Impact of ultra-early coiling on clinical outcome after aneurysmal subarachnoid hemorrhage in elderly patients

Association between geriatric nutritional risk index and clinical outcome of elderly aneurysmal subarachnoid hemorrhage patients: insights from a large cohort study

Geriatric nutritional risk index (GNRI), a simple, objective index for evaluating nutritional status of elderly patients, is demonstrated to be associated with the prognosis of several diseases. This study aims to explore the association between GNRI and prognosis of elderly aneurysmal subarachnoid hemorrhage (aSAH) patients. A total of 168 patients older than 65 years old were included in this research. The modified Rankin Scale (mRS) was applied to assess the prognosis of patients. Favorable outcome was defined as mRS <3 and unfavorable outcome was defined as mRS ≥ 3. The GNRI, calculated by albumin, height, and weight, was used to evaluate the nutritional status of elderly patients. Multivariate logistic regression was performed to identify the association between GNRI and prognosis of elderly aSAH patients. Compared with unfavorable outcome groups, favorable outcome group had higher GNRI level. After adjusting for several important factors, multivariate logistics regression analysis showed that low GNRI was associated with higher risk of unfavorable outcome. The receiver operating curve (ROC) analysis demonstrated that the area under the curve (AUC) was 0.720, which meant GNRI might be a reliable prognostic predictor. A low GNRI was independently associated with unfavorable outcome of elderly aSAH patients. The registration number is NCT04785976 and the registration data is February 2021.

Long-Term Outcomes of Elderly Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

Long-term outcomes after surgical treatment and intensive care have not been investigated in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to analyze 12-month outcomes and prognostic factors of patients with poor-grade aSAH who were at least age 70 years.

METHODS

We performed a single-center, retrospective study including poor-grade (World Federation of Neurological Societies [WFNS] grades IV and V) aSAH patients who were at least age 70 years, were admitted to our stroke center, and received aneurysmal treatment between April 2012 and September 2018. The clinical outcomes were evaluated at months 3 and 12. Univariate/multivariate analyses were performed to identify the independent prognostic factors of good neurologic outcomes (modified Rankin Scale score 0-3). These factors included sex, age, WFNS grade, Fisher group, delayed cerebral ischemia, aneurysm treatment, aneurysm size, aneurysm location, and blood examination data in the 14 days post subarachnoid hemorrhage.

RESULTS

The proportion of patients with good outcomes (modified Rankin Scale score 0-3) was increased at 12 months compared with that at 3 months. No intracerebral hemorrhage was a significant predictor of good neurologic outcomes at 3 months (P = 0.03). The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from normal sodium levels were significant predictors of good neurologic outcomes at months 3 and 12 (P = 0.04 and P = 0.03, respectively).

CONCLUSIONS

The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from the normal sodium levels were independently associated with good neurologic outcomes at 12 months in elderly patients. Intracerebral hemorrhage did not appear to affect long-term outcomes. These findings suggest that elderly patients with severe subarachnoid hemorrhage should not be excluded from receiving surgical treatment on the basis of their age alone.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients

BACKGROUND

Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment.

METHODS

This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge.

RESULTS

The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi² test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment.

CONCLUSION

Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Expanding Indications for Flow Diverters: Ruptured Aneurysms, Blister Aneurysms, and Dissecting Aneurysms

BACKGROUND

The safety and efficacy of flow diversion (FD) in the treatment of cerebral aneurysms have been reported by many studies. FD has enabled the treatment of complex aneurysms and aneurysms that were previously untreatable by conventional means. It has achieved high rates of obliteration with essentially no recanalization, and its indications have continued to expand, now including ruptured aneurysms, blister aneurysms, and dissecting aneurysms.

OBJECTIVE

To provide a review on the outcomes of studies covering the use of FD in the settings of ruptured, blister, and dissecting aneurysms. In addition, to discuss dual antiplatelet therapy (DAPT) used in preparation for FD deployment in these scenarios, including associated complications with DAPT use in the acute rupture setting.

METHODS

References for this topical review were identified by PubMed searches between January 2000 and January 2019. The search terms “aneurysm”, “flow diverter”, “stent”, “pipeline”, “ruptured”, “blister”, and “dissecting aneurysms” were used.

