Aneurysmal subarachnoid hemorrhage in elderly patients: long-term outcome and prognostic factors in an interdisciplinary treatment approach

Clinical Outcome Prediction of Early Brain Injury in Aneurysmal Subarachnoid Hemorrhage: the SHELTER-Score

BACKGROUND

Despite intensive research on preventing and treating vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage (aSAH), mortality and morbidity rates remain high. Early brain injury (EBI) has emerged as possibly the major significant factor in aSAH pathophysiology, emphasizing the need to investigate EBI-associated clinical events for improved patient management and decision-making. This study aimed to identify early clinical and radiological events within 72 h after aSAH to develop a conclusive predictive EBI score for clinical practice.

METHODS

This retrospective analysis included 561 consecutive patients with aSAH admitted to our neurovascular center between 01/2014 and 09/2022. Fourteen potential predictors occurring within the initial 72 h after hemorrhage were analyzed. The modified Rankin Scale (mRS) score at 6 months, discretized to three levels (0-2, favorable; 3-5, poor; 6, dead), was used as the outcome variable. Univariate ordinal regression ranked predictors by significance, and forward selection with McFadden's pseudo-R2 determined the optimal set of predictors for multivariate proportional odds logistic regression. Collinear parameters were excluded, and fivefold cross-validation was used to avoid overfitting.

RESULTS

The analysis resulted in the Subarachnoid Hemorrhage Associated Early Brain Injury Outcome Prediction score (SHELTER-score), comprising seven clinical and radiological events: age (0-4 points), World Federation of Neurosurgical Societies (0-2.5 points), cardiopulmonary resuscitation (CPR) (2 points), mydriasis (1-2 points), midline shift (0.5-1 points), early deterioration (1 point), and early ischemic lesion (2 points). McFadden's pseudo-R2 = 0.339, area under the curve for death or disability 0.899 and 0.877 for death. A SHELTER-score below 5 indicated a favorable outcome (mRS 0-2), 5-6.5 predicted a poor outcome (mRS 3-5), and ≥ 7 correlated with death (mRS 6) at 6 months.

CONCLUSIONS

The novel SHELTER-score, incorporating seven clinical and radiological features of EBI, demonstrated strong predictive performance in determining clinical outcomes. This scoring system serves as a valuable tool for neurointensivists to identify patients with poor outcomes and guide treatment decisions, reflecting the great impact of EBI on the overall outcome of patients with aSAH.

Clipping and coiling of intracranial aneurysms in the elderly patients: clinical features and treatment outcomes

Objective

In recent years, more and more cases of intracranial aneurysms (IAs) have been found in elderly patients, and neurosurgical interventions have increased, but there is still no consensus on the best treatment strategy for elderly patients. In elderly patients, endovascular coiling (EC) is more popular than surgical clipping (SC) due to its advantages of less trauma and faster recovery. However, SC has made great progress in recent years, significantly improving the prognosis of elderly patients. Therefore, it is necessary to further explore the effects of different treatment modalities on clinical prognosis, hospital stay, and hospital cost of elderly IA patients, and select the most appropriate treatment modalities.

Methods

The authors retrospectively analyzed 767 patients with intracranial aneurysms admitted to the facility between August 2017 and December 2022. Prognostic risk factors and multivariate logistic regression were analyzed for elderly patients treated with EC or SC. The area under the receiver operating characteristic (ROC) curve was used to calculate the predictive power of each independent predictor between the treatment groups.

Results

Our study included 767 patients with aneurysms, of whom 348 (45.4%) were elderly, 176 (22.9%) underwent endovascular coiling, and 172 (22.4%) underwent microsurgical clipping. A comparison of elderly patients treated with EC and SC showed a higher prevalence of hypertension in the EC group (P = 0.011) and a higher Hunt-Hess score on admission in the SC group (P = 0.010). Patients in the EC group had shorter hospital stays but higher costs (P = 0.000 and P = 0.000, respectively). Patients treated with SC had a higher incidence of postoperative cerebral infarction and poor prognosis (P = 0.002 and P = 0.008, respectively). Through multi-factor logistic analysis, it was found that age (OR 1.209, 95% CI 1.047-1.397, P = 0.010), length of stay (LOS) (OR 1.160, 95 CI% 1.041-1.289, P = 0.007), and complications (OR 31.873, 95 CI% 11.677-320.701, P = 0.000) was an independent risk factor for poor prognosis in elderly patients with EC. In elderly patients treated with SC, age (OR 1.105, 95% CI 1.010-1.209, P = 0.029) was an independent risk factor for poor prognosis.

