Aggressive surgical treatment of elderly patients following subarachnoid haemorrhage: management outcome results

Aggressive Intraoperative Cisternal Clot Removal After Clipping Aneurismal Subarachnoid Hemorrhage in Elderly Patients

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) in the elderly often has a poor prognosis even after surgical treatment in the acute phase. Additionally, subarachnoid clots are the strongest predictors of cerebral vasospasm and tend to be thicker and heavier due to cerebral atrophy. We aimed to compare the conventional surgical treatment in such patients and identify the independent predictors of a favorable outcome after aggressive surgical clot removal.

METHODS

We included 40 patients with aSAH aged 70 or older. Each patient underwent aneurysmal clipping. We used the modified Rankin Scale to assess the primary outcome of neurologic status at discharge. We performed univariate analysis using the following factors: sex, age, neurologic, and general medical condition, radiographic data, aneurysm location, treatment approach, and timing of the aneurysm surgery. We divided the patients into irrigation and nonirrigation groups. We focused mainly on subarachnoid clots and analyzed them semiquantitatively using computed tomography.

RESULTS

Clot removal was significantly greater in the irrigation group (n = 21) than in the nonirrigation group (n = 19). The period of intrathecal drainage was significantly shorter in the irrigation group (P = 0.002). The rate of occurrence of new low-density areas on CT scans was higher in the nonirrigation group. Outcomes were better in the irrigation group (P = 0.010).

CONCLUSIONS

In elderly patients with aSAH in the acute phase, aggressive surgical clot removal after clipping showed favorable outcomes by facilitating early out-of-bed mobilization.

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.

The role of haptoglobin and hemopexin in the prevention of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a review of current literature

Delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a major cause of mortality and morbidity. The pathophysiology of DCI after aSAH is thought to involve toxic mediators released from lysis of red blood cells within the subarachnoid space, including free haemoglobin and haem. Haptoglobin and hemopexin are endogenously produced acute phase proteins that are involved in the clearance of these toxic mediators. The aim of this review is to investigate the pathophysiological mechanisms involved in DCI and the role of both endogenous as well as exogenously administered haptoglobin and hemopexin in the prevention of DCI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Incidence of subarachnoid haemorrhage: an Australian national hospital morbidity database analysis

Incidences of subarachnoid haemorrhage (SAH) in Australia have been reported in regional studies with variable rates. We investigated the national SAH rate and evaluated the trend over the 10 years from 1998 to 2008. The crude SAH incidence, not related to trauma or arteriovenous malformation, was estimated at 10.3 cases per 100,000 person-years (95% confidence interval [CI]: 10.2-10.4). Females have a higher incidence of SAH (12.5 cases per 100,000; 95% CI: 12.3-12.8) compared to males (8.0 cases per 100,000; 95% CI: 7.8-8.3), with age-adjusted incidence increases with increasing age for both sexes. Less than 10% of SAH occurred in the first three decades of life. The peak age group for patients to experience SAH was between 45 years and 64 years, accounting for almost 45% of the overall annual SAH admissions. Aneurysms located in the anterior circulation were a more common source of rupture compared to those located in the posterior circulation (rate ratio 3.9; 95% CI: 3.6-4.2). Contrary to contemporary observations in the literature, we did not observe a decline in the incidence of SAH during this specified study period.

Subarachnoid hemorrhage in old patients in Chongqing China

BACKGROUND

Subarachnoid hemorrhage (SAH) is a disorder with high mortality in central nervous system, especially in old population. Misdiagnosis and poor outcome frequently occur in old patients with SAH. This research is to investigate the demographic characteristics, clinical features, neuroimaging data, and the outcome of the old patients (≥60 of age) with SAH.

METHODS

The data was from both neurosurgical and neurology departments of two hospitals in Chongqing, China, from October 2007 to March 2009. One hundred and seventy eight patients were enrolled and divided into two groups: the elderly group (≥60 of age) and the non-elderly group (≥18 but <60 of age). The condition on admission was assessed by Hunt-Hess grade (H-H) and the Glasgow scales of coma (GCS). Findings on computerized tomography (CT) were measured by Fisher grades. The outcome after 3 months was evaluated by the modified Rankin Scale (mRS). Statistic analysis was managed by Chi-square test and t-test.

FINDINGS

Compared to the non-elderly group, the clinical conditions on admission in the elderly group was worse, with lower average scores of GCS, higher Fisher grades, systolic blood pressure, and percentage of the H-H IV and V. Some preexisting medical conditions with the old such as arterial hypertension, pulmonary diseases, and diabetes mellitus were worsening. During the clinical course, the elderly group had the following characteristics: the incidence of rebleeding, asymptomatic vasospasm, hydrocephalus, and other severe medical complications were all higher, while the percentage of early surgery was lower. The outcome after 3 months was poorer in the elderly.

