Treatment Risk for Elderly Patients with Unruptured Cerebral Aneurysm from a Nationwide Database in Japan

Surgical Risk in Elderly Patients with Meningiomas in Japan

Background/Objective: No guidelines indicate surgical risk factors for the elderly because of the lack of data from general neurosurgeons. To better understand the management of surgical risk in elderly patients with meningiomas based on a national database in Japan. Methods: Results of surgically treated meningiomas were explored in 8138 patients registered in the Diagnosis Procedure Combination database in Japan during 2010-2015. Age (<65, 65-74, and ≥75 years), sex, Barthel index (BI), medical history, tumor location, oral medication prescriptions on admission, and stroke complications were evaluated. Multivariate logistic regression analysis identified risk factors for stroke complications, BI deterioration between admission and discharge, and in-hospital mortality. Results: Advanced age was the prominent risk factor for BI deterioration (odds ratio: 3.26; 95% confidence interval: 2.69-3.95) but not for in-hospital mortality. Lower BI (60-80) on admission increased the risk of BI deterioration in all age groups; however, BI < 60 demonstrated a significant inverse risk (0.47; 0.32-0.69) in the elderly (≥75 years). Location (falx, parasagittal, and deep) and anticoagulants were not significant risk factors for BI deterioration in patients aged ≥ 75 years, despite being significant risk factors in patients aged <65 and/or 65-74 years. Conclusions: Although advanced age could lead to postoperative functional decline at discharge, it was not sufficiently significant enough to be associated with in-hospital mortality. Because of the possibility of recovery even in elderly patients with severe disabilities, appropriate surgical selection and optimal management may lead to favorable functional outcomes in elderly patients with meningiomas.

Risk Factor Analysis of Complications and Mortality Following Coil Procedures in Patients with Intracranial Unruptured Aneurysms Using a Nationwide Health Insurance Database

(1) Background: Unruptured intracranial aneurysm (UIA) occurs in 1-2% of the population and is being increasingly detected. Patients with UIA are treated with close observation, endovascular coiling or surgical clipping. The proportion of endovascular coiling has been rising. However, complications such as cerebral infarction (CI), intracranial hemorrhage (ICRH), and death remain crucial issues after coil treatment. (2) Methods: We analyzed the incidence and risk factors of complications after the use of coil in patients with UIA based on the patients' characteristics. We utilized the Health Insurance Review and Assessment (HIRA) database. Patients treated with coils for UIA between 1 January 2015 and 1 December 2021 were retrospectively analyzed. (3) Results: Of the total 35,140 patients, 1062 developed ICRH, of whom 87 died, with a mortality rate of 8.2%. Meanwhile, 749 patients developed CI, of whom 29 died, with a mortality rate of 3.9%. The overall mortality rate was 1.8%. In a univariate analysis of the risk factors, older age, males, a higher Charlson Comorbidity Index (CCI) score, and diabetes increase the risk of CI. Meanwhile, males with higher CCI scores and hemiplegia or paraplegia show increased ICRH risk. Older age, males and metastatic solid tumors relate to increased mortality risk. (4) Conclusions: This study is significant in that the complications based on the patient's underlying medical condition were analyzed.

Risk factors of unruptured intracranial aneurysms instability in the elderly

BACKGROUND

Presently, a consistent strategy for determining the stability of unruptured intracranial aneurysms (UIAs) in elderly patients is lacking, primarily due to the unique characteristics of this demographic. Our objective was to assess the risk factors contributing to aneurysm instability (growth or rupture) within the elderly population.

METHODS

In this study, we compiled data from follow-up patients with UIAs spanning from November 2016 to August 2021. We specifically focused on patients aged ≥ 60 years. Clinical histories were gathered, and morphological parameters of aneurysms were measured. The growth of aneurysms was determined using the computer-assisted semi-automated measurement (CASAM). Growth and rupture rates of UIAs were calculated, and both univariate and multivariate Cox regression analyses were conducted. Additionally, Kaplan-Meier survival curves were plotted.

RESULTS

A total of 184 patients with 210 aneurysms were enrolled in the study. The follow-up period encompasses 506.6 aneurysm-years and 401.4 patient-years. Among all the aneurysms, 23 aneurysms exhibited growth, with an annual aneurysm growth rate of 11.0%, and 1 (4.5%) experienced rupture, resulting in an annual aneurysm rupture rate of 0.21%. Multivariate Cox analysis identified poorly controlled hypertension (P = 0.011) and high-risk aneurysms (including anterior cerebral artery (ACA), anterior communicating artery (AcoA), posterior communicating artery aneurysm (PcoA), posterior circulation (PC) > 4 mm or distal internal carotid artery (ICAd), middle cerebral artery (MCA), and PC > 7 mm) (P = 0.006) as independent risk factors for the development of unstable aneurysms.