Conclusion

EC and SC interventions in elderly adults carry higher risks compared to non-older adults, and people should consider these risks and costs when making a decision between intervention and conservative treatment. In elderly patients who received EC or SC treatments, EC showed an advantage in improving outcomes in elderly patients although it increased the economic cost of the patient's hospitalization.

The survival and outcome of older patients with primary aneurysmal subarachnoid haemorrhage: a 2-year follow-up, multi-centre, observational study

BACKGROUND AND PURPOSE

The management of older aneurysmal subarachnoid haemorrhage (aSAH) cases is a clinical challenge. This study aimed to analyse the survival and functional outcomes in older aSAH patients (age ≥ 70 years) to provide evidence for making treatment decisions for such patients.

METHODS

We performed a 2-year follow-up analysis of the Chinese Multi-Centre Cerebral Aneurysm Database for older patients suffering from aSAH from 2017 to 2020. A survival analysis was used to investigate the mean survival and hazard ratios for death. Binary logarithmic regression was performed to investigate the odds ratio for independent survival and dependent survival.

RESULTS

A total of 1,136 consecutive older patients with aSAH were assessed in this study, and 944 patients (83.1%) were followed up. The overall mean survival was 37.79 ± 1.04 months. A total of 380 (40.25%) patients died within 2 years after aSAH. In survival analysis, the predictors of mortality were older age, intracerebral haemorrhage (ICH) history, Hunt-Hess (H-H) grade, World Federation of Neurosurgical Societies (WFNS) grade and operative treatment decreased the risk of mortality compared to conservative treatment. In binary logarithmic regression, the predictors of dependent survival were hypertension, diabetes, WFNS grade.

CONCLUSIONS

The risk for 2-year mortality after aSAH increases markedly with older age, ICH history, H-H grade and WFNS grade. Risk factors for 2-year dependent survival were associated with hypertension, diabetes and WFNS grade in older patients with aSAH. Operative treatment markedly decreased mortality but did not significantly decrease the morbidity of dependent survival compared to conservative treatment.

Prognostic Risk Factors of One-stage Surgical Clipping in aSAH Elderly Patients with MIAs

OBJECTIVE

To discuss the prognostic factors affecting the prognosis of 1-stage surgical clipping in aneurysmal subarachnoid hemorrhage (aSAH) elderly patients with multiple intracranial aneurysms (MIAs).

MATERIALS AND METHODS

A total of 84 elderly patients with aSAH who had MIAs and underwent 1-stage surgical clipping were retrospectively analyzed. Follow-up was conducted with patients 30 days after discharge using the Glasgow Outcome Scale (GOS). A GOS score of 1 to 3 was defined as a poor outcome, and a GOS score of 4 to 5 was defined as a good outcome. General information (gender, age, size of aneurysm, location of rupture of the responsible aneurysm, H-H grade, CT characteristics of aSAH, number of subarachnoid hemorrhages, operation opportunity, postoperative complications, and intraoperative rupture) and complications（cerebral infarction, hydrocephalus, electrolyte disturbance, and encephaledema）were recorded. Univariate analysis and multivariate regression analysis were used to analyze factors that may affect outcomes.

RESULTS

Univariate analysis showed that the number of SAH events ( P =0.005), intraoperative rupture ( P =0.048) and postoperative complications ( P =0.002) were associated with the prognosis of aSAH elderly patients with MIAs undergoing 1-stage surgery. Multivariate analysis showed that the number of SAH events (odds ratio [OR] 4.740, 95% confidence interval [CI] 1.056 to 21.282, P =0.042) and postoperative complications (OR 4.531, 95% CI 1.266 to 16.220, P =0.020) were independently associated with the prognosis of aSAH elderly patients with MIAs undergoing 1-stage surgery.