RESULTS

FD carries a higher complication rate in the acute rupture setting than for unruptured aneurysms. Patient selection is of paramount importance for achieving good functional and angiographic outcomes. DAPT still remains challenging, especially in ruptured aneurysms. Advancements in surface modification of flow diverters can reduce the risk of thromboembolism and perhaps lead to a safer antiplatelet regimen.

CONCLUSION

In summary, FD shows promise to be an effective treatment for ruptured, blister, and dissecting aneurysms.

Better Outcomes and Reduced Hospitalization Cost are Associated with Ultra-Early Treatment of Ruptured Intracranial Aneurysms: A US Nationwide Data Sample Study

BACKGROUND

The benefit of surgical treatment of ruptured aneurysms is well established.

OBJECTIVE

To determine whether ultra-early ruptured aneurysm treatment leads to not only improved outcomes but also reduced hospitalization cost.

METHODS

Using 2008-2011 Nationwide Inpatient Sample data, we analyzed demographic, clinical, and hospital factors for nontraumatic subarachnoid hemorrhage (SAH) patients who were "directly" admitted to the treating hospital where they underwent intervention (clipping/coiling). Patients treated on the day of admission (day 0) formed the ultra-early cohort; others formed the deferred treatment cohort. All Patient Refined Diagnosis-Related Groups were also included in regression analyses.

RESULTS

A total of 17 412 patients were directly admitted to a hospital following nontraumatic SAH where they underwent intervention (clipping/coiling). Mean patient age was 53.87 yr (median 53.00, standard deviation 14.247); 68.3% were women (n = 11 893). A total of 6338 (36.4%) patients underwent treatment on the day of admission (ultra-early). Patients who underwent treatment on day 0 had significantly more routine discharge dispositions than those treated >admission day 0 (P < .0001). In regression analysis, treatment on day 0 was protective against other than routine discharge disposition outcome (P < .0001; odds ratio 0.657; 95% confidence interval 0.614-0.838). Total cost incurred by hospitals was $4.36 billion. Mean cost of hospital charges in the ultra-early cohort was $239 126.05, which was significantly lower than that for the cohort treated >day 0 ($272 989.56, P < .001), Mann-Whitney U-test). Performance of an intervention on admission day 0 was protective against higher hospitalization cost (P < .0001; odds ratio 0.811; 95% confidence interval 0.732-0.899).

CONCLUSION

Ultra-early treatment of ruptured aneurysms is significantly associated with better discharge disposition and decreased hospitalization cost.

Meta-analysis of timing of endovascular aneurysm treatment in subarachnoid haemorrhage: inconsistent results of early treatment within 1 day

BACKGROUND AND PURPOSE

To systematically review and meta-analyse the data on impact of timing of endovascular treatment in aneurysmal subarachnoid haemorrhage (SAH) to determine if earlier treatment is associated with improved clinical outcomes and reduced case fatality.

METHODS

We searched MEDLINE, Cochrane database, EMBASE and Web of Science to identify studies for inclusion. The measures of effect utilised were unadjusted/adjusted ORs. Effect estimates were combined using random effects models for each outcome (poor outcome, case fatality); heterogeneity was assessed using the I² index. Subgroup and sensitivity analyses were performed to account for heterogeneity and risk of bias.

RESULTS

16 studies met the inclusion criteria. Treatment <1 day was associated with a reduced odds of poor outcome compared with treatment >1 day (OR=0.40 (95% CI 0.28 to 0.56; I²=0%)) but not when compared with treatment at 1-3 days (OR=1.16 (95% CI 0.47 to 2.90; I²=81%)). Treatment at <2 days and at <3 days were associated with similar odds of poor outcome compared with later treatment (OR=1.20 (95% CI 0.70 to 2.05; I²=73%; OR=0.71 (95% CI 0.36 to 1.37; I²=71%)). Early treatment was associated with similar odds of case fatality compared with later treatment, regardless of how early/late treatment were defined (OR=1.80 (95% CI 0.88 to 3.67; I²=34%) for treatment <1 day vs days 1-3; OR=1.71 (95% CI 0.72 to 4.03; I²=54%) for treatment <2 days vs later; OR=0.90 (95% CI 0.31 to 2.68; I²=48%) for treatment <3 days vs later).

