Clinical outcomes of treatment for intracranial aneurysm in elderly patients

Clinical Characteristics of Poor-Grade Aneurysmal Subarachnoid Hemorrhage Treatment

Background The initial clinical status after aneurysm rupture, whether primary or secondary, determines the final outcome. The most common cause of patient deterioration is a high Hunt and Hess (HH) score, which correlates closely with a high mortality rate. Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is determined as an HH score 4 or 5. The aim of this study was to evaluate the clinical characteristics of poor graded aneurysmal SAH at our institution.

Patients and Methods During the 5-year period, 415 patients with intracranial aneurysm were admitted to our institution. Patients with poor-grade aneurysmal SAH accounted 31.08% (n = 132) of the total number of ruptured aneurysms. Interventional treatment was predominantly in the form of surgery, whereas conservative treatment included medication and external ventricular drainage. Final outcome was assessed with a modified Rankin score (mRs). Statistical analysis was performed using SPSS version 23.0 with a significance level set to 5% (α = 0.05).

Results The majority of patients (57.6%) were in the age range from 51 to 69 years. Twenty-five patients (18.9%) had an HH score of 4, whereas 107 patients (81.1%) had an HH score of 5. Depending on the location, the majority of patients (n = 43) had an aneurysm on the medial cerebral artery (MCA). The final aneurysm occlusion was performed in 71 patients, of whom 94.36% were treated surgically. A positive outcome (mRs 0–4) was found in 49.25% of patients who underwent primarily surgical, treatment with a mortality of 42.3%. Although the outcome was better in patients with an HH score 4, both groups benefited from surgical treatment.

Conclusion Poor-grade aneurismal SAH is a condition of the middle and older age, with most patients with an HH 5 score and deep comatose state. There was better outcome in patients with an HH score of 4 compared to an HH score of 5 and both groups benefited from surgical treatment, which resulted in a positive outcome in almost 50% of surgically treated patients.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Clinical Outcomes of Large (>10 mm) Unruptured Posterior Circulation Aneurysms and Their Predictors

Objective

The treatment of large aneurysms of the posterior circulation is complicated and remains challenging. We here analyzed our institutional clinical outcomes of large unruptured aneurysms of the posterior circulation.

Methods

This study included 56 patients who presented with a large (>10 mm) unruptured aneurysm of the posterior circulation between 2002 and 2018.

Results

There were 18 (32.1%) male and 38 (67.9%) female patients, with a mean age of 53.4 years. The most common location was the vertebral artery, followed by the basilar tip and posterior cerebral artery. The median follow-up duration was 29 months. Eighteen patients (32.1%) were treated by transcranial surgery and 38 (67.9%) were treated by endovascular treatment (EVT). Posttreatment complications occurred in 16 patients (28.6%), with there being no significant difference between the transcranial surgery and EVT groups. Complete obliteration was achieved in 30 patients (53.6%), with there being no statistically significant difference between the transcranial surgery and EVT groups. Recurrence occurred in 17 patients (30.4%), and the rate of recurrence was higher in the EVT group than in the transcranial surgery group (39.5% vs. 11.1%, p=0.03). Forty-four (84%) of 56 patients showed a favorable functional outcome. In saccular aneurysm, EVT was negative predictor of worsening of functional status.

Conclusion

Treatment of these aneurysms harbors an inherent high risk of morbidity. No superiority was found between transcranial surgery and EVT in terms of complications and complete obliteration, but transcranial surgery showed a higher treatment durability than EVT.

The Outcome of Aneurysm Clipping in Septuagenarians - A Retrospective Analysis in a Basic Neurovascular Unit

Introduction

The management of aneurysmal subarachnoid hemorrhage (SAH) in the elderly is challenging. Clipping as the definitive treatment is less well tolerated by the elderly population. The outcome is anticipated to be more glimmer in poor grade SAH and in a setup which lacks modern neurovascular gadgets. We present our experience of surgical clipping in elderly patients in such a basic neurovascular unit.

