Management outcome for ruptured anterior circulation aneurysms with a Hunt and Hess clinical grade of III in patients in the 9th decade of life

Long-term outcomes, including the survival rate and period to death, in patients over 80 years old after ruptured cerebral aneurysm clipping

OBJECTIVE

This study aimed to identify the long-term outcomes, including the survival rate, period to death, causes of death, and predictors of poor outcomes, in patients aged over 80 years who underwent surgical clipping for a ruptured anterior circulation aneurysm.

MATERIALS AND METHODS

In this retrospective observational study, the medical records of patients from April 1, 1994, to June 30, 2019, were evaluated. All patients underwent surgical clipping within 72 h of subarachnoid hemorrhage (SAH) onset. Information on the patient, SAH, and outcomes were collected.

RESULTS

The mean hospitalization and long-term follow-up periods for all patients were 54.5 days and 53.3 months, respectively. The period to death was significantly shorter in patients with modified Rankin scale (mRS) of 4-5 than for those with an mRS of 0-3 at discharge (p=0.001). The Kaplan-Meier method using the log-rank test demonstrated that patients with an mRS of 4-5 at discharge had a significantly lower survival rate compared to those with an mRS of 0-3 at discharge (p<0.05). Univariate analysis revealed that the proportion of patients with Hunt and Hess grade and presence of surgical complications were significantly larger in the group with an mRS of 4-5 than in that with an mRS of 0-3 at discharge (p=0.0013 and 0.011, respectively). Multivariate analysis demonstrated that presence of surgical complications was the only independent predictor of poor outcomes (p=0.043, odds ratio [OR] 7.937, 95% confidence interval [CI] 1.061-59.38). The Kaplan-Meier method using the log-rank test demonstrated that patients with surgical complications had a significantly lower survival rate compared to those with no surgical complications (p<0.05).

CONCLUSIONS

Especially in patients aged over 80 years, those with H-H grade 2 and a good clinical condition can be candidates for surgical clipping, whereas avoiding surgical complications is essential for achieving good outcomes.

Aneurysmal Subarachnoid Hemorrhage in the Elderly over Age 75: A Systematic Review

The number of elderly patients with an aneurysmal subarachnoid hemorrhage (aSAH) has been increasing in aging- or aged societies in many countries. A treatment strategy for the elderly with aSAH has not been established, although many studies have been published emphasizing poor outcome for aSAH. The aim of this study was to analyze the factors and treatments affecting outcome in aSAH in the elderly in a systematic review of the literature by investigating patients over age 75. A literature search was done for “elderly aSAH” in PubMed and Embase. Literature with a clear description of treatment measures for aneurysmal occlusion and outcome was selected. Twelve studies, consisted of 816 cases, met the eligibility criteria. Patient characteristics included 83.2% female, 33.8% poor clinical grade on admission, 57.1% Fischer group 3, and 41% internal carotid artery aneurysm. As complications, symptomatic vasospasm was seen in 25.5% of patients, hydrocephalus in 31.1%, and medical complication in 38.4%. Favorable outcome was 35.0% in total, 45.3% for clipping, 36.3% for coiling, and 9.0% for conservative treatment. Several studies by multivariate analysis indicated that poor clinical grade on admission could be a risk factor for neurological outcome and mortality. Advanced age and selection of conservative treatment without aneurysmal occlusion could be a risk factor for mortality. Patients under age 85 with good clinical grade on admission can be candidates for treatment of aneurysm repair. However, treatment for patients over age 85 or with poor clinical grade should be carefully determined.

Analysis of Factors That Influence Long-Term Independent Living for Elderly Subarachnoid Hemorrhage Patients

BACKGROUND

The number of elderly subarachnoid hemorrhage (SAH) patients has been increasing. The aim of this study was to analyze long-term outcome for elderly (≥75 years) SAH patients and to establish a treatment strategy.

