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Choi HZ, Kim SU, Huh J, Lee HG, Kim MK, Kim DS, Huh CW. Comparison of treatment outcomes and complications of coil embolization in elderly and very elderly patients with cerebral aneurysms: a propensity score matching analysis. Acta Neurochir (Wien) 2023; 165:3361-3369. [PMID: 37728829 DOI: 10.1007/s00701-023-05793-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE This single center study aims to compare the treatment outcomes and procedure-related complications of coil embolization in elderly patients (60-79 years) and very elderly patients (aged 80 years or older) with cerebral aneurysms. METHODS Data was collected from 504 elderly patients aged 60 years or older who underwent coil embolization for intracranial aneurysms from 2018 to 2021. The study evaluated patient-related and anatomical factors and assessed various outcomes, comparing results between groups using statistical analysis and propensity score matching. RESULTS A total of 503 cerebral aneurysms were analyzed from individuals aged 60-79 years (n = 472) and those aged 80 years or older (n = 31). The majority of the aneurysms were unruptured with an average size of 3.5 mm in height and 3.4 mm in width. The patients were compared using 1:1 propensity score matching, and no significant differences were found in factors other than age and aortic elongation. Logistic analysis revealed that being over 80 years old and having a severe aortic arch elongation were identified as risk factors for procedure-related events in both total and unruptured cases. CONCLUSIONS The study compared coil embolization treatment for cerebral aneurysms in patients aged 60-79 and over 80, finding no significant difference in treatment outcomes except for procedure-related events. Procedure-related events were associated with severe aortic arch elongation and being over 80 years old. Coil embolization can be considered safe and effective for patients over 80, but further trials are needed for accurate conclusions.
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Affiliation(s)
- Han-Zo Choi
- Department of emergency medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Sang-Uk Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea.
| | - Joon Huh
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Hyun-Goo Lee
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Mi-Kyung Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Dal-Soo Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Choon-Woong Huh
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
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Sayyahmelli S, Sayyahmelli S, Ozaydin B, Erginoglu U, Keleş A, Sun Z, Başkaya MK. Safety and efficacy of microsurgery for complex cranial pathologies in the ultra-geriatric population. Clin Neurol Neurosurg 2022; 223:107500. [DOI: 10.1016/j.clineuro.2022.107500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/26/2022]
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3
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Proust F, Bracard S, Thines L, Pelissou-Guyotat I, Leclerc X, Penchet G, Bergé J, Morandi X, Gauvrit JY, Mourier K, Ricolfi F, Lonjon M, Sedat J, Bataille B, Drouineau J, Civit T, Magro E, Cebula H, Chassagne P, David P, Emery E, Gaberel T, Vignes JR, Aghakani N, Troude L, Gay E, Roche PH, Irthum B, Lejeune JP. Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients. Neurochirurgie 2019; 66:1-8. [PMID: 31863744 DOI: 10.1016/j.neuchi.2019.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/13/2019] [Accepted: 11/03/2019] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- F Proust
- Department of Neurosurgery, Hautepierre Hospital, Strasbourg University Hospital, 67098, Strasbourg, France; Department of Neurosurgery, Charles-Nicolle Hospital, Rouen University Hospital, 76000, Rouen, France.