CONCLUSIONS

In the elderly, poorly controlled hypertension and high-risk aneurysms emerge as significant risk factors for aneurysm instability. This underscores the importance of rigorous surveillance or timely intervention in patients presenting with these risk factors.

The 5-Factor Modified Frailty Index as a More Useful Associated Factor Than Chronological Age After Unruptured Cerebral Aneurysm Surgery: A Nationwide Registry Study

BACKGROUND

Although chronological age is associated with mortality and morbidity after surgery for unruptured cerebral aneurysms (UCAs), there is little evidence regarding an association between the simplified 5-factor modified frailty index (mFI-5) and postoperative outcomes based on age group.

OBJECTIVE

To investigate the association of the mFI-5 score with worse outcomes, mortality, and complications in patients after surgery for UCA by chronological age groups using a Japanese national database.

METHODS

This study included 32 902 patients with UCAs enrolled in a Japanese national database between 2011 and 2015. Age group (younger than 65 years, 65-74 years, and 75 years or older), sex, UCA location, treatment, medications, Barthel Index (BI), medical history, mFI-5 score, and in-hospital mortality and complications were evaluated. We identified risk factors for worsening BI score, in-hospital mortality, and overall postoperative complications in each age group.

RESULTS

In total, 14 465 patients were enrolled in this study. Multivariable analysis showed that elderly groups and patients with an mFI-5 score ≥2 items were associated with worsening BI scores (odds ratio 1.95; 95% CI 1.52-2.51) and in-hospital complications (odds ratio 1.79; CI 1.49-2.15), despite having no association with in-hospital mortality. Multivariable analysis by age groups showed that the mFI-5 score ≥2 items was associated with in-hospital complications in all age groups, unlike chronological age in patients younger than 74 years.

CONCLUSION

The mFI-5 score was a more useful associated factor of in-hospital complications than chronological age in patients younger than 74 years undergoing surgery for UCA.

Perioperative Surgical Risks in Patients With Hemangioblastomas: A Retrospective Nationwide Review in Japan

BACKGROUND

The perioperative risk of sporadic hemangioblastomas (HBs) and von Hippel-Lindau disease (VHL)-associated hemangioblastomas (VHL-associated HBs) remains unclear due to the rare prevalence of HB. Therefore, this study aimed to clarify risk factors for better surgical management of patients with HBs.

METHODS

A retrospective analysis of surgically treated HB patients registered in the Diagnosis Procedure Combination database of Japan, between 2010 and 2015, was performed. Age, sex, sporadic HBs or VHL-associated HBs, medical history, tumor location, hospital case load, postoperative complications, and Barthel index (BI) deterioration were assessed. We also evaluated the outcomes and factors of perioperative BI deterioration.

RESULTS

In total, 676 patients with 609 intracranial lesions, 64 spinal lesions, and 3 with both types were eligible. Among them, 618 and 58 patients had sporadic HBs and VHL-associated HBs, respectively. The rates of perioperative BI deterioration were 12.5% and 12.2% for sporadic HBs and VHL-associated HBs, respectively. Perioperative mortality was 1.8% and 0% for sporadic HBs and VHL-associated HBs, respectively. Male sex, old age, high hospital case load, and medical history of diabetes mellitus were significantly associated with perioperative BI deterioration in all cases and sporadic HBs. Only medical history of diabetes mellitus was a significant risk factor for perioperative BI deterioration in VHL-associated HBs.

CONCLUSIONS

No differences in perioperative BI deterioration rates between sporadic HBs and VHL-associated HBs were found. However, different risk factors for perioperative BI deterioration were identified. Consideration of these risk factors is recommended in all patients undergoing surgery for HB.

A nationwide registry study: The 5-factor modified frailty index of meningioma surgery in non-elderly and elderly patients

OBJECTIVES

The simplified 5-factor modified frailty index (mFI-5) is a useful indicator of outcome for patients undergoing surgeries as frailty is considered an important risk factor in elderly patients. However, its usefulness has not been validated based on age groups. Therefore, we aimed to investigate risk factors, including the mFI-5, across age groups for complications and worse outcomes in meningioma surgery using data obtained from the nationwide database in Japan.

