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Arteriovenous Malformations and Other Vascular Anomalies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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: 9] [Impact Index Per Article: 3.0] [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.
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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
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Zheng J, Xu R, Sun X, Zhang X. Small vs. Large Unruptured Cerebral Aneurysm: Concerns With the Age of Patient. Front Neurol 2021; 12:735456. [PMID: 34621238 PMCID: PMC8490624 DOI: 10.3389/fneur.2021.735456] [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: 07/02/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The coiling and clipping of unruptured cerebral aneurysms (UCAs) in older patients has increased rapidly, and aneurysm size was a significant factor for decision-making in the treatment of UCAs. The purpose of the study was to investigate the impact of age on the functional outcomes of patients between the small versus large UCAs. Methods: We conducted a retrospective study for consecutive cases of UCAs admitted from May 2011 to December 2020. According to the maximum diameter of UCA, patients were divided into small UCAs (≤ 5 mm) group and large UCAs (>5 mm) group. Baseline characteristics, clinical complications, and outcomes of patients between the two groups were analyzed. Results: A total of 564 UCA patients received preventive treatment, including 165 small UCAs and 399 large UCAs. Compared with the small UCA group, the incidence of ischemia event in the large UCA group was significantly higher (7.3 vs. 2.4%; p = 0.029). Multivariable analysis demonstrating age (p = 0.006) and treatment modality (p < 0.001) were independent risk factors associated with poor outcome for patients with large UCAs. Conclusions: Preventive treatment of small UCAs is safe and effective, but older patients with large UCAs are at high risk of poor outcome, and the operations should be more cautious.
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Affiliation(s)
- Jianfeng Zheng
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ru Xu
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaochuan Sun
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaodong Zhang
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Daou BJ, Muhlestein WE, Palmateer G, Thompson BG, Pandey AS. Clipping of unruptured intracranial aneurysms in patients older than sixty: An age-based analysis. Clin Neurol Neurosurg 2021; 207:106737. [PMID: 34134009 DOI: 10.1016/j.clineuro.2021.106737] [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: 01/18/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The diagnosis of unruptured intracranial aneurysms (UIAs) is being made more frequently in elderly patients. The goal of this study is to evaluate complications and clinical outcome in patients ≥ 60 years-old who underwent clipping of UIAs. METHODS We performed a retrospective cohort study. Clinical outcome (modified Rankin scale score) was determined at the latest clinical follow-up. Complications and outcomes were compared between age groups (60-69, 70-80) and subgroups (60-64, 65-69, 70-74, and >75). RESULTS The study population consisted of 255 patients (range 60-80 years-old) who underwent 262 clipping procedures for UIAs. Mean follow-up duration was 15.6 months (± 27.5). Major complications occurred in 20 patients (7.6%) and mortality in 3 patients (1.1%). Medical complications occurred in 26 patients (10%). Mean length of hospital-stay was 4.7 days (± 5.8). 89.6% were discharged to home. 87.8% had a favorable clinical outcome. The 70-80 age group had significantly more complications (P = 0.03) than the 60-69 group and a significantly longer hospital stay (6.02 vs. 4.3 days, P = 0.04). The older group was less likely to discharge to home and more likely to require rehabilitation (P = 0.002). Favorable clinical outcome did not significantly differ between the two groups (85.7% vs. 88.4%, P = 0.56). There was a trend for increasing complications from the younger to older subgroups (P = 0.008) and a reduction in the likelihood to discharge to home (P < 0.0001). The rate of ultimate favorable clinical outcome did not differ significantly between subgroups (P = 0.79). CONCLUSION Although complications, length of hospital-stay, and discharge to non-home destinations increase with older age, the majority of patients ≥ 60 may have favorable clinical outcomes.
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Affiliation(s)
- Badih J Daou
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Whitney E Muhlestein
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Gregory Palmateer
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States.