| | - S Bracard
- University Hospital, neuroradiology department, 54000 Nancy, France
| | - L Thines
- University Hospital, neurosurgery department, 25000 Besancon, France
| | | | - X Leclerc
- University Hospital, neuroradiology department, 59000 Lille, France
| | - G Penchet
- University Hospital, neurosurgery department, 33000 Bordeaux, France
| | - J Bergé
- University Hospital, neurosurgery department, 33000 Bordeaux, France
| | - X Morandi
- University Hospital, neurosurgery department, 35000 Rennes, France
| | - J-Y Gauvrit
- University Hospital, neurosurgery department, 35000 Rennes, France
| | - K Mourier
- University Hospital, neurosurgery department, 21000 Dijon, France
| | - F Ricolfi
- University Hospital, neurosurgery department, 21000 Dijon, France
| | - M Lonjon
- University Hospital, neurosurgery department, 06000 Nice, France
| | - J Sedat
- University Hospital, neurosurgery department, 06000 Nice, France
| | - B Bataille
- University Hospital, neurosurgery department, 86000 Poitiers, France
| | - J Drouineau
- University Hospital, neurosurgery department, 86000 Poitiers, France
| | - T Civit
- University Hospital, neurosurgery department, 54000 Nancy, France
| | - E Magro
- University Hospital, neurosurgery department, 29000 Brest, France
| | - H Cebula
- University Hospital, neurosurgery department, 67000 Strasbourg, France
| | - P Chassagne
- University Hospital, Geriatry department, 76000 Rouen, France
| | - P David
- Bicêtre University Hospital, neurosurgery department, 94270 Le Kremlin-Bicêtre, France
| | - E Emery
- University Hospital, neurosurgery department, 14000 Caen, France
| | - T Gaberel
- University Hospital, neurosurgery department, 14000 Caen, France
| | - J R Vignes
- University Hospital, neurosurgery department, 33000 Bordeaux, France
| | - N Aghakani
- Bicêtre University Hospital, neurosurgery department, 94270 Le Kremlin-Bicêtre, France
| | - L Troude
- University Hospital, neurosurgery department, 13000 Marseille, France
| | - E Gay
- University Hospital, neurosurgery department, 38000 Grenoble, France
| | - P H Roche
- University Hospital, neurosurgery department, 13000 Marseille, France
| | - B Irthum
- University Hospital, neurosurgery department, 63000 Clermont Ferrand, France
| | - J-P Lejeune
- Lille University Hospital, neurosurgery department, 59000 Lille, France
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- Department of Neurosurgery, Hautepierre Hospital, Strasbourg University Hospital, 67098, Strasbourg, France; Department of Neurosurgery, Charles-Nicolle Hospital, Rouen University Hospital, 76000, Rouen, France
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Akiyama R, Imamura H, Tani S, Adachi H, Fukumitsu R, Sunohara T, Omura Y, Funakoshi Y, Matsui Y, Sasaki N, Fukuda T, Horiuchi K, Kajiura S, Shigeyasu M, Sakai N. Outcomes of Endovascular Therapy versus Microsurgical Treatment for Aneurysmal Subarachnoid Hemorrhage in Patients ≥70 Years of Age. JOURNAL OF NEUROENDOVASCULAR THERAPY 2019; 14:1-7. [PMID: 37502381 PMCID: PMC10370813 DOI: 10.5797/jnet.oa.2019-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 11/12/2019] [Indexed: 07/29/2023]
Abstract
Purpose This retrospective research aimed to compare the efficacy of endovascular therapy (EVT) versus microsurgical treatment (MST) for elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods Elderly (>70 years) patients with aSAH who underwent aneurysm obliteration during 2007-2017 were selected from our hospital database and enrolled in this retrospective study. We reviewed each patient's background, the severity of the aSAH, and aneurysmal characteristics that compelled EVT or microsurgery treatment and then compared the two treatment groups. A favorable primary outcome was defined by a modified Rankin scale (mRS) score of 0-3 at hospital discharge. The 78 patients formed two cohorts (39 patients each) based on their propensity scores for EVT or MST. We estimated the adjusted odds ratio, followed by a sensitivity analysis of the original 201 patients (118 with EVT and 83 with MST). Results In the propensity score-matched cohorts, favorable outcomes were observed in 33.3% and 7.7% of patients in the EVT and MST groups, respectively (p = 0.01). Results of the sensitivity analysis were similar to the main results. Conclusion The clinical outcomes for the elderly aSAH patients were better in the EVT group than in MST group.
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Affiliation(s)
- Ryo Akiyama
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Shoichi Tani
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hidemitsu Adachi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Ryu Fukumitsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tadashi Sunohara
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yoshihiro Omura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yusuke Funakoshi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yuichi Matsui
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Natsuhi Sasaki
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tatsumaru Fukuda
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Kazufumi Horiuchi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Shinji Kajiura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Masashi Shigeyasu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
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A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage. Neurochirurgie 2018; 64:395-400. [PMID: 30340777 DOI: 10.1016/j.neuchi.2018.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/09/2018] [Accepted: 08/22/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Current aging of the population with good physiological status and the increasing incidence of subarachnoid hemorrhage (SAH) in elderly patients has enhanced the benefit of treatment in terms of independence and long-term quality of life (QoL). METHODS From November 1, 2008 to October 30, 2012, 351 patients aged 70 years or older with aneurysmal SAH underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). Forty-one of these were randomized to EV (n=20) or to MS (n=21). The objectives were to determine the proportion of patients with modified Rankin Scale score≤2 (independence) at 1 year, and, secondarily, to compare cognitive function on the Mini-Mental State Examination (MMSE), autonomy on the Activities of Daily Living Index (ADLI) and Instrumental Activities of Daily Living scale (IADL), and QoL, in the prospective and randomized arms, at 1 year. RESULTS At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference (P=0.29). Mortality was higher after MS during the first 2 postoperative months, and thereafter the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both arms. CONCLUSION In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and QoL.
