Management and long-term outcome following subarachnoid haemorrhage and intracranial aneurysm surgery in elderly patients: an audit of 199 consecutive cases

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Objective

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

Methods

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

Results

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

Conclusions

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

Comparison of Aggressive Surgical Treatment and Palliative Treatment in Elderly Patients with Poor-Grade Intracranial Aneurysmal Subarachnoid Hemorrhage

Objective

To compare the current treatment approach in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) and identify the independent predictors of the outcome after aggressive surgical treatment.

Method

This prospective, multicenter cohort study included 104 poor-grade aneurysmal SAH elderly patients, 60 years or older, treated in our institution from October 2010 to March 2013. Patients were grouped according to three treatment arms. Neurological outcome was assessed using the Glasgow Outcome Scale (GOS) at baseline and at a 12-month follow-up. Univariate and multivariate analysis were performed using the following factors: sex, age, smoking history, breathing ability, alcohol consumption, cerebral hernia, aneurysm location, aneurysm diameter, WFNS grade, CT Fisher grade, treatment approach, and the timing of the aneurysm surgery.

Results

At the 12-month follow-up, patients in the coiling group and clipping group had better prognosis than patients in the palliative treatment group. Univariate analysis confirmed that the treatment approach, WFNS grade, CT Fisher grade, and age are critical factors for neurological outcomes in poor-grade SAH. Multivariate analysis indicated that WFNS grade V, CT Fisher grades 3-5, and palliative treatment were independent predictors of poor prognoses.

Conclusion

Aggressive surgical treatment improves the prognoses in poor-grade aneurysm elderly patients with SAH. Elderly Patients of WFNS grade IV and CT Fisher grades 1-2 are more likely to have a better outcome.

Factors associated with clinical and radiological status on admission in patients with aneurysmal subarachnoid hemorrhage

Grading scales yield objective measure of the severity of aneurysmal subarachnoid hemorrhage and serve as to guide treatment decisions and for prognostication. The purpose of this cohort study was to determine what factors govern a patient's disease-specific admission scores in a representative Central European cohort. The Swiss Study of Subarachnoid Hemorrhage includes anonymized data from all tertiary referral centers serving subarachnoid hemorrhage patients in Switzerland. The 2009-2014 dataset was used to evaluate the impact of patient and aneurysm characteristics on the patients' status at admission using descriptive and multivariate regression analysis. The primary/co-primary endpoints were the GCS and the WFNS grade. The secondary endpoints were the Fisher grade, the presence of a thick cisternal or ventricular clot, the presence of a new focal neurological deficit or cranial nerve palsy, and the patient's intubation status. In our cohort of 1787 consecutive patients, increasing patient age by 10 years and low pre-ictal functional status (mRS 3-5) were inversely correlated with "high" GCS score (GCS ≥ 13) (OR 0.91, 95% CI 0.84-0.97 and OR 0.67, 95% CI 0.31-1.46), "low" WFNS grade (grade VI-V) (OR 1.21, 95% CI 1.04-1.20 and OR 1.47, 95% CI 0.66-3.27), and high Fisher grade (grade III-IV) (OR 1.08, 95% CI 1.00-1.17 and OR 1.54, 95% CI 0.55-4.32). Other independent predictors for the patients' clinical and radiological condition at admission were the ruptured aneurysms' location and its size. In sum, chronological age and pre-ictal functional status, as well as the ruptured aneurysm's location and size, determine the patients' clinical and radiological condition at admission to the tertiary referral hospital.

Factors affecting outcome in poor grade subarachnoid haemorrhage: An institutional study

Context:

Poor grade subarachnoid hemorrhage (SAH) is usually associated with unfavorable outcomes and optimal management is deemed complicated. Most centres follow an expectant management strategy or a less aggressive approach till patients improve to good clinical grades. This approach has been associated with higher mortality and morbidity. However, not all patients with poor clinical condition fare badly. Identification and early aggressive management of this select group of patients may lead to favorable outcomes.

Settings and Design:

Prospective non-randomized study.

Materials and Methods:

We prospectively analyzed 19 cases presented in WFNS grade 4 and 5 and factors affecting their outcome at a tertiary care centre in south India. This study was aimed at identifying those few poor grade patients who are probable candidates for a good outcome.

