Abstracts
Aging is a major risk factor for poor outcome in patients with ruptured or unruptured intracranial aneurysms (IA) submitted to treatment. It impairs several physiologic patterns related to cerebrovascular hemodynamics and homeostasis.
Objective
Evaluate clinical, radiological patterns and prognostic factors of subarachnoid hemorrhage (SAH) patients according to age.
Method
Three hundred and eighty nine patients with aneurismal SAH from a Brazilian tertiary institution (Hospital do Servidor Público Estadual de São Paulo) were consecutively evaluated from 2002 to 2012 according to Fisher and Hunt Hess classifications and Glasgow Outcome Scale.
Results
There was statistically significant association of age with impaired clinical, radiological presentation and outcomes in cases of SAH.
Conclusion
Natural course of SAH is worse in elderly patients and thus, proper recognition of the profile of such patients and their outcome is necessary to propose standard treatment.
subarachnoid hemorrhage; aneurysm; age; outcome; treatment
A idade é considerada fator de risco de mau prognóstico em pacientes com aneurismas intracranianos rotos ou não-rotos; com o aumento da idade, ficam prejudicados vários padrões fisiológicos relacionados à hemodinâmica cerebral e homeostase.
Objetivo
Estudar o quadro clínico, os dados radiológicos e o prognóstico nos pacientes com hemorragia subaracnóide aneurismática em relação à idade.
Método
Foram avaliados consecutivamente, de 2002 a 2012, 389 pacientes com hemorragia subaracnóide aneurismática oriundos de uma instituição terciária brasileira.
Resultados
Houve associação da idade com pior quadro clínico, radiológico e prognóstico nos pacientes com hemorragia subaracnóide aneurismática.
Conclusão
O curso natural da hemorragia subaracnoidea é pior em pacientes idosos. O reconhecimento adequado do perfil desses pacientes e seu prognóstico é importante para estabelecer um tratamento adequado.
hemorragia subaracnóide; aneurisma; idade; prognóstico; tratamento
Aging is a major risk factor for poor outcome in patients with ruptured or unruptured
intracranial aneurysms (IA) submitted to treatment11 . Connolly ES Jr, Rabinstein AA, Carhuapoma JR, American Heart
Association Stroke Council, Council on Cardiovascular Radiology and
Intervention, Council on Cardiovascular Nursing et al. Guidelines for the
management of aneurismal subarachnoid hemorrhage: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association.
Stroke. 2012;43(6):1711-37. http://dx.doi.org/10.1161/str.0b013e3182587839
https://doi.org/10.1161/str.0b013e318258...
,22 . International Study of Unruptured Aneurysms Investigators.
Unruptured intracranial aneurysms: risk of rupture and risk of neurosurgical
intervetion. N Eng J Med. 1998;339(24):1725-33.
http://dx.doi.org/10.1056/NEJM199812103392401
https://doi.org/10.1056/NEJM199812103392...
,33 . Wiebers DO, International Study of Unruptured Intracranial
Aneurysms Investigators. Unruptured intracranial aneurysms: natural history,
clinical outcome, and risks of surgical and endovascular treatment. Lancet.
2003;362(9378):103-10.
http://dx.doi.org/10.1016/S0140-6736(03)13860-3
https://doi.org/10.1016/S0140-6736(03)13...
,44 . Collice M, D'Aliberti G, Arena O, Fontana RA, Bizzozero L,
Solaini C et al. Multidisciplinary (surgical and endovascular) approach to
intracranial aneurysms. J Neurosurg Sci. 1998;42(1 Suppl
1):S131-40.,55 . Rooij NK, Linn FH, Plas JA, Algra A, Rinkel GJ. Incidence of
subarachnoid haemorrhage: a systematic review with emphasis on region, age,
gender and time trends. J Neurol Neurosurg Psychiatr. 2007;78912):1365-72.
http://dx.doi.org/10.1136/jnnp.2007.117655
https://doi.org/10.1136/jnnp.2007.117655...
.