CONCLUSIONS

It is indicated that the elderly patients with SAH have poorer clinical conditions, much lower ratio of early surgery and higher incidence of rebleeding. Together, these factors contribute to a poorer short-term outcome after SAH.

The impact of endovascular management on the outcome of aneurysmal subarachnoid hemorrhage in the elderly in eastern Finland

BACKGROUND

The International Subarachnoid Aneurysm Trial (ISAT) concluded that "there is currently no reason to doubt that the reduction of dependent survival or death after endovascular coiling seen in all patients in the ISAT cohort should not be valid in the elderly". We feel that this generalization requires further investigation to assess its validity.

METHODS

We studied the impact of treatment era and independent risk factors for outcome in 179 consecutive elderly (> or =70 years) aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to Kuopio University Hospital either between 1983 and 1992 (Era I, n = 56), prior to the introduction of endovascular management, or between 1995 and 2004 (Era II, n = 123) when the endovascular treatment was established at our institute. Altogether 150 patients underwent occlusive aneurysm treatment, 47 clipping in the Era I as against 49 clipping, 49 endovascular therapy, and five combination therapy in the Era II.

RESULTS

The 12-month survival (n = 179) did not improve from the Era I to the Era II. The proportion of good outcome (GOS IV-V) after occlusive therapy (n = 150) was equal in the Era I and Era II (n = 27/47; 57% vs. n = 56/103; 54%). In multivariate logistic regression analysis, independent predictors of poor outcome were age, poor grade (Hunt&Hess IV-V), hydrocephalus, hypertension, and intraventricular hemorrhage, but not the mode of occlusive therapy (microsurgical vs. endovascular)

CONCLUSION

Clinical severity of the SAH was the most significant predictor of outcome. Integration of coil treatment in clinical practice has not improved the overall outcome of aSAH in the elderly at our institute.

Preoperative prediction of long-term outcome in poor-grade aneurysmal subarachnoid hemorrhage

OBJECTIVE

To evaluate which presentation indices, demographics, and clinical information predict 12-month outcome in poor-grade aneurysmal subarachnoid hemorrhage (SAH), and to provide a preoperative index of prognosis.

METHODS

Data were obtained on all patients with poor-grade (Hunt and Hess Grades IV and V) aneurysmal SAH from a prospectively maintained SAH database and health outcomes project. Demographics, medical history, presenting clinical condition, and health outcomes were analyzed. Survival analysis was performed and Kaplan-Meier curves were generated. Multivariable logistic regression analysis was used to identify significant predictors of poor outcome at 12 months after hemorrhage, as measured by the modified Rankin disability scale.

RESULTS

Survival curves for open surgery and endovascular treatment did not differ significantly. Overall, 40% of the 98 definitively treated patients had a favorable outcome at 12 months. Multivariable analysis identified patient age older than 65 years (P < 0.001), hyperglycemia (P < 0.03), worst preoperative Hunt and Hess Grade V (P < 0.0001), and aneurysm size of at least 13 mm (P < 0.002) as significant predictors of poor outcome. These variables were weighted and used to compute a poor-grade aneurysmal SAH Prognosis Score (hereafter, Prognosis Score) for each patient. A Prognosis Score of 0 was associated with a 90% favorable outcome; Prognosis Score of 1 with 83%; Prognosis Score of 2 with 43%; Prognosis Score of 3 with 8%; Prognosis Score of 4 with 7%; and a Prognosis Score of 5 with 0%.

CONCLUSION

Outcome in poor-grade aneurysmal SAH is strongly predicted by patient age, worst preoperative Hunt and Hess clinical grade, and aneurysm size. Hyperglycemia on admission after poor-grade aneurysmal SAH increases the likelihood of poor outcome, and is a potentially modifiable risk factor. The Prognosis Score is a useful tool for preoperatively assessing the likelihood of a favorable outcome for poor-grade aneurysmal SAH patients.

Subarachnoid haemorrhage in patients > or = 75 years: clinical course, treatment and outcome

BACKGROUND

The number of elderly patients being admitted with aneurysmal subarachnoid haemorrhage (SAH) has been increasing. Treatment of the aneurysm may be offset by the higher rate of surgical or endovascular complications.

AIM

To study the clinical condition at onset, complications during clinical course, treatment and outcome in a consecutive series of elderly patients.

METHODS

Patients who were > or = 75 years at the onset of SAH were selected from the databases of two hospitals. Data on clinical condition at onset (poor condition defined as World Federation of Neurological Surgeons (WFNS) Scale IV and V), clinical course, treatment and outcome were extracted. Univariate and multivariate regression analyses were carried out to identify predictors for in-hospital death and poor outcome, defined as death or dependency.