Statistical Analysis Used:

All the variables were analyzed for possible correlations with the SPSS version 13 software. The Chi-square test with a P < 0.05 was taken as statistically significant.

Results:

Of 19 cases, 13 were operated and good outcome was seen in 53.8% of the patients who underwent surgery and aggressive management. All 7 patients who were managed conservatively died. 15.8% of the patients had low density changes (P = 0.625). Absence of such changes was associated with a good long term outcome (P = 0.004). 9 patients had intraventricular hemorrhage at presentation and 5 patients having hydrocephalus underwent extra-ventricular drainage. Statistically significant factors precluding good outcome were the presence of infarcts and thick SAH in the cisterns.

Conclusions:

Poor grade (WFNS 4 and 5) SAH patients with or without ICH, IVH, if operated within 3 days can give rise to favorable outcome in around 50%. However, presence of patchy infarcts associated with thick subarachnoid blood (Fisher grade 3) precludes long term survival or meaningful recovery. Hence, aggressive management is unlikely to alter the natural history of such patients.

Prognosis Predicting Score for Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage: A Risk Modeling Study for Individual Elderly Patients

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.

Age limit for surgical treatment of poor-grade patients with subarachnoid hemorrhage: A project of the Chugoku-Shikoku division of the Japan neurosurgical society

Objective:

Management of elderly patients with poor-grade subarachnoid hemorrhage (SAH) remains controversial. The objective of this study was to investigate whether there is an age-dependent difference in the outcome of poor-grade SAH after surgical obliteration of the aneurysm.

Methods:

Data were reviewed retrospectively for 156 patients with poor-grade aneurysmal SAH at multiple centers in Chugoku and Shikoku, Japan. Patients were divided into age groups of 65-74 and ≥75 years old. Factors influencing a favorable outcome at discharge (Glasgow Outcome Scale, good recovery or moderately disabled) were determined using multivariate logistic regression analyses.

Results:

A favorable outcome at discharge was achieved in 37 of the 156 patients (23.7%). Advanced age (≥75 years old, P < 0.01), improvement of World Federation of Neurosurgical Societies (WFNS) Grade after admission (P = 0.02), Fisher grade (P < 0.001), and a low density area (LDA) associated with vasospasm on computed tomography (CT) (P < 0.01) were significantly associated with outcome. Multivariate analysis identified advanced age (≥75 years old, P = 0.01), Fisher group 4 (P = 0.002), and a new LDA associated with vasospasm on CT (P = 0.007) as predictors of a poor outcome in elderly patients with poor-grade SAH after surgical obliteration of the aneurysm. WFNS Grade V at admission (P = 0.052) was weakly associated with a poor outcome.

Conclusions:

Advanced age (≥75 years old), Fisher group 4, and LDA associated with vasospasm on CT were independent predictors of clinical outcome in elderly patients with poor-grade SAH. A favorable outcome in these patients occurred more frequently after Guglielmi detachable coil embolization than after surgical clipping, but without a significant difference.

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Brain oxygen tension and outcome in patients with aneurysmal subarachnoid hemorrhage

Object

Poor outcome is common after aneurysmal subarachnoid hemorrhage (SAH). Clinical studies suggest that cerebral hypoxia after traumatic brain injury is associated with poor outcome. In this study we examined the relationship between brain oxygen tension (PbtO2) and death after aneurysmal SAH.

Methods

Forty-six patients, including 34 women and 12 men (Glasgow Coma Scale Score ≤ 8 and median age 58.5 years) who underwent PbtO2 monitoring were studied prospectively during a 2-year period in a neurosurgical intensive care unit at a University Level I Trauma Center. Brain oxygen tension, intracranial pressure (ICP), mean arterial pressure, cerebral perfusion pressure (CPP), and brain temperature were continuously monitored, and treatment was directed toward ICP, CPP, and PbtO2 targets. The relationship between PbtO2 and 1-month survival was examined.

