1
|
Park SY, Kim SA, An YH, Kim SW, Kim S, Lee JM, Jung Y. Risk Factor Analysis of Complications and Mortality Following Coil Procedures in Patients with Intracranial Unruptured Aneurysms Using a Nationwide Health Insurance Database. J Clin Med 2024; 13:1094. [PMID: 38398408 PMCID: PMC10889784 DOI: 10.3390/jcm13041094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Unruptured intracranial aneurysm (UIA) occurs in 1-2% of the population and is being increasingly detected. Patients with UIA are treated with close observation, endovascular coiling or surgical clipping. The proportion of endovascular coiling has been rising. However, complications such as cerebral infarction (CI), intracranial hemorrhage (ICRH), and death remain crucial issues after coil treatment. (2) Methods: We analyzed the incidence and risk factors of complications after the use of coil in patients with UIA based on the patients' characteristics. We utilized the Health Insurance Review and Assessment (HIRA) database. Patients treated with coils for UIA between 1 January 2015 and 1 December 2021 were retrospectively analyzed. (3) Results: Of the total 35,140 patients, 1062 developed ICRH, of whom 87 died, with a mortality rate of 8.2%. Meanwhile, 749 patients developed CI, of whom 29 died, with a mortality rate of 3.9%. The overall mortality rate was 1.8%. In a univariate analysis of the risk factors, older age, males, a higher Charlson Comorbidity Index (CCI) score, and diabetes increase the risk of CI. Meanwhile, males with higher CCI scores and hemiplegia or paraplegia show increased ICRH risk. Older age, males and metastatic solid tumors relate to increased mortality risk. (4) Conclusions: This study is significant in that the complications based on the patient's underlying medical condition were analyzed.
Collapse
Affiliation(s)
- So Yeon Park
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - So An Kim
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Yu Hyeon An
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Sang Won Kim
- Medical Research Center, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Saeyoon Kim
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea;
| | - Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea;
| | - Youngjin Jung
- Department of Neurosurgery, Yeungnam University Medical Center, Daegu 42415, Republic of Korea
| |
Collapse
|
2
|
Laukka D, Kivelev J, Rahi M, Vahlberg T, Paturi J, Rinne J, Hirvonen J. Detection Rates and Trends of Asymptomatic Unruptured Intracranial Aneurysms From 2005 to 2019. Neurosurgery 2024; 94:297-306. [PMID: 37695560 PMCID: PMC10766300 DOI: 10.1227/neu.0000000000002664] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/09/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The trend in detection rates of asymptomatic unruptured intracranial aneurysms (UIAs) on brain computed tomography angiography/magnetic resonance angiography (CTA/MRA) is not well established. Our objective was to evaluate time trends in asymptomatic UIA detection rates on brain CTA/MRA between 2005 and 2019. METHODS We conducted a retrospective study of all brain computed tomography/magnetic resonance scans (n = 288 336 scans in 130 621 patients) performed between January 2005 and December 2019 at a tertiary referral hospital. Patients who underwent brain CTA/MRA examinations were included (n = 81 261 scans in 48 037 patients). The annual detection rate of new UIA cases was calculated based on the first brain CTA/MRA imaging. Detection rates were compared between three periods and across different age groups. RESULTS The number of first CTA/MRA examinations increased significantly from 2005 to 2009 (n = 12 190 patients) to 2010-2014 (n = 14 969 patients) and 2015-2019 (n = 20 878 patients) ( P < .001). The UIA detection rate also increased significantly from 1.7% in 2005-2009 to 2.5% in 2010-2014 and 3.4% in 2015-2019 ( P < .001). The UIA detection rate increased significantly from 2010-2014 to 2015-2019 (relative risk [RR], 1.33; 95% CI, 1.17-1.51), particularly in patients aged 60-69 years (RR, 1.29; 95% CI, 1.01-1.63), 70-79 years (RR, 1.71; 95% CI, 1.30-2.25), and >79 years (RR, 2.33; 95% CI, 1.56-3.47). Furthermore, the detection rate of <5-mm UIAs increased from 2010-2014 to 2015-2019 (RR, 1.51; 95% CI, 1.28-1.77). CONCLUSION The detection rate of asymptomatic UIAs, particularly in elderly patients, has increased significantly over the past 15 years, coinciding with the increased use of CTA/MRA imaging. Furthermore, the size of the identified UIAs has decreased. These findings raise concerns about the management strategies for UIAs, indicating the need for further research.
Collapse
Affiliation(s)
- Dan Laukka
- Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
- Clinical Neurosciences, University of Turku, Turku, Finland
| | - Juri Kivelev
- Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
- Clinical Neurosciences, University of Turku, Turku, Finland
| | - Melissa Rahi
- Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
- Clinical Neurosciences, University of Turku, Turku, Finland
| | - Tero Vahlberg
- Department of Clinical Medicine, Biostatistics, University of Turku, Turku, Finland
- Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
| | - Jooa Paturi
- Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
- Clinical Neurosciences, University of Turku, Turku, Finland
| | - Jaakko Rinne
- Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
- Clinical Neurosciences, University of Turku, Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, Turku University Hospital and University of Turku, Turku, Finland
- Department of Radiology, University of Tampere, Tampere, Finland
| |
Collapse
|
3
|
Metayer T, Blanc R, Smajda S, Desilles JP, Redjem H, Escalard S, Mazighi M, Tayeb AA, Robichon E, Raaisi AA, Boisseau W, Delvoye F, Piotin M. Treated unruptured cerebral aneurysm in elderly patients: a single center study. Neurochirurgie 2024; 70:101522. [PMID: 38101026 DOI: 10.1016/j.neuchi.2023.101522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION The increase in life expectancy raises the question of the treatment of unruptured intracranial aneurysms in extremely old patients (>80 years). We present results in terms of occlusion and complications in both symptomatic and asymptomatic aneurysm. METHODS All patients aged >80 years admitted to the Foundation Adolphe de Rothschild between January 1, 2005 and March, 2023 were included. Aneurysms were grouped as compressive and non-compressive. Procedural complications were grouped as symptomatic (i.e., leading to any temporary or permanent neurological deficit) and severe (defined by modified Rankin Scale (mRS) ≥3 at follow-up). RESULTS Forty-two aneurysms were treated in the study period. Coiling (with or without remodeling) was the treatment of choice in 30 patients. Eighteen patients had compressive aneurysm. Six complications occurred (14.2%), all ischemic. The majority of complications occurred in symptomatic aneurysms, in 4 patients (66.6%). One of the patients treated by flow-diverter had severe complications (mRs ≥3) with hemiplegia. CONCLUSION In extremely specific cases, treatment of unruptured aneurysm in people older than 80 years may be considered. Compressive aneurysm is associated with a high risk of complications. Treatments can be endovascular. Further prospective studies are required to confirm this hypothesis.
Collapse
Affiliation(s)
- Thomas Metayer
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France; Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000 Caen, France.
| | - Raphael Blanc
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Stanislas Smajda
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Jean Philippe Desilles
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France; Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France
| | - Hocine Redjem
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Simon Escalard
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Mikael Mazighi
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France; Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France
| | - Adnan Al Tayeb
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Erwan Robichon
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Amira Al Raaisi
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - William Boisseau
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Francois Delvoye
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France; University of Liège, Liège, Belgium
| | - Michel Piotin
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| |
Collapse
|
4
|
Salih M, Khorasanizadeh M, Salem MM, Baig AA, Kim H, Lucke-Wold B, Hoh BL, Jankowitz BT, Burkhardt JK, Siddiqui AH, Taussky P, Thomas AJ, Moore JM, Ogilvy CS. Effect of Chronic Anticoagulation on Outcomes of Endovascular Treatment for Unruptured Intracranial Aneurysms-A Propensity-Matched Multicenter Study. Neurosurgery 2023; 93:1007-1018. [PMID: 37255291 DOI: 10.1227/neu.0000000000002523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/21/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular treatment of unruptured intracranial aneurysms (UIAs) in patients receiving anticoagulant medications has not been well studied. Whether long-term anticoagulation (AC) use affects aneurysmal obliteration rates and treatment-related complications is unclear. METHODS Patients with endovascular treatment for UIA from 4 academic centers were identified and divided into AC and non-AC groups. Periprocedural complications, radiographic and clinical outcomes, and retreatment rates were compared between the 2 groups before and after propensity score matching. RESULTS The initial cohort consisted of 70 patients in the AC group and 355 in the non-AC group. After one-to-one nearest neighbor propensity matching, 38 pairs of patients were compared for periprocedural complications. The total number of complications were higher in the AC group yet not significant (18.4% vs 5.3%, P = .15). After adding imaging follow-up duration to matched variables, 36 pairs were obtained. There was no significant difference in Raymond-Roy occlusion rate between the 2 groups ( P = .74). However, retreatment rate trended higher in the AC group compared with the non-AC group (22.2% vs 5.6%, P = .09). When clinical follow-up duration was added among matched variables, 26 pairs of cases were obtained for long-term clinical outcomes. There was no significant difference in modified Rankin Scale score between the 2 groups ( P = .61). One-to-many nearest neighbor propensities matched analysis with bigger sample sizes yielded similar results. CONCLUSION The use of anticoagulants does not affect occlusion rates or long-term outcomes in endovascular treatment of UIAs. Retreatment rates were higher in the AC group; however, this was not statistically significant.
Collapse
Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - MirHojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA
| | - Ammad A Baig
- University at Buffalo Neurosurgery, Buffalo , New York , USA
| | - Hoon Kim
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia , Pennsylvania , USA
| | | | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston , Massachusetts , USA
| |
Collapse
|
5
|
Choi HZ, Kim SU, Huh J, Lee HG, Kim MK, Kim DS, Huh CW. Comparison of treatment outcomes and complications of coil embolization in elderly and very elderly patients with cerebral aneurysms: a propensity score matching analysis. Acta Neurochir (Wien) 2023; 165:3361-3369. [PMID: 37728829 DOI: 10.1007/s00701-023-05793-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE This single center study aims to compare the treatment outcomes and procedure-related complications of coil embolization in elderly patients (60-79 years) and very elderly patients (aged 80 years or older) with cerebral aneurysms. METHODS Data was collected from 504 elderly patients aged 60 years or older who underwent coil embolization for intracranial aneurysms from 2018 to 2021. The study evaluated patient-related and anatomical factors and assessed various outcomes, comparing results between groups using statistical analysis and propensity score matching. RESULTS A total of 503 cerebral aneurysms were analyzed from individuals aged 60-79 years (n = 472) and those aged 80 years or older (n = 31). The majority of the aneurysms were unruptured with an average size of 3.5 mm in height and 3.4 mm in width. The patients were compared using 1:1 propensity score matching, and no significant differences were found in factors other than age and aortic elongation. Logistic analysis revealed that being over 80 years old and having a severe aortic arch elongation were identified as risk factors for procedure-related events in both total and unruptured cases. CONCLUSIONS The study compared coil embolization treatment for cerebral aneurysms in patients aged 60-79 and over 80, finding no significant difference in treatment outcomes except for procedure-related events. Procedure-related events were associated with severe aortic arch elongation and being over 80 years old. Coil embolization can be considered safe and effective for patients over 80, but further trials are needed for accurate conclusions.
Collapse
Affiliation(s)
- Han-Zo Choi
- Department of emergency medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Sang-Uk Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea.
| | - Joon Huh
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Hyun-Goo Lee
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Mi-Kyung Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Dal-Soo Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| | - Choon-Woong Huh
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, 156, Dorimro, Youngdungpo-gu, Seoul, 07417, Republic of Korea
| |
Collapse
|
6
|
Ozono I, Ikawa F, Hidaka T, Matsuda S, Oku S, Horie N, Date I, Suzuki M, Kobata H, Murayama Y, Sato A, Kato Y, Sano H. Different Risk Factors Between Cerebral Infarction and Symptomatic Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 173:e487-e497. [PMID: 36841530 DOI: 10.1016/j.wneu.2023.02.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/27/2023]
Abstract
OBJECTIVE Cerebral infarction due to cerebral vasospasm (IVS) after aneurysmal subarachnoid hemorrhage is associated with poor outcomes and symptomatic cerebral vasospasm (SVS). However, the difference of risk factors between SVS and IVS was unclear to date. In this study, we aimed to elucidate the risk factors for SVS and IVS based on the registry study. METHODS The modified World Federation of Neurosurgical Societies scale study comprises 1863 cases. Patients with aneurysmal subarachnoid hemorrhage who underwent radical treatment within 72 hours with a premorbid modified Rankin Scale score 0-2 as the inclusion criteria were retrospectively examined. The risk factors for SVS and IVS were analyzed using multivariable logistic regression analysis. RESULTS Among them, 1090 patients who met the inclusion criteria were divided into 2 groups according to SVS and IVS; 273 (25%) patients with SVS and 92 (8.4%) with IVS. Age was not a risk factor for SVS, but for IVS, and Fisher scale was a risk factor for SVS, but not for IVS. CONCLUSIONS The prevalence of IVS was not associated with the Fisher scale but with older age, suggesting possible factors other than SVS. Different associated factors between SVS and IVS were confirmed in this study.