METHODS

From January 2005 to December 2013, 86 consecutive cases were treated. We used a modified Rankin Scale (mRS) at the outpatient clinic or a telephone interview of patients and/or families. Kaplan-Meier plots were done for mortality and independent (mRS 0 ∼ 2) state. Multivariate analysis was done to distinguish factors that influence on outcome.

RESULTS

Median age was 79, Hunt-Kosnik grade 1 ∼ 3 was 79%, and the radical intervention (clipping or coiling) rate was 78%. Mean follow-up period was 28.7 ± 3.4 standard error months. Half of deaths occurred during the first two months. The number of cases of independent living gradually decreased to 50% at 28 months after SAH. Half of patients lived independently for 36 months at HK grades 1 to 3, and 3 months at HK grades 4 to 5 (p < 0.05). Half of patients lived independently for 40 months in the radical intervention group, and 14 months in the conservative treatment group (p < 0.05). Multivariate analysis for independent living revealed that gender, pre-morbid condition, HK grade, and postoperative complication were significant (p < 0.05).

CONCLUSIONS

Good-grade elderly SAH cases that were independent pre-stroke should have radical intervention performed for aneurysm. Avoiding perioperative complications have a positive influence on long-term independent living.

Results of Clipping Surgery for Aneurysmal Subarachnoid Hemorrhage in Elderly Patients Aged 90 or Older

BACKGROUND

The number of elderly patients with aneurysmal subarachnoid hemorrhage (SAH) is increasing. Although advanced age is one of the recognized risk factors for poor outcome, conservative treatment for aneurysmal subarachnoid hemorrhage cannot provide satisfactory outcome in elderly patients. The aim of this study is to assess the outcome in patients aged 90 or older, for whom ruptured aneurysms were treated by clipping.

METHODS

We retrospectively reviewed the medical records of non-traumatic SAH patients who were hospitalized at the Chiba Neurosurgical Clinic between 2004 and 2013. Of the 702 patients, 8 patients (1.1 %) were aged 90 or older. Of them, four underwent clipping surgery and the other four died or were managed conservatively. Their preoperative conditions were evaluated with the World Federation of Neurosurgical Societies Grading Scale of SAH, and the Fisher classification was used to assess the bleeding severity. The location of the ruptured aneurysm was determined by three-dimensional computed tomographic angiography or cerebral angiography. The Glasgow Outcome Scale evaluation was assigned at discharge.

RESULTS

Four patients (four female, all WFNS grade 1), aged 90 or older, underwent clipping surgery. Fisher classification was three in two patients and four in the other two. Location of the ruptured aneurysm was internal carotid artery in two, anterior communicating artery in one, and posterior inferior cerebellar artery in one patient. Two of these four patients had a favorable outcome.

CONCLUSIONS

We propose that advanced age alone does not exclude suitable surgical clipping in patients with aneurysmal rupture in the tenth decade of life.

Elderly patients with aneurysmal subarachnoid hemorrhage: Coils but also clips

The ageing of the population in good health or without severe morbidity expose them to the occurrence of a subarachnoid hemorrhage (SAH) and requires effective management. Currently, the pertinence of cerebral aneurysm treatment by clipping or coiling is accepted for patients in the 8th or 9th decade of life, and the risk of postoperative morbidity induced by our therapeutic alternative must be carefully assessed. In these decades, the female/male sex ratio for aneurysmal SAH was greater in female who had a 1.6 times higher ratio than in male. The initial clinical status did not appear worse with age despite the frequent severity of bleeding observed on CT scan probably due to the large subarachnoid space. The aneurysm distribution and size were similar to those classically reported in the global population. The endovascular (EV) coiling appears as the first option with a favorable outcome rate estimated at 48% to 63%. Nevertheless, the benefit of EV coiling compared to microsurgical clipping for treatment of ruptured aneurysm in the elderly has not been demonstrated in a large randomized study. This is the reason why the vascular section of the French Society of Neurosurgery developed a prospective and randomized study of the aneurysmal SAH (PHRC 2007-042/HP) on the elderly patients.