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Park J, Woo H, Kang DH, Kim Y. Critical age affecting 1-year functional outcome in elderly patients aged ≥ 70 years with aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2014; 156:1655-61. [PMID: 24950994 DOI: 10.1007/s00701-014-2133-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 05/08/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND While advanced age is already recognized as an independent risk factor for a poor functional outcome following an aneurysmal subarachnoid hemorrhage (SAH), it is also important to investigate the critical age for defining a higher risk population among elderly patients and the clinical grade at admission in order to provide a prognostic description and help guide the management of patients aged ≥ 70 years. METHODS This retrospective study included 165 patients aged 70-90 years who underwent surgical or endovascular treatment for a ruptured aneurysm. In addition to medical and radiological data, telephone interviews were used to obtain the 1-year functional outcome. RESULTS A multivariate analysis revealed age (p = 0.001) and the World Federation of Neurological Surgeons (WFNS) grade (p = 0.001), regardless of the treatment modalities (surgical versus endovascular), as significant risk factors for a poor outcome, while a receiver operating characteristic analysis revealed 75 years as an appropriate cutoff value for the patient age to predict a poor 1-year functional outcome (area under the curve: 0.683). For the patients aged 70-75 years with good (1-3) and poor (4-5) WFNS grades, 81.9 % and 42.9 % achieved a favorable outcome (modified Rankin Scale 0-3), respectively, whereas for the patients over the critical age (> 75 years) with good and poor WFNS grades, 54.8 % and 5.9 % achieved a favorable outcome, respectively. CONCLUSIONS The long-term outcome for elderly patients with an aneurysmal SAH is affected primarily by the clinical condition at admission and the patient's age in relation to the critical age (> 75 years), regardless of the treatment modalities, including surgical clipping and endovascular coiling.
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Affiliation(s)
- Jaechan Park
- Department of Neurosurgery Cardiocerebrovascular Center, Kyungpook National University, Daegu, Republic of Korea,
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7
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Iosif C, Di Maria F, Sourour N, Degos V, Bonneville F, Biondi A, Jean B, Colonne C, Nouet A, Chiras J, Clarençon F. Is a high initial World Federation of Neurosurgery (WFNS) grade really associated with a poor clinical outcome in elderly patients with ruptured intracranial aneurysms treated with coiling? J Neurointerv Surg 2013; 6:286-90. [PMID: 23709581 DOI: 10.1136/neurintsurg-2013-010711] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Coiling of ruptured intracranial aneurysms in elderly patients remains debatable in terms of technical feasibility and clinical outcome. AIMS In this observational cohort study we aimed to assess the technical feasibility, complication profile and clinical outcomes of elderly patients with subarachnoid hemorrhage (SAH) treated with endovascular therapy. METHODS The study included 59 consecutive patients (47 women) aged ≥70 years (mean age 76 years, range 71-84) admitted to our institution with SAH from January 2002 to July 2011. The patients were treated for 66 aneurysms (regular coiling: n=62 (94%), balloon-assisted technique: n=2 (3%), stent and coil technique: n=2 (3%)). World Federation of Neurosurgery (WFNS) grade at admission was 1 in 13 patients, 2 in 23 patients, 3 in 8 patients, 4 in 11 patients and 5 in 4 patients. We analysed data by univariate and multivariate statistical analyses with an emphasis on the initial clinical situation, complications and clinical outcome. RESULTS The technical success rate was 98% with a procedure-related deficit rate of 10% and procedure-related death rate of 5%. The Glasgow Outcome Scale score at 6 months was 1 in 15 patients (25.4%), 2 in 8 patients (13.6%), 3 in 14 patients (23.7%), 4 in 11 patients (18.6%) and 5 in 11 patients (18.6%). Patients admitted with a high initial WFNS grade did not differ statistically in terms of clinical outcome. The final clinical outcome was not significantly correlated with age, initial Fisher score or procedure-related complications. CONCLUSIONS Endovascular treatment of elderly patients with ruptured cerebral aneurysms is feasible, safe and beneficial regardless of the presenting WFNS score.