CONCLUSIONS

The number of SAH events and postoperative complications are independent risk factors for the prognosis of aSAH elderly patients with MIAs undergoing 1-stage surgery. These factors contribute to the timely treatment of potentially related patients.

Aneurysm management in patients over 80 years old with good grade subarachnoid haemorrhage

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.

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.

Delayed ischemic neurologic deficit with vasospasm in aneurysmal subarachnoid hemorrhage after negative post-bleed day 7 angiography

OBJECTIVE

Routine post-bleed day 7 (PBD7) angiography has been utilized to evaluate for vasospasm in aneurysmal subarachnoid hemorrhage (SAH). We sought to assess the rate of delayed-cerebral ischemia (DCI) associated with angiographic vasospasm following negative PBD7 angiography.

METHODS

Retrospective review of 178 aneurysmal SAH patients was performed. Patients underwent routine angiography on or around 7 days after hemorrhage. Primary variables assessed were the rate of vasospasm detection on PBD7 angiograms and rate of subsequent development of delayed-cerebral ischemia (DCI) associated with angiographic vasospasm in patients without spasm on PBD7. Statistical analysis was carried out for contributing factors.

RESULTS

Eighty-four of 178 patients (47.2 %) developed angiographically proven vasospasm during their hospital course. Seven patients (3.9 %) were clinically suspected to have vasospasm prior to PBD7 with radiographic confirmation. Sixty-nine patients (38.8%) demonstrated novel spasm on routine PBD7 angiogram, with 56.5 % of these patients showing vasospasm on angiography obtained after PBD7 for DCI. One hundred and two patients (57.3 %) had no vasospasm on routine PBD7 angiography. Eight patients in the PBD7 spasm-free subgroup went on to develop DCI with angiographic spasm. These 8 patients represent 4.5 % (8/178) of all patients, 7.8 % (8/102) of the PBD7 negative subgroup, and 9.5 % (8/84) of patients with angiographic spasm during admission.

CONCLUSION

The majority of patients (90.4 %) with angiographic vasospasm manifested on or before PBD7. DCI with angiographically-proven spasm arouse infrequently (7.8 %) after negative PBD7 angiography. Further study of PBD7 angiography may help determine which SAH patients in whom shortened length-of-stay might safely be pursued.

Aneurysm morphological prediction of intracranial aneurysm rupture in elderly patients using four-dimensional CT angiography

OBJECTIVE

The natural history of unruptured intracranial aneurysms (UIAs) in elderly patients remains poorly understood, and the treatment of UIAs is controversial. The presence of irregular pulsation detected by four-dimensional CT angiography (4D-CTA) is associated with ruptured aneurysms. We aimed to investigate the morphological predictors of irregular pulsation of aneurysms in elderly patients.

PATIENTS AND METHODS

We performed a prospective study of intracranial aneurysms detected by 4D-CTA. Elderly patients were defined as those more than 60 years of age. The irregular pulsation was defined as a focal protuberance during a cardiac cycle. We performed multivariate analyses to determine the associations of clinical characteristics and aneurysm morphologies with the irregular pulsation of aneurysms.

RESULTS

A total of 128 elderly patients with 166 intracranial aneurysms was included. The irregular pulsation occurred in 71 (42.8%) aneurysms. The multivariate analysis showed that a large size ratio (p = 0.006), posterior circulation aneurysms (p = 0.033), the presence of a daughter dome (p = 0.006), and aneurysm rupture (p = 0.032) were independently associated with the irregular pulsation. The multivariate analysis of predictors of irregular pulsation of unruptured aneurysms showed that size ratio (p = 0.01) and the presence of a daughter dome (p = 0.016) were independent predictors of irregular pulsation.

CONCLUSION

A large size ratio, posterior circulation aneurysms, the presence of a daughter dome, and aneurysm rupture were independent predictors of the irregular pulsation of aneurysms in elderly patients. The morphological characteristics detected by 4D-CTA may be helpful to evaluate the risk of rupture of aneurysms.

