Results of treatment of aneurysmal subarachnoid hemorrhage in the elderly

Overview

Introduction: The aim of our study is to present the treatment outcomes of patients with aneurysmal subarachnoid hemorrhage (SAH) 3 months after the attack who were treated with clipping (MS) or coiling (EV). Materials and methods: The study was based on a retrospective analysis of a database of patients with cerebral aneurysms who were treated at the University Hospital Brno between 2009 and 2019. A total of 499 patients were included in the study. Of these patients, 345 (69%) were treated with surgical MS and 154 (31%) were treated with EV. Patients were divided into 4 groups: according to the age into 0–64 years and 65+ years group, and according to the modality of treatment of aneurysm by MS or EV. We evaluated the effect of the initial Hunt-Hess (HH) score on the treatment outcome according to age and modality and also the relationship between the current age of the patient and the treatment outcome at 3 months after the SAH attack, as assessed by a modified Rankin scale (mRS), where the successful treatment outcome was mRS 0–2 (self-sufficient patient), and the effect of the initial Hunt-Hess score (HH) on the treatment outcome was based on age and modality. Results: Of the 499 patients, 345 (69%) were treated with MS and 154 (31%) with EV, and the average age of MS and EV treated patients was not statistically significantly different (P = 0.2216). In both surgically and endovascularly treated patients in all age categories; we did not observe a statistically significant difference in HH score (P = 0.1664) or in graphical severity of SAH according to the Fischer score (P = 0.5041). Satisfactory treatment outcome (mRS 0–2) at 3 months after the attack was found in 49 (52.88%) in the 65+ years group after MS and 23 (60.61%) in the 65+ years group after EV. Poor treatment outcome (mRS 3–6) at 3 months was found in 43 (47.12%) in MS treated and 15 (39.39%) in EV treated patients, which was statistically significant (P = 0.0002). Satisfactory treatment outcome (mRS 0–2) at 3 months with good clinical status on admission (HH 1–2) was seen in 136 (55%) patients in the 0–64 years group after MS and 28 (33%) in the 65+ years group after MS. Poor treatment outcome (mRS 3–6) after 3 months with poor initial clinical condition (HH 3–5) had 50 (20%) patients treated with MS in the 0 -64 years group and 39 (44%) treated with MS in the 65+ years group, which is statistically significant (P = 0.0001). Conclusion: Elderly (65+ years) after SAH are at a higher risk of poor neurological status 3 months after the attack compared to younger patients, especially if they are in a severe clinical condition on admission. However, a significant proportion of these patients remain in a good clinical condition after treatment of an aneurysm, so the method of treatment and extent of treatment needs to be assessed individually. In elderly patients treated endovascularly, we observed a better treatment outcome at 3 months compared with patients treated by open surgery.

Keywords:

clipping – seniors – subarachnoid hemorrhage – coiling

This is an unauthorised machine translation into English made using the DeepL Translate Pro translator. The editors do not guarantee that the content of the article corresponds fully to the original language version.

 

Introduction

Intracranial aneurysm rupture is responsible for 80% of cases of non-traumatic subarachnoid haemorrhage (SAC) [1]. The purpose of early treatment of the source of bleeding is to prevent re-rupture of the aneurysm with fatal consequences. Cerebral artery aneurysm is standardly treated by one of two modalities, surgical clipping (NCH) or endovascular coiling (EV) [2].

The increasing average life expectancy of the population that remains in good physical and mental condition has resulted in an increase in the number of patients requiring treatment for SAC from ruptured aneurysms, therefore a multidisciplinary approach that leads to the correct choice of the appropriate modality is very important.

Older age and poor clinical status on admission are among the known risk factors for unsatisfactory treatment outcome after SAC [3-9]. The maximum age at which it is still possible to treat a ruptured aneurysm in a patient and achieve a good treatment outcome is individual. Therefore, according to the literature, it is advisable to actively treat ruptured aneurysms in elderly patients in good or stable clinical condition [10,11].

Indication criteria for modality selection include the patient's clinical condition, age, presence of comorbidities, treatment with blood thinners, aneurysm characteristics, and the presence of a significant intracerebral hematoma [3-6]. The modern approach to the management of SAC involves a targeted, strictly individualized assessment of the patient's disease.

