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Lee KS, Siow I, Yang LW, Foo AS, Zhang JJ, Mathews I, Goh CP, Teo C, Nagarjun B, Chen V, Lwin S, Teo K, Low SW, Sun IS, Pang BC, Yang EW, Yang C, Gopinathan A, Yeo TT, Nga VD. Endovascular coiling versus neurosurgical clipping in the management of aneurysmal subarachnoid haemorrhage in the elderly: a multicenter cohort study. Neurosurg Rev 2024; 47:100. [PMID: 38427140 PMCID: PMC10907408 DOI: 10.1007/s10143-024-02325-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/01/2024] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Abstract
The comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH). Data were obtained from all patients with aSAH aged ≥60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality. Of the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0-2 at 3 months (OR = 2.45 [95%CI:1.16-5.20];p = 0.018), and a lower incidence of in-hospital mortality (OR = 0.31 [95%CI:0.10-0.91];p = 0.026). There were no significant difference between the two treatment groups in terms of good mRS score at 6 months (OR = 1.98 [95%CI:0.97-4.04];p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR = 0.32 [95%CI:0.12-0.90];p = 0.025). Age, admission WFNS score I-III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I-III remained significant predictors of good functional outcomes at 6 months. Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.
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Affiliation(s)
- Keng Siang Lee
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore.
- Department of Neurosurgery, King's College Hospital, London, UK.
- Department of Basic and Clinical Neurosciences, Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK.
| | - Isabel Siow
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore, Singapore
| | - Lily Wy Yang
- Ministry of Health Holdings, Singapore, Singapore
| | - Aaron Sc Foo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - John Jy Zhang
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Ian Mathews
- Emergency Medicine Department, National University Hospital, Singapore, Singapore
| | - Chun Peng Goh
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Colin Teo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Bolem Nagarjun
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Vanessa Chen
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Sein Lwin
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Kejia Teo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Shiong Wen Low
- Division of Neurosurgery, Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Ira Sy Sun
- Division of Neurosurgery, Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Boon Chuan Pang
- Department of Neurosurgery, Khoo Teck Puat Hospital, Alexandra Health Private Limited, National University Health System, Singapore, Singapore
| | - Eugene Wr Yang
- Department of Neurosurgery, Khoo Teck Puat Hospital, Alexandra Health Private Limited, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
| | - Vincent Dw Nga
- Division of Neurosurgery, Department of Surgery, National University Health System, Singapore, Singapore
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Ewbank F, Hall S, Gaastra B, Fisher B, Coe L, Booker J, Kaldas A, Anderson I, Critchley G, Teo M, Toma A, Trivedi R, Uff C, Vindlacheruvu R, Dulhanty L, Javadpour M, Walsh D, Galea J, Patel H, Bulters D. Aneurysm management in patients over 80 years old with good grade subarachnoid haemorrhage. Br J Neurosurg 2023:1-7. [PMID: 37147868 DOI: 10.1080/02688697.2023.2205939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND An increasing proportion of aneurysmal subarachnoid haemorrhage (aSAH) occurs in older patients, in whom there is widespread variability in treatment rates due to a different balance of risks. Our aim was to compare outcomes of patients over 80 years old with good grade aSAH who underwent treatment of their aneurysm with those who did not. METHODS Adult patients with good grade aSAH admitted to tertiary regional neurosciences centres contributing to the UK and Ireland Subarachnoid Haemorrhage Database (UKISAH) and a cohort of consecutive patients admitted from three regional cohorts were included for analysis. Outcomes were functional outcome at discharge, three months and survival at discharge. RESULTS In the UKISAH, patients whose aneurysm was treated were more likely to have a favourable outcome at discharge (OR 2.34, CI 1.12-4.91, p = .02), at three months (OR 2.29, CI 1.11-4.76, p = .04), and lower mortality (10% vs. 29%, OR 0.83, CI 0.72-0.94, p < .01). In the regional cohort, a similar pattern was seen, but after correction for frailty and comorbidity there was no difference in survival (HR 0.45, CI 0.12-1.68, p = .24) or favourable outcome at discharge (OR 0.83, CI 0.23-2.94, p = .77) and at three months (OR 1.03, CI 0.25-4.29, p = .99). CONCLUSIONS Better early functional outcomes in those undergoing aneurysm treatment appear to be explained by differences in frailty and comorbidity. Therefore, treatment decisions in this patient group are finely balanced with no clear evidence overall of either benefit or harm in this cohort.