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Zheng J, Sun X, Zhang X. Influence of Age-Related Complications on Clinical Outcome in Patients With Small Ruptured Cerebral Aneurysms. Front Neurol 2020; 11:131. [PMID: 32194496 PMCID: PMC7066075 DOI: 10.3389/fneur.2020.00131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/05/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Small ruptured cerebral aneurysms (≤5 mm) account for the majority of aneurysmal subarachnoid hemorrhages, and its clinical management remains a challenge. The aim of this study was to identify the effect of age-related complications on the outcome of patients with small ruptured aneurysm. Methods: A retrospective review was performed in patients with small ruptured aneurysms who underwent microsurgical clipping or endovascular coiling from September 2012 to December 2018. According to their ages, the patients were divided into the elderly group and the non-elderly group. Baseline characteristics, clinical complications, and outcome of patients were analyzed between the two groups. A multivariate logistic regression analysis was used to determine the risk factors associated with the poor outcome of the elderly patients. Results: In the elderly group, 83 patients were treated with clipping and 50 were treated with coiling. In the non-elderly group, 188 patients were treated with clipping and 117 were treated with coiling. The incidence of neurological complications with neurologic deficit in the elderly group was significantly higher compared with that in the non-elderly group (P = 0.006). The elderly patients had a longer hospital stay (P = 0.032) and a poorer outcome (P = 0.001) compared with the non-elderly patients. A multivariate analysis showed that irregular aneurysms (P = 0.045) and ischemic events (P < 0.001) were independent risk factors associated with poor outcome in the elderly. Conclusions: Neurological complications with neurologic deficit, especially ischemic complications, were clearly more common in the elderly patients. Irregular small aneurysms or postoperative ischemic events should be paid attention as the higher risk of poor outcome in the elderly.
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Affiliation(s)
- Jianfeng Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaochuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaodong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Ikawa F, Michihata N, Akiyama Y, Iihara K, Matano F, Morita A, Kato Y, Iida K, Kurisu K, Fushimi K, Yasunaga H. Treatment Risk for Elderly Patients with Unruptured Cerebral Aneurysm from a Nationwide Database in Japan. World Neurosurg 2019; 132:e89-e98. [DOI: 10.1016/j.wneu.2019.08.252] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 11/28/2022]
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Ogilvy CS, Jordan NJ, Ascanio LC, Enriquez-Marulanda AA, Salem MM, Moore JM, Thomas AJ. Surgical and Endovascular Comprehensive Treatment Outcomes of Unruptured Intracranial Aneurysms: Reduction of Treatment Bias. World Neurosurg 2019; 126:e878-e887. [PMID: 30872200 DOI: 10.1016/j.wneu.2019.03.005] [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: 01/10/2019] [Revised: 03/01/2019] [Accepted: 03/02/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Determining the risks of treatment of unruptured intracranial aneurysms is critical in the decision-making process of management. Most studies have reported the results for endovascular or surgical management. Our objective was to better delineate the risk estimates for unruptured intracranial aneurysms treated with surgical or endovascular techniques in a comprehensive fashion, according to the patients' risk profiles. METHODS Data were gathered from 553 patients with 658 unruptured intracranial aneurysms treated at a single institution from 2014 to 2017. The decision to treat was determined by a projected morbidity that was lower than the natural history rupture risk. Data on aneurysm size, location, patient age, and outcome at the last clinical visit (modified Rankin scale scores) were collected and analyzed retrospectively. RESULTS The mean patient age was 59 years, and the mean lesion size was 7.3 mm. Microsurgical clipping was used in 251 lesions (38.2%), endovascular coiling in 70 (10.6%), stent-assisted coiling in 89 (13.5%), and a pipeline embolization device in 248 (37.7%). Complications from the procedures or during hospital admission occurred 66 lesions (10% of the total). Of these 66 complications, 28 (4.32% of the total) were non-neurological, treated, and resolved without permanent morbidity. Neurologic complications occurred in 38 procedures (5.7% of the total). Of these, 7 (1%) resulted in a permanent poor outcome (modified Rankin scale score, 3-6). CONCLUSION Aneurysmal obliteration using endovascular and surgical approaches in a comprehensive fashion has low treatment risks for unruptured aneurysms. The nomograms generated are useful in the discussion with patients and families regarding the risks of total institutional treatment of unruptured aneurysms.
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Affiliation(s)
- Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States.