The aim of our work is to evaluate the results of treatment of elderly patients (over 65 years), to compare them with younger patients and the literature and to identify potential areas of improvement in the care and treatment of these patients.

 

Material and methods

The study was based on a retrospective analysis of a database of patients with cerebral aneurysms who were treated between 2009 and 2019. During this interval, a total of 671 patients were hospitalized with a diagnosis of spontaneous SAC, and 499 patients were included in the study who were hospitalized with a diagnosis of SAC from cerebral artery aneurysm rupture and were treated with one of the NCH or EV modalities or both modalities. Patients with SAK who did not have a diagnosis of aneurysm and those treated conservatively only were excluded from the study.

Patients treated with both modalities were included in the group of the modality that definitively removed the aneurysm from the circulation. These were primary coiled patients whose aneurysm was inadequately treated (significant sac filling) or who underwent rebleeding after endovascular treatment. Therefore, they were subsequently treated with a clip. We did not have a case of inadequate clip treatment with the possibility of definitive coil treatment in our cohort.

These patients were always treated within 24 h of SAK attack and treatment with both modalities, i.e. NCH and EV, was always available. Patients with bleeding in both the anterior and posterior basin, in all sites of the intracranial arteries, were included.

We indicated patients with expansive intracerebral hematoma, wide-necked aneurysms, predominantly in the anterior circulation, or where EV was technically not feasible (e.g., due to anatomic conditions or vascular pathology) for NCH. In addition, we indicated younger patients with an unclear age limit of 65 years and patients in good initial neurological condition (Hunt-Hess score [HH] 1-2).

EVs were mainly treated in elderly (65+), polymorbid patients with a pharmacological history of drugs affecting blood coagulation, in poorer clinical condition (HH 3-5), without expansive intracerebral hemorrhage, posterior basin aneurysms, and with aneurysms with a favorable neck/bag ratio.

Patients were divided into 4 groups: according to age, 0-64 years and 65+ years, and according to the modality of treatment of NCH or EV aneurysm. In patients hospitalized after treatment of intracranial aneurysm, we evaluated the relationship between the patient's current age and the treatment outcome 3 months after SAC attack, assessed by the modified Rankin scale (mRS), where the successful treatment outcome was mRS 0-2 (self-sufficient patient), as well as the effect of the initial HH score on the treatment outcome by age and modality.

Data are presented in the form of descriptive statistics, including absolute and relative values, and subsequent analyses. Categorical data were assessed using chi-square test. In the case of continuous data, the distribution of test data was assessed using the D'Agostino-Pearson normality test. Unpaired t-test with Welch's correction, Kruskal-Walis test followed by Dunn's multiple comparison test were used for statistical evaluation of data. The significance level was considered to bea = 0.05. Statistical data processing was performed using GraphPad Prism version 7.03 for Windows software (GraphPad Software, La Jolla, CA, USA).

 

Results

Of the 499 patients, 345 (69%) were treated with NCH and 154 (31%) with EV. The mean age of surgically treated patients was 53.77 years (standard deviation [SD] = 13.69) and the mean age of endovascularly treated patients was 55.35 years (SD = 13.17; p = 0.2216, unpaired t-test with Welch correction).

Table 1 shows the structure of the cohort according to HH, age and type of surgery. In both surgically and endovascularly treated patients in all age categories, the predominant clinical condition corresponding to HH 2, followed by HH3 score. There was no significant difference in the cohort structure according to HH, age and type of procedure (p = 0.1664, chi-square test).

Table 2 shows the structure of the cohort according to Fischer score (Fs), age and type of performance. In both surgically and endovascularly treated patients in all age groups, the predominant graphic severity of SAC on CT was corresponding to Fs 3, followed by Fs 4. There is no significant difference in the structure of the cohort according to Fs, age and type of procedure (p = 0.5041, chi-square test).

The mean mRS at 3 months in the 0-64 years group after NCH was 1.852 and in the EV group was 1.886 (p = 0.9999, Dunn's multiple comparison test).

