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CORRESPONDENCE
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 686-687

Efficacy and safety of thrombolysis in patients aged 80 or more with major ischemic stroke: Special reference to nonagenarians


1 Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission26-Oct-2012
Date of Decision27-Oct-2012
Date of Acceptance27-Oct-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Dheeraj Khurana
Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.105229

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How to cite this article:
Khurana D, Kumari B, Rajan R, Ahuja C, Vyas S. Efficacy and safety of thrombolysis in patients aged 80 or more with major ischemic stroke: Special reference to nonagenarians. Neurol India 2012;60:686-7

How to cite this URL:
Khurana D, Kumari B, Rajan R, Ahuja C, Vyas S. Efficacy and safety of thrombolysis in patients aged 80 or more with major ischemic stroke: Special reference to nonagenarians. Neurol India [serial online] 2012 [cited 2021 Jan 18];60:686-7. Available from: https://www.neurologyindia.com/text.asp?2012/60/6/686/105229


Sir,

We read the article by Kim et al.[1] on "Efficacy and safety of thrombolysis in patients aged 80 years or above with major acute ischemic attack," which showed beneficial effects on functional outcomes. In this study, they used all three modalities (intra-venous recombinant tissue plasminogen activator alone, intra-arterial reperfusion therapy or combination) depending upon clinical and imaging findings. Beneficial outcomes after thrombolysis in the octogenarian strokes have been well documented in results of recently publised International Stroke Trial-3. [2] However, data on the outcome following thrombolysis in patients of 90 years and older is sparse.

A 93-year-old hypertensive female patient presented with left hemiparesis of 90 min duration. At admission, patient had irregularly irregular pulse (80/min), blood pressure of 200/118 mmHg and National Institute of Health Stroke Scale (NIHSS) score was 24. Non contrast cranial computed tomography (CT) scan was normal and CT-angiography showed a right distal middle cerebral artery (M2) occlusion [Figure 1]a. The patient's relatives initially refused consent for thrombolysis considering the increased risk of hemorrhage with advanced age. However, after a delay, they consented and at 5 h and 30 min of stroke onset patient was taken up for intra-arterial thrombolysis. The distal right M2 occlusion was confirmed on digital subtraction angiography (DSA) [Figure 1]b and 20 mg of r-tPA was infused in distal ICA over 50 min via a trans-femoral catheter. Post infusion run showed complete recanalization of right M2 branches [Figure 1]c with normal and adequate filling of the distal cortical branches. Repeat CT at 24 h did not show any hemorrhage and NIHSS score at 6 h was 7 and at 24 h was 5. Patient regained good motor function and swallowing by the 2 nd day. The NIHSS score at discharge was 3 and modified Rankin Scale score at 1 month was 3. Our patient (93-year-old) showed a favorable outcome with 19-point NIHSS improvement at 24 h and Modified Rankin Scale Score of 3 at 1 month of stroke.
Figure 1: Right distal middle cerebral artery (M2) occlusion on (a) computed tomography angiography (maximum intensity projection image) and on (b) digital substraction angiography (DSA) (c) post intra-arterial thrombolysis DSA showing complete recanalization of the right middle cerebral artery (MCA)

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Intravenous thrombolysis in advanced age is associated with increased in-hospital mortality and increased risk of intracranial hemorrhage (ICH), the risk of symptomatic ICH (SICH) being the same as in young strokes. [3] However, if untreated, older stroke patients have a higher mortality [4] with less likelihood of recovery. A recent series also showed multimodal intervention including intra-arterial thrombolysis to be safe in the elderly, however, this series had only one patient in the nonagenarian category. [5] We believe that intra-arterial thrombolysis may be a safe option in nonagenarians with a large-artery ischemic stroke.

 
  References Top

1.Kim SC, Hong KS, Cho YJ, Cho JY, Park HK, Song P. Efficacy and safety of thrombolysis in patients aged 80 years or above with major acute ischemic stroke. Neurol India 2012;60:373-8.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Sandercock P, Joanna MW, Lindley IR, Dennis M, Cohen G, Murray G, et.al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): A randomised controlled trial. Lancet 2012;379:2352-63.  Back to cited text no. 2
    
3.Stefan TE, Bonati LH, Lyrer PA. Intravenous thrombolysis in stroke patients of 80 versus <80 years of age: A systematic review across cohort studies. Age Ageing 2006;35:572-80.  Back to cited text no. 3
    
4.Di Carlo A, Lamassa M, Pracucci G, Basile AM, Trefoloni G, Vanni P, et al. Stroke in the very old: Clinical presentation and determinants of 3-month functional outcome: A European perspective. European BIOMED Study of Stroke Care Group. Stroke 1999;30:2313-9.  Back to cited text no. 4
    
5.Ghobrial GM, Chalouhi N, Rivers L, Witte S, Davanzo J, Dalyai R, et al. Multimodal endovascular management of acute ischemic stroke in patients over 75 years old is safe and effective. J Neurointerv Surg 2012;0:1-5.  Back to cited text no. 5
    


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