Clinicoradiological Profile and Outcome of Microsurgical Clipping of Ruptured Anterior Circulation Aneurysms: A Single-Institute Experience

Introduction:

Prevalence of intracranial aneurysms is estimated to be from 1% to 5% of population, most of them are small and located in the anterior circulation. The real danger is when an aneurysm ruptures, leading to a subarachnoid hemorrhage (SAH). SAH is a catastrophic event with a mortality rate of 25% to 50%. Permanent disability occurs in nearly 50% of the survivors. Fifteen percent of patients expire before reaching the hospital and 25% die within 24 h. The purpose of our study is to report the clinicoradiological data and outcome of microsurgical clipping of ruptured anterior circulation aneurysms in our center.

Materials and Methods:

This study included ruptured anterior circulation aneurysms admitted to tertiary care hospital in northern India from January 2018 to June 2020. The final outcome of patients was analyzed with Glasgow Outcome Score (GOS) at the time of discharge from the hospital.

Results:

A total of 53 patients with ruptured anterior circulation aneurysm underwent microsurgical clipping comprising 25 (47.2%) males and 28 (52.8%) females. The mean neck size of all aneurysms was 3.43 ± 1.66 mm. The mean hospital stay was longer in patients having preoperative intraventricular hemorrhage (IVH) (35.96 ± 27.27 days) and postoperative complications (43.36 ± 29.76 days) compared to patients who did not have IVH (21.10 ± 15.47 days) and postoperative complications (18 ± 6.54 days). P value was ≤0.05. Patients with preoperative hydrocephalus had GOS 3.44 ± 1.20 at discharge compared to nonhydrocephalus who had GOS 4.32 ± 1.07 (P = 0.009). Patients with Intracerebral Hemorrhage (ICH) and non-ICH had GOS 3.31 ± 1.38 and 4.28 ± 1.01, respectively (P = 0.009).

Conclusion:

Poor outcome at the time of discharge after the surgical treatment of anterior circulation aneurysms was associated with poor world federation of neurological surgeons grade on admission, presence of IVH, hydrocephalus, intracerebral hemorrhage, and postoperative cerebral infarcts.

Risk Factors for Prognosis in Elderly Patients with Severe Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study

INTRODUCTION

To investigate the risk factors affecting the prognosis of elderly patients with severe aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Forty-nine elderly patients with severe aSAH (Hunt and Hess [H-H] grade III-V) were enrolled in this retrospective study. Follow-up was conducted with patients 30 days after discharge using the Glasgow Outcome Scale (GOS), on which scores of 1-3 indicated a poor outcome (n = 32) and scores of 4-5 indicated a good outcome (n = 17). The patients' general information (gender, age, presence of hypertension, diabetes, or coronary atherosclerotic heart disease, location of ruptured aneurysm, and H-H grade) and complications (cerebral vasospasm, new cerebral infarction, pulmonary infection, liver dysfunction, hypoalbuminemia, anemia, and electrolyte disturbance) were recorded, and comparison between the different outcome groups was undertaken. Univariate analysis was used to analyze the factors associated with different outcomes, and multivariate logistic regression analysis was used to determine the factors that lead to poor outcomes.

RESULTS

The incidence of all complications increased in patients with higher H-H grades, but without statistical significance (P > 0.05). There was no statistically significant difference between the two outcome (poor and good) groups in general information and complications (all P > 0.05), with the exception of different H-H grades (P < 0.05). H-H grade was a statistically significant risk factor for poor outcomes in elderly patients with severe aSAH (OR 11.627, 95% CI 2.475-55.556, P = 0.002).

CONCLUSION

H-H grade is an independent factor related to the prognosis of elderly patients with severe aSAH.

The Outcome of Aneurysm Clipping in Septuagenarians - A Retrospective Analysis in a Basic Neurovascular Unit

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.

Risk of postprocedural intracerebral hemorrhage in patients with ruptured cerebral aneurysms after treatment with antiplatelet agents

OBJECTIVE

Endovascular treatment of ruptured cerebral aneurysms frequently requires antiplatelet medication to prevent thromboembolism. This might raise concern regarding the risk of postprocedural hemorrhage (pH), e.g. from placement of intracranial probes. We explored the risk of PH associated with standard antiplatelet therapy (sAP: acetylsalicylic acid, and/or clopidogrel) in the context of aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We retrospectively reviewed a total of 146 consecutive cases with cerebral aneurysms treated between 1/2011-12/2015, and distinguished between minor (0.5 cm³) - 4 cm³) or major (> 4 cm³) PH occurring within four weeks after intervention. A separate analysis included hemorrhages related to placement of intracranial probes and drainages in the subgroup of 99 cases with such surgical interventions (pPH). Clinical outcome was assessed via Glasgow Outcome Scale (GOS) twelve months after aSAH.