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Affiliation(s)
- Christina Iosif
- Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Paris, France
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Sturiale CL, Brinjikji W, Murad MH, Lanzino G. Endovascular treatment of intracranial aneurysms in elderly patients: a systematic review and meta-analysis. Stroke 2013; 44:1897-902. [PMID: 23686977 DOI: 10.1161/strokeaha.113.001524] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Carmelo L Sturiale
- Department of Neurologic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
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Brinjikji W, Lanzino G, Rabinstein AA, Kallmes DF, Cloft HJ. Age-related trends in the treatment and outcomes of ruptured cerebral aneurysms: a study of the nationwide inpatient sample 2001-2009. AJNR Am J Neuroradiol 2012; 34:1022-7. [PMID: 23124637 DOI: 10.3174/ajnr.a3321] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Patient age substantially influences treatment decisions for ruptured cerebral aneurysms. It would be useful to understand national age-related trends of treatment techniques and outcomes in patients treated for ruptured cerebral aneurysm in the United States. MATERIALS AND METHODS Using the US Nationwide Inpatient Sample, we evaluated trends in treatment technique (clipping versus coiling) and discharge status of patients undergoing clipping or coiling of ruptured cerebral aneurysms between 2001 and 2009. Outcomes were evaluated in relation to 4 age strata: 1) younger than 50 years of age, 2) 50-64 years of age, 3) 65-79 years of age, and 4) patients 80 years or older. We compared outcomes between treatment groups for patients treated between 2001-2004 with those treated between 2005-2009. RESULTS A significant increase in the proportion of patients undergoing endovascular coiling between 2001 and 2009 was noted for all age groups (P < .0001). For both clipped and coiled patients, mortality and the proportion of patients discharged to long-term facilities increased with age. Overall mortality for patients clipped and coiled decreased modestly for all age groups, and overall proportions of patients discharged home increased modestly (P < .01) for all age groups except those older than 80 years of age. CONCLUSIONS Between 2001 and 2009, there has been a significant increase in the proportion of patients with ruptured aneurysms undergoing endovascular coiling rather than aneurysm clipping. This increase was more pronounced in older patients. Mortality from aneurysmal subarachnoid hemorrhage decreased during the past decade, regardless of aneurysm treatment technique.
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Affiliation(s)
- W Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota 55905, USA
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The impact of microsurgical clipping and endovascular coiling on the outcome of cerebral aneurysms in patients over 60years of age. J Clin Neurosci 2012; 19:1115-8. [DOI: 10.1016/j.jocn.2011.11.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 11/08/2011] [Accepted: 11/10/2011] [Indexed: 11/23/2022]
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Derrey S, Curey S, Hannequin P, Castel H, Langlois O, Tollard E, Fréger P, Proust F. Elderly patients with aneurysmal subarachnoid hemorrhage: Coils but also clips. Neurochirurgie 2012; 58:140-5. [PMID: 22464899 DOI: 10.1016/j.neuchi.2012.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 02/08/2012] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- S Derrey
- Department of Neurosurgery, Rouen University Hospital, 1, rue de Germont, 76031 Rouen cedex, France
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Proust F, Gérardin E, Derrey S, Lesvèque S, Ramos S, Langlois O, Tollard E, Bénichou J, Chassagne P, Clavier E, Fréger P. Interdisciplinary treatment of ruptured cerebral aneurysms in elderly patients. J Neurosurg 2010; 112:1200-7. [DOI: 10.3171/2009.10.jns08754] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of the study was to assess postprocedural neurological deterioration and outcome in patients older than 70 years of age in whom treatment was managed in an interdisciplinary context.
Methods
This prospective longitudinal study included all patients 70 years of age or older treated for ruptured cerebral aneurysm over 10 years (June 1997–June 2007). The population was composed of 64 patients. The neurovascular interdisciplinary team jointly discussed the early obliteration procedure for each aneurysm. Neurological deterioration during the postprocedural 2 months and outcome at 6 months were assessed during consultation according to the modified Rankin Scale (mRS) as follows: favorable (mRS score ≤ 2) and unfavorable (mRS score > 2).
Results
Aneurysm sac obliteration was performed by microvascular clipping in 34 patients (53.1%) and by endovascular coiling in 30 (46.9%). Postprocedural neurological deterioration occurred in 30 patients (46.9%), related to ischemia in 19 (29.7%), rebleeding in 1 (1.6%), and hydrocephalus in 10 (15.6%). At 6 months, the outcome was favorable in 39 patients (60.9%). By multivariate regression logistic analysis, the independent factors associated with unfavorable outcome were age exceeding 75 years (p = 0.005), poor initial grade (p < 0.0001), and the occurrence of ischemia (p < 0.0001).
Conclusions
The baseline characteristics of SAH in the elderly were only slightly different from those in younger patients. In the elderly, the interdisciplinary approach may be considered useful to decrease the ischemic consequences.