Collapse
Affiliation(s)
- Iori Ozono
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan; Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Toshikazu Hidaka
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Shingo Matsuda
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Shinnichiro Oku
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Michiyasu Suzuki
- Department of Advanced ThermoNeuroBiology, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Osaka, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Sato
- Department of Rehabilitation, Gotanda Rehabilitation Hospital, Tokyo, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Hirotoshi Sano
- Department of Neurosurgery, Shinkawabashi Hospital, Kawasaki, Japan
| |
Collapse
|
7
|
Long-term outcomes of ruptured saccular intracranial aneurysm clipping versus coiling: systematic review and meta-analysis of randomized controlled trials. Neurol Sci 2022; 43:4909-4915. [DOI: 10.1007/s10072-022-06039-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
|
8
|
Caffes N, Wenger N, Cannarsa G, Oliver J, Onwukwe C, Gandhi D, Simard JM. Unruptured cerebral aneurysms in elderly patients: key challenges and management. Ann Med 2021; 53:1839-1849. [PMID: 34664535 PMCID: PMC8530485 DOI: 10.1080/07853890.2021.1990393] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/03/2021] [Indexed: 12/01/2022] Open
Abstract
Unruptured cerebral aneurysms are increasingly identified in elderly patients as the global life expectancy continues to rise and non-invasive vascular imaging becomes more prevalent. The optimal management of unruptured aneurysms in elderly patients remains controversial. Variability in life expectancy, comorbidities and rupture risk coupled with heterogenous endovascular and surgical treatments contribute to a paucity of clear guidelines, and current management is highly individualized. Elderly patients present unique considerations including frailty, cognitive dysfunction, vasculopathy, reduced life expectancy and overall worse prognosis in case of rupture which shape the risks and likelihood of success of endovascular and microsurgical treatment. In this review, we provide a comprehensive overview of unruptured cerebral aneurysms in the elderly, with a particular focus on the natural history, key challenges associated with advanced age, management and future innovations to further refine treatment.Key MessagesThe management of unruptured cerebral aneurysms in elderly patients remains controversial.Key challenges including frailty, cognitive dysfunction, reduced life expectancy, vasculopathy and poor prognosis with aneurysm rupture add complexity to endovascular and surgical decision making not encountered with younger demographics.A thorough understanding of available treatment options, likelihood of treatment success and associated risks weighed against the risk of aneurysm rupture informs patient discussion and management.
Collapse
Affiliation(s)
- Nicholas Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicole Wenger
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey Oliver
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chimdiya Onwukwe
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
9
|
Wang Y, Xie Y, Wang H, Zhang J, Li C, Chen F, Ren C, Xu Z, Liu M, Li L, Li T, Wang W. Development and Clinical Translation of a Perioperative Nomogram Incorporating Free Fatty Acids to Predict Poor Outcome of Aneurysmal Subarachnoid Hemorrhage Following Endovascular Treatment. Front Neurol 2021; 12:629997. [PMID: 34385967 PMCID: PMC8354211 DOI: 10.3389/fneur.2021.629997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/04/2021] [Indexed: 12/12/2022] Open
Abstract
Objective: A reliable prediction of clinical outcome is important for clinicians to set appropriate medical strategies in treating patients with aneurysmal subarachnoid hemorrhage (aSAH). In this study, we aim to establish a perioperative nomogram involving serum lipid signatures for predicting poor outcomes at 3 months in patients with aSAH following endovascular therapy. Methods: Data of patients with aSAH receiving endovascular therapy were collected. Univariable and multivariable analyses were performed to screen independent predictors related to unfavorable outcomes defined by the modified Rankin Scale (mFS) ≥3. A novel nomogram based on these significant features was conducted. The clinical application of this nomogram was assessed by decision curve analysis (DCA) and clinical impact curve. Results: A total number of patients included in this study were 213 (average age 58.9 years, 65.7% female), representing a poor 3-month outcome rate of 48.8%. Free fatty acid (FFA) levels on admission were efficient in predicting poor outcomes compared with other contents in serum lipids. Univariable and multivariable analyses revealed advanced age (P = 0.034), poor Hunt Hess (HH) (odds ratio, OR = 3.7, P < 0.001) and mFS (OR = 6.0, P < 0.001), aneurysms in the posterior circulation (OR = 4.4, P = 0.019), and higher FFA levels on admission (OR = 3.1, P = 0.021) were negative independent predictors of poor 3 months outcome. A novel nomogram composed of these significant features presented a concordance index (C-index) of 0.831 while the practical benefit was validated by DCA and clinical impact curve. An online calculator based on R programming promoted the clinical application of this nomogram. Conclusion: Nomogram involving age, HH grade, mFS, aneurysm location, and serum FFA levels was sufficient to provide an individualized prediction of 3-month poor outcome for each patient with aSAH who underwent endovascular therapy.
Collapse
Affiliation(s)
- Yongyi Wang
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Yongfan Xie
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Houzhong Wang
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Jifang Zhang
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Chuanfeng Li
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Feng Chen
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Chengtao Ren
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Zhiming Xu
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Mingxing Liu
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Luo Li
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Tong Li
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Weimin Wang
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| |
Collapse
|
10
|
Lee SH, Lee SU, Kwon OK, Bang JS, Ban SP, Kim T, Kim YD, Byoun HS, Oh CW. Clinical Outcomes of Clipping and Coiling in Elderly Patients with Unruptured Cerebral Aneurysms: a National Cohort Study in Korea. J Korean Med Sci 2021; 36:e178. [PMID: 34227262 PMCID: PMC8258241 DOI: 10.3346/jkms.2021.36.e178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/06/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We aimed to analyze outcomes of clipping and coiling in treating unruptured intracranial aneurysms (UIAs) in elderly patients and to identify the age at which perioperative risk increases based on national cohort data in South Korea. METHODS The incidence of perioperative intracranial hemorrhage (ICRH), perioperative cerebral infarction (CI), mortality, and moderate to severe disability data of the patients who underwent coiling or clipping for UIAs were retrieved. Estimated breakpoint (EBP) was calculated to identify the age at which the risk of treatment increases. RESULTS A total of 38,207 patients were treated for UIAs. Among these, 22,093 (57.8%) patients underwent coiling and 16,114 (42.2%) patients underwent clipping. The incidence of ICRH, requiring a secondary operation, within 3 months in patients ≥ 65 years that underwent coiling and clipping was 1.13% and 4.81%, respectively, and that of both groups assessed were significantly higher in patients ≥ 75 years (coiling, P = 0.013, relative risk (RR) 1.81; clipping, P = 0.015) than younger patients. The incidence of CI within 3 months in patients aged ≥ 65 was 13.90% and 9.19% in the coiling and clipping groups, respectively. The incidence of CI after coiling in patients aged ≥ 75 years (P < 0.001, RR 1.96) and after clipping in patients aged ≥ 70 years (P < 0.001, RR 1.76) was significantly higher than that in younger patients. The mortality rates within 1 year in patients with perioperative ICRH or CI were 2.41% and 3.39% for coiling and clipping groups, respectively, in patients ≥ 65. These rates increased significantly at age 70 in the coiling group and at age 75 for the clipping group (P = 0.012 and P < 0.001, respectively). CONCLUSION The risk of treatment increases with age, and this risk increases dramatically in patients aged ≥ 70 years. Therefore, the treatment decisions in patients aged ≥ 70 years should be made with utmost care.
Collapse
Affiliation(s)
- Sang Hyo Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
| | - O Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young Deok Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam University Sejong Hospital, Sejong, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
| |
Collapse
|
11
|
Rutledge C, Raper DMS, Jonzzon S, Raygor KP, Pereira MP, Winkler EA, Zhang L, Lawton MT, Abla AA. Sensitivity of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) in the Elderly: Retrospective Analysis of Ruptured Aneurysms. World Neurosurg 2021; 152:e673-e677. [PMID: 34129975 DOI: 10.1016/j.wneu.2021.06.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE The prevalence of intracranial aneurysms, as well as the incidence of subarachnoid hemorrhage (SAH), increase with age, and the elderly have poor outcomes after SAH. Age is a key factor in the unruptured intracranial aneurysm treatment score (UIATS),but the sensitivity of the UIATS model in detecting risk of SAH among the elderly is unknown. METHODS We retrospectively analyzed 153 consecutive cases of ruptured aneurysms between 2012 and 2018. We used Fisher's exact test, analysis of variance, and multivariate logistic regression to compare outcomes between those >65 years of age and those younger. We then applied the UIATS model and evaluated the sensitivity of the model as a predictor of SAH in the elderly compared with younger patients. RESULTS Elderly patients made up 32% (n = 49 of 153) of our cohort. They had significantly higher in-hospital mortality (19 of 49, 39%) than younger patients (14 of 104, 13%) (P < 0.01). In a multivariate logistic regression, controlling for Hunt-Hess grade and comorbidities, age >65 years remained a significant predictor of unfavorable outcome at discharge (P = 0.03). The UIATS model had low sensitivity in the elderly compared with younger patients: 63% (59 of 136) of younger patients would have been recommended aneurysm repair had their aneurysm been detected unruptured, compared with only 12% (5 of 42) of elderly patients >65 years (P < 0.01). CONCLUSIONS Elderly patients >65 years in age have far worse outcomes after SAH. The sensitivity of the UIATS model for detecting those at risk of SAH was significantly lower in elderly patients. The UIATS model may lead to undertreatment of elderly patients at risk of SAH.
Collapse
Affiliation(s)
- Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Soren Jonzzon
- School of Medicine, University of California, San Francisco, California, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | | | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Li Zhang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA.
| |
Collapse
|
12
|
Feghali J, Gami A, Rapaport S, Bender MT, Jackson CM, Caplan JM, McDougall CG, Huang J, Tamargo RJ. Aging Patient Population With Ruptured Aneurysms: Trend Over 28 Years. Neurosurgery 2021; 88:658-665. [PMID: 33370795 DOI: 10.1093/neuros/nyaa494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/09/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Given increasing life expectancy in the United States and worldwide, the proportion of elderly patients affected by aneurysmal subarachnoid hemorrhage (aSAH) would be expected to increase. OBJECTIVE To determine whether an aging trend exists in the population of aSAH patients presenting to our institution over a 28-yr period. METHODS A prospectively maintained database of consecutive patients presenting to our institution with subarachnoid hemorrhage between January 1991 and December 2018 was utilized. The 28-yr period was categorized into 4 successive 7-yr quarter intervals. The age of patients was compared among these intervals, and yearly trends were derived using linear regression. RESULTS The cohort consisted of 1671 ruptured aneurysm patients with a mean age of 52.8 yr (standard deviation = 15.0 yr). Over the progressive 7-yr time intervals during the 28-yr period, there was an approximately 4-fold increase in the proportion of patients aged 80 yr or above (P < .001) and an increase in mean patient age from 51.2 to 54.6 yr (P = .002). Independent of this trend but along the same lines, there was a 29% decrease in the proportion of younger patients (<50 yr) from 49% to 35%. On linear regression, there was 1-yr increase in mean patient age per 5 calendar years (P < .001). CONCLUSION Analyses of aSAH patients demonstrate an increase in patient age over time with a considerable rise in the proportion of octogenarian patients and a decrease in patients younger than 50 yr. This aging phenomenon presents a challenge to the continued improvement in outcomes of aSAH patients.