| | - Noah J Jordan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Luis C Ascanio
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Alejandro A Enriquez-Marulanda
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
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Kim YD, Bang JS, Lee SU, Jeong WJ, Kwon OK, Ban SP, Kim TK, Kim SB, Oh CW. Long-term outcomes of treatment for unruptured intracranial aneurysms in South Korea: clipping versus coiling. J Neurointerv Surg 2018; 10:1218-1222. [DOI: 10.1136/neurintsurg-2018-013757] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/23/2018] [Accepted: 04/03/2018] [Indexed: 11/04/2022]
Abstract
BackgroundThe long-term outcomes of endovascular coiling and surgical clipping for the treatment of unruptured intracranial aneurysms are unclear.MethodsWe performed a nationwide retrospective cohort study using claims data from the Korean Health Insurance Review and Assessment Service on patients undergoing surgical clipping or endovascular coiling from 2008 to 2014. Inverse probability treatment weighting for average treatment effect on the treated and the multiple imputation method were used to balance covariates and handle missing values. The primary outcome was all-cause mortality at 7 years.ResultsWe identified 26 411 patients of whom 11 777 underwent surgical clipping and 14 634 underwent endovascular coiling. After adjustment with the use of inverse probability treatment weighting for average treatment effect on the treated, all-cause mortality rates at 7 years were 3.8% in the endovascular coiling group and 3.6% in the surgical clipping group (HR 1.05; 95% CI 0.86 to 1.28; P=0.60, log-rank test). The adjusted probabilities of aneurysm rupture at 7 years were 0.9% after endovascular coiling and 0.7% after surgical clipping (HR 0.9; 95% CI 0.61 to 1.34; P=0.63, log-rank test). The probabilities of retreatment at 7 years after adjustment were 4.9% in the endovascular coiling group and 3.2% in the surgical clipping group (HR 1.52; 95% CI 1.28 to 1.81; P<0.001, log-rank test).ConclusionsAll-cause mortality at 7 years was similar between the elective surgical clipping and endovascular coiling groups in patients with unruptured aneurysms who had no history of subarachnoid hemorrhage due to aneurysm rupture.
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Oravec CS, Motiwala M, Reed K, Kondziolka D, Barker FG, Michael LM, Klimo P. Big Data Research in Neurosurgery: A Critical Look at this Popular New Study Design. Neurosurgery 2017; 82:728-746. [DOI: 10.1093/neuros/nyx328] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023] Open
Affiliation(s)
- Chesney S Oravec
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kevin Reed
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - L Madison Michael
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
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Bernat AL, Clarençon F, André A, Nouet A, Clémenceau S, Sourour NA, Di Maria F, Degos V, Golmard JL, Cornu P, Boch AL. Risk factors for angiographic recurrence after treatment of unruptured intracranial aneurysms: Outcomes from a series of 178 unruptured aneurysms treated by regular coiling or surgery. J Neuroradiol 2017; 44:298-307. [PMID: 28602498 DOI: 10.1016/j.neurad.2017.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 03/13/2017] [Accepted: 05/03/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term stability after intracranial aneurysm exclusion by coiling is still a matter of debate; after surgical clipping little is known. OBJECTIVE To study outcome after endovascular and surgical treatments for unruptured intracranial aneurysms in terms of short- and long-term angiographic exclusion and risk factors for recanalization. METHODS From 2004 and 2009, patients treated for unruptured berry intracranial aneurysms by coiling or clipping were reviewed. Aneurysmal exclusion was evaluated using the Roy-Raymond grading scale; immediate clinical outcome was also assessed. Clinical outcome, recanalization, risk factors for recurrence and bleeding during the follow-up period were analyzed by groups; "surgery" and "embolization". RESULTS From 2004 to 2009, 178 consecutive unruptured aneurysms were treated. The post-procedure angiographic results for "surgery" were: total exclusion 75.6%; residual neck 13.5%; residual aneurysm 10.8%. For "embolization", the results were, respectively: 72%; 20.7%; and 7.2%. Morbidity was 3% for "surgery" and 1.6% for "embolization" (P=0.74); mortality was nil. Mean clinical and angiographic follow-up was 5years. Recurrence rate was of 11.5% for "surgery" vs. 44% for "embolization" with a mean follow-up of 4 and 5.75years, respectively (P=1.10-5). The retreatment rate was 8.4%. Two significant risk factors for recanalization were identified: maximum diameter of the aneurysm sac (P=0.0038) and pericallosal location (P=0.0388). No bleeding event occurred. CONCLUSION Both techniques are safe. The rate of aneurismal recurrence was significantly higher for embolization, especially for large diameter aneurysms and pericallosal locations. No bleeding event occurred after recanalization.
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Affiliation(s)
- Anne-Laure Bernat
- Department of Neurosurgery, Lariboisière University Hospital, AP-HP, 75010 Paris, France; Paris VII University, Paris Diderot, Paris, France.
| | - Frédéric Clarençon
- Department of Interventional Neuroradiology, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France; Paris VI University, Pierre-et-Marie-Curie, Paris, France
| | - Arthur André
- Department of Neurosurgery, Lariboisière University Hospital, AP-HP, 75010 Paris, France; Paris VI University, Pierre-et-Marie-Curie, Paris, France
| | - Aurélien Nouet
- Department of Neurosurgery, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Stéphane Clémenceau
- Department of Neurosurgery, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Nader-Antoine Sourour
- Department of Interventional Neuroradiology, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Federico Di Maria
- Department of Interventional Neuroradiology, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Vincent Degos
- Paris VI University, Pierre-et-Marie-Curie, Paris, France; Department of Anesthesia and Perioperative Care, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Jean-Louis Golmard
- Paris VI University, Pierre-et-Marie-Curie, Paris, France; Department of Biomedical Statistics, Pitié-Salpêtrière University Hospital, AP-HP, 75013 Paris, France
| | - Philippe Cornu
- Department of Neurosurgery, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France; Paris VI University, Pierre-et-Marie-Curie, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
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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.