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Affiliation(s)
- Frederick Ewbank
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Samuel Hall
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Benjamin Gaastra
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Benjamin Fisher
- Department of Neurosurgery, King's College Hospital, London, UK
| | - Laura Coe
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - James Booker
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Antony Kaldas
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Ian Anderson
- Department of Neurosurgery, Leeds Teaching Hospitals, Leeds, UK
| | - Giles Critchley
- Department of Neurosurgery, University Hospitals Sussex, Brighton, UK
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol NHS Trust, Bristol, UK
| | - Ahmed Toma
- Department of Neurosurgery, University College London Hospitals, London, UK
| | - Rikin Trivedi
- Department of Neurosurgery, Cambridge University Hospitals, Cambridge, UK
| | - Chris Uff
- Department of Neurosurgery, Barts Health NHS Trust, London, UK
| | - Raghu Vindlacheruvu
- Department of Neurosurgery, Barking, Havering and Redbridge University Hospitals, Romford, UK
| | - Louise Dulhanty
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester, UK
| | | | - Daniel Walsh
- Department of Neurosurgery, King's College Hospital, London, UK
| | - James Galea
- Department of Neurosurgery, Cardiff and Vale University Health Board, Cardiff, UK
| | - Hiren Patel
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester, UK
| | - Diederik Bulters
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
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Kutty RK, Sivanandapanicker JL, Sreemathyamma SB, Prabhakar RB, Peethambaran A, Libu GK. The Outcome of Aneurysm Clipping in Septuagenarians - A Retrospective Analysis in a Basic Neurovascular Unit. Neurol India 2020; 68:101-107. [PMID: 32129256 DOI: 10.4103/0028-3886.279659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction The management of aneurysmal subarachnoid hemorrhage (SAH) in the elderly is challenging. Clipping as the definitive treatment is less well tolerated by the elderly population. The outcome is anticipated to be more glimmer in poor grade SAH and in a setup which lacks modern neurovascular gadgets. We present our experience of surgical clipping in elderly patients in such a basic neurovascular unit. Materials and Methods A retrospective analysis of hospital records of elderly patients between 70 and 79 of age who underwent surgical clipping of intracranial aneurysms between 2015 and 2017 was done. The patients' characteristics, comorbidities, aneurysm characteristics, intraoperative complications, and postoperative complications were studied to determine the factors influencing an unfavorable outcome. All information was entered into a database (Microsoft Excel) and analyzed using SPSS trial version 16. Outcomes were grouped into a favorable outomce which included Glasgow Outcome Scale scores of 4 and 5, whereas an unfavorable outcome which included Glasgow Outcome Scale scores of 1, 2, and 3. Results There were 21 patients with aneurysms located either in the anterior or posterior circulation or both. All underwent standard craniotomy and clipping pertaining to that particular type of aneurysm. A favorable outcome was achieved in 48% of the patients and 52% had an unfavorable outcome. The duration of surgery, number of days on ventilator, and presence of hydrocephalus were the factors found to be statistically significantly associated with unfavorable outcomes. Conclusion A team approach consisting of a neuroanaesthetist, neurosurgeons, and critical care personnel can have a huge impact on the postoperative outcome.
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Affiliation(s)
- Raja K Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | | | - Rajmohan B Prabhakar
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Anilkumar Peethambaran
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Gnanaseelan K Libu
- Department of Community Medicine and Government Medical College, Thiruvananthapuram, Kerala, India
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Katsuki M, Yamamoto Y, Uchiyama T, Wada N, Kakizawa Y. Clinical characteristics of aneurysmal subarachnoid hemorrhage in the elderly over 75; would temporal muscle be a potential prognostic factor as an indicator of sarcopenia? Clin Neurol Neurosurg 2019; 186:105535. [PMID: 31569058 DOI: 10.1016/j.clineuro.2019.105535] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 09/11/2019] [Accepted: 09/21/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Age of patients with subarachnoid hemorrhage (SAH) is increasing. It is challenging to decide whether to perform aneurysm treatment and to predict their prognosis. We assumed that elderly patients with SAH who do not suffer from sarcopenia tend to have good outcomes. Temporal muscle thickness (TMT) and area (TMA) are useful indicators of sarcopenia. We investigated the clinical characteristics, including temporal muscle, in SAH patients over 75 years old. PATIENTS AND METHODS We retrospectively analyzed 49 SAH patients over 75 years old from 2014 to 2018, who accounted for 37% of the patients in all age group. The correlations between the clinical variables and the modified Rankin Scale (mRS) at discharge were analyzed. RESULTS Of the all 49 SAH patients over 75 years old, premorbid mRS, WFNS grade, lymphocyte, aneurysm size, TMT, TMA, showed significant correlations with mRS at discharge. Men and the absence of hydrocephalus were correlated with favorable outcomes. Thirteen of the 24 patients over 75 years old whose WFNS grade were I to III but also who underwent aneurysm treatment had favorable outcomes (mRS 0-2), and their standardized TMT divided by height, by weight, and TMA divided by weight were significantly larger than that with poor outcomes. CONCLUSION Aneurysm intervention should be considered when patients over 75 years old do not suffer from sarcopenia. Temporal muscle would indicate premorbid mRS and be potentially useful to decide surgical indication and to predict outcome after aneurysm treatment in the elderly.
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Affiliation(s)
- Masahito Katsuki
- Department of Neurosurgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Yasunaga Yamamoto
- Department of Neurosurgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Toshiya Uchiyama
- Department of Neurosurgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Naomichi Wada
- Department of Neurosurgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Yukinari Kakizawa
- Department of Neurosurgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan.
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Goldberg J, Schoeni D, Mordasini P, Z’Graggen W, Gralla J, Raabe A, Beck J, Fung C. Survival and Outcome After Poor-Grade Aneurysmal Subarachnoid Hemorrhage in Elderly Patients. Stroke 2018; 49:2883-2889. [DOI: 10.1161/strokeaha.118.022869] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Johannes Goldberg
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Daniel Schoeni
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology (P.M., J. Gralla), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Werner Z’Graggen
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology (P.M., J. Gralla), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Andreas Raabe
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jürgen Beck
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Christian Fung
- From the Department of Neurosurgery (J. Goldberg, D.S., W.Z., A.R., J.B., C.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
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