Changes in intervention and outcome in elderly patients with subarachnoid hemorrhage

Endovascular coiling versus neurosurgical clipping in the management of aneurysmal subarachnoid haemorrhage in the elderly: a multicenter cohort study

The comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH). Data were obtained from all patients with aSAH aged ≥60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality. Of the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0-2 at 3 months (OR = 2.45 [95%CI:1.16-5.20];p = 0.018), and a lower incidence of in-hospital mortality (OR = 0.31 [95%CI:0.10-0.91];p = 0.026). There were no significant difference between the two treatment groups in terms of good mRS score at 6 months (OR = 1.98 [95%CI:0.97-4.04];p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR = 0.32 [95%CI:0.12-0.90];p = 0.025). Age, admission WFNS score I-III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I-III remained significant predictors of good functional outcomes at 6 months. Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.

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.

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.

“Atypical” Mild Clinical Presentation in Elderly Patients With Ruptured Intracranial Aneurysm: Causes and Clinical Characteristics

Objective

Thunderclap-like severe headache or consciousness disturbance is the common “typical” clinical presentation after aneurysmal subarachnoid hemorrhage (aSAH); however, a slowly developing “atypical” clinical pattern, with mild headache, vomiting, or dizziness, is frequently noted in elderly patients. The aim of this study was to evaluate the clinical characteristics of this “atypical” subgroup, as well as related factors associated with the presence of these mild symptoms.

Methods

The data of 176 elderly patients (≥70 years old) with ruptured intracranial aneurysms (IAs) treated at our center from January 2016 to January 2020 were retrospectively collected and analyzed. The patients were divided into “typical” and “atypical” groups based on their initial and development of clinical symptoms after the diagnosis of aSAH. Intergroup differences were analyzed, and factors related to the presence of these two clinical patterns were explored through multiple logistic regression analyses.

Results

Despite significant admission delay (P < 0.001) caused by mild initial symptoms with slow development, patients in the “atypical” group achieved better clinical prognosis, as indicated by a significantly higher favourable outcome ratio and lower death rate upon discharge and at different time points during the 1-year follow-up, than the “typical” group (P < 0.05). Multiple logistic regression analysis revealed that modified Fisher grade III-IV (OR = 11.182, P = 0.003), brain atrophy (OR = 10.010, P = 0.001), a larger lesion diameter (OR = 1.287, P < 0.001) and current smoking (OR = 5.728, P < 0.001) were independently associated with the presence of “typical” symptoms. Aneurysms with wide necks (OR = 0.013, P < 0.001) were independently associated with the presence of “atypical” symptoms.

Conclusions

“Atypical” presentations, with mild clinical symptoms and slow development, were commonly recorded in elderly patients after the onset of aSAH. Despite the prolonged admission delay, these “atypical” patients achieved better clinical outcomes than those with “typical” symptoms. Modified Fisher grade (III-IV), current smoking, brain atrophy and larger lesion diameter were factors predictive of “typical” symptoms, while aneurysms with wide necks were independently associated with “atypical” symptoms.

Temporal patterns of inflammation-related proteins measured in the cerebrospinal fluid of patients with aneurysmal subarachnoid hemorrhage using multiplex Proximity Extension Assay technology

BACKGROUND

The complexity of the inflammatory response post subarachnoid hemorrhage (SAH) may require temporal analysis of multiple protein biomarkers simultaneously to be more accurately described.

METHODS

Ventricular cerebrospinal fluid was collected at days 1, 4 and 10 after SAH in 29 patients. Levels of 92 inflammation-related proteins were simultaneously measured using Target 96 Inflammation ® assay (Olink Proteomics, Uppsala, Sweden) based on Proximity Extension Assay (PEA) technology. Twenty-eight proteins were excluded from further analysis due to lack of >50% of measurable values. Temporal patterns of the remaining 64 proteins were analyzed. Repeated measures ANOVA and its nonparametric equivalent Friedman's ANOVA were used for comparisons of means between time points.

RESULTS

Four different patterns (Groups A-D) were visually observed with an early peak and gradually decreasing trend (11 proteins), a middle peak (10 proteins), a late peak after a gradually increasing trend (30 proteins) and no specific pattern (13 proteins). Statistically significant early peaks defined as Day 1 > Day 4 values were noticed in 4 proteins; no significant decreasing trends defined as Day 1 > Day 4 > Day 10 values were observed. Two proteins showed significant middle peaks (i.e. Day 1 < Day 4 > Day 10 values). Statistically significant late peaks (i.e. Day 4 < Day 10 values) and increasing trends (i.e. Day 1 < Day 4 < Day 10 values) were observed in 14 and 10 proteins, respectively. Four of Group D proteins showed biphasic peaks and the rest showed stable levels during the observation period.

CONCLUSION

The comprehensive data set provided in this explorative study may act as an illustration of an inflammatory profile of the acute phase of SAH showing groups of potential protein biomarkers with similar temporal patterns of activation, thus facilitating further research on their role in the pathophysiology of the disease.

Neurointensive care results and risk factors for unfavorable outcome in aneurysmatic SAH: a comparison of two age groups

Background

The mean age of actively treated subarachnoid hemorrhage (SAH) patients is increasing. We aimed to compare outcomes and prognostic factors between older and younger SAH patients.

Methods

A retrospective single-center analysis of aneurysmal SAH patients admitted to a neuro-ICU during 2014–2019. We defined older patients as ≥70 years and younger patients as <70 years. For every older patient, we identified three younger patients with the same World Federation of Neurological Surgeons (WFNS) grade. We only included patients receiving active aneurysm treatment. Favorable functional outcome, defined as a Glasgow Outcome Scale (GOS) of 4–5 at 12 months, was our primary outcome. We used logistic regression to compare prognostic factors between the groups.

