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Background: Mechanical thrombectomy represents a mainstay of management for acute ischemic stroke in the setting of large vessel occlusion. However, there are no clinical practice guidelines defining the role of thrombectomy at the extremes of age. In this scoping review, we aimed to summarize the existing medical and neurosurgical literature pertaining to mechanical thrombectomy in nonagenarians. The PubMed database was queried using the following terms and relevant citations assessed: “thrombectomy nonagenarian,” “thrombectomy age 90,” “stroke nonagenarian,” and “ischemic stroke thrombectomy.” Common measurable outcomes, including mortality, modified Rankin scale (mRS) score, and thrombolysis in cerebral infarction (TICI) scale score, were utilized to compare results. Summary: Thrombectomy was shown to improve functional outcomes in all eight of the studies included in the analysis. Mortality was assessed in only two reported studies, and thrombectomy was shown to provide a mortality benefit in 1 study among patients for whom first-pass reperfusion was achieved. Other outcomes of reported interest included greater early neurologic recovery at discharge and improved functional outcomes at 90 days among nonagenarians who underwent thrombectomy as compared to those who received thrombolytic therapy alone. Nonagenarians with good functional status at baseline were the most likely to have favorable outcomes. Key Messages: Mechanical thrombectomy improves outcomes among nonagenarians presenting with acute ischemic stroke due to large vessel occlusion. Further large-scale prospective studies are warranted to optimize patient selection and develop clinical practice guidelines specific to this important patient demographic.

Acute ischemic stroke is one of the leading causes of disability and mortality in the world. Although advances in diagnostic techniques and neurointervention have helped significantly improve patient outcomes, ischemic stroke remains the second leading cause of death worldwide [1]. The widespread implementation of computed tomography (CT), CT perfusion (CTP), and magnetic resonance imaging (MRI) has played a vital role in identifying patients who may benefit from early intravenous thrombolysis. However, evidence-based clinical practice guidelines suggest that only patients presenting within 4.5 h of symptom onset are candidates for intravenous thrombolysis; nearly 40% of patients with acute ischemic stroke arrive at the hospital beyond the time window for pharmacotherapy. In addition, large middle cerebral artery (MCA) and distal carotid artery occlusions are often resistant to intravenous thrombolysis, and thrombolytics are contraindicated in many patients presenting with large territory infarcts [2, 3]. The limitations of intravenous thrombolysis have prompted a growing interest in mechanical thrombectomy and other minimally invasive endovascular interventions.

The results of the landmark multicenter DAWN and DEFUSE-3 trials were used to establish clinical practice guidelines for thrombectomy in acute anterior circulation ischemic stroke. The American Heart Association (AHA) and American Stroke Association (ASA) now provide class I evidence for the use of mechanical thrombectomy in the following scenarios:

  • 1.

    Internal carotid artery (ICA) or MCA-M1y occlusion, symptoms less than 6 h, National Institutes of Health Stroke Scale (NIHSS) score of greater than 6, and Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of greater than or equal to 6.

  • 2.

    Large vessel occlusions (LVOs) in the anterior circulation, symptom onset of 6–16 h, and meeting the DAWN and DEFUSE-3 criteria.

Class IIa evidence supports the utility of mechanical thrombectomy for large vessel anterior circulation occlusion with symptom onset between 16 and 24 h and meeting the DAWN and DEFUSE-3 criteria 3. The DAWN imaging criteria are described as follows:

  • 1.

    Less than one-third of the MCA territory involved, as evidenced by CT or MRI.

  • 2.

    Occlusion of the intracranial ICA and/or MCA-M1, as evidenced by magnetic resonance angiography or computed tomography angiography.

  • 3.

    Clinical-imaging mismatch, defined as one of the following features based on correlation of neurologic examination and diffusion-weighted MRI sequences or CTP [4]:

  • a. Less than 20 mL core infarct and NIHSS ≥10 (and age greater than 80 years).

  • b. Less than 30 mL core infarct and NIHSS ≥10 (and age less than 80 years).

