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| Study fuels very elderly stroke thrombolysis debate |
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23 February 2006
Dutch researchers have questioned the value of thrombolysis in the very elderly, on finding that stroke patients aged 80 years or over may have markedly worse outcomes than younger patients after treatment with recombinant tissue plasminogen activator (rt-PA). However, in an accompanying commentary, German neurologists argue in favour of treating all eligible stroke patients with rt-PA, irrespective of age.
Writing in the Journal of Neurology, Neurosurgery, and Psychiatry, Dr Robert van Oostenbrugge and co-workers from the University Hospital Maastricht detail the outcomes of 184 stroke patients who were treated with rt-PA. They report that 45% of the 139 patients who were younger than 80 years old had a favourable 3-month outcome, defined as a modified Rankin Scale (mRS) score of 0 or 1, compared with just 27% of the 45 patients aged 80 years or older. A good outcome, defined as a mRS score of 2 or less, was seen in 63% and 36% of the younger and older patients, respectively. Patients aged upwards of 80 years also had a higher rate of symptomatic intracranial haemorrhage, at 11%, compared with 3% of younger patients.
The researchers state that these differences in outcomes could not be explained by baseline characteristics such as blood pressure, stroke severity, or time to treatment. These data "raise the question whether the use of rt-PA is justified in patients over 80 years of age," they conclude.
Stating the opposing case in a related editorial, Dr Christian Schwark and Dr Peter Schellinger from the University of Heidelberg, asked: "Is it justified to withhold a therapy that, based on current data, is the only effective therapy for acute ischaemic stroke?" They said: "Doctors fear the potential harm of any invasive therapy, following the saying 'primum nil nocere' (first do no harm)," but pointed out that stroke risk increases with age, while the willingness of doctors to undertake aggressive treatment decreases. "This leads to a self fulfilling prophecy," they explained, and results in an "unjustifiably high number of stroke patients ending up in nursing homes or dying of complications." They conceded that there are still questions to be answered regarding the role of thrombolysis in stroke care, but warn that doctors should not be "mesmerised by open questions into an inability to act."
Reference:
J Neurol Neurosurg Psychiatry 2006; 77 (3): 375-377.
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