RESULTS

The data of 170 patients were retrieved, of whom 25 (15%) patients were independent at discharge; none of these patients had been admitted in a poor condition. Poor clinical condition on admission (odds ratio (OR) 7.9; 95% confidence interval (CI) 3.7 to 17) and recurrent haemorrhage (OR 7.5; 95% CI 2.5 to 23) were the strongest predictors for in-hospital death. Recurrent haemorrhage was the strongest predictor for poor outcome in the subset of patients who were admitted in good clinical condition. In all, 10 of 47 (21%) patients were independent at discharge after neurosurgical clipping (n = 34) or endovascular coiling (n = 13).

CONCLUSION

Elderly patients with SAH have a poor prognosis. The effect of the initial haemorrhage is the most common reason for poor outcome. For patients who are admitted in good clinical condition, the most important complication leading to poor outcome is recurrent haemorrhage. Treatment of the aneurysm in patients > or = 75 years is feasible, may improve the outcome and should be strongly considered in patients who are admitted in a good condition.

Reference Table Predicting the Outcome of Subarachnoid Hemorrhage in the Elderly, Stratified by Age

Although the recovery from an aneurysmal subarachnoid hemorrhage (SAH) is hampered by advanced age, the impact of age on surgical outcome has not been evaluated quantitatively. We studied 168 patients with SAH treated between 2000 and 2002. Study variables included sex, age, location of aneurysm, preoperative Glasgow coma scale (GCS) score, and presence of intracerebral hematoma, vasospasm, or hydrocephalus. Univariate and multiple logistic regression analyses were applied to test the effect of age and preoperative GCS scores on the likelihood of a favorable outcome. Multivariate logistic regression analysis showed that advanced age (odds ratio [OR] = 1.109; 95% confidence interval [CI] = 1.051-1.169) and decrements of preoperative GCS score (OR = 0.69; 95% CI = 0.586-0.812) were inversely associated with the likelihood of a favorable outcome. Based on the results, we generated a reference table that depicts the outcome based on the preoperative GCS score stratified by age. This simple reference table is useful in predicting surgical outcome in emergent situations. This study indicated that a 10-year advance in age is equivalent to a 2.3-point reduction in the GCS score.

Partial aortic obstruction improves cerebral perfusion and clinical symptoms in patients with symptomatic vasospasm

OBJECTIVE

Stroke studies in animals showed that aortic obstruction increases cerebral blood flow (CBF) and reduces infarct size. In this study we evaluate the safety and efficacy of a device providing partial and transitory aortic obstruction.

METHODS

We report the results in 24 selected patients with symptomatic vasospasm by aneurysmal subarachnoid hemorrhage treated by partial and transitory aortic obstruction with a novel device (NeuroFlo, CoAxia, MN). Aneurysms were secured by coils prior to the procedure. We studied the adverse effects related to the aorta-obstructing device, and changes in CBF and neurological outcome.

RESULTS

Mean flow velocity increased in both middle cerebral arteries over 15%, and the score in the National Institute of Health Stroke Scale decreased >or=2 point in 20 patients (83%). During the procedure, three patients developed symptoms that were controlled. At 30 days follow-up, three patients had 6 points (unrelated death), three had 3 points, six had 1 point, and 12 had 0 points, in the modified Rankin scale.

DISCUSSION

Partial aortic obstruction was safe, the cerebral blood flow increased without inducing significant hypertension and the neurological defects improved in most of the patients. Efficacy with a better level of evidence will be determined by a randomized study.

Epidemiological aspects of spontaneous subarachnoid haemorrhage in Queensland, Australia

AIMS

To examine the epidemiology of spontaneous subarachnoid haemorrhage (SAH) within the population of Queensland, Australia in 2002.

METHODS

A retrospective population and hospital-based survey of all cases of spontaneous SAH occurring within the population of Queensland (3.7 million) during the calendar year 2002 was performed. Cases were identified from hospital separation coding data and the register of births, deaths and marriages. Standard demographic data was recorded for each case identified.

RESULTS

The annual incidence of SAH in our population was 9.4 cases per 100,000. There was a steady increase in the incidence of SAH with increasing age, with the incidence rising to 38.8 per 100,000 in those aged greater than 80. The overall mortality rate was 33.1%, with 6% of all cases dying before reaching hospital care. The annual incidence in the indigenous population of Queensland was 8.9 /100,000.

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

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

Treatment and outcome of aneurysmal subarachnoid haemorrhage in the elderly patient

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

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

OBJECTIVE:

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

METHODS:

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

RESULTS:

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

CONCLUSION:

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

Untreated subarachnoid hemorrhage: who, why, and when?

OBJECT

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

METHODS

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

CONCLUSIONS

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