Results

Ninety-five (85%) of 112 older patients and 317 (94%) of 336 younger patients received aneurysm treatment. Of the younger patients, 91% with a good-grade SAH (WFNS I-III) had a favorable outcome compared to 52% in the older good-grade SAH group. In poor-grade patients (WFNS IV-V), favorable outcome was seen in 51% of younger patients, compared to 24% of older patients. Acute hydrocephalus and intracerebral hemorrhage were associated with unfavorable outcome in the younger (OR 4.7, 95% CI 2.6–8.4, and OR 3.7, 95% CI 2.1–6.4), but not in the older patients (OR 1.8, 95% CI 0.8–4.2, and OR 1.3, 95% CI 0.5–3.1, respectively).

Conclusions

In actively treated SAH patients, age was a major determinant of outcome. Factors reflecting increases in intracranial pressure associated with outcome only among younger patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-04731-4.

Effect of Osteoporotic Condition on Ventriculomegaly and Shunt-Dependent Hydrocephalus After Subarachnoid Hemorrhage

BACKGROUND AND PURPOSE

Hydrocephalus is a common complication in aneurysmal rupture subarachnoid hemorrhage (SAH). As both the bone and arachnoid trabeculae are composed of type 1 collagen, we identified the possible relationship between bone mineral density and ventriculomegaly and shunt-dependent hydrocephalus (SDHC) development after aneurysmal rupture SAH in younger patients.

METHODS

We measured frontal skull Hounsfield unit (HU) values on brain computed tomography upon admission, and mean frontal skull HU values were used instead of T-score value. Hazard ratios were calculated using Cox regression analysis to identify whether osteoporotic condition is an independent predictor for ventriculomegaly and SDHC after surgical clipping for SAH in younger patients.

RESULTS

Altogether, 412 patients (≤65 years) who underwent surgical clipping for primary spontaneous SAH from a ruptured aneurysm were enrolled in this 11-year analysis in 2 hospitals. We observed that the first tertile group of skull HU was an independent predictor of SDHC after SAH compared with the third tertile of skull HU values (hazard ratio, 2.55 [95% CI, 1.25-5.20]; P=0.010). There were no significant interactions between age and skull HU with respect to ventriculomegaly and SDHC in younger patients.

CONCLUSIONS

Our study suggests a relationship between possible osteoporotic conditions and ventriculomegaly and SDHC development after SAH in younger patients. Our findings may be useful in predicting hydrocephalus in young SAH patients using a convenient method of measuring skull HU value on brain computed tomography upon admission.

Endovascular coil embolization for unruptured intracranial aneurysms in patients over 80 years of age

Objective

As the average life span in modern society continues to increase, much interest is focused on high-risk procedures in elderly patients, including major surgical operations. We investigated the results of endovascular coiling of unruptured intracranial aneurysms (UIA) in patients over 80 years of age.

Methods

We retrospectively analyzed 39 patients aged over 80 years who underwent coil embolization for UIA between April 2007 and April 2019 at our hospital.

Results

Complete occlusion on digital subtraction angiography (DSA) immediately after surgery was performed in 44 (84.6%) of 52 cases of cerebral aneurysms. Four patients (7.7%) had residual aneurysmal necks, and four (7.7%) had contrast flow in the aneurysmal sac. Follow-up magnetic resonance angiography (mean: 8.2 months) was performed in 37 aneurysms in 24 patients. There was evidence of blood flow in the neck in seven cases (18.9%) and aneurysm in two cases (5.4%). Follow-up DSA (mean: 20.5 months) was performed in 14 aneurysms in 11 patients, and 11 aneurysms (78.6%) had complete occlusion, 1 aneurysm (7.1%) had an aneurysmal neck, and 2 aneurysms (14.3%) had contrast filling into the aneurysmal sac. Coil embolization procedure-related complications occurred in 3 patients (7.7%). Cerebral infarction occurred in 1 (2.6%), arterial dissection in 1 (2.6%), and hypoesthesia in 1 (2.6%).

Conclusions

Active treatment of UIA in elderly patients over 80 years of age through endovascular coil embolization can be considered.

Long-Term Outcomes of Elderly Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

Long-term outcomes after surgical treatment and intensive care have not been investigated in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to analyze 12-month outcomes and prognostic factors of patients with poor-grade aSAH who were at least age 70 years.

METHODS

We performed a single-center, retrospective study including poor-grade (World Federation of Neurological Societies [WFNS] grades IV and V) aSAH patients who were at least age 70 years, were admitted to our stroke center, and received aneurysmal treatment between April 2012 and September 2018. The clinical outcomes were evaluated at months 3 and 12. Univariate/multivariate analyses were performed to identify the independent prognostic factors of good neurologic outcomes (modified Rankin Scale score 0-3). These factors included sex, age, WFNS grade, Fisher group, delayed cerebral ischemia, aneurysm treatment, aneurysm size, aneurysm location, and blood examination data in the 14 days post subarachnoid hemorrhage.

RESULTS

The proportion of patients with good outcomes (modified Rankin Scale score 0-3) was increased at 12 months compared with that at 3 months. No intracerebral hemorrhage was a significant predictor of good neurologic outcomes at 3 months (P = 0.03). The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from normal sodium levels were significant predictors of good neurologic outcomes at months 3 and 12 (P = 0.04 and P = 0.03, respectively).

CONCLUSIONS

The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from the normal sodium levels were independently associated with good neurologic outcomes at 12 months in elderly patients. Intracerebral hemorrhage did not appear to affect long-term outcomes. These findings suggest that elderly patients with severe subarachnoid hemorrhage should not be excluded from receiving surgical treatment on the basis of their age alone.

Incidence and Case-Fatality of Aneurysmal Subarachnoid Hemorrhage in Australia, 2008-2018

BACKGROUND

Contemporary aneurysmal subarachnoid hemorrhage (aSAH) and case-fatality studies have suggested a diminishing worldwide incidence. The purpose of this study was to examine whether such epidemiologic trends occur in Australia.