CONCLUSIONS

In only 1 of the analyses was there a statistically significant result, which favoured treatment <1 day. The inconsistent results and heterogeneity within most analyses highlight the lack of evidence for best timing of endovascular treatment in SAH patients.

Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion

OBJECT

Flow-diversion treatment has been shown to be associated with high rates of angiographic obliteration; however, the treatment is relatively contraindicated in the acute phase following subarachnoid hemorrhage (SAH) as these patients require periprocedural dual antiplatelet therapy. Acute coiling followed by flow diversion has emerged as an intriguing and feasible treatment option for ruptured complex and giant aneurysms. In this study the authors report outcomes and complications of patients with ruptured aneurysms undergoing coiling in the acute phase followed by planned delayed flow diversion.

METHODS

This case series includes patients from 2 institutions. All patients underwent standard endovascular coiling in the acute phase after SAH with the intention and plan to proceed with flow diversion at a later date. Outcomes studied included angiographic occlusion, procedure-related complications, and long-term clinical outcome as measured using the modified Rankin Scale.

RESULTS

A total of 31 patients underwent coiling in the acute phase with the intention to undergo flow diversion at a later date. The mean aneurysm size was 15.8 ± 7.9 mm. Of the 31 patients undergoing coiling, 4 patients could not undergo further flow-diverter therapy: 3 patients (9.7%) died of complications of subarachnoid hemorrhage and 1 patient had permanent morbidity as a result of perioperative ischemic stroke (3.1%). Twenty-seven patients underwent staged placement of flow diverters after adequate recovery. The median time to treatment was 16 weeks. There was one case of aneurysm rebleeding following coil treatment. There were no cases of permanent morbidity or mortality resulting from flow-diverter treatment. Twenty-four patients underwent imaging follow-up; 18 of these patients had aneurysms that were completely or nearly completely occluded (58.1% on an intent-to-treat basis). At last follow-up (mean 18.3 months), 25 patients had mRS scores ≤ 2 (80.6% on an intent-to-treat basis).

CONCLUSIONS

Staged treatment of ruptured complex and giant intracranial aneurysms with coiling in the acute phase and flow-diverter treatment following recovery from SAH is both safe and effective. In this series, no cases of rebleeding occurred during the interval between coiling and flow diversion. This strategy should be considered as a valid option in patients presenting with these challenging ruptured aneurysms.

Transfer time to a high-volume center for patients with subarachnoid hemorrhage does not affect outcomes

OBJECTIVES

The objective of our study was to examine patients with aneurysmal subarachnoid hemorrhage transferred and directly admitted to our institution in order to determine how transfer time affects outcomes.

METHODS

A retrospective cohort study was performed of all patients undergoing treatment for aneurysmal subarachnoid hemorrhage between 2005 and 2012 at the University of Michigan. Variables, including transfer time, were tested for their independent association with the primary outcomes of symptomatic vasospasm and 12-month outcome as well as secondary outcomes of aneurysm rebleeding and 12-month mortality.

RESULTS

During the study period, 263 (87.4%) patients were transferred to our institution and 38 (12.6%) were directly admitted for treatment of aneurysmal subarachnoid hemorrhage. Transfer time was not associated with the occurrence of symptomatic vasospasm, 12-month outcome, rebleeding, or 12-month mortality. Higher Hunt-Hess grade was associated with the occurrence of symptomatic vasospasm as well as with poorer 12-month outcome.

CONCLUSIONS

Transfer time was not associated with the occurrence of symptomatic vasospasm, 12-month outcome, rebleeding, or 12-month mortality. We believe our data argue that protocols should emphasize early resuscitation and stabilization followed by safe transfer rather than a hyperacute transfer paradigm. However, transfer time should be minimized as much as possible so as not to delay time to definitive treatment.

Aneurysm treatment <24 versus 24-72 h after subarachnoid hemorrhage

INTRODUCTION

In patients with aneurysmal subarachnoid hemorrhage (aSAH), it is unclear whether aneurysm treatment <24 h after ictus results in better outcomes than treatment 24-72 h after aSAH. We studied whether aneurysm occlusion <24 h is associated with better outcomes than occlusion 24-72 h after aSAH.