  • c. 31 to 50 mL core infarct and NIHSS ≥20 (and age less than 80 years).

Notably, the specific ages of patients over 80 years were not documented in the DAWN study; the number of patients, if any, aged 90 years or older remains unknown. The DEFUSE-3 study excluded individuals over the age of 90 years, and thus, nonagenarians remained unstudied [5].

Retrospective studies evaluating the use of thrombectomy for ischemic stroke in patients over the age of 90 years have been conducted since the publication of the DAWN and DEFUSE-3 trials. In the following review, we summarize the key findings to further elucidate the utility of thrombectomy in nonagenarians.

A comprehensive literature review was performed to identify studies investigating the use of thrombectomy in nonagenarians. The PubMed database was queried using the following terms: “thrombectomy nonagenarian,” “thrombectomy age 90,” “stroke nonagenarian,” and “ischemic stroke thrombectomy.” All relevant retrospective studies were included in the analysis. Common measurable outcomes, including the modified Rankin scale (mRS) and thrombolysis in cerebral infarction (TICI) scale, were used to compare the results of the obtained articles. Mortality and procedural outcomes were also compared between the articles.

A total of eight articles were included in the review, all of which were retrospective in design and used data collected from 2008 onward. All studies are detailed below and summarized in Table 1.

Table 1.

