Should We Give Delayed Lytics for Stroke Over Age 80?

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Elderly stroke patients over age 80 who received tPA >3 - 4.5 hours from time of onset were more likely to have symptomatic intracranial hemorrhage (SICH), 10% vs 8% in the <3-hour group, but overall mortality and percentage with good neurological outcome was the same in the delayed group as patients who received it in under 3 hours.

Why does this matter?
US guidelines don't recommend tPA be given to patients >80 years who present > 3 hours from onset.  This study raises questions about that. But it also demands a frank discussion of the very real risks with patients and their families.

Sooner is better
This was a retrospective analysis of the SITS-ISTR registry.  They found that most patients over 80 had tPA given under 3 hours (10682 patients), but 3558 got it >3 -4.5 hours after onset. This dataset had some missing information on hundreds of patients, so it's hard to feel great that the conclusions are solid.  Given that limitation, they found that the odds of SICH were higher in the later tPA group, 9.8% if 3-4.5h vs. 8% if <3h (using the NINDS definition).  But the percentage with a favorable neurological outcome was the same in both groups, about 23%.  90-day mortality was also nearly the same, about 32% in each group.  This is a tough call.  While it appears tPA can be given to very elderly patients with a delayed presentation, there is serious risk in doing so.  Families deserve to know that there may still be a small benefit, but there is also a greater risk with delayed administration.

Source
Outcome after stroke thrombolysis in patients >80 years treated within 3 hours vs >3-4.5 hours.  Neurology. 2017 Sep 8. pii: 10.1212/WNL.0000000000004499. doi: 10.1212/WNL.0000000000004499. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.

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