RESULTS

A total of 49 cases (33.6%) in the overall sample sustained PH, there were 19 cases of pPH. Multifactorial analyses yielded sAP as an independent predictor for minor, but not major PH (p < 0.001 vs. p = 0.829), with comparable results for pPH (p = 0.001 vs. p = 0.184). sAP did not influence the clinical outcome in either group.

CONCLUSIONS

sAP was associated with a higher rate of minor PH and, more specifically, of minor pPH. However, it was neither accompanied by the occurrence of major hemorrhages nor by unfavorable clinical outcome. Future prospective studies should confirm these observations and hemorrhage risks associated with extended anticoagulation regimes after complex interventions and intra-arterial vasospasm therapy should be explored in order to facilitate interdisciplinary decision-making in aSAH.

The changing face of neurosurgery for the older person

Increased life expectancy and illness prevention and treatment have led to a growing population of older patients. These changes in patient population are apparent in neurosurgery; however, relatively little is reported about specific outcomes and prognostication in this group. This review summarises the challenges and management changes occurring in the treatment of three common neurosurgical pathologies; aneurysmal subarachnoid haemorrhage, head injury, and haemorrhagic stroke. A move towards less invasive neurosurgical techniques has implications on the risk-benefit profile of interventions. This creates the opportunity to intervene in older patients with greater co-morbidity, as long as improved outcomes can be evidenced. A critical part of assessing appropriateness for surgical intervention in older patients may be to change from a mindset of age to one of frailty and growing interest in scales assessing this may aid treatment decisions in the future.

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.

Outcome after Interdisciplinary Treatment for Aneurysmal Subarachnoid Hemorrhage-A Single Center Experience

Background and Objectives: To identify predictors of outcome after aneurysmal subarachnoid hemorrhage (aSAH) in our interdisciplinary setting. Materials and Methods: 176 patients who had been treated for aSAH by a team of neurosurgeons and neuroradiologists between 2009 and 2017 were analyzed retrospectively. Age, gender, clinical presentation according to the Hunt and Hess (H&H) grading on admission, overall clot burden, aneurysm localization, modality of aneurysm obliteration, early deterioration (ED), occurrence of vasospasm in transcranial Doppler ultrasonography, delayed cerebral ischemia (DCI), spasmolysis, decompressive craniectomy (DC), cerebrospinal fluid (CSF) shunt placement, deep vein thrombosis (DVT), pulmonary embolism (PE), severe cardiac events (SCE), mortality on Days 14, and 30 after admission, and outcome at one year after the hemorrhage according to the Glasgow Outcome Scale (GOS) were recorded. Chi square, Fisher’s exact, Welch’s t, and Wilcoxon rank sum served as statistical tests. Generalized linear models were fitted, and ordered logistic regression was performed. Results: SCE (p = 0.049) were a significant predictor of mortality at 14 days after aSAH, but not later during the first year after the hemorrhage. Clipping as opposed to coiling (p = 0.049) of ruptured aneurysms was a significant predictor of survival on Day 30 after aSAH, but not later during the first year after the hemorrhage, while coiling as opposed to clipping of ruptured aneurysms was significantly related to a lower frequency of DVT during hospitalization (p = 0.024). Aneurysms of the anterior circulation were significantly more often clipped, while aneurysms of the posterior circulation were significantly more often coiled (p < 0.001). Age over 70 years (p = 0.049), H&H grade on admission (p = 0.022), overall clot burden (p = 0.035), ED (p = 0.009), DCI (p = 0.013), DC (p = 0.0005), and CSF shunt placement (p = 0.038) proved to be predictive of long-term outcome after aSAH. Conclusion: Long-term results after clipping and coiling of ruptured aneurysms appear equal in an interdisciplinary setting that takes aneurysm localization, available staff, and equipment into account.

