Direct versus Bridging Mechanical Thrombectomy in Elderly Patients with Acute Large Vessel Occlusion: A Multicenter Cohort Study

Yating Jian,1 Lili Zhao,1 Baixue Jia,2 Xu Tong,2 Tao Li,1 Yulun Wu,1 Xiaoya Wang,1 Zhen Gao,1 Yu Gong,1 Xuelei Zhang,2 Huqing Wang,1 Ru Zhang,1 Lei Zhang,1 Zhongrong Miao,2 Guilian Zhang1 On behalf of ANGEL-ACT Study Group1Department of Neurology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710004, Shaanxi, People’s Republic of China; 2Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of ChinaCorrespondence: Guilian ZhangDepartment of Neurology, the Second Affiliated Hospital of Xi’an Jiaotong University, No. 157 Xiwulu, Xi’an, 710004, Shaanxi, People’s Republic of ChinaTel +86 29 87679346Fax +86 29 87678599Email zhgl_2006@126.comZhongrong MiaoDepartment of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No. 119 South West Road, Fengtai District, Beijing, People’s Republic of ChinaTel +8613601243293Email zhongrongm@163.comPurpose: Elderly people represent a growing stroke population with different pathophysiological states than younger. Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is beneficial for elderly patients remains unclear. This study compared the efficacy and safety between elderly patients treated with MT alone and those treated with both IVT and MT.Patients and Methods: Patients aged ≥ 65 years who were eligible for IVT within 4.5 h from symptom onset were selected from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke) registry, a prospective registry program for patients with endovascular treatment from 111 Chinese stroke centers. The primary efficacy outcome was the 90-day modified Rankin Scale score. We compared efficacy and safety outcomes using ordinal or binary logistic regression or a generalized linear model.Results: In total, 482 elderly patients were included: 187 (38.8%) received IVT and MT (bridging MT) and 295 (61.2%) received MT alone (direct MT). There was no significant difference in the 90-day modified Rankin Scale score between the two groups (median: 4 vs 4 points, respectively; adjusted β=− 0.048, P=0.822). The direct MT group had a shorter onset-to-puncture time (225 vs 255 min, respectively; adjusted β=− 55.074, P=0.002) and a lower rate of parenchymal hemorrhage type 2 within 24 h (2.80% vs 6.63%, respectively; adjusted odds ratio [OR]=0.287, 95% confidence interval [CI]=0.096– 0.856, P=0.025). In addition, the direct MT group showed a trend toward a lower incidence of sICH (5.67% vs 10.06%, adjusted OR=0.453, P=0.061), procedure-related complications (7.12% vs 12.30%, adjusted OR=0.499, P=0.052) and distal or new territorial embolization (4.07% vs 6.95%, adjusted OR=0.450, P=0.093).Conclusion: Direct MT had similar efficacy to bridging MT in terms of the 90-day functional outcome in elderly patients, whereas bridging MT had a longer onset-to-puncture time and increased risk of hemorrhagic transformation and procedure-related complications.Keywords: acute ischemic stroke, endovascular treatment, intravenous thrombolysis, elderly patient