Materials and Methods

A retrospective analysis of hospital records of elderly patients between 70 and 79 of age who underwent surgical clipping of intracranial aneurysms between 2015 and 2017 was done. The patients' characteristics, comorbidities, aneurysm characteristics, intraoperative complications, and postoperative complications were studied to determine the factors influencing an unfavorable outcome. All information was entered into a database (Microsoft Excel) and analyzed using SPSS trial version 16. Outcomes were grouped into a favorable outomce which included Glasgow Outcome Scale scores of 4 and 5, whereas an unfavorable outcome which included Glasgow Outcome Scale scores of 1, 2, and 3.

Results

There were 21 patients with aneurysms located either in the anterior or posterior circulation or both. All underwent standard craniotomy and clipping pertaining to that particular type of aneurysm. A favorable outcome was achieved in 48% of the patients and 52% had an unfavorable outcome. The duration of surgery, number of days on ventilator, and presence of hydrocephalus were the factors found to be statistically significantly associated with unfavorable outcomes.

Conclusion

A team approach consisting of a neuroanaesthetist, neurosurgeons, and critical care personnel can have a huge impact on the postoperative outcome.

Correlation of intracranial and aortic aneurysms: current trends and evidence

The correlation between intracranial and aortic aneurysms remains elusive. Data in the literature are scattered, and outcome reporting is swamped with heterogeneity and single-center bias. This calamity is adding to confusion on decision-making and delays the instigation of appropriate clinical applications. This literature review delves into the abyss of the lack of clinically driven scientific input, and highlights the trends explored thus far.

Clinical outcome of endovascular coil embolization for cerebral aneurysms in Asian population in relation to risk factors: a 3-year retrospective analysis

Background

Long term results of endovascular coiling are yet scarce. This study reviews the impact of comorbidities on the success of endovascular coiling of both ruptured and unruptured intracranial aneurysms. Endovascular treatment has become thetreatment of choice after the ISAT trials. Independent risk factors that influence recovery are age, sex, smoking, and hypertension.

Methods

This is a 3-year retrospective analysis, performed to assess the clinical and radiological outcome of patients with cerebral aneurysms treated with detachable coils in an Asian population with relation to comorbidities including smoking and hypertension with age and gender as mediators. From July 2015 to August 2018, a total of 297 consecutive patients (mean age: 45.5 years) with cerebral aneurysms both ruptured and unruptured who were treated at a single center with endovascular coiling procedures are included in the study. Clinical information and radiological outcomes were evaluated on regular follow-ups and telephonic interviews. A modified Rankin Scale was used to measure the clinical outcomes in patients.

Results

We have found that smoking harmed clinical outcome, with smokers 35% less likely to recover, while hypertension played a smaller role with only 15%. It was found that while aneurysms are more prevalent in women than men, women not only have a higher chance of getting an aneurysm but also have poorer outcomes. Similarly, patients who were above the age of 40 had a lower chance of recovery compared to younger patients due to comorbidities irrespective of gender.

Conclusion

Asian sub-continent has different genetic markers that lead to poorer outcomes of aneurysms in women, while outcomes are similar in men and women in developed nations. Smoking does not play a major role in women’s recovery. Men with comorbidity seemed to be at higher risk and age played a major role in their recovery.

Alanine Aminotransferase Predicts Outcomes in Elderly Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

With the aging of the world population, the number of elderly patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) is gradually growing. We aim to investigate the potential association between plasma ALT level and clinical complications of elderly aSAH patients, and explore its predictive value for clinical outcomes of elderly aSAH patients.

METHODS

Between January 2013 and March 2018, 152 elderly aSAH patients were analyzed in this study. Clinical information, imaging findings and laboratory data were reviewed. According to the Glasgow Outcome Scale (GOS), clinical outcomes at 3 months were classified into favorable outcomes (GOS 4-5) and poor outcomes (GOS 1-3). Logistic regression analysis was used to assess the indicators associated with poor outcomes, and receiver curves (ROC) and corresponding area under the curve (AUC) were used to detect the accuracy of the indicator.

