS was 17 vs. 15 (p=0.23); the MT group had better baseline mRS (1 vs 3, p=0.005), but despite this, there were no significant differences in mortality (57% vs 41%) or discharge mRS (5 vs. 5). Median LOS was not significantly different (6 vs. 5 days). Mortality in MT was 75% for transfers vs. 53% for local arrivals (p=0.36). Conclusion: Despite safe and technically successful treatment, outcomes were poor overall in the nonagenarian population after both MT +/- IVT, with very high morbidity and mortality.