Addressing Discrepancies in Elderly Representation in Endovascular Thrombectomy Trials: A Propensity Score Matching Analysis of Outcomes in Patients Aged ≥80 with Low ASPECTS

Introduction: Elderly patients (≥80 years) have been consistently underrepresented in clinical trials assessing the efficacy of endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion acute ischemic stroke (LVO-AIS), particularly those with ASPECTS (≤5). This gap has led to significant discrepancies in how the elderly are treated in clinical practice versus what is known from trial data, potentially skewing treatment recommendations and outcomes for this age group.

Methods: This study analyzed data from 37 thrombectomy centers, focusing on LVO-AIS patients aged ≥80 with ASPECTS ≤5 from 2013 to 2023. By applying propensity score matching (PSM) with selection criteria typically used for younger patients, the study sought to better represent the elderly in a way that aligns with the treatment protocols applied to younger populations. The primary outcome was a favorable modified Rankin Scale (mRS) score of 0-3 at 90 days.

Results: Of the 15,233 patients undergoing EVT, 1,741 were ≥80, with 122 presenting low ASPECTS. While successful recanalization rates were similar between elderly and younger patients, the elderly demonstrated significantly lower favorable 90-day mRS scores and higher mortality rates before PSM. However, after applying PSM, the discrepancies in mortality and symptomatic intracranial hemorrhage (sICH) rates were no longer significant. Higher ASPECTS Was an independent predictor of favorable outcomes for elderly patients, but it was not associated with 90-day mortality. For the elderly subgroup with low ASPECTS, favorable outcomes were associated with lower atrial fibrillation rates, better baseline functioning (mRS 0-1), fewer thrombectomy passes, and a higher likelihood of first-pass reperfusion within 30 minutes of puncture.

Conclusion : Significant discrepancies between how elderly patients are represented in thrombectomy trials and how they are treated in clinical practice. By applying the same selection criteria used for younger patients through PSM, there are potential benefits of EVT for carefully selected elderly patients with low ASPECTS. Despite the increased risk of mortality and disability associated with age, certain clinical factors suggest that individualized treatment strategies may allow some elderly patients to benefit from EVT.