Results

Data were available from 5424 hours of PbtO2 monitoring. For the entire cohort the mean ICP, CPP, and PbtO2 were 13.85 ± 2.40, 84.05 ± 3.41, and 30.79 ± 1.91 mm Hg, respectively. Twenty-five patients died (54%). The mean daily PbtO2 was higher in survivors than nonsurvivors (33.94 ± 2.74 vs 28.14 ± 2.59 mm Hg; p = 0.05). In addition, survivors had significantly shorter episodes of compromised PbtO2 (defined as 15–25 mm Hg) than nonsurvivors (125.85 ± 15.44 vs 271.14 ± 55.23 minutes; p < 0.01). Intracranial pressure was similar in survivors and nonsurvivors. In contrast, the average CPP was significantly lower in nonsurvivors than survivors (76.96 ± 5.50 vs 92.49 ± 2.75 mm Hg; p = 0.01). When PbtO2 was stratified according to CPP level, survivors had higher PbtO2 levels. Following logistic regression, the number of episodes of compromised PbtO2 (odds ratio 1.1, 95% confidence interval 1.003–1.2) and number of episodes of cerebral hypoxia (< 15 mm Hg; odds ratio 1.3, 95% confidence interval 1.0–1.7) were more frequent in those who died.

Conclusions

Patient deaths after SAH may be associated with a lower mean PbtO2 and longer periods of compromised cerebral oxygenation than in survivors. This knowledge may be used to help direct therapy.

International subarachnoid aneurysm trial of neurosurgical clipping versus endovascular coiling: subgroup analysis of 278 elderly patients

BACKGROUND AND PURPOSE

It is often thought that elderly patients in particular would benefit from endovascular aneurysm treatment. The aim of this analysis was therefore to compare the efficacy and safety of endovascular coiling (EVT) with neurosurgical clipping (NST) in the subgroup of elderly SAH patients in the International Subarachnoid Aneurysm Trial (ISAT).

METHODS

In the ISAT cohort 278 SAH patients, 65 years or older, were enrolled. The patients were randomly allocated EVT (n=138) or NST (n=140). The primary outcome was the proportion of patients with a modified Rankin scale score of 0 to 2 (independent survival) at 1 year after the SAH. The rates of procedural complications and adverse events were also recorded.

RESULTS

83 of 138 (60.1%) patients allocated EVT were independent compared to 78 of 140 (56.1%) allocated NST (N.S.). 36 of 50 (72.0%) patients with internal carotid and posterior communicating artery aneurysms allocated EVT were independent compared to 26 of 50 (52.0%) allocated NST (P<0.05). 10 of 22 (45.5%) patients with middle cerebral artery aneurysms allocated EVT were independent compared to 13 of 15 (86.7%) allocated NST (P<0.05). The epilepsy frequency was 0.7% in the EVT group compared to 12.9% in the NST group (P<0.001).

CONCLUSIONS

In good grade elderly SAH patients with small anterior circulation aneurysms, EVT should probably be the favored treatment for ruptured internal carotid and posterior communicating artery aneurysms, whereas elderly patients with ruptured middle cerebral artery aneurysms appear to benefit from NST. EVT resulted in a lower epilepsy frequency than NST.

NO LONG-TERM EXCESS MORTALITY IN 280 PATIENTS WITH RUPTURED DISTAL ANTERIORCEREBRAL ARTERY ANEURYSMS

OBJECTIVE

The aim of this study was to assess the long-term excess mortality after the rupture of distal anterior cerebral artery (DACA) aneurysms compared with that of a matched general Finnish population in an unselected, population-based series.

METHODS

We identified 280 consecutive patients (119 men, 161 women) treated for ruptured DACA aneurysms (clipped, 262; coiled, 10; no intervention, 8) at two neurosurgical centers serving solely the southern and eastern parts of Finland from 1976 to 2003. All patients were followed from subarachnoid hemorrhage until death or the end of 2004. No patients were lost to follow-up. Long-term excess mortality was estimated using the annual relative survival ratio compared with the general Finnish population matched by age, sex, and calendar time.

RESULTS

The median follow-up period was 9.6 years (range, 0.1-29 yr). The 3-year cumulative relative survival ratio was 0.84 (95% confidence interval, 0.78-0.88), implying 16% excess mortality in the patient group during the first 3 years after subarachnoid hemorrhage. The annual relative survival ratio attained 1.0 at the fourth year of follow-up, indicating no excess mortality thereafter. There were four episodes of recurrent subarachnoid hemorrhage and only one from a treated DACA aneurysm, with a 10-year cumulative risk of 1.4% (95% confidence interval, 0.0-3.0). Cardiovascular disease and cancer were the leading causes of death after 10 years of follow-up.