Collapse
Affiliation(s)
- James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Abhishek Gami
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarah Rapaport
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cameron G McDougall
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
13
|
Application of unruptured aneurysm scoring systems to a cohort of ruptured aneurysms: are we underestimating rupture risk? Neurosurg Rev 2021; 44:3487-3498. [PMID: 33797630 DOI: 10.1007/s10143-021-01523-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/21/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
The predictive values of current risk stratification scales such as the Unruptured Intracranial Aneurysm Treatment Score (UIATS) and the PHASES score are debatable. We evaluated these scores using a cohort of ruptured intracranial aneurysms to simulate their management recommendations had the exact same patients presented prior to rupture. A prospectively maintained database of ruptured saccular aneurysm patients presenting to our institution was used. The PHASES score was calculated for 992 consecutive patients presenting between January 2002 and December 2018, and the UIATS was calculated for 266 consecutive patients presenting between January 2013 and December 2018. A shorter period was selected for the UIATS cohort given the larger number of variables required for calculation. Clinical outcomes were compared between UIATS-recommended "observation" aneurysms and all other aneurysms. Out of 992 ruptured aneurysms, 54% had a low PHASES score (≤5). Out of the 266 ruptured aneurysms, UIATS recommendations were as follows: 68 (26%) "observation," 97 (36%) "treatment," and 101 (38%) "non-definitive." The UIATS conservative group of patients developed more SAH-related complications (78% vs. 65%, p=0.043), had a higher rate of non-home discharge (74% vs. 46%, p<0.001), and had a greater incidence of poor functional status (modified Rankin scale >2) after 12-18 months (68% vs. 51%, p=0.014). Current predictive scoring systems for unruptured aneurysms may underestimate future rupture risk and lead to more conservative management strategies in some patients. Patients that would have been recommended for conservative therapy were more likely to have a worse outcome after rupture.
Collapse
|
14
|
Wang Y, Kong XQ, Wu F, Xu B, Bao DJ, Cheng CD, Wei XP, Dong YF, Niu CS. SOCS1/JAK2/STAT3 axis regulates early brain injury induced by subarachnoid hemorrhage via inflammatory responses. Neural Regen Res 2021; 16:2453-2464. [PMID: 33907034 PMCID: PMC8374552 DOI: 10.4103/1673-5374.313049] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The SOCS1/JAK2/STAT3 axis is strongly associated with tumor growth and progression, and participates in cytokine secretion in many diseases. However, the effects of the SOCS1/JAK2/STAT3 axis in experimental subarachnoid hemorrhage remain to be studied. A subarachnoid hemorrhage model was established in rats by infusing autologous blood into the optic chiasm pool. Some rats were first treated with JAK2/STAT3 small interfering RNA (Si-JAK2/Si-STAT3) or overexpression plasmids of JAK2/STAT3. In the brains of subarachnoid hemorrhage model rats, the expression levels of both JAK2 and STAT3 were upregulated and the expression of SOCS1 was downregulated, reaching a peak at 48 hours after injury. Simultaneously, the interactions between JAK2 and SOCS1 were reduced. In contrast, the interactions between JAK2 and STAT3 were markedly enhanced. Si-JAK2 and Si-STAT3 treatment alleviated cortical neuronal cell apoptosis and necrosis, destruction of the blood-brain barrier, brain edema, and cognitive functional impairment after subarachnoid hemorrhage. This was accompanied by decreased phosphorylation of JAK2 and STAT3 protein, decreased total levels of JAK2 and STAT3 protein, and increased SOCS1 protein expression. However, overexpression of JAK2 and STAT3 exerted opposite effects, aggravating subarachnoid hemorrhage-induced early brain injury. Si-JAK2 and Si-STAT3 inhibited M1-type microglial conversion and the release of pro-inflammatory factors (inducible nitric oxide synthase, interleukin-1β, and tumor necrosis factor-α) and increased the release of anti-inflammatory factors (arginase-1, interleukin-10, and interleukin-4). Furthermore, primary neurons stimulated with oxyhemoglobin were used to simulate subarachnoid hemorrhage in vitro, and the JAK2 inhibitor AG490 was used as an intervention. The in vitro results also suggested that neuronal protection is mediated by the inhibition of JAK2 and STAT3 expression. Together, our findings indicate that the SOCS1/JAK2/STAT3 axis contributes to early brain injury after subarachnoid hemorrhage both in vitro and in vivo by inducing inflammatory responses. This study was approved by the Animal Ethics Committee of Anhui Medical University and the First Affiliated Hospital of University of Science and Technology of China (approval No. LLSC-20180202) on March 1, 2018.
Collapse
Affiliation(s)
- Yang Wang
- Department of Neurosurgery, First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Xiang-Qian Kong
- Department of Vascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University; Department of Vascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Fei Wu
- Department of Neurosurgery, First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Bin Xu
- Anhui Medical College, Anhui Provincial Medical Genetics Center, Hefei, Anhui Province, China
| | - De-Jun Bao
- Department of Neurosurgery, First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Chuan-Dong Cheng
- Department of Neurosurgery, First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Xiang-Ping Wei
- Department of Neurosurgery, First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Yong-Fei Dong
- Department of Neurosurgery, First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Chao-Shi Niu
- Department of Neurosurgery, First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China; Anhui Province Key Laboratory of Brain Function and Brain Disease, Hefei, Anhui Province, China
| |
Collapse
|
15
|
Edlmann E, Whitfield PC. The changing face of neurosurgery for the older person. J Neurol 2020; 267:2469-2474. [PMID: 32335794 PMCID: PMC7223995 DOI: 10.1007/s00415-020-09854-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 11/30/2022]
Abstract
Increased life expectancy and illness prevention and treatment have led to a growing population of older patients. These changes in patient population are apparent in neurosurgery; however, relatively little is reported about specific outcomes and prognostication in this group. This review summarises the challenges and management changes occurring in the treatment of three common neurosurgical pathologies; aneurysmal subarachnoid haemorrhage, head injury, and haemorrhagic stroke. A move towards less invasive neurosurgical techniques has implications on the risk-benefit profile of interventions. This creates the opportunity to intervene in older patients with greater co-morbidity, as long as improved outcomes can be evidenced. A critical part of assessing appropriateness for surgical intervention in older patients may be to change from a mindset of age to one of frailty and growing interest in scales assessing this may aid treatment decisions in the future.
Collapse
Affiliation(s)
- Ellie Edlmann
- Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, N14, ITTC Building, Plymouth Science Park, Plymouth, PL6 8BX, UK.
- Southwest Neurosurgical Centre, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK.
| | - Peter C Whitfield
- Southwest Neurosurgical Centre, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, PL6 8DH, UK
| |
Collapse
|
16
|
Cho WC, Shin YS, Kim BS, Choi JH. Treatment outcome after coiling or clipping for elderly patients with unruptured intracranial aneurysms. J Cerebrovasc Endovasc Neurosurg 2020; 22:78-84. [PMID: 32665914 PMCID: PMC7329562 DOI: 10.7461/jcen.2020.22.2.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/03/2020] [Accepted: 04/04/2020] [Indexed: 11/23/2022] Open
Abstract
Objective The purpose of this study was to analyze treatment outcomes according to treatment modality for elderly patients over 75 years with unruptured intracranial aneurysm. Methods Fifty-four elderly patients treated in a single tertiary institute between January 2010 and December 2018 were retrospectively reviewed. We compared clinical outcome, radiological results, and complications between the coiling and clipping groups. Results A total of 55 procedures were performed in 54 patients. Of 55 aneurysms, 44 were treated endovascularly and 11 were treated surgically. There was no significant difference in patient baseline characteristics including mean age, sex, and preexisting co-morbidity between the two groups. Even though there was no significant difference (p=0.373), procedure-related symptomatic complication occurred only in coiling group (3 out of 44 patients, 6.6%). Mortality rate was significantly higher in clipping group (1 out of 11 patients, 9.1%) than in coiling group (0%, p=0.044). Good clinical outcome (modified Rankin Scale 0–2) at 90 days was achieved in 43 cases treated with coiling (97.7%), and 10 cases with clipping (90.9%, p=0.154). Conclusions Clipping is more invasive procedure and takes longer operation time, which might lead to unpredictable mortality in elderly patients. Coiling might have high procedure-related stroke rate due to tortuous vessels with atherosclerosis. Therefore, aggressive treatment of elderly patients should be carefully considered based on patient’s medical condition and angiographic findings.
Collapse
Affiliation(s)
- Woo Cheul Cho
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Bum-Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jai Ho Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| |
Collapse
|
17
|
Lu D, Xiong J, Liu H, Zhou H, Cheng J, Yue Y, Zhang H, Yao X, Ren J, Feng Y. Surgical clipping of ophthalmic artery aneurysms: a single center series. Br J Neurosurg 2020; 35:157-160. [PMID: 32515998 DOI: 10.1080/02688697.2020.1775787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIM The purpose of this study was to summary the characteristics of ophthalmic artery (OphA) aneurysms and to obtain the independent risk factors for poor prognosis of microsurgical clipping treatment for OphA aneurysms. METHODS The clinical and microsurgical clipping results of all 63 patients with ophthalmic aneurysm were investigated and reviewed. The OphA aneurysm patient's case records were reviewed including clinical characteristics, image findings, and clinical outcomes. Then, the risk factors of poor prognosis were analyzed retrospectively. RESULTS Monocular blindness persisted in 4 patients (6.35%), 1 patient developed persistent vegetate state (PVS) (1.59%), while 4 patients (6.35%) died. The matching process constructed a cohort consisting of 9 poor outcome (Glasgow Outcome Scale, GOS 1-3) patients (14.3%), and 54 good outcome (GOS 4-5) patients (85.7%). Univariate analysis between the good outcome and poor outcome revealed statistical significance in age > 60 (p = 0.045), size (p = 0.016), and rupture before operation (p = 0.049). Further, multivariate logistic regression analysis identified age > 60 (odds ratio [OR], 5.877; 95% confidence interval [CI], 1.039-33.254; p = 0.045) and aneurysm size > 10mm (OR, 9.417; 95% CI, 1.476-60.072; p = 0.018) as the independent risk factors for poor outcome in microsurgical clipping treatment for OphA aneurysms. CONCLUSION The significant independent risk factors associated with clipping OphA aneurysms are age (>60) and size (>10mm).
Collapse
Affiliation(s)
- Donglin Lu
- Departments of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Jing Xiong
- Departments of Geriatrics Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Hengjian Liu
- Departments of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Han Zhou
- Departments of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Jing Cheng
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yong Yue
- Departments of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Huawei Zhang
- Departments of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Xujin Yao
- Departments of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Jinyang Ren
- Departments of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yugong Feng
- Departments of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| |
Collapse
|
18
|
Effect of treatment modality and cerebral vasospasm agent on patient outcomes after aneurysmal subarachnoid hemorrhage in the elderly aged 75 years and older. PLoS One 2020; 15:e0230953. [PMID: 32271814 PMCID: PMC7145106 DOI: 10.1371/journal.pone.0230953] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022] Open
Abstract
Objective We sought to examine whether the effect of treatment modality and drugs for cerebral vasospasm on clinical outcomes differs between elderly and non-elderly subarachnoid hemorrhage (SAH) patients in Japan. Methods We analyzed the J-ASPECT Study Diagnosis Procedure Combination database (n = 17,343) that underwent clipping or coiling between 2010 and 2014 in 579 hospitals. We stratified patients into two groups according to their age (elderly [≥75 years old], n = 3,885; non-elderly, n = 13,458). We analyzed the effect of treatment modality and anti-vasospasm agents (fasudil hydrochloride, ozagrel sodium, cilostazol, statin, eicosapentaenoic acid [EPA], and edaravone) on in-hospital poor outcomes (mRS 3–6 at discharge) and mortality using multivariable analysis. Results The elderly patients were more likely to be female, have impaired levels of consciousness and comorbidity, and less likely to be treated with clipping and anti-vasospasm agents, except for ozagrel sodium and statin. In-hospital mortality and poor outcomes were higher in the elderly (15.8% vs. 8.5%, 71.7% vs. 36.5%). Coiling was associated with higher mortality (odds ratio 1.43, 95% confidence interval 1.2–1.7) despite a lower proportion of poor outcomes (0.84, 0.75–0.94) in the non-elderly, in contrast to no effect on clinical outcomes in the elderly. A comparable effect of anti-vasospasm agents on mortality was observed between non-elderly and elderly for fasudil hydrochloride (non-elderly: 0.20, 0.17–0.24), statin (0.63, 0.50–0.79), ozagrel sodium (0.72, 0.60–0.86), and cilostazol (0.63, 0.51–0.77). Poor outcomes were inversely associated with fasudil hydrochloride (0.59, 0.51–0.68), statin (0.84, 0.75–0.94), and EPA (0.83, 0.72–0.94) use in the non-elderly. No effect of these agents on poor outcomes was observed in the elderly. Conclusions In contrast to the non-elderly, no effect of treatment modality on clinical outcomes were observed in the elderly. A comparable effect of anti-vasospasm agents was observed on mortality, but not on functional outcomes, between the non-elderly and elderly.