Determining rural risk for aneurysmal subarachnoid hemorrhages: A structural equation modeling approach

An aneurysmal subarachnoid hemorrhage (aSAH) carries a high disability burden. The true impact of rurality as a predictor of outcome severity is unknown. Our aim is to clarify the relationship between the proposed explanations of regional and rural health disparities linked to severity of outcome following an aSAH. An initial literature search identified limited data directly linking geographical location, rurality, rural vulnerability, and aSAH. A further search noting parallels with ischemic stroke and acute myocardial infarct literature presented a number of diverse and interrelated predictors. This a priori knowledge informed the development of a conceptual framework that proposes the relationship between rurality and severity of outcome following an aSAH utilizing structural equation modeling. The presented conceptual framework explores a number of system, environmental, and modifiable risk factors. Socioeconomic characteristics, modifiable risk factors, and timely treatment that were identified as predictors of severity of outcome following an aSAH and within each of these defined predictors a number of contributing specific individual predictors are proposed. There are considerable gaps in the current knowledge pertaining to the impact of rurality on the severity of outcome following an aSAH. Absent from the literature is any investigation of the cumulative impact and multiplicity of risk factors associated with rurality. The proposed conceptual framework hypothesizes a number of relationships between both individual level and system level predictors, acknowledging that intervening predictors may mediate the effect of one variable on another.

Long-term outcomes among octogenarians with aneurysmal subarachnoid hemorrhage

OBJECTIVE

Data evaluating the long-term outcomes, particularly with regard to treatment modality, of aneurysmal subarachnoid hemorrhage (SAH) in octogenarians are limited. The primary objectives were to evaluate the disposition (living at home vs institutional settings) and analyze the predictors of long-term survival and return to home for octogenarians after SAH.

METHODS

Data pertaining to patients age 80 and older who underwent microsurgical clipping or endovascular coiling for SAH were extracted from 100% nationwide Medicare inpatient claims and linked with the Minimum Data Set (2008-2011). Patient disposition was tracked for 2 years after index SAH admission. Multivariable logistic regression stratified by aneurysm treatment modality, and adjusted for patient factors including SAH severity, evaluated predictors of return to home at 60 and 365 days after SAH. Survival 365 days after SAH was analyzed with a multivariable Cox proportional hazards model.

RESULTS

A total of 1298 cases were included in the analysis. One year following SAH, 56% of the patients had died or were in hospice care, 8% were in an institutional post-acute care setting, and 36% had returned home. Open microsurgical clipping (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.54-0.81), male sex (aHR 0.70, 95% CI 0.57-0.87), tracheostomy (aHR 0.63, 95% CI 0.47-0.85), gastrostomy (aHR 0.60, 95% CI 0.48-0.76), and worse SAH severity (aHR 0.94, 95% CI 0.92-0.97) were associated with reduced likelihood of patients ever returning home. Older age (aHR 1.09, 95% CI 1.05-1.13), tracheostomy (aHR 2.06, 95% CI 1.46-2.91), gastrostomy (aHR 1.55, 95% CI 1.14-2.10), male sex (aHR 1.66, 95% CI 1.20-2.23), and worse SAH severity 1.51 (95% CI 1.04-2.18) were associated with reduced survival.

CONCLUSIONS

In this national analysis, 56% of octogenarians with SAH died, and 36% returned home within 1 year of SAH. Coil embolization predicted returning to home, which may suggest a benefit to endovascular treatment in this patient population.

Treatment Strategy for Unruptured Intracranial Aneurysm in Elderly Patients: Coiling, Clipping, or Conservative?