In both surgically and endovascularly treated patients in all age categories, the predominant treatment outcome at 3 months was mRS 1, followed by mRS 2, except in the NCH 65+ group, where mRS 4 (17.24%) was the next most common treatment outcome - see Table 3.

Table 4 describes the summary of the number of patients with satisfactory vs. unsatisfactory treatment outcome by treatment modality and age. Differences were statistically significant (p = 0.0002, chi-square test).

The treatment outcome according to the initial clinical condition for each age group and treatment modality is shown in Table 5. The differences were statistically significant (p = 0.0001, chi-square test).

 

Discussion

The aim of our study was to evaluate the results of treatment of elderly patients (65+ years), to compare them with younger patients, literature and to identify potential areas of improvement in the care and treatment of these patients.

Our study shows that we treated more patients surgically over the 11 years, with a ratio of 345 (69%) NCH: 154 (31%) EV.

Older age and more severe clinical condition on admission in patients with SAK is associated with the risk of poor treatment outcome and thus worse neurological deficit [4,12-17]. Similarly, in our study, we found that higher patient age and severe clinical condition at admission were risk factors for poor neurological status at clinical follow-up after 3 months, a relatively short treatment outcome.

Our study focused on the comparison of treatment outcome (assessed by mRS) after microsurgical clipping and endovascular coiling [18-23]. In the follow-up at 3 months after the attack, the 65+ group appeared to have a better treatment outcome than those treated with EV than those who underwent clipping from craniotomy, which is in contrast to Capatan el al [12], who based their study on the BRAT study [24-27] and whose study set an age limit also of 65 years, but which implied NCH as a more successful treatment modality.

Similar results to our study were obtained by Ikawa et al [11], who also evaluated their results at a similar follow-up horizon and reported endovascular treatment as having better treatment outcomes than open neurosurgical interventions. Furthermore, we learn from this study that in Japan, the general trend is to treat more ruptured aneurysms with NCH, at a ratio of about 3:1, which is different from other countries that have shifted to EV after the ISAT study [18]. This ratio of clip vs. coil treatment was similar to that of our department in 2009-2019, and is currently 1:1 at our department.

Bekelis et al. [28] in their 2016 study do not report a statistically significant difference in treatment outcome between the modalities in the elderly and the same is true in the 2018 paper by Proust et al. [29]. However, these papers are based on follow-up after one year.

The better treatment outcome after EV in the elderly is usually explained by the shorter duration of the procedure and thus shorter general anaesthesia. Also, there is no manipulation of brain tissue and no microtraumatization of the edematous brain. Furthermore, elderly patients are at a higher risk of surgical complications due to malnutrition and decreased immunity [30]. However, in our study cohort, we did not observe a significant increase in early surgical complications in operated patients over 65 years of age.

Today, we also consider treatment in patients over 80 years of age, especially when we know that their previous quality of life has been satisfactory and they are in good condition after SAC (HH 1-2). Even according to our results, an age of about 65 years is a blunt threshold for surgical treatment of aneurysms with a chance of minimal early complications and a good treatment outcome, taking into account other factors. Ohkuma et al. report this threshold even at the age of 85 years [10]. In the 0-64 years group, we did not observe a significant difference in treatment outcome between the NCH or EV treated group.

The HH and Fs scores assessing the clinical and graphic severity of SAC on admission did not, according to our results, influence the modality chosen for aneurysm treatment - except for expansive intracerebral hematomas in which NCH from craniotomy was indicated. According to the retrospectively available data, the anatomy of the aneurysm (location, size, direction of the sac, and width of the neck vs. the sac) was the most important factor for the choice of treatment modality. Lavage of the affected area and reduction of the amount of blood thought to be the cause of vasospasm could be beneficial [31]. Another procedure applied in the surgical procedure at our institution is fenestration of the lamina terminalis. According to some authors, fenestration of the lamina terminalis can reduce the risk of hydrocephalus [32-35].

That clinical and graphic status on admission did not have a major influence on the choice of treatment modality is also described by Zanaty et al [19]. In their study, however, decision making is influenced by the fact that the treatment procedure is performed by a neurosurgeon trained in both treatment modalities.