Collapse
|
19
|
Jee TK, Nam TM, Yeon JY, Kim KH, Jeon P, Kim JS, Hong SC. Intracranial Aneurysms in Young Adult Patients: Surgical and Endovascular Treatment Outcomes. World Neurosurg 2020; 136:e214-e222. [PMID: 31899407 DOI: 10.1016/j.wneu.2019.12.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite its relative rarity, the potential for loss of productive years makes aneurysmal subarachnoid hemorrhage (SAH) a considerably important entity in young adult patients (20-39 years of age). This study aimed to analyze outcomes of microsurgery (MS) and endovascular treatment (EVT) for saccular intracranial aneurysms (IAs) in young adult patients. METHODS A total of 276 young adult patients with 315 IAs, treated with MS or EVT between January 2001 and December 2015, were studied. Major recurrence and treatment-related complications were the primary outcome measures. Functional outcomes in patients with SAH were also assessed. RESULTS Major recurrence occurred in 21 cases (6.7%). Younger age (adjusted hazard ratio [aHR], 3.77; 95% confidence interval [CI], 1.45-9.83; P = 0.007), ruptured IA (aHR, 6.44; 95% CI, 2.09-19.89; P = 0.001), size (aHR, 1.84; 95% CI, 1.06-3.18; P = 0.030), and EVT (aHR, 7.21; 95% CI, 2.44-21.35; P < 0.001) were independently related to major recurrence. Treatment-related complications occurred in 5 cases (1.6%) and did not differ between the MS and EVT groups (P > 0.999). Unfavorable outcomes (modified Rankin scale score ≥2) were identified in 30 patients (19.6%) with SAH, and only Hunt and Hess grade was independently associated with unfavorable functional outcome. CONCLUSIONS Both MS and EVT are safe for treating IAs in young adult patients. MS showed better durability of treatment and may be preferred over EVT in young patients in view of their longer life expectancy compared with older patients.
Collapse
Affiliation(s)
- Tae Keun Jee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taek Min Nam
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
20
|
Malhotra A, Wu X, Miller T, Matouk CC, Sanelli P, Gandhi D. Comparative effectiveness analysis of Pipeline device versus coiling in unruptured aneurysms smaller than 10 mm. J Neurosurg 2020; 132:42-50. [PMID: 30641830 DOI: 10.3171/2018.8.jns181080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/24/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Both endovascular coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for treatment of small (< 10 mm) aneurysms. The authors conducted a comparative effectiveness analysis to compare the utility of these treatment methods in terms of health benefits. METHODS A decision-analytical study was performed with Markov modeling methods to simulate patients with small unruptured aneurysms undergoing endovascular coiling, stent-assisted coiling (SAC), or PED placement for treatment. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses were performed to assess model and input parameter uncertainty. RESULTS The base case calculation for a 50-year-old man reveals PED to have a higher health benefit (17.48 quality-adjusted life years [QALYs]) than coiling (17.44 QALYs) or SAC (17.36 QALYs). PED is the better option in 6020 of the 10,000 iterations in probabilistic sensitivity analysis. When the retreatment rate of PED is lower than 9.53%, and the coiling retreatment is higher than 15.6%, PED is the better strategy. In the 2-way sensitivity analysis varying the retreatment rates from both treatment modalities, when the retreatment rate of PED is approximately 14% lower than the retreatment rate of coiling, PED is the more favorable treatment strategy. Otherwise, coiling is more effective. SAC may be better than PED when the unfavorable outcome risk of SAC is lower than 70% of its reported current value. CONCLUSIONS With the increasing use of PEDs for treatment of small unruptured aneurysms, the current study indicates that these devices may have higher health benefits due to lower rates of retreatment compared to both simple coiling and stent-assisted techniques. Longer follow-up studies are needed to document the rates of recurrence and retreatment after coiling and PED to assess the cost-effectiveness of these strategies.
Collapse
Affiliation(s)
- Ajay Malhotra
- 1Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Wu
- 1Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Timothy Miller
- 2Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles C Matouk
- 1Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
- 3Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Pina Sanelli
- 4Department of Radiology, Northwell Health, Manhasset, New York; and
| | - Dheeraj Gandhi
- 5Division of Interventional Neuroradiology, Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
21
|
Asymptomatic Intracranial Aneurysms in the Elderly: Long-Term Clinical and Radiologic Follow-Up of 193 Consecutive Patients. World Neurosurg 2020; 133:e600-e608. [DOI: 10.1016/j.wneu.2019.09.103] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 11/19/2022]
|
22
|
Akiyama R, Imamura H, Tani S, Adachi H, Fukumitsu R, Sunohara T, Omura Y, Funakoshi Y, Matsui Y, Sasaki N, Fukuda T, Horiuchi K, Kajiura S, Shigeyasu M, Sakai N. Outcomes of Endovascular Therapy versus Microsurgical Treatment for Aneurysmal Subarachnoid Hemorrhage in Patients ≥70 Years of Age. JOURNAL OF NEUROENDOVASCULAR THERAPY 2019; 14:1-7. [PMID: 37502381 PMCID: PMC10370813 DOI: 10.5797/jnet.oa.2019-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 11/12/2019] [Indexed: 07/29/2023]
Abstract
Purpose This retrospective research aimed to compare the efficacy of endovascular therapy (EVT) versus microsurgical treatment (MST) for elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods Elderly (>70 years) patients with aSAH who underwent aneurysm obliteration during 2007-2017 were selected from our hospital database and enrolled in this retrospective study. We reviewed each patient's background, the severity of the aSAH, and aneurysmal characteristics that compelled EVT or microsurgery treatment and then compared the two treatment groups. A favorable primary outcome was defined by a modified Rankin scale (mRS) score of 0-3 at hospital discharge. The 78 patients formed two cohorts (39 patients each) based on their propensity scores for EVT or MST. We estimated the adjusted odds ratio, followed by a sensitivity analysis of the original 201 patients (118 with EVT and 83 with MST). Results In the propensity score-matched cohorts, favorable outcomes were observed in 33.3% and 7.7% of patients in the EVT and MST groups, respectively (p = 0.01). Results of the sensitivity analysis were similar to the main results. Conclusion The clinical outcomes for the elderly aSAH patients were better in the EVT group than in MST group.
Collapse
Affiliation(s)
- Ryo Akiyama
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Shoichi Tani
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hidemitsu Adachi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Ryu Fukumitsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tadashi Sunohara
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yoshihiro Omura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yusuke Funakoshi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yuichi Matsui
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Natsuhi Sasaki
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Tatsumaru Fukuda
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Kazufumi Horiuchi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Shinji Kajiura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Masashi Shigeyasu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| |
Collapse
|
23
|
ARIMURA K, IIHARA K, SATOW T, NISHIMURA A, TOKUNAGA S, SAKAI N. Safety and Feasibility of Neuroendovascular Therapy for Elderly Patients: Analysis of Japanese Registry of Neuroendovascular Therapy 3. Neurol Med Chir (Tokyo) 2019; 59:305-312. [PMID: 31130572 PMCID: PMC6694018 DOI: 10.2176/nmc.oa.2018-0325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/01/2019] [Indexed: 11/24/2022] Open
Abstract
Japan has a rapidly aging population and the application of neuroendovascular therapy (NET) for cerebrovascular diseases among elderly patients has increased, but feasibility and safety of NET for elderly patients are still debated. Therefore, this study aimed to elucidate feasibility and safety of NET by analyzing the Japanese nationwide database, the Japanese Registry of Neuroendovascular Therapy 3 (JR-NET 3). In total, 35,972 patients in the JR-NET 3 were analyzed retrospectively. "Elderly patients" were defined as those aged ≥75 years. Approximately one-quarter of patients who received NET were elderly patients. The proportion of patients with modified Rankin Scale (mRS) 0-2 before treatment and 30 days after NET was significantly low across all diseases in the elderly patients. Technical success rates were generally high across all procedures, but complication rate was significantly higher among elderly patients; ischemic complications were significantly higher with NET for unruptured aneurysms (UA) and carotid artery stenosis (CAS). Multivariate analysis revealed that mRS 0-2 before treatment [odds ratio (OR): 0.56, 95% confidence interval (CI): 0.34-0.94, P = 0.03], middle cerebral artery aneurysm (OR: 0.33, 95% CI: 0.12-0.92, P = 0.04), and complete obliteration (OR: 0.66, 95% CI: 0.44-0.97, P = 0.03) were associated with ischemic complications with NET for UA. Moreover, mRS 0-2 before treatment (OR: 0.55, 95% CI: 0.36-0.86, P < 0.01), high intensity with time-of-flight magnetic resonance angiography (OR: 1.55, 95% CI: 1.03-2.32, P = 0.04), open-cell stent (OR: 2.20, 95% CI: 1.50-3.22, P <0.01) were associated with ischemic complications with NET for CAS. Taken together, our findings indicate that cautious and precise selection of patients suitable for NET is necessary.
Collapse
Affiliation(s)
- Koichi ARIMURA
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Koji IIHARA
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Tetsu SATOW
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Ataru NISHIMURA
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - So TOKUNAGA
- Department of Neurosurgery, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan
| | - Nobuyuki SAKAI
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - JR-NET investigators
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Neurosurgery, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| |
Collapse
|
24
|
Dasenbrock H, Gormley WB, Lee Y, Mor V, Mitchell SL, Fehnel CR. Long-term outcomes among octogenarians with aneurysmal subarachnoid hemorrhage. J Neurosurg 2019; 131:426-434. [PMID: 30117766 PMCID: PMC6358513 DOI: 10.3171/2018.3.jns173057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Data evaluating the long-term outcomes, particularly with regard to treatment modality, of aneurysmal subarachnoid hemorrhage (SAH) in octogenarians are limited. The primary objectives were to evaluate the disposition (living at home vs institutional settings) and analyze the predictors of long-term survival and return to home for octogenarians after SAH. METHODS Data pertaining to patients age 80 and older who underwent microsurgical clipping or endovascular coiling for SAH were extracted from 100% nationwide Medicare inpatient claims and linked with the Minimum Data Set (2008-2011). Patient disposition was tracked for 2 years after index SAH admission. Multivariable logistic regression stratified by aneurysm treatment modality, and adjusted for patient factors including SAH severity, evaluated predictors of return to home at 60 and 365 days after SAH. Survival 365 days after SAH was analyzed with a multivariable Cox proportional hazards model. RESULTS A total of 1298 cases were included in the analysis. One year following SAH, 56% of the patients had died or were in hospice care, 8% were in an institutional post-acute care setting, and 36% had returned home. Open microsurgical clipping (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.54-0.81), male sex (aHR 0.70, 95% CI 0.57-0.87), tracheostomy (aHR 0.63, 95% CI 0.47-0.85), gastrostomy (aHR 0.60, 95% CI 0.48-0.76), and worse SAH severity (aHR 0.94, 95% CI 0.92-0.97) were associated with reduced likelihood of patients ever returning home. Older age (aHR 1.09, 95% CI 1.05-1.13), tracheostomy (aHR 2.06, 95% CI 1.46-2.91), gastrostomy (aHR 1.55, 95% CI 1.14-2.10), male sex (aHR 1.66, 95% CI 1.20-2.23), and worse SAH severity 1.51 (95% CI 1.04-2.18) were associated with reduced survival. CONCLUSIONS In this national analysis, 56% of octogenarians with SAH died, and 36% returned home within 1 year of SAH. Coil embolization predicted returning to home, which may suggest a benefit to endovascular treatment in this patient population.
Collapse
Affiliation(s)
- Hormuzdiyar Dasenbrock
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School
| | - William B. Gormley
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Susan L. Mitchell
- Harvard Medical School
- Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| | - Corey R. Fehnel
- Harvard Medical School
- Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA USA
| |
Collapse
|
25
|
Kwinta BM, Kliś KM, Krzyżewski RM, Wilk A, Dragan M, Grzywna E, Popiela T. Elective Management of Unruptured Intracranial Aneurysms in Elderly Patients in a High-Volume Center. World Neurosurg 2019; 126:e1343-e1351. [DOI: 10.1016/j.wneu.2019.03.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 10/27/2022]
|
26
|
Malhotra A, Wu X, Brinjikji W, Miller T, Matouk CC, Sanelli P, Gandhi D. Pipeline Endovascular Device vs Stent-Assisted Coiling in Small Unruptured Aneurysms: A Cost-Effectiveness Analysis. Neurosurgery 2019; 85:E1010-E1019. [DOI: 10.1093/neuros/nyz130] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/24/2018] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUNDBoth stent-assisted coiling (SAC) and flow diversion with the Pipeline Embolization device (PED; Medtronic Inc) have been shown to be safe and clinically effective for treatment of small (<10 mm) unruptured aneurysms. However, the economic impact of these different techniques has not been established.OBJECTIVETo analyze the cost-effectiveness between stent-assisted coiling and flow diversion using PED, including procedural costs, long-term outcomes, and aneurysm recurrence.METHODSA decision-analytical study was performed with Markov modeling methods to simulate patients undergoing SAC or PED for treatment for unruptured aneurysms of sizes 5 and 7 mm. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses (PSA) were performed.RESULTSIn base case calculation and PSA, PED was the dominant strategy for both the size groups, with and without consideration of indirect costs. One-way sensitivity analyses show that the conclusion remained robust when varying the retreatment rate of SAC from 0% to 50%, and only changes when the retreatment rate of PED > 49%. PED remained the more cost-effective strategy when the morbidity and mortality of PED increased by <55% and when those of SAC decreased by <37%. SAC only became cost-effective when the total cost of PED is >$73000 more expensive than the total cost of SAC.CONCLUSIONWith increasing use of PED for treatment of small unruptured anterior circulation aneurysms, our study indicates that PED is cost-effective relative to stent coiling irrespective of aneurysm size. This is due to lower aneurysm recurrence rate, as well as better health outcomes.