METHODS

We extracted data from the nationwide registry database in Japan between 2010 and 2015. Age (< 65, 65-74, and ≥ 75 years), sex, Barthel Index (BI), mFI-5 scores, and complications were evaluated. Multivariate logistic regression analyses identified risk factors for worsening BI scores and complications after surgery across all age groups.

RESULTS

Among 8138 included patients, an mFI-5 score ≥ 2 items was a significant risk factor for worsening BI scores in patients aged < 65 years (odds ratio: 2.3; 95 % confidence interval: 1.5-3.4), but not in patients aged 65-74 years and those aged ≥ 75 years, contrary to chronological age. Similar results were noted for any complications in patients aged < 65 years (2.5; 1.8-3.6) and aged 65-74 years (1.5; 1.1-2.1), but not in patients aged ≥ 75 years.

CONCLUSION

Although the mFI-5 scores could predict the risk of in-hospital worsening outcomes, mortality, and complications, it was more useful in non-elderly patients aged < 65 years rather than in elderly patients aged ≥ 75 years, contrary to chronological age. Further prospective studies should be performed in the future to clarify the utility of the mFI-5.

Small vs. Large Unruptured Cerebral Aneurysm: Concerns With the Age of Patient

Objective: The coiling and clipping of unruptured cerebral aneurysms (UCAs) in older patients has increased rapidly, and aneurysm size was a significant factor for decision-making in the treatment of UCAs. The purpose of the study was to investigate the impact of age on the functional outcomes of patients between the small versus large UCAs. Methods: We conducted a retrospective study for consecutive cases of UCAs admitted from May 2011 to December 2020. According to the maximum diameter of UCA, patients were divided into small UCAs (≤ 5 mm) group and large UCAs (>5 mm) group. Baseline characteristics, clinical complications, and outcomes of patients between the two groups were analyzed. Results: A total of 564 UCA patients received preventive treatment, including 165 small UCAs and 399 large UCAs. Compared with the small UCA group, the incidence of ischemia event in the large UCA group was significantly higher (7.3 vs. 2.4%; p = 0.029). Multivariable analysis demonstrating age (p = 0.006) and treatment modality (p < 0.001) were independent risk factors associated with poor outcome for patients with large UCAs. Conclusions: Preventive treatment of small UCAs is safe and effective, but older patients with large UCAs are at high risk of poor outcome, and the operations should be more cautious.

Clinical Outcomes of Clipping and Coiling in Elderly Patients with Unruptured Cerebral Aneurysms: a National Cohort Study in Korea

BACKGROUND

We aimed to analyze outcomes of clipping and coiling in treating unruptured intracranial aneurysms (UIAs) in elderly patients and to identify the age at which perioperative risk increases based on national cohort data in South Korea.

METHODS

The incidence of perioperative intracranial hemorrhage (ICRH), perioperative cerebral infarction (CI), mortality, and moderate to severe disability data of the patients who underwent coiling or clipping for UIAs were retrieved. Estimated breakpoint (EBP) was calculated to identify the age at which the risk of treatment increases.

RESULTS

A total of 38,207 patients were treated for UIAs. Among these, 22,093 (57.8%) patients underwent coiling and 16,114 (42.2%) patients underwent clipping. The incidence of ICRH, requiring a secondary operation, within 3 months in patients ≥ 65 years that underwent coiling and clipping was 1.13% and 4.81%, respectively, and that of both groups assessed were significantly higher in patients ≥ 75 years (coiling, P = 0.013, relative risk (RR) 1.81; clipping, P = 0.015) than younger patients. The incidence of CI within 3 months in patients aged ≥ 65 was 13.90% and 9.19% in the coiling and clipping groups, respectively. The incidence of CI after coiling in patients aged ≥ 75 years (P < 0.001, RR 1.96) and after clipping in patients aged ≥ 70 years (P < 0.001, RR 1.76) was significantly higher than that in younger patients. The mortality rates within 1 year in patients with perioperative ICRH or CI were 2.41% and 3.39% for coiling and clipping groups, respectively, in patients ≥ 65. These rates increased significantly at age 70 in the coiling group and at age 75 for the clipping group (P = 0.012 and P < 0.001, respectively).

CONCLUSION

The risk of treatment increases with age, and this risk increases dramatically in patients aged ≥ 70 years. Therefore, the treatment decisions in patients aged ≥ 70 years should be made with utmost care.