METHODS

This retrospective cross-sectional study was based on data retrieved from the Nationwide Hospital Morbidity Database for all aSAH cases across hospital networks in Australia between 2008 and 2018. Information on patient characteristics, aneurysm location, procedures performed, and discharge disposition were extracted. We estimated the crude and age-adjusted incidences, trends of aSAH, and case fatality rate over time. Putative risk factors were investigated with univariate and multivariate logistic regression analysis to identify independent predictors of unfavorable discharge outcome (death and dependency).

RESULTS

A total of 12,915 acute hospital admissions with aSAH were identified. Annual aSAH rate remained stable (mean 5.5, range 5.3-6.0 cases per 100,000 person-years) with no decline. The overall aSAH-associated 30-day case-fatality rate was 26.7% of admissions and declined by approximately 0.7% annually (P < 0.0001). Age-adjusted incidence increased with advancing age at increments of 1.3 cases per 100,000 person-years for each 5 years after the age of 40 years. Endovascular therapy accounted for 63.1% of the overall treatment strategy. Logistic regression demonstrated older age (P < 0.0001), presence of intracerebral or intraventricular hemorrhage (P < 0.0001), and hypertension (P = 0.0007) were significant predictors of unfavorable outcome.

CONCLUSIONS

A decline in 30-day case-fatality rate but not aSAH incidence from 2008 to 2018 was observed.

One-Year Outcome After Aneurysmal Subarachnoid Hemorrhage in Elderly Patients

BACKGROUND

The number of elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) admitted to intensive care units (ICUs) has increased. We aimed to analyze the characteristics and outcomes of such patients in a tertiary university hospital during a 5-year period.

METHODS

A retrospective single-center analysis was performed of patients with aSAH ≥70 years old admitted to a tertiary neuro-ICU during January 2014-May 2019 based on medical records and computed tomography scans. The primary outcome was functional outcome at 12 months. We used multivariable logistic regression to assess factors associated with unfavorable outcome (Glasgow Outcome Scale score 1-3 and institutionalized).

RESULTS

Of 117 included patients, 49% had a favorable outcome at 12 months, and mortality was 41%. In multivariable analysis, poor-grade aSAH and intraventricular hemorrhage were predictors of poor outcome (odds ratio, 4.7, 95% confidence interval, 1.7-12.5 and odds ratio, 2.8, 95% confidence interval, 1.1-7.2, respectively). None of the patients with a Glasgow Coma Scale (GCS) motor score of 1-3 three days after admission was alive at 12 months. In contrast, 65% of those with a GCS motor score 6 had favorable outcome.

CONCLUSIONS

Half of elderly patients with aSAH admitted to a neuro-ICU were able to live at home after 12 months. Mortality was significant, but the number of severely disabled patients was low. Clinical status at admission was the strongest predictor of outcome, whereas intraventricular hemorrhage increased the risk of poor outcome as well. GCS motor score 3 days after admission seemed to predict mortality and outcome.

Practical Incidence of Complications and Degree of Patient Satisfaction After Endovascular Coil Embolization for Unruptured Intracranial Saccular Aneurysm Based on Patients' Surveys

OBJECTIVE

Endovascular treatment for unruptured intracranial aneurysms (UIAs) has been regarded as second to none management nowadays as the result of its proven efficacy and need for less-invasive treatment. Most researchers have focused on the anatomical outcome after endovascular treatment, so in this study we estimated the real incidence of untoward effect and degree of patients' satisfaction based on s survey.

METHODS

This retrospective study was approved by the institutional review board, and 112 patients treated for saccular UIAs were evaluated among a total of 135 patients. After informed consent was obtained, these patients were sent a questionnaire regarding treatment effectiveness, complications, and patient satisfaction. These data were collected and compared with angiographic and clinical outcome.

RESULTS

The response rate was 87.5% (98/112). Intracranial complications occurred in 10 aneurysms (10.2%): 7 ischemic and 3 hemorrhagic strokes. Other complications occurred in 30 patients (30.6%): 17 alopecia, 15 bleeding tendency, and 3 puncture-site complications. Overall, 89 (90.8%) patients reported being satisfied with their treatment. Patient satisfaction was closely correlated with clinically successful outcome of treatment.

CONCLUSIONS

Ninety percent of patients were satisfied with the results after endovascular treatment of UIAs. Endovascular coil embolization was effective and safe procedure, with high clinical success rate and degree of satisfaction.

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.

Interleukin-6 Levels in Cerebrospinal Fluid and Plasma in Patients with Severe Spontaneous Subarachnoid Hemorrhage

BACKGROUND

Inflammatory processes play a key role in the pathophysiology of subarachnoid hemorrhage (SAH). This study evaluated whether different temporal patterns of intrathecal and systemic inflammation could be identified in the acute phase after SAH. The intensity of the inflammation was also assessed in clinical subgroups.

METHODS

Cerebrospinal fluid (CSF) and blood samples were collected at days 1, 4, and 10 after ictus in 44 patients with severe SAH. Interleukin-6 (IL-6) was analyzed by a routine monoclonal antibody-based method. Median IL-6 values for each day were calculated. Day 4 IL-6 values were compared in dichotomized groups (age, sex, World Federation of Neurosurgical Societies [WFNS] grade, Fisher scale grade, outcome, vasospasm, central nervous system infection and systemic infections).

RESULTS

CSF IL-6 levels were significantly elevated from day 1 to days 4 and 10, whereas plasma IL-6 showed a different trend at lower levels. Median CSF IL-6 concentrations for days 1, 4, and 10 were 876.5, 3361, and 1567 ng/L, whereas plasma was 26, 27.5, and 15.9 ng/L, respectively. No significant differences in CSF concentrations were observed between the subgroups, with the most prominent one being in day 4 IL-6 in the WFNS subgroups (grades 1-3 vs. 4-5, 1158.5 vs. 5538 ng/L; P = 0.056). Patients with systemic infection had significantly higher plasma IL-6 concentrations than patients without infection (31 vs. 16.05 ng/L, respectively; P = 0.028).

