Introduction: National clinical guidelines in England and Wales recommend that intravenous thrombolysis is provided without restriction based on age. However, thrombolysis trials have included very few patients aged 90 and over. We therefore analysed data from the national stroke register of England and Wales to describe the safety and outcomes of thrombolysis in patients aged 90 and over.
Methods: Data were extracted from the national stroke register (Sentinel Stroke National Audit Programme (SSNAP)) of adults with acute ischemic stroke treated in all hospitals in England and Wales from April 2013-March 2015.
Results: Of 128826 adults with acute ischemic stroke admitted to 202 hospitals, 14854 (11.5%) were aged 90 or over. Of these, 1262 (8.5%) were treated with intravenous alteplase (iv-tPA).
Females comprised 70.0% of treated patients aged 90 or over, 6.3% had stroke onset whilst already an inpatient, 65.0% were independent prior to stroke (mRS of 2 or less), 71.2% were fully conscious upon arrival at hospital and 37.2% had a diagnosis of atrial fibrillation prior to stroke. The median age of the thrombolysed patients was 92 (IQR 91-94), similar to patients aged 90 or over who were not treated. Median NIHSS score was 14 (IQR 9-20).
Following tPA, 12.5% of patients had complications; 4.8% had symptomatic intracranial hemorrhage, 0.7% had angioedema, 0.6% had extracranial bleeds and 6.6% had some other type of tPA complication.
The median NIHSS 24h after tPA was 10 (IQR 4-18). Of the 871 patients (69.0%) who had a fully completed NIHSS at arrival and at 24h after thrombolysis, the median improvement was 3 points on the scale (IQR 0-7).
Inpatient case fatality rate was 32.8%, 20.9% were independent upon discharge from inpatient care (Rankin 2 or below), 14.1% were newly institutionalised into a care home (21.0% of those discharged alive).
Conclusions: Patients aged 90 and over treated with iv-tPA have a similar rate of complications as reported for younger patients in national registries and clinical trials. However stroke in this age group carries a high risk of mortality and a high proportion of survivors are discharged to long term care for the first time.