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[Aneurismal subarachnoid hemorrhage in the elderly subject. Should this patient participate in a randomized clinical trial?]. Neurochirurgie 2010; 56:67-72. [PMID: 20060549 DOI: 10.1016/j.neuchi.2009.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 09/01/2009] [Indexed: 11/23/2022]
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Alexander BL, Riina HA. The combined approach to intracranial aneurysm treatment. ACTA ACUST UNITED AC 2009; 72:596-606; discussion 606. [PMID: 19818994 DOI: 10.1016/j.surneu.2009.06.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 06/24/2009] [Indexed: 12/25/2022]
Abstract
BACKGROUND A consecutive series of patients with intracranial aneurysms in the practice of one neurovascular surgeon was retrospectively reviewed to illustrate that one physician can become proficient in microneurosurgery as well as endovascular surgery and achieve favorable outcomes in both disciplines. This supports one model of training for cerebrovascular surgeons that includes the complimentary practice of open microneurovascular surgery with endovascular surgery. METHODS The senior author (HAR) treated 351 patients with 413 aneurysms between July 2001 and March 2007. Of these, 172 patients (216 aneurysms) were treated with open microneurosurgical techniques and 179 patients (197 aneurysms) were treated using endovascular techniques. RESULTS Complete obliteration was attained in 94.3% of clipped aneurysms, and 61.9% and 65.9% of coiled aneurysms immediately and after at least 6 months of follow-up, respectively. At latest evaluation, 93% of endovascular patients and 90% of microneurosurgical patients had good clinical outcomes (GOS, 4 or 5; mean follow-up, 23 months; combines ruptured and unruptured cohorts). Procedure-related mortality included 1 surgical patient and 2 endovascular patients. CONCLUSIONS Because the fields of microvascular and endovascular surgeries are both technically complex, there has been concern that hybrid cerebrovascular surgeons cannot perform each technique with the skill necessary to achieve good outcomes. When compared to clipping and coiling reviews in the neurosurgical literature, we illustrate that one hybrid neurovascular surgeon is capable of attaining great facility in both techniques and that this type of physician will represent one practice model of cerebrovascular specialist in the future. This has potential implications for the training of hybrid cerebrovascular surgeons.
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Affiliation(s)
- Brian L Alexander
- Department of Anesthesiology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY 10021, USA
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Bradac GB, Bergui M, Stura G, Fontanella M, Daniele D, Gozzoli L, Berardino M, Ducati A. Periprocedural morbidity and mortality by endovascular treatment of cerebral aneurysms with GDC: a retrospective 12-year experience of a single center. Neurosurg Rev 2007; 30:117-25; discussion 125-6. [PMID: 17216530 DOI: 10.1007/s10143-006-0059-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 08/08/2006] [Accepted: 10/05/2006] [Indexed: 10/23/2022]
Abstract
Despite increasing experience and improved material, endovascular treatment of cerebral aneurysms still has risks linked to the technique itself and to the specificity of the pathology treated. The purpose of this report is to examine procedural technical and clinical negative events, even minimal ones, occurring in this type of treatment. We considered 557 procedures carried out from January 1994 to December 2005 in 533 patients harboring 550 aneurysms. Of the patients, 448 presented with SAH and 85 with unruptured aneurysms. All procedures were performed under general anesthesia. The GDC-10 system was routinely used. Additional devices like the balloon remodeling technique, Trispan and stents were also occasionally used. Every procedural complication occurring during or soon after treatment was registered. Endovascular treatment was completed in 539 out of 557 procedures. There were 18 failures (3.3%). Occlusion of the aneurysm was judged complete in 343 (64%), near complete in 184 (34%) and incomplete in 12 (2%). Procedural complications occurred in 72 (13%) of the cases. The most frequent negative events were thromboembolisms (6.6%) and ruptures (3.9%). Other types (coil migration, transient occlusions of the parent vessel, dissections and early rebleeding) were rarer (2.5%). In the majority of cases there were no clinical consequences. Procedural morbidity and mortality were 1.1 and 1.8%, respectively. Considering the 449 procedures performed in ruptured and the 90 in the unruptured aneurysms separately, morbidity and mortality were 1.1 and 2.2% in the former group and 1.1 and 0% in the latter. Many factors influence the risk of complications. Being progressively aware of this and with increasing experience, the frequency can be limited. Negative events linked to the procedure have more significant serious clinical consequences in patients admitted in a critical clinical condition after SAH, because of the already present changes involving the brain parenchyma and cerebral circulation.
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Affiliation(s)
- G B Bradac
- Division of Neuroradiology, Department of Neuroscience, University of Torino, Via Cherasco 15, 10126 Torino, Italy.
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