CONCLUSIONS

Distinctly different inflammatory patterns could be seen intrathecally compared with the systemic circulation. In plasma, a significant difference in the intensity of the inflammation was seen in cases with systemic infection. No other subgroup showed statistically significant differences.

Analysis of Factors That Influence Long-Term Independent Living for Elderly Subarachnoid Hemorrhage Patients

BACKGROUND

The number of elderly subarachnoid hemorrhage (SAH) patients has been increasing. The aim of this study was to analyze long-term outcome for elderly (≥75 years) SAH patients and to establish a treatment strategy.

METHODS

From January 2005 to December 2013, 86 consecutive cases were treated. We used a modified Rankin Scale (mRS) at the outpatient clinic or a telephone interview of patients and/or families. Kaplan-Meier plots were done for mortality and independent (mRS 0 ∼ 2) state. Multivariate analysis was done to distinguish factors that influence on outcome.

RESULTS

Median age was 79, Hunt-Kosnik grade 1 ∼ 3 was 79%, and the radical intervention (clipping or coiling) rate was 78%. Mean follow-up period was 28.7 ± 3.4 standard error months. Half of deaths occurred during the first two months. The number of cases of independent living gradually decreased to 50% at 28 months after SAH. Half of patients lived independently for 36 months at HK grades 1 to 3, and 3 months at HK grades 4 to 5 (p < 0.05). Half of patients lived independently for 40 months in the radical intervention group, and 14 months in the conservative treatment group (p < 0.05). Multivariate analysis for independent living revealed that gender, pre-morbid condition, HK grade, and postoperative complication were significant (p < 0.05).

CONCLUSIONS

Good-grade elderly SAH cases that were independent pre-stroke should have radical intervention performed for aneurysm. Avoiding perioperative complications have a positive influence on long-term independent living.

Neurosurgical Care in the Elderly: Increasing Demands Necessitate Future Healthcare Planning

OBJECTIVES

The worldwide elderly population is steadily increasing. It has been recommended that age-appropriate information should be available for older patients, but little exists in neurosurgery. We aim to better understand the clinical characteristics, bed occupancy and outcomes of elderly patients admitted to a UK neurosurgical unit.

METHODS

Retrospective review of medical records of all patients aged 75 years and older admitted for at least 1 night to the Southwest Neurosurgery Centre from 2007 to 2010. Mortality data up to 31 December 2012 were obtained from a national registry.

RESULTS

Eight hundred and eighty-six elderly patients were admitted, for whom 877 records were available. Three hundred and eighty-nine patients were admitted electively; 488 were emergency or urgent; 48.8% had cranial pathology and 50.7% had spinal disease. Emergency cases were significantly older and more likely to be male than elective patients. The median length of stay for emergency patients was significantly longer than that of elective patients (P < 0.0001, 3 vs. 8 days). One elective patient died as an inpatient, compared with 46 emergency patients. Of emergency and elective patients, 25.6% and 3.6%, respectively, had died by 6 months after discharge. Age and length of stay were not associated with early death.

CONCLUSIONS

The demographics and outcomes of the elderly admitted to a UK neurosurgical center are discussed. Differences between elective and emergency groups are attributable to both the pathologic processes and case selection. Neurosurgical treatment should not be denied based on age, however the high risks of emergency surgery in this age group should be acknowledged.

A meta-analysis of acupuncture use in the treatment of cognitive impairment after stroke

OBJECTIVE

This meta-analysis was conducted to evaluate the efficacy of acupuncture on cognitive impairment (function) after a stroke.

DESIGN

Randomized controlled trials (RCTs) comparing acupuncture with no acupuncture in addition to medicine or rehabilitation were identified from databases (PubMed, Cochrane Central Register of Controlled Trials, Chinese National Knowledge Infrastructure, VIP Chinese Periodical Database, Wangfang Chinese Periodical Database, Chinese Bio-medicine Database, Cochrane Library, and Chinese medical literature databases) and two relevant journals (Chinese Acupuncture and Moxibustion and the Journal of Shanghai Acupuncture and Moxibustion). Meta-analyses were conducted for the eligible RCTs.

RESULTS

Twenty-one trials with a total of 1421 patients met inclusion criteria. Pooled random-effects estimates of the change in the Mini-Mental State Examination were calculated for the comparison of acupuncture with no acupuncture in addition to medicine or rehabilitation. Following 4 weeks and 8 weeks of intervention with acupuncture, the merged mean difference was 3.14 (95% confidence interval [CI], 2.06-4.21; p<.00001) and 2.03 (95% CI, 0.26-3.80; p=0.02), respectively. For the comparison of 3-4 weeks of acupuncture with no acupuncture in addition to medicine or rehabilitation groups, the merged MD in Neurobehavioral Cognitive State Examination total scores was 5.63 (95% CI, 3.95-7.31; p<.00001). For the comparison of 8-12 weeks of acupuncture with no acupuncture in addition to medicine or rehabilitation groups, the P300 latency merged MD was -12.80 (95% CI, -21.08 to -4.51; p<.00001), while the P300 amplitude merged MD was 1.38 (95% CI, 0.93-1.82; p<.00001). Overall, the study quality was rated as moderate on the basis of the Cochrane Handbook for Systematic Reviews of Interventions (part 2: 8.5).

CONCLUSIONS

This meta-analysis suggests that acupuncture had positive effects on cognitive function after stroke and supports the need for additional research on the potential benefits of this therapeutic approach.

Outcome from spontaneous subarachnoid haemorrhage--results from 2007-2011 and comparison with our previous series

OBJECTIVES

The management of patients with spontaneous subarachnoid haemorrhage (SAH) has changed, in part due to interventions now being extended to patients who are older and in a worse clinical condition. This study evaluates the effects of these changes on a complete 5-year patient material.