Sensitivity of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) in the Elderly: Retrospective Analysis of Ruptured Aneurysms

BACKGROUND/PURPOSE

The prevalence of intracranial aneurysms, as well as the incidence of subarachnoid hemorrhage (SAH), increase with age, and the elderly have poor outcomes after SAH. Age is a key factor in the unruptured intracranial aneurysm treatment score (UIATS),but the sensitivity of the UIATS model in detecting risk of SAH among the elderly is unknown.

METHODS

We retrospectively analyzed 153 consecutive cases of ruptured aneurysms between 2012 and 2018. We used Fisher's exact test, analysis of variance, and multivariate logistic regression to compare outcomes between those >65 years of age and those younger. We then applied the UIATS model and evaluated the sensitivity of the model as a predictor of SAH in the elderly compared with younger patients.

RESULTS

Elderly patients made up 32% (n = 49 of 153) of our cohort. They had significantly higher in-hospital mortality (19 of 49, 39%) than younger patients (14 of 104, 13%) (P < 0.01). In a multivariate logistic regression, controlling for Hunt-Hess grade and comorbidities, age >65 years remained a significant predictor of unfavorable outcome at discharge (P = 0.03). The UIATS model had low sensitivity in the elderly compared with younger patients: 63% (59 of 136) of younger patients would have been recommended aneurysm repair had their aneurysm been detected unruptured, compared with only 12% (5 of 42) of elderly patients >65 years (P < 0.01).

CONCLUSIONS

Elderly patients >65 years in age have far worse outcomes after SAH. The sensitivity of the UIATS model for detecting those at risk of SAH was significantly lower in elderly patients. The UIATS model may lead to undertreatment of elderly patients at risk of SAH.

In-Hospital Complications After Surgery in Elderly Patients with Asymptomatic or Minor Symptom Meningioma: A Nationwide Registry Study

BACKGROUND

Asymptomatic or minor symptom meningiomas (AMSMs) in the elderly are incidental findings, with no consensus reached on the optimal management strategy. In the present study, we aimed to determine the surgical risk factors for elderly patients with AMSMs using a nationwide registry database in Japan.

METHODS

We identified patients with surgically treated AMSMs using the Diagnosis Procedure Combination database from 2010 to 2015 and reviewed the medical records for age (<65 years; pre-elderly, 65-74 years; and elderly, ≥75 years), sex, Barthel index (BI) score, medical history, tumor location, and complications. An AMSM was defined by a BI score of 100 points at admission. The risk factors for all stroke complications, BI deterioration at discharge, and in-hospital mortality were determined using multivariate logistic regression analyses.

RESULTS

From a total of 10,535 patients with meningioma, 6628 were included. Advanced age was a significant risk factor (odds ratio, 3.54; 95% confidence interval, 2.80-4.46) for BI deterioration but not for all-stroke complications or in-hospital mortality. Midline and posterior fossa tumors, diabetes mellitus, and chronic heart disease were significant risk factors for in-hospital mortality.

CONCLUSIONS

For elderly patients with surgically treated AMSMs, advanced age was a prominent risk factor for functional decline at discharge. Our study identified several factors that should be evaluated before proceeding with surgery for AMSMs in elderly and pre-elderly patients. These findings could, not only improve decision-making among clinicians treating patients with AMSMs, but also help in predicting the results of surgery for elderly patients with AMSMs.

Analysis of the Surgical Outcome of Unruptured Intracranial Saccular Aneurysms in Octogenarians (80-89 Years)

Background:

The prevalence of unruptured intracranial aneurysms is increasing in elderly population in Japan. Octogenarians (80–89 years) are more prone to complications due to increased age, comorbidities, increased risk of vasospasm, and treatment risks.

Aim:

The aim is to study the surgical outcome of unruptured intracranial saccular aneurysms in elderly patients aged between 80 and 89 years.

Patients and Methods:

A retrospective study was conducted involving all the cases of unruptured intracranial saccular aneurysms operated surgically in elderly patients aged between 80 and 89 years. All the cases operated between January 2017 and October 2019 were included in the study. The preoperative neurological status was assessed using the Glasgow Coma Scale (GCS). The comorbidities and risk factors involved were assessed. Postoperative neurological status was assessed by (1) postoperative GCS score and by the (2) presence or absence of the motor weakness of limbs.