A limitation of our study is that we obtained treatment results 3 months after the attack, which may not be a long enough follow-up period for many people, especially if we want to assess quality of life as an outcome of treatment. The minimum time to assess treatment outcome is 1 year after the attack by many authors [29,36].

 

Conclusion

Seniors (65+ years) after SAC are at increased risk of poor neurological status 3 months after the attack compared to younger patients, especially if they are in severe clinical condition on admission. However, a significant proportion of these patients remain in good clinical condition after treatment of the aneurysm, so the method of treatment and extent of treatment needs to be assessed on an individual basis. In elderly patients treated endovascularly, we observed a better treatment outcome at 3 months compared with patients treated by open surgery.

 

Ethical aspects

The work was carried out in accordance with the Helsinki Declaration of 1975 and its revisions in 2004 and 2008. The study is not subject to ethics committee approval. Patients signed consent for the diagnostic and treatment process.

 

Grant support

Supported by the Ministry of Health of the Czech Republic - RVO (FNBr, 65269705).

 

Conflict of interest

The authors declare that they have no conflict of interest in relation to the subject of the study.

 

Tables

Table 1. The table shows the structure of the cohort according to HH, age and type of surgery.

	0-64 EV		0-64 NCH		65+ EV		65+ NCH
	n	%	n	%	N	%	n	%
HH1	13	11,02	35	13,78	2	5,55	8	8,79
HH2	46	38,98	112	44,10	17	47,22	26	28,57
HH3	35	29,66	57	22,44	10	27,78	31	34,07
HH4	13	11,02	28	11,02	5	13,89	11	12,09
HH5	11	9,32	22	8,66	2	5,56	15	16,48

EV - coiling; HH - Hunt Hess score; n - number; NCH - clipping

 

 

 

Table 2. The table shows the structure of the cohort according to Fischer score, age and type of surgery.

	0-64 EV		0-64 NCH		65+ EV		65+ NCH
	n	%	n	%	N	%	n	%
F1	3	2,56	6	2,37	0	0,00	3	3,26
F2	9	7,69	25	9,88	1	2,70	4	4,35
F3	67	57,27	139	54,94	25	67,57	45	48,91
F4	38	32,48	83	32,81	11	29,73	40	43,48

EV - coiling; F - Fischer score; n - number; NCH - clipping

 

 

Table 3. Structure of the cohort broken down by mRS, age and treatment method.

	0-64 EV		0-64 NCH		65+ EV		65+ NCH
	n	%	N	%	n	%	N	%
mRS 0	6	5,26	6	2,47	1	3,03	0	0,00
mRS 1	66	56,14	149	60,49	12	30,31	35	37,94
mRS 2	15	12,29	36	14,40	10	27,27	14	14,94
mRS 3	14	11,40	20	7,82	7	18,18	10	10,34
mRS 4	8	6,14	15	5,76	3	6,06	16	17,24
mRS 5	5	3,51	13	4,94	2	6,06	10	11,49
mRS 6	6	5,26	10	4,12	3	9,09	7	8,05

EV, coiling; mRS, modified Rankin Scale; n, number; NCH, clipping

 

 

Table 4: Summary of the number of patients with satisfactory vs. unsatisfactory treatment outcome by treatment modality and age.

	0-64 EV		0-64 NCH		65+ EV		65+ NCH
	n	%	n	%	n	%	n	%
good	88	73,68	192	77,37	23	60,61	49	52,87
wrong	32	26,32	57	22,63	15	39,39	43	47,13

EV - coiling; n - number; NCH - clipping

 

 

 

Table 5: Treatment outcome according to baseline HH in different age groups and treatment modalities (HH+: HH 1-2, HH-: HH 3-5, mRS+: mRS 0-2, mRS-: mRS 3-6).

	0-64 EV		0-64 NCH		65+ EV		65+ NCH
	n	%	n	%	n	%	N	%
HH+ mRS+	55	46	136	55	13	37	28	33
HH+ mRS-	8	5	9	3	5	13	4	3
HH- mRS+	34	28	56	22	8	22	18	20
HH- mRS-	26	21	50	20	10	28	39	44

EV, coiling; HH, Hunt Hess score; mRS, modified Rankin Scale; n, number; NCH, clipping