METHODS

Demographic data and results from 615 patients with SAH admitted from 2007 to 2011 were put together. Aneurysms were found in 448 patients (72.8%). They were compared with the aneurysm group (n = 676) from a previously published series from our centre (2001-2006). Linear regression was used to determine variables predicting functional outcome in the whole aneurysm group (2001-2011).

RESULTS

Patients in the more recent aneurysm group were older, and they were in a worse clinical condition on admission. Regarding younger patients admitted in World Federation of Neurosurgical Societies SAH grading (WFNS) 3, there were fewer with a good outcome. In the whole aneurysm group 2001-2011, outcome was best predicted by age, clinical condition at admission, and the size of the bleeding, and not by treatment mode or localization of aneurysm.

CONCLUSION

It seems important for the outcome that aneurysms are treated early. The clinical course after that depends largely on the condition of the patient on admission rather than on aneurysm treatment method. This, together with the fact that older patients and those in worse condition are now being admitted, increases demands on neurointensive care. Further improvement in patient outcome depends on better understanding of acute brain injury mechanisms and improved neurointensive care as well as rehabilitation measures.

Improved outcome of patients with severe thalamic hemorrhage treated with cerebrospinal fluid drainage and neurocritical care during 1990-1994 and 2005-2009

INTRODUCTION

Patients with thalamic hemorrhage, depressed level of consciousness and/or signs of elevated intracranial pressure may be treated with neurocritical care (NCC) and external ventricular drainage (EVD) for release of cerebrospinal fluid.

METHODS

Forty-three patients with thalamic hemorrhage treated with NCC from 1990 to 1994 (n = 21) and from 2005-2009 (n = 22) were evaluated. Outcome was assessed using the Glasgow Coma Scale (GCS) score at discharge from our unit and the modified Rankin Scale (mRS) for long-term outcome.

RESULTS

Patients' age was 59.5 ± 7 years in 1990-1994, and 58.2 ± 9 years in 2005-2009. The median (25th and 75th percentile) GCS score on admission for the two time periods was 9 (6-12) and 9 (4-14), respectively. Long-term follow-up was assessed at a mean of 37.1 (range 19-65) months after disease onset for the 1990-1994 cohort and at 37.4 (range 14-58) months for the 2005-2009 cohort. Compared to patients from 1990 to 1994, patients from 2005 to 2009 had a significantly better outcome (median mRS [25th and 75th percentile]: 5 [4-6] vs. 4 [2-4.5]; p < 0.01). Most patients (13/21, 62 %) treated from 1990 to 1994 had unchanged or lower GCS scores during their NCC stay in contrast to 7/22 (32 %) from 2005 to 2009. At the last follow-up, 13/21 (62 %) patients from 1990 to 1994 were dead in comparison to 4/21 (19 %) from 2005 to 2009 (p < 0.05). Negative prognostic factors were the 120 h post-admission GCS score in the 1990-1994 patient cohort (p = 0.07) and high age in the recent cohort (p = 0.04).

CONCLUSIONS

Patients with thalamic hemorrhage and depressed level of consciousness on admission had a worse outcome in the early 1990s compared with the late 2000s, which may at least be partially attributed to refined neurocritical care.

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.

Active treatments are a rational approach for hepatocellular carcinoma in elderly patients

AIM: To determine whether an active intervention is beneficial for the survival of elderly patients with hepatocellular carcinoma (HCC).

METHODS: The survival of 740 patients who received various treatments for HCC between 1983 and 2011 was compared among different age groups using Cox regression analysis. Therapeutic options were principally selected according to the clinical practice guidelines for HCC from the Japanese Society of Hepatology. The treatment most likely to achieve regional control capability was chosen, as far as possible, in the following order: resection, radiofrequency ablation, percutaneous ethanol injection, transcatheter arterial chemoembolization, transarterial oily chemoembolization, hepatic arterial infusion chemotherapy, systemic chemotherapy including molecular targeting, or best supportive care. Each treatment was used alone, or in combination, with a clinical goal of striking the best balance between functional hepatic reserve and the volume of the targeted area, irrespective of their age. The percent survival to life expectancy was calculated based on a Japanese national population survey.

RESULTS: The median ages of the subjects during each 5-year period from 1986 were 61, 64, 67, 68 and 71 years and increased significantly with time (P < 0.0001). The Child-Pugh score was comparable among younger (59 years of age or younger), middle-aged (60-79 years of age), and older (80 years of age or older) groups (P = 0.34), whereas the tumor-node-metastasis stage tended to be more advanced in the younger group (P = 0.060). Advanced disease was significantly more frequent in the younger group compared with the middle-aged group (P = 0.010), whereas there was no difference between the middle-aged and elderly groups (P = 0.75). The median survival times were 2593, 2011, 1643, 1278 and 1195 d for 49 years of age or younger, 50-59 years of age, 60-69 years of age, 70-79 years of age, or 80 years of age or older age groups, respectively, whereas the median percent survival to life expectancy were 13.9%, 21.9%, 24.7%, 25.7% and 37.6% for each group, respectively. The impact of age on actual survival time was significant (P = 0.020) with a hazard ratio of 1.021, suggesting that a 10-year-older patient has a 1.23-fold higher risk for death, and the overall survival was the worst in the oldest group. On the other hand, when the survival benefit was evaluated on the basis of percent survival to life expectancy, age was again found to be a significant explanatory factor (P = 0.022); however, the oldest group showed the best survival among the five different age groups. The youngest group revealed the worst outcomes in this analysis, and the hazard ratio of the oldest against the youngest was 0.35 for death. The survival trends did not differ substantially between the survival time and percent survival to life expectancy, when survival was compared overall or among various therapeutic interventions.

CONCLUSION: These results suggest that a therapeutic approach for HCC should not be restricted due to patient age.