Summary of clinical studies on thrombectomy in nonagenarians

TitleAuthorSample sizeJournalYearSignificant findings
Mechanical Thrombectomy in Nonagenarians with Acute Ischemic Stroke Meyer et al. [679 nonagenarians with LVO Journal of NeuroInterventional Surgery 2019 The technical success rate was 69.6%, and the 90-day mortality was 46.7% 
Final Infarct Volume of <10 cm3 Is a Strong Predictor of Return to Home in Nonagenarians Undergoing Mechanical Thrombectomy Tonetti et al. [730 nonagenarians with pre-stroke mRS ≤2 and evidence of perfusion defect suggesting LVO World Neurosurgery 2018 The technical success rate was 90%, and the 90-day mortality was 70% 
Endovascular Stroke Treatment of Nonagenarians Möhlenbruch et al. [829 nonagenarians with a median pre-stroke mRS of 2 American Journal of Neuroradiology (AJNR) 2017 The technical success rate was 75.9%, and the 90-day mortality was 44.8% 
Mechanical Thrombectomy in Acute Ischemic Stroke Patients Greater than 90 Years of Age: Experience in 26 Patients in a Large Tertiary Care Center and Outcome Comparison with Younger Patients Sweid et al. [926 nonagenarians compared with 314 patients aged 60–89 World Neurosurgery 2019 No significant difference in periprocedural hemorrhage (11.54% vs. 6.05%), postprocedural symptomatic ICH (3.85% vs. 4.14%), technical success rate (88.46% vs. 87.58), good mRS at 3-month follow-up (34.62% vs. 49.36%), and in-hospital mortality (11.54% vs. 13.06%) 
Endovascular Treatment of Acute Ischemic Stroke in Nonagenarians Compared with Younger Patients in a Multicenter Cohort Khan et al. [1018 nonagenarians were compared to 175 patients aged 18–89 Journal of NeuroInterventional Surgery 2017 No significant difference in technical success rate (67% vs. 62%, p= 0.999), parenchymal hemorrhage (33.3% vs. 26.3% p= 0.58), and infarct volume (130 vs. 84 mL, p= 0.08) 
Impact of Reperfusion for Nonagenarians Treated by Mechanical Thrombectomy: Insights from the ETIS Registry Drouard-de Rousiers et al. [11124 nonagenarians presenting with ischemic stroke related to LVO Stroke 2019 Those with successful reperfusion had the lowest 90-day mRS (OR, 3.26; 95% CI, 1.04–10.25). Additionally, this study found that only patients with successful reperfusion after the first pass had a reduced 90-day mortality (OR, 0.15; 95% CI, 0.05–0.45) and an increased rate of good outcomes (OR, 4.55; 95% CI, 1.38–15.03) 
Efficacy and Safety of Endovascular Thrombectomy for Ischemic Stroke in Nonagenarians Wu et al. [1223 nonagenarians (9 had tPA alone and 14 had mechanical thrombectomy) European Neurology 2019 The thrombectomy group had greater early neurologic recovery at discharge (71.4 vs. 33.3%, p = 0.102) and improved functional outcomes with mRS 0–2 at 90 days (71.4 vs. 44.4%, p = 0.383) 
Outcomes of Reperfusion Therapy for Acute Ischaemic Stroke in Patients Aged 90 Years or Older: A Retrospective Study Gomes et al. [13167 nonagenarians and 46.1% were included in the reperfusion treatment arm of the study (59 had IVT, 11 had MT, and 7 had both) Internal and Emergency Medicine 2020 Hemorrhagic transformation was more prevalent in the reperfusion group (26.0% vs. 7.8%, p= 0.001) and was more often symptomatic (14.3% vs. 3.3%, p= 0.011) and severe (PH1/2 15.6% vs. 2.2%, p= 0.012) when compared to the non-reperfusion therapy group 
TitleAuthorSample sizeJournalYearSignificant findings
Mechanical Thrombectomy in Nonagenarians with Acute Ischemic Stroke Meyer et al. [679 nonagenarians with LVO Journal of NeuroInterventional Surgery 2019 The technical success rate was 69.6%, and the 90-day mortality was 46.7% 
Final Infarct Volume of <10 cm3 Is a Strong Predictor of Return to Home in Nonagenarians Undergoing Mechanical Thrombectomy Tonetti et al. [730 nonagenarians with pre-stroke mRS ≤2 and evidence of perfusion defect suggesting LVO World Neurosurgery 2018 The technical success rate was 90%, and the 90-day mortality was 70% 
Endovascular Stroke Treatment of Nonagenarians Möhlenbruch et al. [829 nonagenarians with a median pre-stroke mRS of 2 American Journal of Neuroradiology (AJNR) 2017 The technical success rate was 75.9%, and the 90-day mortality was 44.8% 
Mechanical Thrombectomy in Acute Ischemic Stroke Patients Greater than 90 Years of Age: Experience in 26 Patients in a Large Tertiary Care Center and Outcome Comparison with Younger Patients Sweid et al. [926 nonagenarians compared with 314 patients aged 60–89 World Neurosurgery 2019 No significant difference in periprocedural hemorrhage (11.54% vs. 6.05%), postprocedural symptomatic ICH (3.85% vs. 4.14%), technical success rate (88.46% vs. 87.58), good mRS at 3-month follow-up (34.62% vs. 49.36%), and in-hospital mortality (11.54% vs. 13.06%) 
Endovascular Treatment of Acute Ischemic Stroke in Nonagenarians Compared with Younger Patients in a Multicenter Cohort Khan et al. [1018 nonagenarians were compared to 175 patients aged 18–89 Journal of NeuroInterventional Surgery 2017 No significant difference in technical success rate (67% vs. 62%, p= 0.999), parenchymal hemorrhage (33.3% vs. 26.3% p= 0.58), and infarct volume (130 vs. 84 mL, p= 0.08) 
Impact of Reperfusion for Nonagenarians Treated by Mechanical Thrombectomy: Insights from the ETIS Registry Drouard-de Rousiers et al. [11124 nonagenarians presenting with ischemic stroke related to LVO Stroke 2019 Those with successful reperfusion had the lowest 90-day mRS (OR, 3.26; 95% CI, 1.04–10.25). Additionally, this study found that only patients with successful reperfusion after the first pass had a reduced 90-day mortality (OR, 0.15; 95% CI, 0.05–0.45) and an increased rate of good outcomes (OR, 4.55; 95% CI, 1.38–15.03) 
Efficacy and Safety of Endovascular Thrombectomy for Ischemic Stroke in Nonagenarians Wu et al. [1223 nonagenarians (9 had tPA alone and 14 had mechanical thrombectomy) European Neurology 2019 The thrombectomy group had greater early neurologic recovery at discharge (71.4 vs. 33.3%, p = 0.102) and improved functional outcomes with mRS 0–2 at 90 days (71.4 vs. 44.4%, p = 0.383) 
Outcomes of Reperfusion Therapy for Acute Ischaemic Stroke in Patients Aged 90 Years or Older: A Retrospective Study Gomes et al. [13167 nonagenarians and 46.1% were included in the reperfusion treatment arm of the study (59 had IVT, 11 had MT, and 7 had both) Internal and Emergency Medicine 2020 Hemorrhagic transformation was more prevalent in the reperfusion group (26.0% vs. 7.8%, p= 0.001) and was more often symptomatic (14.3% vs. 3.3%, p= 0.011) and severe (PH1/2 15.6% vs. 2.2%, p= 0.012) when compared to the non-reperfusion therapy group 

