Comparative Effectiveness of Endovascular Thrombectomy in Elderly Stroke Patients

Background and Purpose- Strokes in patients aged ≥80 years are common, and advanced age is associated with relatively poor poststroke functional outcome. The current guidelines do not recommend an upper age limit for endovascular thrombectomy (EVT). The purpose of this study is to evaluate the effectiveness of EVT in acute stroke because of large vessel occlusion for elderly patients >age 80 years. Methods- A Markov decision analytic model was constructed from a societal perspective to evaluate health outcomes in terms of quality-adjusted life years (QALYs) after EVT for acute ischemic stroke because of large vessel occlusion in patients above age 80 years. Age-specific input parameters were obtained from the most recent/comprehensive literature. Good outcome was defined as a modified Rankin Scale score ≤2. Probabilistic, 1-way, and 2-way sensitivity analyses were performed for both healthy patients and patients with disability at baseline. Results- Base case calculation showed in functionally independent patients at baseline, intravenous thrombolysis (IVT) with tPA (tissue-type plasminogen activator) only to be the better strategy with 3.76 QALYs compared to 2.93 QALYs for patients undergoing EVT. The difference in outcome is 0.83 QALY (equivalent to 303 days of life in perfect health). For patients with baseline disability, IVT only yields a utility of 1.92 QALYs and EVT yields a utility of 1.65 QALYs. The difference is 0.27 QALYs (equivalent to 99 days of life in perfect health). Multiple sensitivity analyses showed that the effectiveness of EVT is significantly determined by the morbidity and mortality after both IVT and EVT strategies, respectively. Conclusions- Our study demonstrates the impact of relevant factors on the effectiveness of EVT in patients above 80 years of age. Morbidity and mortality after both IVT and EVT strategies significantly influence the outcomes in both healthy and disabled patients at baseline. Better identification of patients not benefiting from IVT would optimize the selective use of EVT thereby improving its effectiveness.