CONCLUSION

After surviving 3 years after the rupture of a DACA aneurysm, the patients' long-term survival became similar to that of the matched general population. Rebleeding of treated DACA aneurysm was rare.

Endovascular treatment of cerebral aneurysms in elderly patients

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

Treatment and outcome of aneurysmal subarachnoid haemorrhage in the elderly patient

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

Intracerebral aneurysms: a review with special attention to geriatric aspects

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

Surgical Indications to Maintain Quality of Life in Elderly Patients with Ruptured Intracranial Aneurysms

OBJECTIVE

We performed a retrospective study to assess long-term outcomes in very old patients with ruptured intracranial aneurysms. The aim of the study was to develop guidelines for choosing surgical or conservative treatment with the goal of maintaining patients' quality of life.

METHODS

Between 1996 and 1999, 76 consecutive patients, aged 80 to 89 years, with ruptured intracranial aneurysms were treated at 18 participating centers. They were divided retrospectively into operated and nonoperated groups, and their preoperative characteristics and treatment outcomes were analyzed. Their Glasgow Outcome Scale and Barthel Index scores at least 2 years after the insult were recorded and analyzed from the perspective of their admission Hunt and Hess grade.

RESULTS

Our retrospective review encompassed 5.9 years. Of the original 76 patients, 54 (71.1%) died, 13 (17.1%) had a good outcome (Barthel Index ≥60), and 9 (11.8%) had a poor outcome (Barthel Index &lt;60). All patients with Hunt and Hess grades of III or higher at admission had poor outcomes irrespective of treatment. Of 32 patients with an initial Hunt and Hess grade of I or II, 19 (59.4%) underwent surgery; 9 of these patients (47.4%) had good outcomes. Conversely, of 13 nonoperated patients (40.6%), only 2 (15.4%) experienced good outcomes. In seven of the nine operated patients with good outcomes, the aneurysm was small (&lt;12 mm) and located at the internal carotid artery-posterior communicating artery junction.

CONCLUSION

Our results suggest that patients in the 9th decade of life with ruptured intracranial aneurysms can be considered for surgical treatment if they have a Hunt and Hess grade of I or II. The highest rate of favorable results was achieved in patients with small internal carotid artery-posterior communicating artery aneurysms.

[Aneurysms surgery in the patients aged seventy to eighty years]

Elderly patients are a growing population group in developing countries because of optimal health care. 13% of Cuba population is older than sixty years and it is expected to grow to 20% in 2005. Subarachnoid hemorrhage secondary to ruptured aneurysms in geriatric patients carries a high mortality but a few patients are selected for surgical treatment. Manuel Ascunce Domenech Hospital attended 1112 patients older than 60 years between January 1994 and December 2001. Of these there were 96 patients with symptomatic intracranial aneurysms and we selected 30 for surgical treatment. They were all in clinical grades I and II of the WFNS scale. They had good health to face surgery and familiar consent. The size and location of the aneurysms were not considered among the exclusion criteria. Aneurysms were mainly localized at posterior communicating and middle cerebral arteries. There were two deaths, one due to a medical cause an the other to the surgical procedure. 74% of the patients obtained satisfactory outcome six month after the operation. The clue is to not consider age as a negative point for surgery. Surgical procedures can be performed in patients with good clinical grade (WFNS). New technical advances, stroke units, accurately selected patients and minimal invasive surgical methods will help to obtain good results.

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

This report presents 74 consecutive cases of subarachnoid haemorrhage (SAH) in patients aged 70 years or older, compared with the 317 consecutive younger patients treated during the same period. An ultra-early surgical strategy for all SAH cases was used throughout the study period. Management outcome for all grades of elderly patients was independent in 38%, dependent in 14% and death in 49%. Surgical 3-month outcome of good grade elderly patients was independent 53%, dependent 19% and death 28%; and for poor grades was independent 35%, dependent 15% and death 50%. Elderly poor grade patients had similar outcome to younger patients, although good grade patients had better outcome in the younger group than the elderly group. Despite ultra-early surgery, rebleeding (<12 h of SAH) occurred in 9% of the elderly series. Aggressive, ultra-early treatment is likely to benefit elderly SAH patients, the potential benefit being greater for poor grade elderly patients.