ETIS, Endovascular Treatment in Ischemic Stroke.

In a 2019 retrospective analysis by Meyer et al. [6], investigators reviewed data collected between 2013 and 2017 across three neurointerventional centers. The stated objective was to evaluate if there should be an upper age limit for thrombectomy. A total of 79 patients over the age of 90 years with anterior circulation LVO were included in the analysis. Good functional outcomes, defined as an mRS of 2 or less, were described in 16% of the patients (12/79). The 90-day mortality was 46.7% (35/79). The technical success rate, defined as a TICI of 2b or greater, was 69.6% (55/79). The rate of recanalization failure was 21.5%, which is similar to the average rate reported across the neurosurgical literature. The rate of major complications, specifically defined as symptomatic intracranial hemorrhage (ICH), was 5.1%. No independent predictor of favorable outcomes was found through regression analysis.

In a 2018 single-center retrospective study by Tonetti et al. [7], authors evaluated 30 patients who underwent thrombectomy between January 2013 and July 2017 and met the following inclusion criteria: (1) age over 90 years; (2) pre-stroke mRS ≤2; and (3) presented with clinical and CTP evidence of an LVO. Patients with both anterior and posterior circulation LVO were included in the analysis; implicated vessels included the ICA, proximal MCA, and basilar artery. The technical success rate, defined as TICI 2b or greater, was 90%. However, only 20% of patients (6/30) were able to return home following the acute intervention, and only 4 patients had good functional outcomes, as defined as an mRS ≤2 at 30 days. The 90-day mortality rate was 70%. Complications occurred in 13% of patients and included vessel perforation, soft tissue hematoma, and, in 2 patients, ICH. Notably, all 6 of the patients who returned home following thrombectomy had a final infarct volume <7 cm3. Indeed, authors found that a final infarct volume of less than 10 cm3 predicted the likelihood of returning home (p < 0.002). The pre-thrombectomy infarct volume was not predictive of post-stroke mRS.

In a 2017 analysis by Möhlenbruch et al. [8], authors reviewed the outcomes of 29 nonagenarians with a median pre-stroke mRS of 2 who underwent thrombectomy for acute infarct between January 2011 and January 2016. Four patients had presented with basilar artery occlusion, while the remaining 25 presented with an anterior circulation LVO. Successful recanalization, defined as TICI 2b or greater, was achieved in 75.9% (22/29) of the patients included in the cohort. At 90-day follow-up, 17.2% of individuals were found to be at their pre-stroke mRS or have an mRS of 0–2. However, the average mRS score of surviving patients was 4. Only one procedure-related complication was reported: a vessel perforation with a small subarachnoid hemorrhage (1/29). The overall mortality rate at 3 months was found to be 44.8%.

