This study explored the use of tPA at a community-based certified stroke center. Similar to previous studies, it demonstrates the large proportion of patients presenting with acute neurological findings consistent with ischemic stroke are ≥ 80 years old [3,6]. Our incidence of acute ischemic stroke in the oldest patients may be slightly lower than reported elsewhere, which may reflect community differences, with higher rates of younger patients with multiple comorbidities presenting with stroke-like symptoms. Amongst this very old cohort, age was positively correlated with stroke severity. Mortality in patients ≥ 80 years old who present with acute ischemic stroke approaches 25%.
The majority of patients who did not receive tPA had documented contraindications to receiving the medication. The most common reason was rapidly improving symptoms with repeat NIHSS often ≤ 4. The second most common reason was presentation outside the treatment window of 3 hours. We compared those who either arrived too late to receive treatment with tPA or already had ischemic changes on CT to those who received tPA as this suggests the natural history of stroke progression and outcome without effective, early treatment. The outcomes at this institution support this trend. Very old patients who received tPA did not experience harm as evidenced by similar lengths of stay and rates of discharge to home. Also, rates of symptomatic ICH were lower than those reported in the literature. In fact, patients who received tPA were less likely to experience in-hospital death and more likely to be discharged to acute rehabilitation hospitals, suggesting more functional ability to tolerate aggressive recovery efforts.
Very few people who presented with acute ischemic stroke and were eligible for treatment with tPA failed to receive it. This suggests that despite the perceived increased risk to treating these patients with tPA, the specialized stroke team aggressively treats patients age ≥ 80 years who present with acute ischemic stroke. However, those who did not receive tPA were more likely to have presented with mild or severe strokes. This may suggest that treatment time frames are more strongly held, or that treatment teams are more likely to use time frames as a reason to not treat with tPA for patients with mild or severe strokes. Also, very few patients and families who were eligible to receive tPA declined treatment despite the associated risks. This suggests that patients and families are eager for aggressive treatment in attempt to prevent death or disability associated with ischemic stroke.
There are several limitations associated with this evaluation. First, this is a retrospective analysis of a single institution’s acute stroke procedures. Data was collected in an effort to evaluate the processes and outcomes of the specialized stroke team in evaluating and treating this very old cohort who present to a community-based hospital. It involved individualized clinical evaluation and decision making by multiple care providers who may offer different perspectives on the risk of treating patients ≥ 80 years old with tPA, which may result in selection bias. While comparing those who arrived outside treatment windows offers a comparison group who represents the natural course of untreated strokes, patient characteristics that prevented timely evaluation may also impact their outcomes including baseline mobility, care giving availability and underlying medical comorbidities. The similarity in mean presenting NIHSS scores of the two groups, however, argues against this possibility. Lastly, exclusion criteria to receiving tPA may represent intrinsic characteristics that impart higher risk of negative outcomes.