Collapse
Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Waleed Brinjikji
- Department of Radiology and Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Timothy Miller
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Dheeraj Gandhi
- Interventional Neuroradiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
27
|
Daou B, Atallah E, Chalouhi N, Starke RM, Oliver J, Montano M, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Aneurysms with persistent filling after failed treatment with the Pipeline embolization device. J Neurosurg 2019; 130:1376-1382. [PMID: 29726765 DOI: 10.3171/2017.12.jns163090] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/14/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Pipeline embolization device (PED) has become a valuable tool in the treatment of cerebral aneurysms. Although failures with PED treatment have been reported, the characteristics and course of these aneurysms remain a topic of uncertainty. METHODS Electronic medical records and imaging studies were reviewed for all patients treated with the PED between July 2010 and March 2015 to identify characteristics of patients and aneurysms with residual filling after PED treatment. RESULTS Of 316 cases treated at a single institution, 281 patients had a long-term follow-up. A total of 52 (16.4%) aneurysms with residual filling were identified and constituted the study population. The mean patient age in this population was 58.8 years. The mean aneurysm size was 10.1 mm ± 7.15 mm. Twelve aneurysms were fusiform (23%). Of the aneurysms with residual filling, there were 20 carotid ophthalmic (CO) aneurysms (20% of all CO aneurysms treated), 10 other paraclinoid aneurysms (16.4% of all paraclinoid aneurysms), 7 posterior communicating artery (PCoA) aneurysms (21.9% of all PCoA aneurysms), 7 cavernous internal carotid artery (ICA) aneurysms (14.9% of all cavernous ICA aneurysms), 4 vertebrobasilar (VB) junction aneurysms (14.8% of all VB junction aneurysms), and 3 middle cerebral artery (MCA) aneurysms (25% of all MCA aneurysms). Eleven patients underwent placement of more than one PED (21.2%), with a mean number of devices of 1.28 per case. Eight of 12 aneurysms were previously treated with a stent (15.4%). Nineteen patients underwent re-treatment (36.5%); the 33 patients who did not undergo re-treatment (63.5%) were monitored by angiography or noninvasive imaging. In multivariate analysis, age older than 65 years (OR 2.65, 95% CI 1.33-5.28; p = 0.05), prior stent placement across the target aneurysm (OR 2.94, 95% CI 1.15-7.51; p = 0.02), aneurysm location in the distal anterior circulation (MCA, PCoA, and anterior choroidal artery: OR 2.72, 95% CI 1.19-6.18; p = 0.017), and longer follow-up duration (OR 1.06, 95% CI 1.03-1.09; p < 0.001) were associated with incomplete aneurysm occlusion. CONCLUSIONS While the PED can allow for treatment of large, broad-necked aneurysms with high efficacy, treatment failures do occur (16.4%). Aneurysm size, shape, and previous treatment may influence treatment outcome.
Collapse
Affiliation(s)
- Badih Daou
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Elias Atallah
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Nohra Chalouhi
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Robert M Starke
- Departments of2Neurosurgery and
- 3Radiology, University of Miami, Florida
| | - Jeffrey Oliver
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Maria Montano
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Robert H Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Stavropoula I Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| |
Collapse
|
28
|
Malhotra A, Wu X, Forman HP, Matouk CC, Hughes DR, Gandhi D, Sanelli P. Management of Unruptured Intracranial Aneurysms in Older Adults: A Cost-effectiveness Analysis. Radiology 2019; 291:411-417. [PMID: 30888931 DOI: 10.1148/radiol.2019182353] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Unruptured intracranial aneurysms (UIAs) are relatively common and are being increasingly diagnosed, with a significant proportion in older patients (˃ 65 years old). Serial imaging is often performed to assess change in size or morphology of UIAs since growing aneurysms are known to be at high risk for rupture. However, the frequency and duration of surveillance imaging have not been established. Purpose To evaluate the cost-effectiveness of routine treatment (aneurysm coil placement) versus four different strategies for imaging surveillance of UIAs in adults older than 65 years. Materials and Methods A Markov decision-analytic model was constructed from a societal perspective. Age-dependent input parameters were obtained from published literature. Analysis included adults older than 65 years, with incidental detection of UIA and no prior history of subarachnoid hemorrhage. Five different management strategies for UIAs in older adults were evaluated: (a) annual MR angiography, (b) biennial MR angiography, (c) MR angiography every 5 years, (d) coil placement and follow-up, and (e) limited MR angiography follow-up for the first 2 years after detection only. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Probabilistic, one-way, and two-way sensitivity analyses were performed. Results Imaging follow-up for the first 2 years after detection is the most cost-effective strategy (cost = $24 572, effectiveness = 13.73 QALYs), showing the lowest cost and highest effectiveness. The conclusion remains robust in probabilistic and one-way sensitivity analyses. Time-limited imaging follow-up remains the optimal strategy when the annual growth rate and rupture risk of growing aneurysms are varied. If annual rupture risk of nongrowing aneurysms is greater than 7.1%, coil placement should be performed directly. Conclusion Routine preventive treatment or periodic, indefinite imaging follow-up is not a cost-effective strategy in all adults older than 65 years with unruptured intracranial aneurysms. More aggressive management strategies should be reserved for patients with high risk of rupture, such as those with aneurysms larger than 7 mm and those with aneurysms in the posterior circulation. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Cloft in this issue.
Collapse
Affiliation(s)
- Ajay Malhotra
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Xiao Wu
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Howard P Forman
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Charles C Matouk
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Danny R Hughes
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Dheeraj Gandhi
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Pina Sanelli
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| |
Collapse
|
29
|
Mohammed N, Hung YC, Xu Z, Starke RM, Kano H, Lee J, Mathieu D, Kaufmann AM, Grills IS, Cifarelli CP, Vargo JA, Chytka T, Janouskova L, Feliciano CE, Mercado RR, Lunsford LD, Sheehan JP. A Propensity Score-Matched Cohort Analysis of Outcomes After Stereotactic Radiosurgery in Older versus Younger Patients with Dural Arteriovenous Fistula: An International Multicenter Study. World Neurosurg 2019; 125:e1114-e1124. [PMID: 30790731 DOI: 10.1016/j.wneu.2019.01.253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aims to evaluate the outcomes of Gamma Knife stereotactic radiosurgery (SRS) for dural arteriovenous fistulas (dAVFs) in older patients (≥65 years) compared with younger patients (age <65 years). METHODS Two groups with a total of 96 patients were selected from a database of 133 patients with dAVF from 9 international medical centers with a minimum 6 months follow-up. A 1:2 propensity matching was performed by nearest-neighbor matching criteria based on sex, Borden grade, maximum radiation dose given, and location. The older cohort consisted of 32 patients and the younger cohort consisted of 64 patients. The mean overall follow-up in the combined cohort was 42.4 months (range, 6-210 months). RESULTS In the older cohort, a transverse sinus location was found to significantly predict dAVF obliteration (P = 0.01). The post-SRS actuarial 3-year and 5-year obliteration rates were 47.7% and 78%, respectively. There were no cases of post-SRS hemorrhage. In the younger cohort, the cavernous sinus location was found to significantly predict obliteration (P = 0.005). The 3-year and 5-year actuarial obliteration rates were 56% and 70%, respectively. Five patients (7.8%) hemorrhaged after SRS. Margin dose ≥25 Gy was predictive of unfavorable outcome. The obliteration rate (P = 0.3), post-SRS hemorrhage rate (P = 0.16), and persistent symptoms after SRS (P = 0.83) were not statistically different between the 2 groups. CONCLUSIONS SRS achieves obliteration in most older patients with dAVF, with an acceptable rate of complication. There was no increased risk of postradiosurgery complications in the older cohort compared with the younger patients.
Collapse
Affiliation(s)
- Nasser Mohammed
- Department of Neurological Surgery, University of Virginia, Virginia, USA
| | - Yi-Chieh Hung
- Department of Neurological Surgery, University of Virginia, Virginia, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Virginia, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Florida, USA
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburg, USA
| | - John Lee
- Department of Neurological Surgery, University of Pennsylvania, Philadelphia, USA
| | - David Mathieu
- Department of Neurological Surgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada
| | - Anthony M Kaufmann
- Department of Neurological Surgery, University of Manitoba, Winnipeg, Canada
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Michigan, USA
| | | | - John A Vargo
- Department of Neurological Surgery, West Virginia University, Morgantown, USA
| | - Tomas Chytka
- Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | | | - Caleb E Feliciano
- Department of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburg, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Virginia, USA.
| |
Collapse
|
30
|
Yang H, Jiang H, Ni W, Leng B, Bin X, Chen G, Tian Y, Gu Y. Treatment Strategy for Unruptured Intracranial Aneurysm in Elderly Patients: Coiling, Clipping, or Conservative? Cell Transplant 2019; 28:767-774. [PMID: 30648433 PMCID: PMC6686429 DOI: 10.1177/0963689718823517] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- H Yang
- 1 Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - H Jiang
- 1 Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - W Ni
- 1 Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - B Leng
- 1 Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - X Bin
- 1 Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - G Chen
- 1 Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Y Tian
- 1 Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Y Gu
- 1 Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
31
|
O'Neill AH, Chandra RV, Slater LA, Chong W, Xenos C, Danks AR, Lai LT. Influence of comorbidities on treatment of unruptured intracranial aneurysms in the elderly. J Clin Neurosci 2019; 62:38-45. [PMID: 30655235 DOI: 10.1016/j.jocn.2019.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/15/2018] [Accepted: 01/03/2019] [Indexed: 11/30/2022]
Abstract
Current evidence does not conclusively justify conservative management of unruptured intracranial aneurysms (UIA) in the elderly (age ≥ 65 years). To rationalise intervention, the authors investigated the role of age and comorbidity burden on treatment outcomes. A retrospective chart review for consecutive cases of UIAs treated in the elderly between 2007 and 2018 was performed. Preoperative Charlson Comorbidity Index (CCI) and Neurovascular Comorbidities Index (NCI) were calculated. Standard statistical methods with univariate and multiple logistic regression were used. A total of 123 patients (46 surgery, 77 endovascular) with 131 UIAs were treated. The mean age was 70.6 ± 4.1 years, and 90 patients were female (73.1%). The mean aneurysm size was 8.6 ± 5.0 mm, and the mean follow up period was 22.9 ± 21.3 months. The rates of poor outcome (mRS > 1) at discharge, 6 weeks and 6 months were 9.8%, 5.8% and 3.6%, respectively. There was no difference in outcomes between surgical and endovascular treatment. Correlation and regression analyses revealed that aneurysm size, higher preoperative comorbidity index (CCI > 4), and endovascular treatment with a stent or flow diverter (p = 0.009, 0.02, and 0.005, respectively) were associated with a poor outcome. When adjusted in a multivariate analysis, only high comorbidity burden (CCI > 4) predicted unfavourable outcome (p = 0.01). Elderly patients who undergo treatment for UIAs are at high risk of postoperative deterioration. Careful preoperative case selection based on comorbidity burden, rather than chronological age, would be useful for improved risk stratification.