In a 2020 retrospective review by Sweid et al. [9], investigators compared the outcomes of nonagenarians and patients aged 60–89 years who underwent thrombectomy for acute ischemic stroke. A total of 453 patients were included in the study, 26 of whom were 90 years of age or older. Only patients who presented with anterior circulation LVO were included in the analysis. The mean NIHSS score on presentation was higher among nonagenarians as compared to their younger counterparts (17 vs. 15, respectively). However, there was no significant difference in periprocedural and postprocedural complications, good TICI scores (88.5% vs. 87.6%, respectively), good mRS scores (34.6% vs. 49.4%, respectively), or mortality (11.5% vs. 13.1%, respectively) between the two groups. The authors concluded that thrombectomy was safe and potentially effective for nonagenarians presenting with acute ischemic stroke.

The results of the first four studies included in this review are summarized in Figure 1. A 2017 multicenter retrospective study by Khan et al. [10] compared the outcomes of 18 nonagenarians and 175 patients aged 18–89 years who underwent thrombectomy between January 2012 and August 2014. The technical success rate, defined as a TICI score of 2b or greater, was similar between the two groups. There was also no significant difference in functional outcomes between the two groups when adjusting for pre-stroke mRS score. However, nonagenarians presented with a significantly higher pre-stroke mRS relative to their younger counterparts and therefore tended to experience worse functional outcomes. The authors concluded that a subset of nonagenarians with good functional status at baseline may be appropriate candidates for thrombectomy.

Fig. 1.

A bar chart displaying the mRS ≤2 percentages at 90 days (i.e., good functional outcomes) and TICI scores ≥ 2b (technical success rate) for studies by Meyer et al. (study 1) [6], Tonetti et al. (study 2) [7], Mohlenbruch et al. (study 3) [8], and Sweid et al. (study 4) [9]. Study 4 shows the mRS percentage and TICI scores between one group greater than the age of 90 and another group aged 60–89. The results of study 4 did not show statistical significance between the two groups.

Fig. 1.

A bar chart displaying the mRS ≤2 percentages at 90 days (i.e., good functional outcomes) and TICI scores ≥ 2b (technical success rate) for studies by Meyer et al. (study 1) [6], Tonetti et al. (study 2) [7], Mohlenbruch et al. (study 3) [8], and Sweid et al. (study 4) [9]. Study 4 shows the mRS percentage and TICI scores between one group greater than the age of 90 and another group aged 60–89. The results of study 4 did not show statistical significance between the two groups.

Close modal

In a 2019 retrospective study by Drouard-de Rousiers et al. [11], authors reviewed clinical and imaging data from all patients over the age of 90 years who were included in the Endovascular Treatment in Ischemic Stroke (ETIS) Registry from October 2013 through April 2018. A total of 124 nonagenarians who underwent thrombectomy for acute ischemic stroke were included in the analysis. Investigators found that successful reperfusion was associated with an increased likelihood of achieving an mRS score of 3 or lower (OR, 3.26; 95% CI, 1.04–10.25). In addition, successful first-pass reperfusion was associated with significantly decreased 90-day mortality (OR, 0.15; 95% CI, 0.05–0.45) and increased likelihood of a good functional outcome, defined as a post-thrombectomy mRS score of 3 or lower (OR, 4.55; 95% CI, 1.38–15.03).

A 2019 review by Wu et al. [12] compared the safety and efficacy of thrombectomy and thrombolytic therapy for nonagenarians presenting with an anterior circulation LVO and MRI evidence of salvageable brain tissue. A total of 23 patients were included in the analysis, 14 of whom underwent thrombectomy and nine of whom received only intravenous tissue plasminogen activator (tPA). Thrombectomy was associated with greater early neurologic recovery at discharge and improved functional outcomes at 90 days when compared to tPA alone (71.4 vs. 33.3%, p = 0.102, and 71.4 vs. 44.4%, p = 0.383, respectively). In addition, thrombectomy was associated with a significantly lower risk of symptomatic ICH relative to tPA (European-Australasian Acute Stroke Study II criteria, 0 vs. 33.3%, p = 0.047; National Institute of Neurological Disorders and Stroke criteria, 7.1 vs. 66.7%, p = 0.005). There was no statistically significant difference in 90-day mortality. Authors concluded that thrombectomy may be superior to thrombolytic therapy alone for nonagenarians presenting with an anterior circulation LVO.