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

RATIONALE AND OBJECTIVES

The incidence of aneurysmal subarachnoid hemorrhage is increasing in the elderly as life expectancy increases. The purpose of this study was to analyze whether ultra-early coiling of ruptured intracranial aneurysms improves clinical outcomes in elderly patients.

MATERIALS AND METHODS

Records of patients (aged ≥ 70 years) with aneurysmal subarachnoid hemorrhage treated with endovascular coiling were retrieved. Patients were classified into two groups: group A (patients coiled within 24 hours of subarachnoid hemorrhage) and group B (patients coiled ≥24 hours after subarachnoid hemorrhage). For each group, patient demographics, World Federation of Neurological Surgeons clinical grade, Fisher computed tomographic grade, aneurysm characteristics, and clinical outcomes were recorded. Outcomes were measured using the Modified Rankin Scale at 6 months.

RESULTS

Fifty-six patients were coiled within 24 hours of subarachnoid hemorrhage (group A) and 40 patients at ≥24 hours after subarachnoid hemorrhage (group B). Groups A and B had similar clinical and angiographic characteristics. Clinical outcomes showed that a total of 87.5% of patient (49 of 56) in group A were independent (Modified Rankin Scale score 0-2) compared with 70.0% of patients (28 of 40) in group B (P = .034). In multivariate logistic regression analysis, ultra-early coiling (odds ratio, 3.860; 95% confidence interval, 1.125-13.249; P = .032) proved to be an independent predictor of better clinical outcome (Modified Rankin Scale score 0-2).

CONCLUSIONS

Ultra-early (<24 hours after subarachnoid hemorrhage) coiling of ruptured aneurysms was marginally associated with improved clinical outcomes compared to coiling at ≥24 hours in elderly patients. Larger, prospective studies are required to adequately assess outcome differences between these two groups.

Endovascular treatment of intracranial aneurysms in patients 65 years or older: clinical outcomes

BACKGROUND AND PURPOSE

A controversial discussion concerning treatment of aneurysms in elderly patients exists. The aim of this study was to analyze clinical outcome in patients older than 65 years harboring intracranial aneurysms after endovascular treatment.

MATERIALS AND METHODS

A total of 108 patients aged 65 years or older (mean age, 72 years, range, 65-87 years) were selected for endovascular treatment between 1997 and 2005. A total of 85 (78.7%) patients had an acute subarachnoid hemorrhage (SAH). SAH was classified according to Hunt and Hess (HH) grade: I (n = 16), II (n = 11), III (n = 33), IV (n = 19), and V (n = 6). There were 69 aneurysms that were small; 46, medium; 8, large; and 5, giant. Occlusion rate was categorized as complete (100%), subtotal (95% to 99%), and incomplete (<95%) obliteration according to the Raymond scale.

RESULTS

Endovascular treatment was technically feasible in 108 of 113 aneurysms. Complete occlusion could be achieved in 80 patients; basal remnant was seen in 26 patients and a dog ear in 2 patients. Procedural complications included thrombotic vessel occlusion (n = 9), aneurysmal rupture (n = 4), and stenosis of the parent vessel (n = 2). The Glasgow Outcome Scale (GOS) for the patients with SAH after 6 months was good recovery (n = 43), moderate disability (n = 12), severe disability (n = 28), persistent vegetative state (n = 5), and death (n = 18). Outcome for the patients with unruptured aneurysms was good recovery in all 23 patients. On follow-up digital subtraction angiography (DSA) in 69 patients, complete aneurysmal occlusion was confirmed in 81% after 6 months. Five patients with recanalization were re-treated with coiling.

CONCLUSION

Endovascular treatment of ruptured and unruptured intracranial aneurysms in this subgroup was safe and effective.