Changes in intervention and outcome in elderly patients with subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The elderly constitute a significant and increasing proportion of the population. The aim of this investigation was to study time trends in clinical management and outcome in elderly patients with subarachnoid hemorrhage.

METHODS

Two hundred eighty-one patients >/=65 years of age with aneurysmal subarachnoid hemorrhage who were accepted for treatment at the Uppsala University Hospital neurosurgery clinic during 1981 to 1998 were included. Hunt and Hess grades on admission, specific management components, and clinical outcomes were recorded. Three periods were compared: A, 1981 to 1986 (before neurointensive care); B, 1987 to 1992; and C, 1993 to 1998.

RESULTS

The volume of elderly patients (>/=65 years of age) increased with time, especially patients >/=70 years of age. Furthermore the proportion of patients with more severe clinical conditions increased. A greater proportion of patients had a favorable outcome (A, 45%; B, 61%; C, 58%) despite older ages and more severe neurological and clinical conditions. In period C, Hunt and Hess I to II patients had a favorable outcome in 85% of cases compared with 64% in period A. This was achieved without any increase in the number of severely disabled patients.

CONCLUSIONS

Elderly patients with subarachnoid hemorrhage can be treated successfully, and results are still improving. The introduction of neurointensive care may have contributed to the improved outcome without increasing the proportion of severely disabled patients. A defeatist attitude toward elderly patients with this otherwise devastating disease is not justified.

Considerations on surgical treatment for elderly patients with intracranial aneurysms

BACKGROUND

The purpose of this study was to investigate why elderly patients have poorer outcomes and to determine indications for surgery in elderly patients.

METHODS

One hundred fifty-four patients with intracranial aneurysms admitted to the Department of Neurosurgery, Showa University School of Medicine, from 1990 through 1996 were reviewed. The patients were classified by age into three groups (young group, middle-aged group, elderly group).

RESULTS

Forty-four patients (28.6%) were in the elderly group (mean age, 73 years). No difference in outcome was found between middle-aged and elderly patients if patients were stratified according to clinical grade. In addition, the main factors related to unfavorable outcomes in elderly patients were infection, organ failure, aneurysm rerupture before operation, and delayed ischemic deterioration. Elderly patients were more likely to experience rebleeding and have poor outcomes.

CONCLUSIONS

Our results suggest that elderly patients should have early surgery. Furthermore, we found that the presence of hypertension or atherosclerosis had no significant effect on outcome. We conclude that early surgical treatment of aneurysms is indicated for elderly patients with good clinical grades in the absence of organ failure.

Surgery and long-term outcome for ruptured anterior circulation aneurysms in patients in their ninth decade of life

BACKGROUND

The present pilot study was undertaken to analyze the long-term results of surgery for ruptured anterior circulation aneurysms in patients in their 9th decade of life.

METHODS

Between 1992 and 1997, we treated 10 consecutive patients with ruptured anterior circulation aneurysms who were 80 years or older on admission and judged eligible for surgery based on stringent criteria. The outcomes at discharge and the latest outcomes (obtained at a median of 41.6 months) were assessed using the Glasgow Outcome Scale and the Barthel Score, respectively.

RESULTS

Upon discharge, six of the 10 patients showed good recovery, two patients were moderately disabled, and two patients who suffered symptomatic vasospasm were severely disabled. As for the latest outcomes, assessed using Barthel Score, four patients had the maximum score of 100, two a score of 90, one a score of 35, two a score of 10, and one patient died. Of four patients who were in poor condition, two experienced deterioration attributable to unrelated causes 18 and 32 months after the ictus.

CONCLUSION

Advanced age alone does not preclude successful surgery for ruptured anterior circulation aneurysms. Carefully selected patients over 80 years should also be considered for surgical treatment.