In a 2021 single-center retrospective cohort study by Gomes et al. [13], investigators compared the effect of reperfusion therapy versus no treatment among nonagenarians presenting with acute ischemic stroke. A total of 167 nonagenarians were included in the analysis, including a control group of 90 patients and a reperfusion group of 77 patients who underwent thrombolysis, thrombectomy, or both. Within the reperfusion group, 59 patients received intravenous thrombolytic therapy, 11 patients underwent thrombectomy, and 7 patients underwent both interventions. Authors reported that there was no significant difference in favorable outcomes or 90-day mortality between the control and reperfusion groups (26.1% vs. 17.1%, p = 0.164, and 25.3% vs. 39.3%, p = 0.053, respectively). In addition, the rate of symptomatic hemorrhagic transformation was significantly lower in the control group relative to the treatment group (3.3% vs. 14.3%, respectively). Notably, patients in the treatment group presented with higher median NIHSS scores than those in the control group (16 vs. 9.5, p < 0.001, respectively), yet experienced similar functional outcomes, suggesting that reperfusion therapy may be of value for select nonagenarians presenting with acute ischemic stroke.

The limited existing data suggest that thrombectomy is safe and feasible for nonagenarians presenting with acute ischemic stroke. Individuals with good functional status at baseline are most likely to benefit from endovascular intervention. In addition, some evidence indicates that a lower infarct volume is associated with an increased likelihood of achieving functional independence in the post-thrombectomy setting.

The technical success of thrombectomy is typically defined as achievement of a TICI score of 2b or greater. The preponderance of the evidence suggests that the technical success rate is similar when comparing nonagenarians with younger individuals. In the 2020 analysis by Sweid et al. [9], authors described similar success rates among nonagenarians and patients aged 60–89 years. Other studies have reported similar findings [6‒8]. Limited data from larger clinical trials, including MR CLEAN, EXTEND-IA, ESCAPE, SWIFT PRIME, and REVASCAT, also suggest that technical success rates are not affected by patient age [14]. However, in the 2019 analysis by Meyer et al. [6], authors did report a strikingly high number of unsuccessful recanalization attempts, which was attributed to increased vessel tortuosity that complicated arterial access and intracranial navigation. The findings described by the Meyer group suggest that thrombectomy may be unusually challenging among nonagenarians, underscoring the importance of operator experience.

Complications associated with thrombectomy include vessel perforation and ICH. The majority of studies included in this review reported relatively low complication rates; the highest complication rate across the literature was 13%. There was no evidence that nonagenarians are at increased risk of complications relative to their younger counterparts. Moreover, the risk of symptomatic ICH may be lower among patients undergoing thrombectomy relative to those receiving thrombolytic therapy, which is particularly important among nonagenarians with low physiological reserve [12].

The success rate and clinical utility of thrombectomy among the nonagenarian population may be related to individual patient factors, including pre-stroke morbidities and degree of functional independence. The Möhlenbruch group included patients with a pre-stroke mRS score ranging from 0 to 4; although nearly 20% of the patients included in the analysis had a favorable clinical outcome, all 3 patients with a pre-stroke mRS score of 4 experienced poor outcomes, including two who died shortly after the intervention and one who remained severely disabled [8]. The Drouard-de Rousiers group also reported that pre-stroke mRS score was a strong predictor of post-intervention outcomes [11]. Other investigators, including Meyer et al. and Tonetti et al. [6, 7], reported relatively high technical success rates with many patients returning to functional independence. However, patients with an mRS score greater than 2 were excluded from these analyses, and it is uncertain if similar results would be achieved in patients with higher degrees of pre-stroke disability. The limited evidence suggests that the decision to pursue thrombectomy should be individualized based on pre-stroke functional status and goals of care. Nonagenarians with a pre-stroke mRS score of 2 or lower tend to experience improved outcomes relative to their counterparts with higher mRS scores. However, the mRS does not delineate the underlying causes of disability, and it is conceivable that otherwise healthy patients with higher mRS scores related to orthopedic or non-cognitive disabilities may benefit from thrombectomy. In the absence of validated clinical practice guidelines, a holistic approach that considers multiple patient-related factors in the context of risks and benefits may be required to identify appropriate thrombectomy candidates.