Collapse
Affiliation(s)
| | - Ronil V Chandra
- Department of Surgery, Monash University, Melbourne, Australia; Neuro-Interventional Radiology Unit, Department of Imaging, Monash Health, Melbourne, Australia
| | - Lee-Anne Slater
- Neuro-Interventional Radiology Unit, Department of Imaging, Monash Health, Melbourne, Australia
| | - Winston Chong
- Neuro-Interventional Radiology Unit, Department of Imaging, Monash Health, Melbourne, Australia
| | | | - Andrew Robert Danks
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia.
| |
Collapse
|
32
|
Silva NA, Shao B, Sylvester MJ, Eloy JA, Gandhi CD. Unruptured aneurysms in the elderly: perioperative outcomes and cost analysis of endovascular coiling and surgical clipping. Neurosurg Focus 2018; 44:E4. [DOI: 10.3171/2018.1.focus17714] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVEObservation and neurosurgical intervention for unruptured intracranial aneurysms (UIAs) in the elderly population is rapidly increasing. Cerebral aneurysm coiling (CACo) is favored over cerebral aneurysm clipping (CAC) in elderly patients, yet some elderly individuals still undergo CAC. The cost-effectiveness of treating UIAs requires further exploration. Understanding the effect of intervention on hospital charges and length of stay (LOS) as well as perioperative mortality and complications can further shed light on its economic impact. The purpose of this study was to analyze the cost and perioperative outcomes of UIAs in elderly patients (≥ 65 years of age) after CACo or CAC intervention.METHODSRetrospective cohorts of CACo and CAC admissions were extracted from National (Nationwide) Inpatient Sample data obtained between 2002 and 2013, forming parallel intervention groups to compare the following outcomes between elderly and nonelderly patients: average LOS and mean hospital admission costs, in-hospital mortality, and complications. Covariates included sex, race or ethnicity, and comorbidities.RESULTSElderly patients undergoing CAC experienced an average LOS of 8.0 days, whereas elderly patients undergoing CACo stayed an average of 3.2 days. The mean hospital charges incurred during admission totaled $95,960 in the elderly patients who underwent CAC versus $87,960 in the ones who underwent CACo. Elderly patients in whom CAC was performed had a 2.2% rate of in-hospital mortality, with a 2.6 greater adjusted odds of in-hospital mortality than nonelderly patients treated with CAC. In contrast, elderly patients who underwent CACo had a 1.36 greater adjusted odds of in-hospital mortality than their nonelderly counterparts. Compared to nonelderly patients receiving both interventions, elderly individuals had a significantly higher prevalence of various comorbidities and incidence of complications. Elderly patients who received CAC experienced a 10.3% incidence rate of perioperative stroke, whereas their CACo counterparts experienced this complication at a rate of 3.5%. Elderly patients treated with CAC had greater odds of perioperative acute renal failure, whereas their CACo counterparts had greater odds of perioperative deep venous thrombosis and pulmonary embolism.CONCLUSIONSIntervention with CAC and CACo in the elderly is resource intensive and is associated with higher risk than in the nonelderly. Those deciding between intervention and conservative management should consider these risks and costs, especially the 2.2% postoperative mortality rate associated with CAC in the elderly population. Further comparative cost-effectiveness research is needed to weigh these costs and outcomes against those of conservative management.
Collapse
Affiliation(s)
| | | | - Michael J. Sylvester
- 2Department of Otolaryngology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Jean Anderson Eloy
- 1Department of Neurological Surgery and
- 3Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan; and
- 4Department of Neurological Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
| | | |
Collapse
|
33
|
Ikawa F, Abiko M, Ishii D, Ohshita J, Okazaki T, Sakamoto S, Kobayashi S, Kurisu K. Effect of actual age on outcome at discharge in patients by surgical clipping and endovascular coiling for ruptured cerebral aneurysm in Japan. Neurosurg Rev 2018; 41:1007-1011. [PMID: 29335886 DOI: 10.1007/s10143-017-0942-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 10/18/2022]
Abstract
The Japanese population features the highest rate of elderly individuals worldwide. However, the difference of actual age indication for surgical clipping (SC) and endovascular coiling (EC) has never reported. We clarified the effect of actual age on poor outcome at discharge in patients by each treatment for ruptured cerebral aneurysm according to the Japanese Stroke Data Bank. A total of 3593 patients with ruptured saccular cerebral aneurysm were treated by SC and/or EC between 2000 and 2013. The effect of actual age on poor outcome (modified Rankin scale [mRS] score > 2) at discharge was evaluated by the cutoff age using receiver operating characteristic analysis for each treatment. There were 2666 cases in the SC group and 881 cases in the EC group. The cutoff age for poor outcome was 3 to 9 years older for EC than for SC. The gap of cutoff age between two treatments was 3 years shorter in mild subarachnoid hemorrhage than severe cases. The gap of cutoff age between two treatments was 7 years in elderly patients over 65 years old. The cutoff age was 78 years old for both SC and EC in elderly female patients. In conclusion, the cutoff age for poor mRS score > 2 was 3 to 9 years older for EC than for SC. Actual age was one of the indications for elderly patients to achieve the optimum outcome; however, the treatment indication should be carefully considered based on the condition in each country.
Collapse
Affiliation(s)
- Fusao Ikawa
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Masaru Abiko
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Jyumpei Ohshita
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takahito Okazaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | | | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| |
Collapse
|
34
|
Mori K, Wada K, Otani N, Tomiyama A, Toyooka T, Fujii K, Kumagai K, Takeuchi S, Tomura S, Yamamoto T, Nakao Y, Arai H. Validation of effectiveness of keyhole clipping in nonfrail elderly patients with unruptured intracranial aneurysms. J Neurosurg 2017; 127:1307-1314. [DOI: 10.3171/2016.9.jns161634] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVEAdvanced age is known to be associated with a poor prognosis after surgical clipping of unruptured intracranial aneurysms (UIAs). Keyhole clipping techniques have been introduced for less invasive treatment of UIAs. In this study, the authors compared the complications and clinical and radiological outcomes after keyhole clipping between nonfrail elderly patients (≥ 70 years) and nonelderly patients.METHODSKeyhole clipping (either supraorbital or pterional) was performed to treat 260 cases of relatively small (≤ 10 mm) anterior circulation UIAs. There were 62 cases in the nonfrail elderly group (mean age 72.9 ± 2.6 years [± SD]) and 198 cases in the nonelderly group (mean age 59.5 ± 7.6 years). The authors evaluated mortality and morbidity (modified Rankin Scale score > 2 or Mini–Mental State Examination [MMSE] score < 24) at 3 months and 1 year after the operation, the general cognitive function by MMSE at 3 months and 1 year, anxiety and depression by the Beck Depression Inventory (BDI) and Hamilton Rating Scale for Depression (HAM-D) at 3 months, and radiological abnormalities and recurrence at 1 year.RESULTSBasic characteristics including comorbidities, frailty, and BDI and HAM-D scores were not significantly different between the 2 groups, whereas the MMSE score was slightly but significantly lower in the elderly group. Aneurysm location, largest diameter, type of keyhole surgery, neck clipping rate, and hospitalization period were not significantly different between the 2 groups. The incidence of chronic subdural hematoma was not significantly higher in the elderly group than in the nonelderly group (8.1% vs 4.5%, p = 0.332); rates of other complications including stroke and epilepsy were not significantly different. Lacunar infarction occurred in 3.2% of the elderly group and 3.0% of the nonelderly group. No patient in the elderly group required re-treatment or demonstrated recurrence of clipped aneurysms. The MMSE score at 3 months significantly improved in the nonelderly group but did not change in the elderly group. The BDI and HAM-D scores at 3 months were significantly improved in both groups. No patient died in either group. The morbidity at 3 months and 1 year in the elderly group (1.6% and 4.8%, respectively) was not significantly different from that in the nonelderly group (2.0% and 1.5%, respectively).CONCLUSIONSKeyhole clipping for nonfrail elderly patients with relatively small anterior circulation UIAs did not significantly increase the complication, mortality, or morbidity rate; hospitalization period; or aneurysm recurrence compared with nonelderly patients, and it was associated with improvement in anxiety and depression. Keyhole clipping to treat UIAs in the nonfrail elderly is an effective and long-lasting treatment.
Collapse
Affiliation(s)
- Kentaro Mori
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Kojiro Wada
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Naoki Otani
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Arata Tomiyama
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Terushige Toyooka
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Kazuya Fujii
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Kosuke Kumagai
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Satoru Takeuchi
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Satoshi Tomura
- 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama
| | - Takuji Yamamoto
- 2Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Izunokuni, Shizuoka; and
| | - Yasuaki Nakao
- 2Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Izunokuni, Shizuoka; and
| | - Hajime Arai
- 3Department of Neurosurgery, Juntendo University, Tokyo, Japan
| |
Collapse
|
35
|
Adeeb N, Moore JM, Wirtz M, Griessenauer CJ, Foreman PM, Shallwani H, Gupta R, Dmytriw AA, Motiei-Langroudi R, Alturki A, Harrigan MR, Siddiqui AH, Levy EI, Thomas AJ, Ogilvy CS. Predictors of Incomplete Occlusion following Pipeline Embolization of Intracranial Aneurysms: Is It Less Effective in Older Patients? AJNR Am J Neuroradiol 2017; 38:2295-2300. [PMID: 28912285 DOI: 10.3174/ajnr.a5375] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 07/08/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diversion with the Pipeline Embolization Device (PED) for the treatment of intracranial aneurysms is associated with a high rate of aneurysm occlusion. However, clinical and radiographic predictors of incomplete aneurysm occlusion are poorly defined. In this study, predictors of incomplete occlusion at last angiographic follow-up after PED treatment were assessed. MATERIALS AND METHODS A retrospective analysis of consecutive aneurysms treated with the PED between 2009 and 2016, at 3 academic institutions in the United States, was performed. Cases with angiographic follow-up were selected to evaluate factors predictive of incomplete aneurysm occlusion at last follow-up. RESULTS We identified 465 aneurysms treated with the PED; 380 (81.7%) aneurysms (329 procedures; median age, 58 years; female/male ratio, 4.8:1) had angiographic follow-up, and were included. Complete occlusion (100%) was achieved in 78.2% of aneurysms. Near-complete (90%-99%) and partial (<90%) occlusion were collectively achieved in 21.8% of aneurysms and defined as incomplete occlusion. Of aneurysms followed for at least 12 months (211 of 380), complete occlusion was achieved in 83.9%. Older age (older than 70 years), nonsmoking status, aneurysm location within the posterior communicating artery or posterior circulation, greater aneurysm maximal diameter (≥21 mm), and shorter follow-up time (<12 months) were significantly associated with incomplete aneurysm occlusion at last angiographic follow-up on univariable analysis. However, on multivariable logistic regression, only age, smoking status, and duration of follow-up were independently associated with occlusion status. CONCLUSIONS Complete occlusion following PED treatment of intracranial aneurysms can be influenced by several factors related to the patient, aneurysm, and treatment. Of these factors, older age (older than 70 years) and nonsmoking status were independent predictors of incomplete occlusion. While the physiologic explanation for these findings remains unknown, identification of factors predictive of incomplete aneurysm occlusion following PED placement can assist in patient selection and counseling and might provide insight into the biologic factors affecting endothelialization.
Collapse
Affiliation(s)
- N Adeeb
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery (N.A.), Louisiana State University, Shreveport, Louisiana
| | - J M Moore
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - M Wirtz
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - C J Griessenauer
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - P M Foreman
- Department of Neurosurgery (P.M.F., M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
| | - H Shallwani
- Department of Neurosurgery (H.S., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - R Gupta
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - A A Dmytriw
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - R Motiei-Langroudi
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - A Alturki
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - M R Harrigan
- Department of Neurosurgery (P.M.F., M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
| | - A H Siddiqui
- Department of Neurosurgery (H.S., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - E I Levy
- Department of Neurosurgery (H.S., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - A J Thomas
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - C S Ogilvy
- From the Neurosurgical Service (N.A., J.M.M., M.W., C.J.G., R.G., A.A.D., R.M.-L., A.A., A.J.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
36
|
Abstract
BACKGROUND Intracranial saccular aneurysms are acquired lesions that often present with neuro-ophthalmologic symptoms and signs. Recent advances in neurosurgical techniques, endovascular treatments, and neurocritical care have improved the optimal management of symptomatic unruptured aneurysms, but whether the chosen treatment has an impact on neuro-ophthalmologic outcomes remains debated. EVIDENCE ACQUISITION A review of the literature focused on neuro-ophthalmic manifestations and treatment of intracranial aneurysms with specific relevance to neuro-ophthalmologic outcomes was conducted using Ovid MEDLINE and EMBASE databases. Cavernous sinus aneurysms were not included in this review. RESULTS Surgical clipping vs endovascular coiling for aneurysms causing third nerve palsies was compared in 13 retrospective studies representing 447 patients. Complete recovery was achieved in 78% of surgical patients compared with 44% of patients treated with endovascular coiling. However, the complication rate, hospital costs, and days spent in intensive care were reported as higher in surgically treated patients. Retrospective reviews of surgical clipping and endovascular coiling for all ocular motor nerve palsies (third, fourth, or sixth cranial nerves) revealed similar results of complete resolution in 76% and 49%, respectively. Improvement in visual deficits related to aneurysmal compression of the anterior visual pathways was also better among patients treated with clipping than with coiling. The time to treatment from onset of visual symptoms was a predictive factor of visual recovery in several studies. Few reports have specifically assessed the improvement of visual deficits after treatment with flow diverters. CONCLUSIONS Decisions regarding the choice of therapy for intracranial aneurysms causing neuro-ophthalmologic signs ideally should be made at high-volume centers with access to both surgical and endovascular treatments. The status of the patient, location of the aneurysm, and experience of the treating physicians are important factors to consider. Although a higher rate of visual recovery was reported with neurosurgical clipping, this must be weighed against the potentially longer intensive care stays and increased early morbidity.