An increasing number of unruptured intracranial aneurysms (UIAs) has been discovered in elderly patients in recent years, but the optimal treatment strategy for these patients remains controversial. We report our six-year experience treating UIAs in elderly patients (≥ 70 years old). A retrospective review was conducted of elderly patients who harbored UIAs treated by conservative observation, microsurgical clipping, or endovascular coiling between January 2009 and December 2014. The patients’ clinical and imaging information was recorded. Treating methods, procedure-related complications, imaging results, and clinical outcomes were analyzed. A total of 141 consecutive elderly patients with 166 UIAs were enrolled in our study. In all, 64 patients with 79 aneurysms were treated with coiling, and 14 patients with 14 aneurysms were treated with clipping. The remaining 63 patients with 73 aneurysms were placed under conservative observation. The average modified Rankin scale was 0.99 (range 0–6) in the full cohort after a mean follow-up of 50.4 months (range 0–70 months). There was no significant difference of modified Rankin scale in patients with UIAs treated by different methods. Multivariate analysis showed that age (p=0.030) and aneurysm size (p=0.011) were independent risk factors for unfavorable outcome of UIAs in the elderly. Patient age (p=0.010) and aneurysm size (p=0.020) were also significantly associated with unfavorable outcome of UIAs managed with observation initially. Our results indicated that endovascular coil embolization and clipping were both safe and effective treatment methods for UIAs in the elderly. Aggressive treatment for UIAs in elderly patients with risk factors of aneurysm rupture should be considered positively.

A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage

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.

Rupture of a non-traumatic anterior communicating artery aneurysm: Does location of aneurysm associate with functional independence following post-acute in-patient neurorehabilitation?

OBJECTIVE

Patients with non-traumatic rupture of an aneurysm located at the anterior communicating artery (ACoA) often experience cognitive disabilities. It is unknown whether location of aneurysm also affects the possibility for improvement in functional independence compared to patients with an aneurysmal subarachnoid hemorrhage (a-SAH) located elsewhere. The aim was to explore the association between location of aneurysm (ACoA versus other) and level of functional independence, measured by Functional Independence Measure (FIM), at discharge from rehabilitation. Additionally, age and FIM at admission were explored.

METHOD

Historical cohort study among 107 patients with a-SAH based on data from a clinical database and a population-based register. Data were analyzed using multivariable logistic regression.

RESULTS

Patients with ACoA were admitted with poorer cognitive FIM (median 6 (IQR 5-14) compared to patients with aneurysms located elsewhere (median 12 (IQR 6-23) (p = 0.0129); no difference at discharge. No association between aneurysm location and functional independence was observed. Higher age was associated with poorer outcome in bowel management OR 0.54 (95% CI 0.31-0.92), bladder management OR 0.59 (95% CI 0.35-0.98), comprehension OR 0.53 (95% CI 0.30-0.94), and memory OR 0.48 (95% CI 0.25-0.93). Overall, FIM at admission was associated with functional independence at discharge with the exception of stair walking and bladder management which did not reach statistical significance.

CONCLUSION

ACoA was not associated with poorer level of functional independence compared to patients with a-SAH located elsewhere. Higher age was associated with poorer outcome in continence, comprehension, and memory, whereas higher FIM was associated with better functional independence across items at discharge.

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.

Stroke: an update

Cerebrovascular diseases are one of the favorite topics of manuscripts submitted to the Journal of Neurology. In this summary paper, we briefly present those manuscripts that in our opinion were most relevant in selected areas of vascular diseases of the brain.

Is aneurysm repair justified for the patients aged 80 or older after aneurysmal subarachnoid hemorrhage?

BACKGROUND

With the advancement of an aging society in the world, an increasing number of elderly patients have been hospitalized due to aneurysmal subarachnoid hemorrhage (aSAH). There is no study that compares the elderly cases of aSAH who receive the definitive treatment with those who treated conservatively. The aim of this study was to investigate the feasibility of the definitive surgery for the acute subarachnoid cases aged 80 or older.

METHODS

We reviewed 500 consecutive cases with acute aSAH with surgical indication for aneurysm repair. Inoperable cases such as dead-on-arrival and the cases with both pupils dilated were excluded. We compared the cases aged 80 or older that received clipping or coil embolization with the controls that the family selected conservative treatment.

RESULTS

69 cases were included in this study (ranged 80-98, male:female=9:60). 56 cases (81.2%) had an aneurysm in the anterior circulation. 23 cases received clipping, 20 cases coil embolization and 26 cases treated conservatively. The cases with aneurysm repair showed significantly better clinical outcome than the controls, while World Federation of Neurological Surgeons (WFNS) grade on admission and premorbid modified Rankin Scale showed no difference between them.

CONCLUSIONS

Better prognosis was obtained when ruptured aneurysm was repaired in the elderly than it was treated conservatively. From the results of this study, we should not hesitate to offer the definitive surgery for the elderly with aSAH.