Treatment of ruptured intracranial aneurysms: Report from a low-volume center

BACKGROUND

The aim of this retrospective analysis was to present our experience and results in treating subarachnoid hemorrhage due to ruptured intracranial aneurysms at a neurosurgical department with a small annual number of cases (i.e. a low-volume center) and to discover which factors could influence treatment and reliably predict the outcome of hemorrhage.

METHODS

All patients with aneurysmal subarachnoid hemorrhage treated at our department between 1973 and 2003 were retrospectively analyzed. We performed 293 operations and 21 endovascular procedures. In the majority of patients we excluded the aneurysm from circulation by placing a clip on the aneurysmal neck. Relevant data were obtained on patients' performance, imaging studies, treatment and outcome.

RESULTS

According to the Hunt & Hess grade, the majority of patients were in groups 1 or 2. Perioperative mortality was 3%. Postoperative mortality due to complications related to subarachnoid hemorrhage was 10%. Vasospasm was detected in 18% of patients and was a direct cause of death in 5%. The outcome was good in 68% (grades 4 or 5 on the Glasgow outcome scale). In multivariate analysis, the Hunt & Hess grade, age and clinical vasospasm all had important predictive value for the outcome.

CONCLUSIONS

The results of treatment in our series of patients fall within reported norms and are comparable to results from other low-volume centers. For successful treatment of aneurysmal subarachnoid hemorrhage, fast diagnosis, correct surgical or endovascular treatment and proper intensive pre- and postoperative care are of utmost importance.

Endovascular management for intracranial ruptured aneurysms in elderly patients: outcome and technical aspects

The definition of an elderly person is debateable; however, age is a recognised negative prognostic factor for outcome after subarachnoid haemmorrhage, and the age cut-off of 60 years is accepted to define a high risk population. The goal of this article is to access the outcome in this precise population of patients that underwent endovascular treatment (EVT) after aneurysm rupture. Forty-two patients (mean age = 70.24) had 40 aneurysms located at the anterior circulation and nine at the posterior circulation. Thirty-seven (87.9%) patients had Fisher III or IV. Forty-six (93.8%) aneurysms were smaller than 15 mm. Twenty-eight (66.7%) patients were in good neurological state on admission (Hunt and Hess I-III) and 14 (33.3%) in poor state. Satisfactory occlusion rate (total occlusion or neck flow) was achieved in 75% of patients. Follow-up was available in 19 (43.18%) out of the 44 aneurysms treated. Aneurysm recanalization was disclosed in three cases. Satisfactory outcome was achieved on: 60.7% of good grades, 21.4% of poor grades, 43.7% of patients with and 57.6% of patents without comorbidites. Fisher grade (P = 0.0346), comorbidities (P = 0.525) and risk factors (P = 0.515) were not associated with clinical outcome. No age cut-off (65,70 and 75) for favourable outcome could be established, P-values were 0.723, 0.741 and 0.738, respectively. Advancing of age was not associated with an increase number of unfavourable outcome (P = 0.125). Poor neurological status on admission was the only variable associated with unfavourable outcome (P = 0.02). Mortality and morbidity rate related to the procedure were 4.8% and 9.5% respectively. Age should not be taken alone for precluding treatment in ruptured aneurysms, EVT can be considered as a first therapeutic option for elderly persons, since an overall favourable outcome could be achieved in most cases, mainly in non-comatose patients.

Treatment and outcome of aneurysmal subarachnoid haemorrhage in the elderly patient