Collapse
|
37
|
Abstract
The prevalence of unruptured cerebral aneurysms (UCAs) in elderly patients is increasing in our aging population. UCA management in elderly patients has some difficulties, such as reduced life expectancy, increased comorbidities and treatment risks, and poor prognosis in case of rupture. In this review article, we summarize the most recent findings on the natural history, therapeutic options and treatment results for UCAs exclusively in elderly patients, and describe possible medical treatments for patients with UCAs.
Collapse
Affiliation(s)
- Tomohito Hishikawa
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| |
Collapse
|
38
|
Rinaldo L, Lanzino G. Increased Age Associated with Reduced Likelihood of Recurrence After Coiling of Ruptured Aneurysms. World Neurosurg 2017; 100:381-387. [DOI: 10.1016/j.wneu.2017.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 12/01/2022]
|
39
|
Thiarawat P, Jahromi BR, Kozyrev DA, Intarakhao P, Teo MK, Choque-Velasquez J, Hernesniemi J. Microneurosurgical Management of Posterior Communicating Artery Aneurysm: A Contemporary Series from Helsinki. World Neurosurg 2017; 101:379-388. [PMID: 28213191 DOI: 10.1016/j.wneu.2017.02.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objectives of this study were to analyze microsurgical techniques and to determine correlations between microsurgical techniques and the radiographic findings in the microneurosurgical treatment of posterior communicating artery aneurysms (PCoAAs). METHODS We retrospectively analyzed radiographic findings and videos of surgeries in 64 patients with PCoAAs who underwent microsurgical clipping by the senior author from August 2010 to 2014. RESULTS From 64 aneurysms, 30 (47%) had acute subarachnoid hemorrhage (SAH) that necessitated lamina terminalis fenestration (odds ratio [OR], 67.67; P < 0.001) and Liliequist membrane fenestration (OR, 19.62; P < 0.001). The low-lying aneurysms significantly necessitated the coagulation of the dura covering the anterior clinoid process (ACP) (OR, 7.43; P = 0.003) or anterior clinoidectomy (OR, 91.0; P < 0.001). We preferred straight clips in 45 (83%) of 54 posterolateral projecting aneurysms (OR, 45.0; P < 0.001), but preferred curved clips for posteromedial projecting aneurysms (OR, 6.39; P = 0.008). The mean operative time from the brain retraction to the final clipping was 17 minutes and 43 seconds. Postoperative computed tomography angiography revealed complete occlusion of 60 (94%) aneurysms. Three (4.6%) patients with acute SAH suffered postoperative lacunar infarction. CONCLUSIONS For ruptured aneurysms, lamina terminalis and Liliequist membrane fenestration are useful for additional cerebrospinal fluid drainage. For low-lying aneurysms, coagulation of the dura covering the ACP or tailored anterior clinoidectomy might be necessary for exposing the proximal aneurysm neck. Type of clips depends on the direction of projection. The microsurgical clipping of the PCoAAs can achieve good immediate complete occlusion rate with low postoperative stroke rate.
Collapse
Affiliation(s)
- Peeraphong Thiarawat
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Surgery, Naresuan University, Phitsanulok, Thailand.
| | | | - Danil A Kozyrev
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Neurosurgery, North-Western State Medical University, Saint Petersburg, Russia
| | - Patcharin Intarakhao
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland; Department of Anesthesiology, Naresuan University, Phitsanulok, Thailand
| | - Mario K Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol University Hospital, Bristol, United Kingdom
| | | | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
40
|
Duan G, Wen W, Zuo Q, Yang P, Zhang L, Hong B, Xu Y, Liu J, Huang Q. Development and Validation of the Procedure-Related Neurologic Complications Risk Score for Elderly Patients with Ruptured Intracranial Aneurysm Undergoing Endovascular Treatment. World Neurosurg 2017; 100:648-657.e2. [PMID: 28153618 DOI: 10.1016/j.wneu.2017.01.085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Our aim was to develop and validate a procedure-related neurologic complications (PNC) risk score for individual elderly patients with ruptured intracranial aneurysms undergoing endovascular treatment (EVT). METHODS Preoperatively collected data, including clinical, lesion, and procedure characteristics of consecutive elderly patients (≥60 years), were used to develop a PNC risk predictive score based on the coefficients (β) of a multivariable logistic regression analysis. The PNC included intraprocedural rupture, thromboembolic events, and rebleeding within 30 days after EVT. RESULTS Overall, 520 elderly patients who underwent EVT were enrolled. At 30 days, the PNC rate was 13.08%. Six risk factors were independently associated with PNC and comprised the PNC score (PNC score, 0-16 points): hypertension (2 points), Hunt-Hess grade ≥4 (3 points), Fisher grade ≥3 (2 points), wide-necked aneurysm (2 points), with a bleb on the aneurysm sac (3 points), and aneurysm size (3-10 mm, 1 point; <3 mm, 4 points). The PNC score model predicted the risk of PNC at a sensitivity of 63.22% and specificity of 84.79%. Moreover, the PNC score demonstrated significant discrimination (area under curve, 0.799; P < 0.001) and calibration (Hosmer-Lemeshow test, P = 0.319). Excellent prediction, discrimination, and calibration properties were reproduced by the internal validation group with bootstrapping techniques. CONCLUSIONS The PNC score can be an easily applicable tool for predicting the risk of PNC for individual elderly patients with ruptured intracranial aneurysms undergoing EVT. Our study provides large case-based evidence supporting the integration of individual clinical, lesion, and procedure characteristics to predict PNC risk.
Collapse
Affiliation(s)
- Guoli Duan
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wanling Wen
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qiao Zuo
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Lei Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
| |
Collapse
|
41
|
Cagnazzo F, Brinjikji W, Lanzino G. Effect of age on outcomes and practice patterns for patients with anterior communicating artery aneurysms. J Neurosurg Sci 2017; 64:225-230. [PMID: 28079351 DOI: 10.23736/s0390-5616.16.03942-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND With widespread utilization of noninvasive imaging, small unruptured anterior communicating artery (AcoA) aneurysms are increasingly detected in the general population, particularly in elderly patients. We investigated the association between age and clinical characteristics and outcomes of patients with unruptured AcoA aneurysms. METHODS Between January 2008 and May 2016, information on 179 consecutive patients with unruptured AcoA aneurysms was obtained and included demographic data, aneurysm features, risk factors for formation and rupture, treatment type, complications, and follow-up information. A 2-tailed t test was used for continuous data and the chi-square test for categorical variables. Statistical significance was set at P value < 0.05. RESULTS There were 76 patients 65 and older (42.5%) and 103 younger than 65 (57.5%). Conservative management was more common in older patients (67.1% vs. 41.7%, P=0.001). Endovascular treatment was more commonly used in the older population (80% vs. 61% of the treated aneurysms in older and younger group, P=0.16). Treatment-related complications were 8% but resulted in permanent neurological deficits in one patient (1.2%). Among conservatively treated aneurysms, three (3.2%) ruptured at follow-up resulting in patient death in two cases (2.4%). All three ruptures occurred in elderly patients. CONCLUSIONS With a modern approach that emphasizes endovascular therapy, especially in older individuals, unruptured AcoA aneurysms can be treated with a very low morbidity. Among patients with small aneurysms for which treatment was not deemed indicated or necessary, the rate of rupture at follow-up was not negligible, with 5.8% of older patients experiencing bleeding from the aneurysm.
Collapse
Affiliation(s)
| | | | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA -
| |
Collapse
|
42
|
Sugiyama SI, Niizuma K, Sato K, Rashad S, Kohama M, Endo H, Endo T, Matsumoto Y, Ohta M, Tominaga T. Blood Flow Into Basilar Tip Aneurysms. Stroke 2016; 47:2541-7. [DOI: 10.1161/strokeaha.116.013555] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 08/15/2016] [Indexed: 12/28/2022]
Abstract
Background and Purpose—
Hemodynamic forces may play a role in the recanalization of coiled aneurysms. The purpose of this study was to investigate the influence of presurgical hemodynamics on the efficacy of coil embolization for basilar tip aneurysms.
Methods—
We identified 82 patients who underwent endovascular coil embolization for basilar tip aneurysms with a follow-up of >1 year. Presurgical hemodynamics were investigated using computational fluid dynamics with 3-dimensional data derived from rotational angiography. During postprocessing, we quantified the rate of net flow entering the aneurysm through its neck and calculated the proportion of the aneurysmal inflow rate to the basilar artery flow rate. In addition, we investigated the correlation between the basilar bifurcation configuration and the hemodynamics.
Results—
Twenty-five of the 82 patients were excluded because of difficult vascular geometry reconstruction. Among the 57 examined patients, angiographic recanalization was observed in 19 patients (33.3%). The proportion of the aneurysmal inflow rate to the basilar artery flow rate and a coil packing density <30% were independent and significant predictors for the recanalization of coiled aneurysms. Additional investigation revealed that a small branch angle formed by the basilar artery and the posterior cerebral artery increased blood flow into the aneurysm.
Conclusions—
The proportion of the aneurysmal inflow rate to the basilar artery flow rate, influenced by the basilar bifurcation configuration, was an independent and significant predictor for recanalization after coil embolization in basilar tip aneurysms.
Collapse
Affiliation(s)
- Shin-ichiro Sugiyama
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| | - Kuniyasu Niizuma
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| | - Kenichi Sato
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| | - Sherif Rashad
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| | - Misaki Kohama
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| | - Hidenori Endo
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| | - Toshiki Endo
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| | - Yasushi Matsumoto
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| | - Makoto Ohta
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| | - Teiji Tominaga
- From the Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (S.-i.S., K.N., S.R., T.T.); Graduate School of Biomedical Engineering (S.-i.S., M.O.) and Institute of Fluid Science (M.O.), Tohoku University, Sendai, Japan; and Department of Neuroanesthesia (S.-i.S., M.K.), Department of Neuroendovascular Therapy (K.S., Y.M.), and Department of Neurosurgery (H.E., T.E.), Kohnan Hospital, Sendai, Japan
| |
Collapse
|
43
|
Abstract
PURPOSE OF REVIEW This article provides an overview of the major neurologic complications of common neurosurgical and endovascular procedures. RECENT FINDINGS Brain edema, seizures, postoperative hemorrhage, and cerebral ischemia can complicate neurosurgical procedures and produce neurologic decline. The high variability of reporting, types of operations, patient characteristics, and acuity of cases make estimating the incidence and severity of complications difficult. Overall, the complication rate of neurosurgical procedures is approximately 14%, but these are commonly systemic complications (eg, bleeding requiring transfusion, need for mechanical ventilation). In addition to intracranial hemorrhage, ischemia, and seizures after craniotomies, additional characteristic complications include hyperperfusion syndrome and cranial nerve palsies after carotid endarterectomy, cerebrospinal fluid leaks and aseptic meningitis after posterior fossa surgery, and arterial dissections or groin hematomas after endovascular procedures. SUMMARY Neurologic decline can be caused by a variety of causes in the postoperative period. The indication for surgery, type of surgery, and time of decline is helpful in narrowing the differential diagnosis. Brain edema, elevated intracranial pressure (ICP), seizures, intracranial hemorrhage, ischemic infarction, and cranial nerve palsies are some of the more common complications in patients that neurologists may be asked to evaluate or comanage in the postoperative setting.