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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
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Bekelis K, Gottlieb DJ, Su Y, O’Malley AJ, Labropoulos N, Goodney P, Lawton MT, MacKenzie TA. Comparison of clipping and coiling in elderly patients with unruptured cerebral aneurysms. J Neurosurg 2017; 126:811-818. [PMID: 27203150 PMCID: PMC5116411 DOI: 10.3171/2016.1.jns152028] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The comparative effectiveness of the 2 treatment options-surgical clipping and endovascular coiling-for unruptured cerebral aneurysms remains an issue of debate and has not been studied in clinical trials. The authors investigated the association between treatment method for unruptured cerebral aneurysms and outcomes in elderly patients. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who had treatment for unruptured cerebral aneurysms between 2007 and 2012. To control for measured confounding, the authors used propensity score conditioning and inverse probability weighting with mixed effects to account for clustering at the level of the hospital referral region (HRR). An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding and to create pseudo-randomization on the treatment method. RESULTS During the study period, 8705 patients underwent treatment for unruptured cerebral aneurysms and met the study inclusion criteria. Of these patients, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular coiling. Instrumental variable analysis demonstrated no difference between coiling and clipping in 1-year postoperative mortality (OR 1.25, 95% CI 0.68-2.31) or 90-day readmission rate (OR 1.04, 95% CI 0.66-1.62). However, clipping was associated with a greater likelihood of discharge to rehabilitation (OR 6.39, 95% CI 3.85-10.59) and 3.6 days longer length of stay (LOS; 95% CI 2.90-4.71). The same associations were present in propensity score-adjusted and inverse probability-weighted models. CONCLUSIONS In a cohort of Medicare patients, there was no difference in mortality and the readmission rate between clipping and coiling of unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to a rehabilitation facility and a longer LOS.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
| | - Daniel J. Gottlieb
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
| | - Yin Su
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
- Department of Biomedical Data Science, Hanover, New Hampshire
| | - Nicos Labropoulos
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Michael T. Lawton
- Department of Neurosurgery, University of California, San Francisco Medical Center, San Francisco, California
| | - Todd A. MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
- Department of Biomedical Data Science, Hanover, New Hampshire
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon
- Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon
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Nanda A, Patra DP, Bir SC, Maiti TK, Kalakoti P, Bollam P. Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Single Surgeon's Experience over 16 Years. World Neurosurg 2017; 100:85-99. [PMID: 28057589 DOI: 10.1016/j.wneu.2016.12.099] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Unruptured intracranial aneurysms (UIAs) have become an issue of greater significance as their detection rates have increased over the years. We present the overall experience of microsurgical clipping of unruptured aneurysms by a single surgeon over a period of more than 16 years. METHODS The clinical and radiologic data were reviewed retrospectively. Clinical outcome at follow-up was assessed with Glasgow Outcome Scale, and angiograms were reviewed for the degree of occlusion. RESULTS One hundred ninety-six patients with 221 UIAs were included in the analysis. The median age of patients was 54 years, with a female preponderance. Eighty-two percent of the patients had chronic headache on presentation. Middle cerebral artery aneurysms (32.2%) and posterior-inferior-cerebellar-artery aneurysms (46.1%) were most common in the anterior and posterior circulation, respectively. The perioperative complication rate was 17.3%. The overall surgical morbidity and mortality were 2.1% and 1.5%, respectively. With median follow-up of 11.3 months, 82% of patients were almost asymptomatic with a complete occlusion rate of 94%. The proportion of UIAs being coiled has significantly increased in the last decade, with a concomitant increase in the risk of poor clinical outcome after surgery. CONCLUSION Surgical clipping is effective and can provide a good long-term outcome. The most commendable consequence that it provides is a better long-term occlusion rate. The experience of the individual surgeon is important for a superior and enduring overall outcome. An increase in the rate of coiling in recent years has affected the outcome rate after surgery that calls for further evaluation.