Intracranial aneurysms and subarachnoid hemorrhage management of the poor grade patient

Between 20 and 30% of patients who suffer cerebral aneurysm rupture are in poor clinical grade when first evaluated. Management of these patients is controversial and challenging but can be successful with an aggressive proactive approach that begins with in the field resuscitation and continues through rehabilitation. In this article we review the epidemiology, pathology and pathophysiology, clinical features, evaluation, surgical and endovascular management, critical care, cost, and outcome prediction of patients in poor clinical grade after subarachnoid hemorrhage.

Mortality rates, hospital length of stay, and the cost of treating subarachnoid hemorrhage in older patients: institutional and geographical differences

The risk of disability and death and the cost of medical care are particularly high for patients with aneurysmal subarachnoid hemorrhage (SAH) who are 65 years of age or older. A retrospective analysis of 47,408 Medicare patients treated over an 8-year period was performed to determine whether a relationship exists between the mortality rate and surgical volume for older patients with SAH. The mortality rate, length of stay in the hospital, and cost of treatment for patients with SAH in California and New York state were also compared. The mortality rate was 14.3% for patients with SAH who were 65 years old or older and who were treated surgically in hospitals in which an average of five or more craniotomies were performed per year; in hospitals averaging between one and five craniotomies annually the mortality rate was 18.4%; and in those averaging less than one such operation per year the rate was 20.5% (trend p = 0.01). There was no difference in the mortality rate for patients in California versus the rate for those in New York. Surgically and medically treated patients, respectively, left the hospital an average of 6.7 and 5.1 days sooner in California than in New York. The unadjusted average reimbursement from Medicare to hospitals for surgically treated patients averaged $1468 more in New York than in California (p < 0.0001), but was equivalent for medically treated patients in the two states. The mortality rate in older patients who are treated surgically for SAH may be inversely correlated with the annual number of craniotomies performed for SAH in patients 65 years of age or older at a given institution. Hospital stays for patients with SAH are significantly shorter in California than in New York.

Mortality rates, hospital length of stay, and the cost of treating subarachnoid hemorrhage in older patients: institutional and geographical differences

The risk of disability and death and the cost of medical care are particularly high for patients with aneurysmal subarachnoid hemorrhage (SAH) who are 65 years of age or older. A retrospective analysis of 47,408 Medicare patients treated over an 8-year period was performed to determine whether a relationship exists between the mortality rate and surgical volume for older patients with SAH. The mortality rate, length of stay in the hospital, and cost of treatment for patients with SAH in California and New York were also compared. The mortality rate was 14.3% for patients with SAH who were 65 years old or older and who were treated surgically in hospitals in which an average of five or more craniotomies were performed per year; in hospitals averaging between one and five craniotomies annually the mortality rate was 18.4%; and in those averaging less than one such operation per year the rate was 20.5% (trend p = 0.01). There was no difference in the mortality rate for patients in California versus the rate for those in New York. Surgically and medically treated patients, respectively, left the hospital an average of 6.7 and 5.1 days sooner in California than in New York. The unadjusted average reimbursement from Medicare to hospitals for surgically treated patients averaged $1468 more in New York than in California (p < 0.0001), but was equivalent for medically treated patients in the two states. The mortality rate in older patients who are treated surgically for SAH may be inversely correlated with the annual number of craniotomies performed for SAH in patients 65 years of age or older at a given institution. Hospital stays for patients with SAH are significantly shorter in California than in New York.

Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse?