From January 1999 to May 2003, 316 aneurysms were treated, among them 40 patients (12.7%) over 65 years with subarachnoid haemorrhage (SAH). The results of this sub-group are presented. Mean age was 71 years (range 65-83 years), 40% of the patients were in (Hunt & Hess) grade I-III and 60% grade IV-V. Eighty-five percent of the aneurysms were located in the anterior circulation (35% ACom aneurysms). Nineteen aneurysms were coiled (all basilar tip and small-based ACom aneurysms), two among them subsequently clipped after coil compaction, 18 were initially clipped (most of MCA and all broad-based ACom aneurysms), two wrapped and one trapped. A total of 66.7% of the patients with coiled and 60.0% with clipped aneurysms had been hospitalized in poor condition (Hunt & Hess IV-V). The average follow-up period was 16 months. Overall, 35% of patients fully recovered, 5% returned to normal activity with some deficit, 33% remained dependent and 27% died. All seven patients with MCA aneurysms and intracerebral haematoma were clipped, but died or remained vegetative. Ten of 17 coiled patients (58.8%) had a favourable outcome, compared to 4/11 (36.4%) in the clip group, but two primarily coiled aneurysms rebled due to coil compaction. The outcome is dependent on the primary Hunt & Hess grade. A total of 48.5% of SAH patients without intracerebral bleeding fully recovered, even patients in poor primary grade. Additional intracerebral haemorrhage is linked to a bad outcome. As primary procedure, the less traumatic coiling seems to be superior to clipping primarily. Better Hunt & Hess grades have a statistically significant chance for a promising outcome.

Surgical Treatment for Aneurysmal Subarachnoid Hemorrhage in the 8th and 9th Decades of Life

OBJECTIVE:

Industrialized countries are facing a rapid increase of their senior populations. Consequently, the number of elderly patients with aneurysmal subarachnoid hemorrhage is increasing. The purpose of this study was to assess the results of surgical repair for ruptured aneurysm in elderly patients.

METHODS:

We retrospectively investigated elderly patients (ages 70–89 yr) who were undergoing surgical treatment for ruptured aneurysm during the 15-year period 1988 to 2002 and compared patients in the 8th and 9th decades of life. Generally, patients were treated surgically within 72 hours after ictus.

RESULTS:

Of the total of 2835 patients, there were 509 patients (18.0% of total patients) in the 8th decade and 99 patients (3.5%) in the 9th decade of life. Because data were incomplete and patients who received ventricular drainage or ventriculoperitoneal shunt without aneurysmal repair were excluded, 449 and 89 patients in the 8th and 9th decades of life, respectively, were analyzed. No differences in sex, preoperative grade, preoperative computed tomographic findings, location of aneurysm, and aneurysm size were observed between the two decades. Preoperative grade and computed tomographic findings were predictors of favorable outcomes in the 8th and 9th decades. Patient age was a significant predictor of outcome in the 8th but not in the 9th decade.

CONCLUSION:

To the best of our knowledge, this study is the largest series of its kind to date. Advanced age alone does not exclude adequate surgical repair in patients with aneurysmal rupture in the 9th decade of life.

Incidence and early prognosis of aneurysmal subarachnoid hemorrhage in Kumamoto Prefecture, Japan

OBJECTIVE

We analyzed the community incidence and early prognosis of first-ever aneurysmal subarachnoid hemorrhages (SAHs) to obtain the same prognostic information used by physicians and families in a defined geographic area in Japan.

METHODS

During the 5-year period from January 1, 1996, to December 31, 2000, 2115 patients were registered in the Data Bank for Cerebral Aneurysms of Kumamoto Prefecture, a defined area in Japan with a population of 1.86 million. Registration was based on a comprehensive referral system for SAH patients; computed tomographic scans were available for all patients, including those who were moribund or dead on arrival. We compared the treatment outcomes at 3 months after the first-ever SAH in surgically and conservatively treated patients.

RESULTS

The age-adjusted annual incidence of SAH for men, women, and both sexes was 15.9, 26.6, and 21.6 per 100,000 person-years, respectively. In men, the incidence reached a plateau after age 40 years. In women, conversely, it rose after age 40 and peaked in the 9th decade of life. Of the 1634 surgically treated patients, 1153 (70.6%) had a favorable outcome; this was true for only 27 of 477 (5.7%) conservatively treated patients. Four patients were lost to follow-up. The clinical outcome did not differ between patients treated by open surgery and those treated endovascularly. Approximately 30% of our patients were older than 70 years at the time they experienced their first SAH.