Recent advances in medical technology and the potential for radical life extension have been accompanied by fierce debate related to healthcare spending. End-of-life care accounts for 8–12% of healthcare expenditures in the USA and European Union; nearly 25% of expenditures can be attributed to care delivered during the last 3 years of life [15]. A significant proportion of end-of-life spending is related to aggressive and often futile therapies for late-stage cancer and burdensome transitions to and from skilled nursing facilities [16, 17]. Mechanical thrombectomy, in contrast, has high upfront costs, but is widely recognized as a cost-effective intervention when accounting for quality-adjusted life-year gains [18]. However, the cost-effectiveness of thrombectomy has not been evaluated in the nonagenarian population. The 90-day post-thrombectomy mortality rate in the nonagenarian population ranges from 45 to 70%, which is an order of magnitude higher than the reported 21% mortality rate among the general population presenting with LVO [19]. Moreover, even in the setting of a favorable outcome, the life expectancy of a nonagenarian is relatively short. The life-year gains and cost-effectiveness would undoubtedly be significantly lower among nonagenarians undergoing thrombectomy as compared to any other population. Stringent selection criteria with careful consideration of pre-stroke morbidities and goals of care can help reduce healthcare costs by minimizing the risk of futile intervention. Consultation with the institutional bioethics committee may be of value in challenging cases.

It is challenging to accurately evaluate the mortality benefit of thrombectomy among nonagenarians given the presence of multiple comorbidities and relatively short life expectancy within the population. Moreover, it has been established that older patients presenting with acute ischemic stroke have worse outcomes than their younger counterparts, even when thrombolytic therapy is administered within the 4.5-h window [20]. Mortality was assessed in two of the eight trials included in this review. In the 2019 retrospective study by Drouard-de Rousiers et al. [11], authors reported significantly decreased 90-day mortality among patients who underwent successful first-pass reperfusion as compared to those in whom first-pass reperfusion was unsuccessful (OR, 0.15; 95% CI, 0.05–0.45). However, in a subsequent single-center retrospective cohort study by Gomes et al. [13], investigators reported no significant difference in 90-day mortality between the control and reperfusion groups (25.3% vs. 39.3%, p = 0.053, respectively). The effect of thrombectomy on mortality among nonagenarians with acute ischemic stroke therefore remains controversial. Nevertheless, there is convincing evidence that thrombectomy improves functional outcomes in the elderly, and a mortality benefit may be inferred. Indeed, in the MR CLEAN trial, authors concluded that the relative benefit of successful reperfusion may be higher among patients over the age of 80 years [21]. Further studies will be required to understand the role of thrombectomy in reducing mortality within the nonagenarian population.

The limited existing data suggest that thrombectomy may improve functional outcomes and reduce mortality among select nonagenarians presenting with acute ischemic stroke in the setting of anterior or posterior circulation LVO. Individuals with good functional status at baseline are most likely to experience favorable outcomes, irrespective of age. Future research should evaluate the utility of MRI in patient selection and the impact of first-pass reperfusion. The number of nonagenarians is steadily growing across the globe, and thus, clinical practice guidelines should continue to evolve in order to optimize quality and quantity of life for this expanding patient demographic.

The authors have no conflicts of interest to declare.

This study was not supported by any sponsor or funder.

B.P.S. and N.E.D.: conceptualization and writing – original draft. J.L.: data curation. B.D.B.: writing – review and editing. A.E.M.: data curation and writing – review and editing. J.J.P.C. and L.L.: data curation and formal analysis. B.J.T.: supervision.

All data that support the findings of this review are available within the manuscript and its cited articles. Further inquiries can be directed to the corresponding author.

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