Collapse
|
44
|
Brinjikji W, Kallmes DF, Cloft HJ, Lanzino G. Age-related outcomes following intracranial aneurysm treatment with the Pipeline Embolization Device: a subgroup analysis of the IntrePED registry. J Neurosurg 2016; 124:1726-30. [DOI: 10.3171/2015.5.jns15327] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The association between age and outcomes following aneurysm treatment with flow diverters such as the Pipeline Embolization Device (PED) have not been well established. Using the International Retrospective Study of the Pipeline Embolization Device (IntrePED) registry, the authors assessed the age-related clinical outcomes of patients undergoing aneurysm embolization with the PED.
METHODS
Patients with unruptured aneurysms in the IntrePED registry were divided into 4 age groups: ≤ 50, 51–60, 61–70, and > 70 years old. The rates of the following postoperative complications were compared between age groups using chi-square tests: spontaneous rupture, intracranial hemorrhage (ICH), ischemic stroke, parent artery stenosis, cranial neuropathy, neurological morbidity, neurological mortality, combined neurological morbidity and mortality, and all-cause mortality. The association between age and these complications was tested in a multivariate logistic regression analysis adjusted for sex, number of PEDs, and aneurysm size, location, and type.
RESULTS
Seven hundred eleven patients with 820 unruptured aneurysms were included in this study. Univariate analysis demonstrated no significant difference in ICH rates across age groups (lowest 1.0% for patients ≤ 50 years old and highest 5.0% for patients > 70 years old, p = 0.097). There was no difference in ischemic stroke rates (lowest 3.6% for patients ≤ 50 years old and highest 6.0% for patients 50–60 years old, p = 0.73). Age > 70 years old was associated with higher rates of neurological mortality; patients > 70 years old had neurological mortality rates of 7.4% compared with 3.3% for patients 61–70 years old, 2.7% for patients 51–60 years old, and 0.5% for patients ≤ 50 years old (p = 0.006). On multivariate logistic regression analysis, increasing age was associated with higher odds of combined neurological morbidity and mortality (odds ratio 1.02, 95% confidence interval 1.00–1.05; p = 0.03).
CONCLUSIONS
Increasing age is associated with higher neurological morbidity and mortality after Pipeline embolization of intracranial aneurysms. However, the overall complication rates of PED treatment in this group of highly selected elderly patients (> 70 years) were acceptably low, suggesting that age alone should not be considered an exclusion criterion when considering treatment of intracranial aneurysms with the PED.
Collapse
Affiliation(s)
| | - David F. Kallmes
- Departments of 1Radiology and
- 2Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Harry J. Cloft
- Departments of 1Radiology and
- 2Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Giuseppe Lanzino
- Departments of 1Radiology and
- 2Neurosurgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
45
|
Shimamura N, Naraoka M, Katagai T, Katayama K, Kakuta K, Matsuda N, Ohkuma H. Analysis of Factors That Influence Long-Term Independent Living for Elderly Subarachnoid Hemorrhage Patients. World Neurosurg 2016; 90:504-510. [PMID: 27025452 DOI: 10.1016/j.wneu.2016.03.057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 03/17/2016] [Accepted: 03/18/2016] [Indexed: 12/01/2022]
Abstract
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.
Collapse
Affiliation(s)
- Norihito Shimamura
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan.
| | - Masato Naraoka
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Takeshi Katagai
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Kosuke Katayama
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Kiyohide Kakuta
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Naoya Matsuda
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| |
Collapse
|
46
|
Delgado-López PD, López-Martínez JL, Gero-Escapa M, Martín-Alonso J, Castaño-Blazquez M, Ossa-Echeverri S, Martín-Velasco V, Castilla-Díez JM. [Aneurysmal subarachnoid haemorrhage: Results after introducing endovascular therapy in a medium-low volume centre]. Neurocirugia (Astur) 2016; 27:207-19. [PMID: 26975879 DOI: 10.1016/j.neucir.2016.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 01/17/2016] [Accepted: 01/18/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the impact of introducing endovascular therapy for patients with aneurysmal subarachnoid haemorrhage (aSAH) in a medium-low volume centre. MATERIAL AND METHODS A retrospective observational study was conducted by comparing the clinical outcome of patients with aSAH before and after introducing endovascular therapy in our centre. The main variables analysed were: type of treatment, hospital and late mortality, intra-procedural morbidity, rate of re-bleeding and vasospasm, and clinical outcome according to the Glasgow Outcome Score (GOS). RESULTS Seventy-one patients were treated in two periods: 2010-2011 (32 patients; 19 clipped, 6 coiled, 7 untreated), and 2012-2013 (39 patients, 3 clipped, 34 coiled, 2 untreated). No significant differences were found in age, sex, clinical grade at admission, type and location of aneurysm, Fisher score, or in hospital mortality (28.1% vs 25.6%, P=.35), GOS (except for GOS 5: 43.37% vs 53.8%, P=.045), rate of hydrocephalus and rate of vasospasm. The second cohort obtained better results for aggregated GOS 1+2+3 (36.3% vs 43.75%, P=.034) and for GOS 4+5 (61.5% vs 56.25%, P=.078). The percentage of patients left untreated was significantly lower in the second period (5.1% vs 21.8%, P<.01), as well as the rate of re-bleeding (0% vs 9.4%, P<.01). Patients were treated earlier (2.51 vs 3.95 days), and hospital and total stay were lower (15.2 and 24.6 vs 10.3 and 18 days) in the second period, these differences not reaching statistical significance. CONCLUSIONS Endovascular therapy allowed treating more patients with aSAH, and with a lower re-bleeding rate. This led to a modest reduction in morbidity and mortality.
Collapse
Affiliation(s)
| | - José Luis López-Martínez
- Servicio de Radiología, Sección de Neurorradiología Intervencionista, Hospital Universitario de Burgos, Burgos, España
| | - María Gero-Escapa
- Servicio de Cuidados Intensivos, Hospital Universitario de Burgos, Burgos, España
| | | | - Miguel Castaño-Blazquez
- Servicio de Radiología, Sección de Neurorradiología Intervencionista, Hospital Universitario de Burgos, Burgos, España
| | | | | | | |
Collapse
|
47
|
Duan G, Yang P, Li Q, Zuo Q, Zhang L, Hong B, Xu Y, Zhao W, Liu J, Huang Q. Prognosis Predicting Score for Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage: A Risk Modeling Study for Individual Elderly Patients. Medicine (Baltimore) 2016; 95:e2686. [PMID: 26886607 PMCID: PMC4998607 DOI: 10.1097/md.0000000000002686] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 10/09/2015] [Accepted: 01/11/2016] [Indexed: 11/30/2022] Open
Abstract
The elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) have a greater risk of poor clinical outcome after endovascular treatment (EVT) than younger patients do. Hence, it is necessary to explore which factors are associated with poor outcome and develop a predictive score specifically for elderly patients with aSAH receiving EVT. The aim of this study was to develop and validate a predictive score for 1-year outcomes in individual elderly patients with aSAH underwent EVT.In this 10-year prospective study, 520 consecutive aSAH elderly (age ≥ 60 years) patients underwent EVT in a single center were included. The risk factors, periprocedural, and 1-year follow-up data of all patients were entered in a specific prospective database. The modified Rankin scale was used for evaluating clinical outcome. To optimize the model's predictive capacity, the original matrix was randomly divided in 2 submatrices (learning and testing). The predictive score was developed using Arabic numerals for all variables based on the variable coefficients (β) of multivariable logistic regression analysis in the learning set and the predictive performance evaluation was assessed in the testing set. The risk classes were constructed using classification criteria based on sensitivity and specificity. The poor outcome rate at 1 year was 26.15%. Six risk factors, including age, hypertension, Hunt-Hess scale, Fisher scale, aneurysm location, and periprocedural complications, were independently associated with poor outcome and assembled the Changhai score. The discriminative power analysis with the area under the receiver operating characteristic curve (AUC) of the Changhai score was statistically significant (0.864, 0.824-0.904, P < 0.001). The sensitivity and specificity of the Changhai score were 82.07% and 78.06%, respectively. Our study indicated that age, hypertension, Hunt-Hess scale, Fisher scale, aneurysm location, and periprocedural complications were independent risk factors of poor outcome for elderly aSAH patients underwent EVT. In combination with these risk factors, the Changhai score can be a useful tool in the prediction of clinical outcome but needs to be validated in various centers before it can be recommended for application.
Collapse
Affiliation(s)
- Guoli Duan
- From the Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Xu JP, Shi JJ, Xiao GD, Duan GX, Zhang CY, Cao YJ. Endovascular Treatment of a Distal C1 Dissecting Aneurysm in a Patient with Double Aortic Arch. Chin Med J (Engl) 2016; 129:112-3. [PMID: 26712446 PMCID: PMC4797531 DOI: 10.4103/0366-6999.172608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | | | - Yong-Jun Cao
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215004; Jiangsu Key Laboratory of Translational Research and Therapy for Neuro-Psycho-Diseases and Institute of Neuroscience, Soochow University, Suzhou,, China
| |
Collapse
|
49
|
Hishikawa T, Date I, Tokunaga K, Tominari S, Nozaki K, Shiokawa Y, Houkin K, Murayama Y, Ishibashi T, Takao H, Kimura T, Nakayama T, Morita A. Risk of rupture of unruptured cerebral aneurysms in elderly patients. Neurology 2015; 85:1879-85. [PMID: 26511450 PMCID: PMC4662696 DOI: 10.1212/wnl.0000000000002149] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/28/2015] [Indexed: 11/25/2022] Open
Abstract
Objectives: The aim of this study was to identify risk factors for rupture of unruptured cerebral aneurysms (UCAs) in elderly Japanese patients aged 70 years or older. Methods: The participants included all patients 70 years of age or older in 3 prospective studies in Japan (the Unruptured Cerebral Aneurysm Study of Japan [UCAS Japan], UCAS II, and the prospective study at the Jikei University School of Medicine). A total of 1,896 patients aged 70 years or older with 2,227 UCAs were investigated. The median and mean follow-up periods were 990 and 802.7 days, respectively. Results: The mean aneurysm size was 6.2 ± 3.9 mm. Sixty-eight patients (3.6%) experienced subarachnoid hemorrhage during the follow-up period. Multivariable analysis per patient revealed that in patients aged 80 years or older (hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.16–3.49, p = 0.012), aneurysms 7 mm or larger (HR, 3.08; 95% CI, 1.35–7.03, p = 0.007 for 7–9 mm; HR, 7.82; 95% CI, 3.60–16.98, p < 0.001 for 10–24 mm; and HR, 43.31; 95% CI, 12.55–149.42, p < 0.001 for ≥25 mm) and internal carotid–posterior communicating artery aneurysms (HR, 2.45; 95% CI, 1.23–4.88, p = 0.011) were independent predictors for UCA rupture in elderly patients. Conclusions: In our pooled analysis of prospective cohorts in Japan, patient age and aneurysm size and location were significant risk factors for UCA rupture in elderly patients.
Collapse
Affiliation(s)
- Tomohito Hishikawa
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
| | - Isao Date
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Koji Tokunaga
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Shinjiro Tominari
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuhiko Nozaki
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yoshiaki Shiokawa
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kiyohiro Houkin
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yuichi Murayama
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Toshihiro Ishibashi
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroyuki Takao
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Toshikazu Kimura
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Takeo Nakayama
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Akio Morita
- From the Department of Neurological Surgery (T.H., I.D., K.T.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama; Department of Health Informatics (S.T., T.N.), Kyoto University School of Public Health, Kyoto; Department of Neurosurgery (K.N.), Shiga University of Medical Science, Shiga; Department of Neurosurgery (Y.S.), Kyorin University School of Medicine, Tokyo; Department of Neurosurgery (K.H.), Hokkaido University Graduate School of Medicine, Sapporo; Division of Endovascular Neurosurgery (Y.M., T.I., H.T.), Department of Neurosurgery, The Jikei University School of Medicine, Tokyo; Department of Neurosurgery (T.K.), NTT Medical Center Tokyo; and UCAS Coordinating Office (A.M.), University of Tokyo, Department of Neurological Surgery, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | | |
Collapse
|
50
|
Anxionnat R, Tonnelet R, Derelle AL, Liao L, Barbier C, Bracard S. Endovascular treatment of ruptured intracranial aneurysms: Indications, techniques and results. Diagn Interv Imaging 2015; 96:667-75. [PMID: 26160704 DOI: 10.1016/j.diii.2015.06.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 06/10/2015] [Indexed: 11/30/2022]
Affiliation(s)
- R Anxionnat
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France.
| | - R Tonnelet
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
| | - A L Derelle
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
| | - L Liao
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
| | - C Barbier
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
| | - S Bracard
- Department of diagnostic and therapeutic neuroradiology, Neurology Hospital, Central Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, CO 60034, 54035 Nancy cedex, France
| |
Collapse
|