CONCLUSION

The incidence of SAH obtained in this study was similar to earlier Japanese reports and Finnish studies. The importance of managing elderly patients with cerebral aneurysms will continue to increase.

Untreated subarachnoid hemorrhage: who, why, and when?

OBJECT

When subarachnoid hemorrhage (SAH) is caused by an aneurysm or other vascular anomaly, surgery or endovascular treatment is generally indicated. Nevertheless, some patients with SAH do not receive such therapy. The objective of this study was to characterize the patients who do not receive treatment.

METHODS

The records of all patients with SAH who were admitted to a tertiary care center during a 9-year period were retrospectively reviewed. Untreated patients were classified into one of three groups based on angiographic results. Demographic, clinical, and neuroimaging findings and outcomes were compared between these three groups and between treated and untreated patients. Definitive treatment of SAH was provided in 477 patients and 166 were untreated. Untreated patients were older, had a worse neurological status on presentation, and a higher mortality rate (43.4% compared with 11.7%). Among these, 76 had normal angiographic results and a low mortality rate (6.6%). Fifty-two patients in whom no cerebral angiogram was obtained (mostly because of their neurological condition) had the highest mortality rate (92.3%). Of 38 patients with abnormal angiographic results 50% died, mostly due to rebleeding. Among elderly patients or those with a severe neurological deficit, outcome was significantly better in the ones who were treated.

CONCLUSIONS

A significant proportion of patients who were admitted with SAH did not receive definitive therapy. Major reasons for this included normal results on angiographic studies and poor clinical grade. Untreated patients with normal angiographic results had a good outcome, whereas those in whom angiography was not performed and those with abnormal angiographic results had a high mortality rate from the consequences of the initial hemorrhage in the first instance or rebleeding in the second. Although among elderly patients and those with a poor clinical grade the mortality rate was lower among those who received treatment, a definitive conclusion favoring treatment in these high-risk groups can only be drawn from a prospective randomized study.

Surgical Indications to Maintain Quality of Life in Elderly Patients with Ruptured Intracranial Aneurysms

OBJECTIVE

We performed a retrospective study to assess long-term outcomes in very old patients with ruptured intracranial aneurysms. The aim of the study was to develop guidelines for choosing surgical or conservative treatment with the goal of maintaining patients' quality of life.

METHODS

Between 1996 and 1999, 76 consecutive patients, aged 80 to 89 years, with ruptured intracranial aneurysms were treated at 18 participating centers. They were divided retrospectively into operated and nonoperated groups, and their preoperative characteristics and treatment outcomes were analyzed. Their Glasgow Outcome Scale and Barthel Index scores at least 2 years after the insult were recorded and analyzed from the perspective of their admission Hunt and Hess grade.

RESULTS

Our retrospective review encompassed 5.9 years. Of the original 76 patients, 54 (71.1%) died, 13 (17.1%) had a good outcome (Barthel Index ≥60), and 9 (11.8%) had a poor outcome (Barthel Index &lt;60). All patients with Hunt and Hess grades of III or higher at admission had poor outcomes irrespective of treatment. Of 32 patients with an initial Hunt and Hess grade of I or II, 19 (59.4%) underwent surgery; 9 of these patients (47.4%) had good outcomes. Conversely, of 13 nonoperated patients (40.6%), only 2 (15.4%) experienced good outcomes. In seven of the nine operated patients with good outcomes, the aneurysm was small (&lt;12 mm) and located at the internal carotid artery-posterior communicating artery junction.

CONCLUSION

Our results suggest that patients in the 9th decade of life with ruptured intracranial aneurysms can be considered for surgical treatment if they have a Hunt and Hess grade of I or II. The highest rate of favorable results was achieved in patients with small internal carotid artery-posterior communicating artery aneurysms.