RESULTS

A total of 48 (31.6 %) elderly patients with aSAH had poor outcome at 3 months. In addition to ICH, IVH, Hunt-Hess 4 or 5 Grade and Modified Fisher 3 or 4 Grade, plasma ALT level was also strongly associated with poor outcome of elderly aSAH patients. After adjusting for other covariates, plasma ALT level remained independently associated with pulmonary infection (OR 1.05; 95% CI 1.00-1.09; P = 0.018), cardiac complications (OR 1.05; 95% CI 1.01-1.08; P = 0.014) and urinary infection (OR 1.04; 95% CI 1.00-1.08; P = 0.032). Besides, plasma ALT level had a predictive ability in the occurrence of systemic complications (AUC 0.676; 95% CI: 0.586- 0.766; P<0.001) and poor outcome (AUC 0.689; 95% CI: 0.605-0.773; P<0.001) in elderly aSAH patients.

CONCLUSION

Plasma ALT level of elderly patients with aSAH was significantly associated with systemic complications, and had additional clinical value in predicting outcomes. Given that plasma ALT levels on admission could help to identify high-risk elderly patients with aSAH, these findings are of clinical relevance.

Asymptomatic unruptured intracranial aneurysms in the older people

Purpose

Unruptured intracranial aneurysm commonly occurs in the older people. Because the rupture risk increases with age, the factors associated with aneurysms might be different according to age. We aimed to evaluate unruptured intracranial aneurysm characteristics in healthy, symptom-free older patients.

Methods

Patients who visited the health examination center of two regional university hospitals and underwent computed tomography angiography between March 2001 and March 2017 were included. The putative aneurysm risk factors were identified; the aneurysm size and shape were determined by CT angiography, and measuring the ASPECT and dome/neck ratios. All images were interpreted independently by a neurosurgeon and a neurologist for improving size measurement accuracy.

Results

The unruptured intracranial aneurysm prevalence was 2.23% and 2.75% in the patients aged ≤ 60 and > 60 years, respectively. Among the younger group, female sex [odds ratio (OR), 1.85; P = 0.002], age (OR, 1.05; P < 0.001), hypertension (OR, 1.88; P < 0.001), coronary artery disease (OR, 0.26; P < 0.001), smoking (OR, 2.04; P < 0.001), and stroke family history (OR, 1.36; P = 0.047) were independently associated with aneurysm; anterior communicating artery aneurysms were the largest. Among the older group, female sex (OR, 1.76; P = 0.005), hypertension (OR, 2.54; P < 0.001), coronary artery disease (OR, 0.27; P < 0.001), and stroke family history (OR, 1.94; P = 0.003) were independently associated with aneurysm; internal carotid artery aneurysms were the largest.

Conclusions

The factors related to unruptured intracranial aneurysm formation varied by age, and coronary artery disease protected against aneurysm formation regardless of age. The factors affecting unruptured intracranial aneurysm formation are different according to age and aneurysm location.

Unruptured intracranial aneurysms in patients over 80 years: natural history and management implications

PURPOSE

Patients over the age of 80 years when diagnosed with an unruptured intracranial aneurysm (UIA) pose unique decision-making challenges due to shortened life-expectancy and increased risk of treatment. Thus, we investigated the risk of rupture and survival of a consecutive series of patients who were diagnosed with an UIA after the age of 80 years.

METHODS

Data of consecutive patients with an UIA were reviewed, and patients were included in our study if they were first evaluated for a UIA by the senior author during their ninth decade of life. Outcomes were aneurysm rupture and overall survival after diagnosis. Survival was estimated from a Kaplan-Meier survival curve. Incidence of risk factors was compared to a population of patients less than 65 years who were seen by the senior author over the same time period.

RESULTS

Eighty-three patients who were over 80 years when diagnosed with a UIA were included in this study. In our population, there is a risk of rupture of 3.2% per patient-year. One-, three-, and five-year survival rates for our population were estimated to be 92, 64, and 35%, respectively. When compared to patients under 65 years diagnosed with a UIA, "over 80" patients had a significantly higher incidence of hypertension, and a significantly lower incidence of smoking history and familial aneurysm history.