Results:

Thirty-three aneurysms were operated in 27 patients. Two patients were operated two times at separate occasions for different aneurysms during the study period and hence making a total of 29 surgeries. The age range was 80–88 years, with a mean of 82.4 years ± 2.64 standard deviation (SD). There were 7 (24.1%) males and 22 (75.86%) females. All the patients had a preoperative GCS score of 15/15 without focal neurological deficit. The mean size (mm) of the aneurysms was 6.57 ± 4.04 SD. There were 31 (93.94%) aneurysms in the anterior circulation and 2 (6.06%) aneurysms in the posterior circulation. The comorbidities and risk factors were analyzed and found to be not influencing the outcome of the patients. Clipping was done in 32 aneurysms. One case of posterior inferior cerebellar artery (PICA) aneurysm underwent occipital artery to PICA bypass surgery. The postoperative complications include chronic subdural hematoma (CSDH) in 7 (24.13%) patients, extradural hematoma in 1 (3.4%), meningitis in 1 (3.4%), and lower cranial nerve palsy in 1 (3.4%) patient. All the patients were discharged with GCS score 15/15 without motor weakness of the limbs. The mean duration of stay was 16.62 days ± 9.98 SD.

Conclusion:

Surgery for unruptured saccular aneurysms in octogenarians has got a good result in the tertiary care facility. Advanced age alone should not be considered for preferring coiling over clipping. Octogenarians are more prone to developing postoperative CSDH.

White Matter Lesions as Brain Frailty and Age are Risk Factors for Surgical Clipping of Unruptured Intracranial Aneurysms in the Elderly

INTRODUCTION

We aimed to identify the risk factors for surgical treatment of unruptured intracranial aneurysms (UIAs) in individuals aged >60 years, particularly focusing on white matter lesions (WMLs).

MATERIAL AND METHODS

We investigated a total of 214 patients with UIAs. The patient group comprised 53 males and 151 females with an average age of 68.2 years. UIA size ranged from 2.7 to 26 (mean: 7.3) mm. The primary endpoint of the study was patient prognosis evaluated at the time of discharge using the modified Rankin Scale. We examined the risk factors for poor outcome and WMLs using magnetic resonance imaging.

RESULTS

Poor outcome was observed in 23 (10.7%) patients. Significant correlations were observed between poor outcome and UIA size (P < 0.0001), UIAs located posteriorly (P = 0.0204), UIA thrombosis (P = 0.0002), and presence of WMLs (P < 0.0001) in univariate regression analysis. However, no significant correlations were noted between poor outcome and age (P = 0.1438). Multivariate logistic regression analyses showed significant correlations between poor outcome and UIA size (P < 0.0001), presence of WMLs (P = 0.001). Severe WMLs based on the Fazekas classification was correlated to age (P < 0.0001) and atherosclerosis (P = 0.0001). Severe WMLs were associated with ischemia (P < 0.001) and epilepsy (P = 0.0502) as well as length of hospitalization (P < 0.0001).

CONCLUSION

Severe WMLs are risk factors for surgical treatment of UIAs in the elderly. Surgical indications must be considered and caution should be taken when managing patients with severe WMLs.

Propensity Score Matching Analysis for the Patients of Unruptured Cerebral Aneurysm from a Post Hoc Analysis of a Nationwide Database in Japan

BACKGROUND

This study aimed to compare the functional outcome at discharge for unruptured cerebral aneurysms (UCAs) between surgical clipping and endovascular coiling in total, nonelderly (<65 years), and elderly (≥65 years) patients by nonbiased analysis based on a national database in Japan.

METHODS

A total of 15,671 patients with UCA were registered in the Diagnosis Procedure Combination, the nationwide database, from 2010 to 2015 in Japan. The outcome of the Barthel Index (BI) at discharge was investigated, and propensity score-matched analysis was conducted in total, nonelderly, and elderly patient groups.

RESULTS

Propensity score-matched analysis found no significant difference for in-hospital mortality between the 2 treatment methods in the total and both age-groups. The rate of morbidity of BI <90 at discharge was higher after surgical clipping than after endovascular coiling in the total (4.9% vs. 3.9%; P = 0.040; risk difference, -1.0%; 95% confidence interval, -3.6 to 2.3%) and the elderly age-group (8.1% vs. 5.0%; P < 0.001; risk difference, -3.1%; -4.8% to 1.5%), however, no significant association between the 2 treatment methods (2.4% vs. 2.6%; P = 0.67; risk difference, 0.22%; -0.79 to 1.22%) was found in the nonelderly group.

CONCLUSIONS

In elderly patients with UCA, a better outcome at discharge after endovascular coiling was found. However, no significantly different functional outcome at discharge between surgical clipping and endovascular coiling for UCA in nonelderly patients was confirmed by propensity score-matched analysis from a nationwide database in Japan.