Endovascular treatment for unruptured intracranial aneurysms in elderly patients: single-center report

BACKGROUND AND PURPOSE

The optimal management of patients with unruptured intracranial aneurysms remains controversial in elderly populations. The aim of this study was to evaluate technical results and clinical outcomes in a single center of consecutive elderly patients with unruptured intracranial aneurysms treated with endovascular embolization.

MATERIALS AND METHODS

Between May 2003 and February 2010, 96 patients older than 70 years (men, 16 patients; women, 80 patients; mean age, 73 years) with 122 saccular unruptured intracranial aneurysms were treated in our hospital with an endovascular approach. The endovascular procedures and technique, angiographic follow-up, and complications were evaluated.

RESULTS

Successful embolizations without complications were completed in 95.9%. Five patients had procedure-related events, including thromboembolism in 1 patient, aneurysm perforation during the procedure in 1, and 3 postoperative transient minor symptoms (headache, otalgia, and trigeminal pain) in 3. The degree of occlusion of the treated aneurysm was complete in 46.7%; there was a small neck remnant in 40.9% and residual filling in 12.2%. Imaging (MR angiography) follow-up was performed in 68.7% of the patients. The mean follow-up duration was 19.4 months (range, 5-57 months). Fifty-five patients (93.9%) showed no interval change of the residual neck. Four (6%) demonstrated recanalizations, all of which were successfully recoiled.

CONCLUSIONS

Endovascular treatment of unruptured intracranial aneurysms in patients older than 70 years of age appears to be safe. Favorable outcomes with low morbidities may replace surgery or conservative treatment as an active management alternative.

Treatment Outcome of Aneurysmal Subarachnoid Hemorrhage in Patients Aged 70 Years and Older

BACKGROUND:

The incidence of subarachnoid hemorrhage is increasing, especially in the elderly as life expectancy increases. Aggressive treatment of aneurysms in the elderly is usually avoided because of a presumed poor prognosis.

OBJECTIVE:

The aim of this study was to assess the outcome of treatment in patients older than 70 years old.

METHODS:

We performed a retrospective chart review of 150 patients aged 70 years and older who were treated at Jefferson Hospital from 2004 to 2009. Data including World Federation of Neurological Surgeons grade and Hunt and Hess classification, specific management components, and treatment outcome on discharge were analyzed.

RESULTS:

One hundred ten patients had aneurysms coiled, 9 patients had aneurysms clipped, 11 patients had aneurysms that were not treated, and 20 patients had no visible aneurysms. Overall, increased World Federation of Neurological Surgeons grades correlated strongly with poor clinical outcome. Statistical tests indicate that patients who died (mean, 78.8, n = 35) or who went into rehabilitation (mean, 76.5, n = 81) were significantly older than patients who were discharged home (mean, 73.1, n = 20). However, day of presentation after initial symptom(s) of subarachnoid hemorrhage and placement of ventriculoperitoneal shunt also influenced clinical outcome. Patients who had a ventriculoperitoneal shunt were more likely to go into rehabilitation than patients who did not, and patients without a ventriculoperitoneal shunt were more likely to die.

CONCLUSION:

Older age should not preclude a patient from aneurysm treatment. Factors such as low Hunt and Hess or World Federation of Neurological Surgeons grades, earlier presentation to the hospital after initial symptoms, early shunting, prompt interventions, and tailored postoperative management can result in favorable clinical outcomes.

Patient Age and Vasospasm After Subarachnoid Hemorrhage

BACKGROUND:

Subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm is a devastating disease with high mortality and morbidity. The incidence of SAH increases with advancing age.

OBJECTIVE:

To determine whether age is an independent predictor of angiographic vasospasm, delayed ischemic neurological deficits (DINDs), or abnormal transcranial Doppler (TCD) measurements in patients with aneurysmal subarachnoid hemorrhage.

METHODS:

Data from CONSCIOUS-1 (Clazosentan to Overcome Neurological Ischemia and Infarct Occurring After Subarachnoid Hemorrhage study), a dose-finding study of clazosentan, were used. Data on angiographic vasospasm, DINDs, and TCD abnormalities were prospectively recorded as well as baseline characteristics and treatment data. Patient age was considered in 3 ways: as a continuous variable, dichotomized at age 65 years, and categorized by decade. Age was investigated as the main variable, whereas other possible confounding variables were adjusted for in the multiple logistic regression modeling with each of 3 dichotomized vasospasm outcome measures, presence or absence of angiographic vasospasm, DINDs, and TCD abnormalities as the dependent variable.

RESULTS:

The proportions of patients with angiographic vasospasm, DINDs, and TCD abnormalities were 45%, 19%, and 81%, respectively. Age, whether considered as a continuous, dichotomous, or a categorical variable, was not significantly associated with angiographic vasospasm, DINDs, or abnormal TCD measurements.

CONCLUSION:

Age does not seem to be a significant predictor for cerebral vasospasm after subarachnoid hemorrhage.

Neurointensive care is justified in elderly patients with severe subarachnoid hemorrhage--an outcome and secondary insults study

PURPOSE

The aim was to study the outcome and the occurrence of secondary brain insults in elderly patients with severe subarachnoid hemorrhage (SAH) in comparison to younger patients.

METHODS

Ninety-nine patients with severe SAH requiring a ventriculostomy and management at the neurointensive care unit with at least 120 h of multimodality monitoring data during the first 240 h following SAH were included. Data were continuously recorded for intracranial pressure (ICP), cerebral perfusion pressure, blood pressure, oxygen saturation, and temperature. Secondary insult levels were defined and quantified as percent of good monitoring time at insult level. Outcome according to the Glasgow Outcome Scale was evaluated at 6 months after the SAH. Age-dependent differences in occurrence of secondary insults and clinical characteristics were analyzed with multiple regression analysis.