CONCLUSIONS

In our study population, UIAs greater than 7 mm carry a non-negligible risk of rupture of 3.2% per patient-year, and further studies investigating the risk-to-benefit ratio of treatment in this population are warranted.

Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage

OBJECTIVE The impact of treatment method-surgical clipping or endovascular coiling-on the cost of care for patients with aneurysmal subarachnoid hemorrhage (SAH) is debated. Here, the authors investigated the association between treatment method and long-term Medicare expenditures in elderly patients with aneurysmal SAH. METHODS The authors performed a cohort study of 100% of the Medicare fee-for-service claims data for elderly patients who had undergone treatment for ruptured cerebral aneurysms in the period from 2007 to 2012. To control for measured confounding, the authors used propensity score-adjusted multivariable regression analysis with mixed effects to account for clustering at the hospital referral region (HRR) level. An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method. RESULTS During the study period, 3210 patients underwent treatment for ruptured cerebral aneurysms and met the inclusion criteria. Of these patients, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had endovascular coiling. The median total Medicare expenditures in the 1st year after admission for SAH were $113,000 (IQR $77,500-$182,000) for surgical clipping and $103,000 (IQR $72,900-$159,000) for endovascular coiling. When the authors adjusted for unmeasured confounders by using an instrumental variable analysis, clipping was associated with increased 1-year Medicare expenditures by $19,577 (95% CI $4492-$34,663). CONCLUSIONS In a cohort of Medicare patients with aneurysmal SAH, after controlling for unmeasured confounding, surgical clipping was associated with increased 1-year expenditures in comparison with endovascular coiling.

Comparison of clipping and coiling in elderly patients with unruptured cerebral aneurysms

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.

Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for unruptured cerebral aneurysms

BACKGROUND

The cost difference between the two treatment options (surgical clipping and endovascular therapy) for unruptured cerebral aneurysms remains an issue of debate. We investigated the association between treatment method for unruptured cerebral aneurysms and Medicare expenditures in elderly patients.

METHODS

We performed a cohort study of 100% Medicare fee-for-service claims data for elderly patients who underwent treatment for unruptured cerebral aneurysms from 2007 to 2012. In order to control for measured confounding we used multivariable regression analysis with mixed effects to account for clustering at the Hospital Referral Region (HRR) level. An instrumental variable (regional rates of endovascular treatment) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method.

RESULTS

During the study period 8705 patients underwent treatment for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular treatment. The median total Medicare expenditures in the first year after the admission for the procedure were $46 800 (IQR $31 000-$74 400) for surgical clipping and $48 100 (IQR $34 500-$73 900) for endovascular therapy. When we adjusted for unmeasured confounders, using an instrumental variable analysis, clipping was associated with increased 7-day Medicare expenditures by $3527 (95% CI $972 to $5736) and increased 1-year Medicare expenditures by $15 984 (95% CI $9017 to $22 951).

CONCLUSIONS

In a cohort of Medicare patients, after controlling for unmeasured confounding, we demonstrated that surgical clipping of unruptured cerebral aneurysms was associated with increased 1-year expenditures compared with endovascular treatment.

Methazolamide improves neurological behavior by inhibition of neuron apoptosis in subarachnoid hemorrhage mice

Subarachnoid hemorrhage (SAH) results in significant nerve dysfunction, such as hemiplegia, mood disorders, cognitive and memory impairment. Currently, no clear measures can reduce brain nerve damage. The study of brain nerve protection after SAH is of great significance. We aim to evaluate the protective effects and the possible mechanism of methazolamide in C57BL/6J SAH animal model in vivo and in blood-induced primary cortical neuron (PCNs) cellular model of SAH in vitro. We demonstrate that methazolamide accelerates the recovery of neurological damage, effectively relieves cerebral edema, and improves cognitive function in SAH mice as well as offers neuroprotection in blood- or hemoglobin-treated PCNs and partially restores normal neuronal morphology. In addition, western blot analyses show obviously decreased expression of active caspase-3 in methazolamide-treated SAH mice comparing with vehicle-treated SAH animals. Furthermore, methazolamide effectively inhibits ROS production in PCNs induced by blood exposure or hemoglobin insult. However, methazolamide has no protective effects in morality, fluctuation of cerebral blood flow, SAH grade, and cerebral vasospasm of SAH mice. Given methazolamide, a potent carbonic anhydrase inhibitor, can penetrate the blood–brain barrier and has been used in clinic in the treatment of ocular conditions, it provides potential as a novel therapy for SAH.