METHODS

We used two cohorts of patients with aSAH: (1) the UMC Utrecht cohort with patients admitted between 2008 and 2012 and (2) the International Subarachnoid Aneurysm Trial cohort. Aneurysm treatment was categorized into <24 h and 24-72 h after ictus. We calculated adjusted risk ratios (aRRs) with 95% confidence intervals (CIs) using Poisson regression analyses for poor functional outcome (death or dependency) for both cohorts separately, and performed a pooled analysis based on individual patient data. We also performed a worst-case scenario analysis wherein all patients with rebleeding >3 h after admission were re-categorized into the group with aneurysm treatment 24-72 h after aSAH.

RESULTS

We included 1,238 patients (UMC Utrecht cohort: n = 330; ISAT: n = 908). The aRR for poor outcome after treatment <24 h was in the UMC Utrecht cohort 1.84 (95% CI: 1.25-2.70), in ISAT 1.14 (95% CI 0.84-1.55), in the pooled analysis 1.37 (95% CI 1.11-1.68), and in the worst-case scenario pooled analysis 1.24 (95% CI 1.01-1.52).

CONCLUSION

Our results suggest that aneurysm occlusion can be performed in day time within 72 h after ictus, instead of on an emergency basis. However, due to the retrospective, non-randomized design of our study, our results cannot be considered as definitive evidence.

Endovascular treatment of intracranial aneurysms in elderly patients: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Use of endovascular coiling for treatment of ruptured and unruptured intracranial aneurysms (IAs) in the elderly is increasing. We performed a meta-analysis of the literature examining clinical and angiographic outcomes for treatment of IAs in the elderly.

METHODS

We performed a comprehensive review of the literature from 1995 to 2012, reporting series of patients ≥65 years of age with ruptured or unruptured IAs treated with endovascular approach. Event rates were pooled across studies using random effects meta-analysis.

RESULTS

A total of 21 studies reporting on 1511 patients were included. Long-term aneurysm occlusion rates were 79% (95% confidence interval [CI], 70%-85%). Perioperative stroke occurred in 4% (95% CI, 3%-6%), with similar rates between patients with ruptured (5%; 95% CI, 3%-7%) and unruptured aneurysms (4%; 95% CI, 1%-14%; P=0.68). Intraprocedural rupture occurred in 1% (95% CI, 0%-3%) and 4% (95% CI, 2-6%; P=0.04) of patients with unruptured and ruptured aneurysms, respectively. Perioperative mortality rate for patients with ruptured aneurysms was 23% (95% CI, 17%-30%) and 1% (95% CI, 0%-6%) for patients with unruptured aneurysms (P<0.01). Rates of good clinical outcome at 1 year were 93% (95% CI, 88%-96%) and 66% (95% CI, 59%-72%) in patients with unruptured and ruptured aneurysms, respectively.

CONCLUSIONS

This study suggests that endovascular treatment of IAs in the elderly is associated with high long-term occlusion rates. Given the morbidity and mortality associated with endovascular treatment of IAs in the elderly, careful patient selection, especially in the case of patients with unruptured aneurysm, is recommended.

Early endovascular treatment of subarachnoid hemorrhage

Subarachnoid hemorrhage is an important cause of morbidity and mortality. Rebleeding is one of its major complications, which occurs mainly within the first 24 h and worsens the clinical outcome in a very dramatic way. It may be prevented by aneurysm treatment: surgical clipping or endovascular coiling. We review the evidence of and recent advances in endovascular treatment and timing of the intervention. Data supporting the benefit of early (<72 h) and ultra-early (<24 h) treatment is based on observational studies. An earlier approach may be relevant for the prevention of rebleeding and improvement of clinical outcome, but several disadvantages should be considered, such as an increased rate of periprocedural complications. Hence, a well-designed randomized controlled trial deems necessary to be able to define the optimal time of treatment. The possibility of treatment concomitant with the initial angiography should also be taken into account in this trial. This fact might represent a benefit favoring coiling over clipping in the prevention of rebleeding, and thus avoiding the inevitable delay necessary for the preparation for surgery.