RESULTS

Good recovery or moderate disability was achieved in 24.1% of the elderly and in 42.9% of the younger patients. The frequency of severe disability was 41.4% in the elderly and 37.1% in the younger patients. The occurrence of ICP insults was lower and the occurrence of hypertensive, hypotensive, and hypoxemic insults were higher in the elderly patients.

CONCLUSIONS

An independent outcome was achieved in a substantial proportion of the elderly with severe SAH, and the proportion of severe disability was not greater than among the younger patients, which justifies neurointensive care also in elderly patients. The occurrence of secondary insults was age dependent. Future studies of multimodality monitoring may provide age-specific secondary insult levels necessary for a tailored neurointensive care specific for elderly patients with severe SAH.

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.

Physical Determinants, Emerging Concepts, and Training Approaches in Gait of Individuals with Spinal Cord Injury

The aim of this review is to examine the physical determinants for functional walking as well as the efficacy of gait rehabilitation after spinal cord injury (SCI) in humans. The results indicate several important physical determinants in gait. Examples are provided of different interventions that produce beneficial effects on outcome measures of gait such as gait speed, stride length, walking endurance, motor recovery, and gait quality. These findings need to be considered in current SCI rehabilitation practices, but the efficacy of certain interventions remains unclear. Well-designed clinical trials are needed to provide evidence of the role of physical determinants in the development of new concepts and principles in locomotor recovery after SCI. This review focuses on relevant literature, and informs rehabilitation specialists and basic scientists about the physical determinants and factors to consider for optimization of gait training in individuals with incomplete SCI.

Endovascular treatment of cerebral aneurysms in elderly patients

We report our experience in the endovascular treatment with detachable platinum coils of ruptured or symptomatic unruptured cerebral aneurysms in 61 patients aged 70-82 years. Complete occlusion was achieved in 38, subtotal in 17 and partial in one. The treatment failed in five patients. Clinical follow-up was performed in all patients for 8 months to 8 years. No bleeding occurred during the follow-up period. Outcome was favourable in 63% of the patients. When we compared the outcome of elderly patients with those of younger age endovascularly treated in the same period of time, we found a significantly higher frequency of poorer outcome in the elderly group (chi(2) = 9.084; P = 0.011). The frequency of favourable outcome in the elderly was significantly lower than in the younger group for H-H IV-V (chi(2) = 9.299; P = 0.010). The most important factor influencing the outcome was not age itself, but primary clinical condition on admission. The therapy of symptomatic aneurysms in elderly patients should not be purely conservative--a direct approach of the aneurysm should be considered. Endovascular treatment whenever possible seems to be a good alternative to surgery.

Impact of Coil Embolization on Overall Management and Outcome of Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE:

We report on the consequences of introducing coil embolization for the total management of and outcome in patients with subarachnoid hemorrhage (SAH).

METHODS:

In southern Sweden, a prospective analysis of all patients with SAH of verified aneurysmal origin was conducted during the 3 years when coiling was gradually being introduced. The incidence of acute or chronic hydrocephalus, vasospasm, delayed ischemic deterioration, and outcome at 3 to 6 months after bleeding was analyzed.

RESULTS:

Coiling of aneurysms was used progressively more compared with clipping during the study period. The number of patients subjected to coiling was 26 (36%) of 73 patients during calendar year 1997, 43 (53%) of 81 patients in 1999, and 55 (74%) of 74 patients in 2001 (P &lt; 0.0001). Gradually, more elderly patients were admitted during the study period. Virtually all aneurysms located in the posterior circulation were treated by coil embolization, even at the start of the study, whereas aneurysms at all other locations were progressively more likely to be treated similarly. The incidence of hydrocephalus in the acute (average for all 3 yr, 39%) or chronic (16%) phase, vasospasm as measured by Doppler sonography (33%), and delayed ischemic deterioration (29%), as well as outcome at 3 to 6 months (61% good recovery, 13% deceased), did not change significantly during the study. The main cause of unfavorable outcome was the severity of the SAH.

CONCLUSION:

The increasing use of coil embolization for ruptured aneurysms in the anterior circulation did not have any significant impact on the overall incidence of SAH-related complications or outcome. The main determinant for outcome after SAH is still the severity of the SAH.

Clinical practice. Rehabilitation after stroke

A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities?

Does Acupuncture Help Stroke Patients Become More Independent?

This short speculative report describes the outcome of three studies looking at the effect of acupuncture on stroke recovery and the subsequent place of residence of the subjects entered. It is not a systematic review and does not endeavor to provide comprehensive data on the effect of acupuncture on post-stroke recovery. Our observations demonstrate that patients may be more likely to remain independent and in their own homes one year post stroke if they receive acupuncture. This conclusion is supported by our study and two previous trials. It may be that acupuncture improves post-stroke perception, thereby enhancing independence.

Trends in Surgical and Management Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage in Izumo City, Japan, between 1980–1989 and 1990–1998

BACKGROUND AND PURPOSE

The purpose of this community-based study was to evaluate temporal changes in surgical and management outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

The subjects were 358 patients with aneurysmal SAH who were treated during the 19-year period from 1980 to 1998 in Izumo City, Japan. We compared data during the 9-year period 1990-1998 (period B; 188 patients) with those during the 10-year period 1980-1989 (period A; 170 patients).

RESULTS

The proportion of patients 80 years of age or older or those with World Federation of Neurosurgical Societies grade V increased significantly (period A, 5 and 25%; period B, 18 and 35%, respectively). The operability rate did not change for patients 69 years of age or younger, whereas it increased significantly for those 70-79 years of age (period A, 48%; period B, 72%). The 6-month and 2-year case fatality rates in surgically treated patients decreased significantly (period A, 12 and 20%; period B, 2 and 8%, respectively), whereas they were virtually unchanged for overall management (period A, 41 and 46%; period B, 38 and 42%, respectively). In patients who underwent surgery, the incidence of permanent symptomatic vasospasm decreased from 21% during period A to 11% during period B, and there was no death from vasospasm in the later period. However, no significant difference was found in the functional outcome between the two periods, regardless of whether surgery was performed. The most important determinants of 6-month and 2-year survival rates were grade on admission, rebleeding and the site of the ruptured aneurysms. Age was also a significant predictor of the 6-month case fatality rate.