Early outcomes and perioperative complications of endovascular embolization in patients with aneurysmal SAH

BACKGROUND

We still lack reliable data on the outcomes of endovascular coiling for ruptured cerebral aneurysms. As this is still an evolving technique, the outcomes of the procedures performed in the past and more recently cannot be directly compared. We present the early outcomes of endovascular coiling in a relatively large group of patients with ruptured intracranial aneurysms.

METHOD

The study included 190 consecutive patients (a total of 216 aneurysms) subjected to endovascular coiling in 2006-2013 (127 women aged 56±13 years and 63 men aged 50± 15 years). Up to 87.5% of the aneurysms were located within anterior circulation. Most patients presented with "mild to moderate" subarachnoid hemorrhages (85% of Hunt &Hess scores 1-3, and 72% of Fisher scores 1-3).

RESULTS

Embolization was feasible in 176 (92.6%) patients. In 14 cases, the embolization was not attainable due to unfavorable anatomy of the aneurysm, intraoperative vasospasm and/or aneurysm rupture, or prolapse of a coil. Early complications related to the procedure were recorded in 23 (13.1%) patients. The most common perioperative complication was aneurysm rupture. All fatal complications occurred in patients with aneurysms located at the anterior circle of Willis. At the time of discharge, 126 patients scored 4 or 5 on the Glasgow Outcome Scale.

CONCLUSIONS

Endovascular embolization is an effective and relatively safe method for treatment of ruptured cerebral aneurysms. Complications related to the procedure are significantly less frequent in the case of vertebral-basilar complex aneurysms.

Clinical outcome after surgical clipping or endovascular coiling for cerebral aneurysms: a pragmatic meta-analysis of randomized and non-randomized trials with short- and long-term follow-up

BACKGROUND

Two randomized trials have evaluated clipping and coiling in patients with ruptured aneurysms. Aggregated evidence for management of ruptured and unruptured aneurysms is missing.

OBJECTIVE

To conduct a meta-analysis evaluating clinical outcome after aneurysm treatment.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov were searched for studies evaluating aneurysm treatment. The primary outcome measure was an independent clinical outcome (modified Rankin scale 0-2, Glasgow Outcome Scale 4-5, or equivalent). Secondary outcomes were poor outcome and mortality. ORs were calculated on an intention-to-treat basis with 95% CIs. Outcome heterogeneity was evaluated with Cochrane's Q test (significance level cut-off value at <0.10) and I² (significance cut-off value >50%) with the Mantel-Haenszel method for dichotomous outcomes. A p value <0.05 was regarded as statistically significant.

RESULTS

Searches yielded 18 802 articles. All titles were assessed, 403 abstracts were evaluated, and 183 full-text articles were read. One-hundred and fifty articles were qualitatively assessed and 85 articles were included in the meta-analysis. Patients treated with coiling (randomized controlled trials (RCTs)) had higher independent outcome at short-term follow-up (OR=0.67, 95% CI 0.57 to 0.79). Independent outcome was favored for coiling at intermediate and long-term follow-up (RCTs and observational studies combined-OR=0.80, 0.68 to 0.94 and OR=0.81, 0.71 to 0.93, respectively). Independent outcome and lower mortality was favored after coiling in unruptured aneurysms (database registry studies) at short-term follow-up (OR=0.34, 0.29 to 0.41 and OR=1.74, 1.52 to 1.98, respectively).

CONCLUSIONS

This meta-analysis evaluating clinical outcome after coiling or clipping for intracranial aneurysms, indicates a higher independent outcome and lower mortality after coiling.