Advanced age is a recognized prognostic indicator of poor outcome after subarachnoid hemorrhage (SAH). The relationship of age to other prognostic factors and outcome was evaluated using data from the multicenter randomized trial of nicardipine in SAH conducted in 21 neurosurgical centers in North America. Among the 906 patients who were studied, five different age groups were considered: 40 years or less, 41 to 50, 51 to 60, 61 to 70, and more than 71 years. Twenty-three percent of the individuals enrolled were older than 60 years of age. Women outnumbered men in all age groups. Level of consciousness (p = 0.0002) and World Federation of Neurological Surgeons grade (p = 0.0001) at admission worsened with advancing age. Age was also related to the presence of a thick subarachnoid clot (p = 0.0001), intraventricular hemorrhage (p = 0.0003), and hydrocephalus (p = 0.0001) on an admission computerized tomography scan. The rebleeding rate increased from 4.5% in the youngest age group to 16.4% in patients more than 70 years of age (p = 0.002). As expected, preexisting medical conditions, such as diabetes (p = 0.028), hypertension (p = 0.0001), and pulmonary (p = 0.0084), myocardial (p = 0.0001), and cerebrovascular diseases (p = 0.0001), were positively associated with age. There were no age-related differences in the day of admission following SAH, timing of the surgery and/or location, and size (small vs. large) of the ruptured aneurysm. During the treatment period, the incidence of severe complications (that is, those complications considered life threatening by the reporting investigator) increased with advancing age, occurring in 28%, 33%, 36%, 40%, and 46% of the patients in each advancing age group, respectively (p = 0.0002). No differences were observed in the reported frequency of surgical complications. No age-related differences were found in the overall incidence of angiographic vasospasm; however, symptomatic vasospasm was more frequently reported in the older age groups (p = 0.01). Overall outcome, assessed using the Glasgow Outcome Scale at 3 months post-SAH, was poorer with advancing age (p < 0.001). Multivariate analysis of overall outcome, adjusting for the different prognostic factors, did not remove the age effect, which suggests that the aging brain has a less optimal response to the initial bleeding. Age as a risk factor is a continuum; however, there seems to be a significant increased risk of poor outcome after the age of 60 years.

Surgical neurology and clinical neurosciences in Edinburgh, Scotland

Surgical neurology in Edinburgh started > 70 years ago with Norman Dott, after his apprenticeship with Harvey Cushing. It continued under the chairmanship of John Gillingham, until 1980, and then Douglas Miller, who merged the Departments of Surgical Neurology and Medical Neurology to form the Department of Clinical Neurosciences in 1986. Particular strengths of the Edinburgh program have been the management of intracranial aneurysms, stereotactic and functional neurosurgery, the management of head and spinal injury and stroke, and neuro-oncology.

Predicting outcome in poor-grade patients with subarachnoid hemorrhage: a retrospective review of 159 aggressively managed cases

To determine what factors predict outcome, the authors retrospectively reviewed the management of all 159 poor-grade patients admitted to Harborview Medical Center at the University of Washington who suffered aneurysmal subarachnoid hemorrhage between 1983 and 1993. Favorable outcome (assessed by the Glasgow Outcome Scale) occurred in 53.9% of Hunt and Hess Grade IV, and 24.1% of Grade V patients. Outcome was largely determined by the initial hemorrhage and subsequent development of intractable intracranial hypertension or cerebral infraction. Using multivariate analysis, the authors developed three models to predict outcome. It was found that predicting outcome based only on clinical and diagnostic criteria present at admission may have resulted in withholding treatment from 30% of the patients who subsequently experienced favorable outcomes. It is concluded that aggressive management including surgical aneurysm obliteration can benefit patients with poor neurological grades and should not be denied solely on the basis of the neurological condition on admission.

Intracranial aneurysm surgery in the 8th and 9th decades of life: impact on population-based management outcome

Thirteen percent of Sweden's population (8.6 million) is aged 70 years or older, and this percentage is expected to increase over the coming decades. We have traced every diagnosed case of subarachnoid hemorrhage in patients older than 70 years in a well-defined catchment population of 953,000 individuals. The age-specific incidence for this group was 16 per 100,000 individuals per year, corresponding to 2.3 per 100,000 inhabitants per year. In most recent population-based surgical series on ruptured aneurysms, few patients in this age group are included, corresponding to only 20 to 25% of the actual number of patients, as shown in this study. Surgery is, in many cases, refused to the "elderly" because of age. However, patients who are neurologically intact after the bleed and who are without severe intercurrent diseases are potential candidates for surgical treatment. In our series, surgery yielded good results in two-thirds of 76 patients aged 70 to 74 years who returned to independent living in good mental condition. Among matched patients being refused surgery because of age, 75% suffered morbidity and mortality, with more than half of the patients having died within the 1st 3 months. When calculated for the entire population of Sweden, our data show that a 14% increase in the number of individuals achieving complete remedy from aneurysm rupture each year can be expected with more active therapy among the elderly. Most of these patients are between 70 and 74 years old. In the 9th decade of life, aneurysm surgery probably best remains an exception.