CONCLUSIONS

For patients with SAH who underwent surgery, there were trends towards decreases in the case fatality rate and in the incidence of permanent symptomatic vasospasm. Nevertheless, the overall management outcome was still unsatisfactory, mainly because of increasing numbers of very elderly and/or high-risk patients. .

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.

Intracerebral aneurysms: a review with special attention to geriatric aspects

Rupture of an intracranial aneurysm (ICA) remains a devastating complication associated with a high degree of morbidity and mortality. In the past 2 decades, older people were often excluded from active treatment on the unique basis of their chronological age. Recent developments of less-invasive techniques for the diagnosis and treatment of ruptured and unruptured ICAs suggest that this fatalistic attitude toward older patients should be reconsidered. Furthermore, taking into account the heterogeneity of the elderly population, the use of a comprehensive geriatric assessment approach, based on a multidisciplinary evaluation, appears particularly helpful in proposing the optimal treatment strategy for each older patient. This article reviews the geriatric features of epidemiological, physiopathological, as well as clinical and therapeutic aspects of ruptured and unruptured ICAs.

Acupuncture during labor can reduce the use of meperidine: a controlled clinical study

OBJECTIVE

To evaluate the effectiveness of acupuncture as an analgesic during labor.

DESIGN

A randomized, unblinded, controlled study.

SETTING

A labor ward in a University Hospital.

PATIENTS

Parturients at term.

INTERVENTIONS

One group received acupuncture (N = 106); another did not (N = 92). A second control group (N = 92), drawn from the labor ward protocol, consisted of patients who met the eligibility criteria for the study and were matched to the "no acupuncture" group by parity, but who had not been offered the opportunity to take part. Outcome measure "effectiveness of acupuncture" was measured by the requirement for use of meperidine.

RESULTS

Meperidine was given to 11% of the acupuncture group, 37% of the no acupuncture group (P < 0.0001), and 29% of the control group. The use of other analgesics was also lower in the acupuncture group. Patient satisfaction was high: 89 of 103 patients asked said they would want acupuncture during another labor.

CONCLUSIONS

Acupuncture during labor reduced the requirement for other painkillers and has high patient satisfaction in this randomized, unblinded, controlled study.

Feasibility of a Curvature-based Enhanced Display System for Detecting Cerebral Aneurysms in MR Angiography

PURPOSE

To assess the feasibility of a curvature-based enhanced display system for detecting cerebral aneurysms in MR angiography.

METHODS

MR angiography studies of 18 patients (eight male and 10 female, average age 65.7, age range 50 to 75 years old) with 23 known aneurysms were evaluated with a curvature-based display system. The two curvature features-the volumetric shape index and curvedness values-were calculated at each voxel. These were displayed independently on a workstation, overlaid on volume-rendered images. Two neuroradiologists evaluated the images for visibility and diagnosis of the cerebral aneurysms. The diagnostic results were compared with the original reports.

RESULTS

The calculation time for each curvature index was 30 to 40 s for 120 to 140 slices of original MR angiography data. Shape index images emphasized smooth and round aneurysms more than aneurysms with irregular surfaces. Curvedness images revealed aneurysms well when the aneurysms had diameters that differed from those of the surrounding vessels. The computer-assisted-detection method detected 24 aneurysms, three of which were not pointed out in the initial report.

CONCLUSION

Our results show that the curvature-based display system we have developed is feasible and that it may help to detect small aneurysms that are prone to be overlooked in routine readings.

Critical care issues in stroke and subarachnoid hemorrhage

The outcomes of devastating neurological emergencies such as stroke and subarachnoid hemorrhage may be measurably improved by timely treatment in a neurointensive care unit (NICU). Optimal care requires a multidisciplinary approach, with attention to a wide range of treatment issues. This review examines the key therapeutic concerns in the NICU management of acute ischemic and hemorrhagic stroke and subarachnoid hemorrhage, including mechanical ventilation, blood pressure management, cardiac monitoring, intracranial pressure assessment, vasospasm, seizures, sedation, fluids, electrolytes, and nutrition. The discussion of mechanical ventilation includes rapid sequence induction and intubation, indication for intubation and extubation, and prognostic factors in mechanical ventilation. Differing blood pressure management concerns in hemorrhagic and ischemic events are discussed, and specific target blood pressures and pharmacologic interventions are reviewed. The discussion of cardiac monitoring includes concurrent stroke and cardiac ischemia and arrhythmias, cardiac imaging, anticoagulation, and vasopressor therapy. The importance, monitoring and management of cerebral blood flow and intracranial pressure (ICP) are discussed, and strategies for treatment of elevated ICP are outlined in detail. The discussion of vasospasm includes evaluation, prophylaxis, and treatment with medications, hypervolemic hemodilution, and angioplasty. Management of seizure and status epilepticus in stroke and subarachnoid hemorrhage are reviewed and current algorithms are presented. The management of fluids, electrolytes and enteral nutrition are also reviewed.

The role of rehabilitation in the recovery of walking in the neurological population

Recent studies demonstrate that neurological patients show great potential for recovery in both the early and late stages following injury. Enhancement of the recovery process could be achieved with new rehabilitation approaches alone or in combination with pharmacological intervention. These new approaches have evolved from fundamental advances in both animal and human studies. To date few randomized clinical trials have addressed the efficacy or effectiveness of these new approaches. In this paper, important quantitative studies will be reviewed and discussed in relation to the important mechanisms of locomotor control and plasticity that take place following lesions of the central nervous system.