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Affiliation(s)
- Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA.
| | - Devi Prasad Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
| | - Shyamal C Bir
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
| | - Tanmoy K Maiti
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
| | - Piyush Kalakoti
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
| | - Papireddy Bollam
- Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana, USA
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Hopmans EM, Ruigrok YM, Bor AS, Rinkel GJ, Koffijberg H. A cost-effectiveness analysis of screening for intracranial aneurysms in persons with one first-degree relative with subarachnoid haemorrhage. Eur Stroke J 2016; 1:320-329. [PMID: 31008294 DOI: 10.1177/2396987316674862] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 09/26/2016] [Indexed: 11/15/2022] Open
Abstract
Introduction Although persons with one first-degree relative with aneurysmal subarachnoid haemorrhage have an increased risk of aneurysm formation and aneurysmal subarachnoid haemorrhage, screening them for unruptured intracranial aneurysms was not beneficial in a modelling study from the 1990s. New data on the risk of aneurysmal subarachnoid haemorrhage in these persons and improved treatment techniques call for reassessment of the cost-effectiveness of screening. Patients and methods We used a cost-effectiveness analysis using a Markov model and Monte Carlo simulation comparing screening and preventive aneurysm treatment with no screening in persons with one first-degree relative with aneurysmal subarachnoid haemorrhage. We analyzed the impact on quality-adjusted life years, costs and net health benefit of single screening (at varying screening age) and serial screening (with varying screening age and intervals) using a cost-effectiveness threshold of €20,000/quality-adjusted life year. Results In 17 of the 24 strategies assessed, additional costs for screening for unruptured intracranial aneurysm were <€20,000 per quality-adjusted life year gained. The strategy with highest net health benefit was screening at age 40 and 55. Screening every five years from age 20 to 70 yielded the highest health benefits at the highest additional costs. Discussion Based on current risks of aneurysmal subarachnoid haemorrhage and complications of preventive treatment, several strategies to screen for unruptured intracranial aneurysm in persons with one first-degree relative with aneurysmal subarachnoid haemorrhage are cost effective compared with no screening, when applying a cost-effectiveness threshold of €20,000/quality-adjusted life year. Conclusion We recommend discussing with persons at risk the option of screening twice, at age 40 and 55, which will result overall in substantial health benefits at acceptable additional costs.
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Affiliation(s)
- Esther M Hopmans
- Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, Utrecht, The Netherlands
| | - Ynte M Ruigrok
- Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, Utrecht, The Netherlands
| | - Anne Se Bor
- Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, Utrecht, The Netherlands
| | - Gabriel Je Rinkel
- Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus, Utrecht, The Netherlands
| | - Hendrik Koffijberg
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
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Bekelis K, Missios S, Coy S, Singer RJ, MacKenzie TA. New York State: Comparison of Treatment Outcomes for Unruptured Cerebral Aneurysms Using an Instrumental Variable Analysis. J Am Heart Assoc 2015; 4:JAHA.115.002190. [PMID: 26169534 PMCID: PMC4608094 DOI: 10.1161/jaha.115.002190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background There is wide regional variation in the predominant treatment for unruptured cerebral aneurysms. We investigated the association of elective surgical clipping and endovascular coiling with mortality, readmission rate, length of stay, and discharge to rehabilitation. Methods and Results We performed a cohort study involving patients with unruptured cerebral aneurysms, who underwent surgical clipping or endovascular coiling from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System database. An instrumental variable analysis was used to investigate the association of treatment technique with outcomes. Of the 4643 patients undergoing treatment, 3190 (68.7%) underwent coiling, and 1453 (31.3%) underwent clipping. Using an instrumental variable analysis, we did not identify a difference in inpatient mortality (marginal effect, 0.13; 95% CI, −0.30, 0.57), or the rate of 30-day readmission (marginal effect, −1.84; 95% CI −4.06, −0.37) between the 2 treatment techniques for patients with unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to rehabilitation (marginal effect, 2.31; 95% CI 0.21, 4.41), and longer length of stay (β, 2.01; 95% CI 0.85, 3.04). In sensitivity analysis, mixed-effect regression, and propensity score, adjusted regression models demonstrated identical results. Conclusions Using a comprehensive all-payer cohort of patients in New York State with unruptured cerebral aneurysms, we did not identify an association of treatment method with mortality or 30-day readmission. Clipping was associated with a higher rate of discharge to rehabilitation and longer length of stay.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (K.B., R.J.S.)
| | - Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA (S.M.)
| | - Shannon Coy
- Geisel School of Medicine at Dartmouth, Hanover, NH (S.C.)
| | - Robert J Singer
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (K.B., R.J.S.)
| | - Todd A MacKenzie
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (T.A.M.K.) Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (T.A.M.K.) The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.M.K.)
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