In those patients, there is increased impairment of consciousness, thick subarachnoid
clot, intraventricular hemorrhage, acute hydrocephalus and higher probability of
rebleeding after subarachnoid hemorrhage (SAH)44 . Collice M, D'Aliberti G, Arena O, Fontana RA, Bizzozero L,
Solaini C et al. Multidisciplinary (surgical and endovascular) approach to
intracranial aneurysms. J Neurosurg Sci. 1998;42(1 Suppl
1):S131-40.. In the case of unruptured aneurysms, early and late
complications are usually more severe in older patients, due to association with
systemic morbidities and loss of adequate physiologic homeostasis22 . International Study of Unruptured Aneurysms Investigators.
Unruptured intracranial aneurysms: risk of rupture and risk of neurosurgical
intervetion. N Eng J Med. 1998;339(24):1725-33.
http://dx.doi.org/10.1056/NEJM199812103392401
https://doi.org/10.1056/NEJM199812103392...
,33 . Wiebers DO, International Study of Unruptured Intracranial
Aneurysms Investigators. Unruptured intracranial aneurysms: natural history,
clinical outcome, and risks of surgical and endovascular treatment. Lancet.
2003;362(9378):103-10.
http://dx.doi.org/10.1016/S0140-6736(03)13860-3
https://doi.org/10.1016/S0140-6736(03)13...
.
We present our series and report nuances in the characterization and outcome of patients with IA.
METHOD
Three hundred and eighty nine patients who suffered subarachnoid hemorrhage from a Brazilian tertiary institution (Hospital do Servidor Público Estadual de São Paulo) were consecutively evaluated from 2002 to 2012. Our analysis is a retrospective discussion, based in medical records.
Although the concept of elder patient varies (most developed countries consider over
65 years old and World Health Organization warrants over 60 years old), we have
chosen the cutoff of 70 years old, which is the most addressed threshold in
pertinent guidelines as a landmark for therapeutic decision of IA11 . Connolly ES Jr, Rabinstein AA, Carhuapoma JR, American Heart
Association Stroke Council, Council on Cardiovascular Radiology and
Intervention, Council on Cardiovascular Nursing et al. Guidelines for the
management of aneurismal subarachnoid hemorrhage: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association.
Stroke. 2012;43(6):1711-37. http://dx.doi.org/10.1161/str.0b013e3182587839
https://doi.org/10.1161/str.0b013e318258...
,22 . International Study of Unruptured Aneurysms Investigators.
Unruptured intracranial aneurysms: risk of rupture and risk of neurosurgical
intervetion. N Eng J Med. 1998;339(24):1725-33.
http://dx.doi.org/10.1056/NEJM199812103392401
https://doi.org/10.1056/NEJM199812103392...
.
Inclusion criteria: all patients diagnosed with ruptured intracranial aneurysms submitted to treatment based in surgical approach and/or endovascular approach.
Exclusion criteria: unruptured intracranial aneurysms.
SAH patients were divided in two groups. Group 1 was composed of patients 70 years old or above and group 2 was composed of patients below 70 years. They were submitted to complete neurological examination during hospitalization. At admission they were classified according to Fisher and Hunt-Hess (HH) classification. Treatment modalities were classified as surgical or endovascular. At discharge, they were classified according to Glasgow Outcome Scale (GOS).
This study was approved by Hospital do Servidor Público Estadual de São Paulo Ethics Committee and informed consent was obtained from each patient.
Statistics
In this study, numerical data are presented as mean±standard deviation or median with range when appropriate. Categorical data are presented as percentages. To determine the distribution of our data, the Kolmogorov-Smirnov Test was used. Statistical analysis was performed by Student's t-test and Chi-Square test when appropriate. Multiple logistic regression analysis was used to evaluate outcome in GOS. When comparing groups, the level of significance is considered when p<0.05.
RESULTS
Characterization of patients
Three hundred and eighty nine patients have suffered SAH. Seventy two (18.5%) were 70 years old or above (group 1) and 317 (81.5%) were below 70 years old (group 2) (Table 1).
Features of 389 subarachnoid hemorrhage (SAH) patients (age, gender, Fisher classification, Hunt Hess classification and treatment modality).
Fisher classification
Thirty one patients (43%) in group 1 presented with Fisher 1 or 2. 41 (57%) patients in the same group presented with Fisher 3 or 4. In group 2, 213 patients (67%) presented with Fisher 1 or 2 and 104 (33%) with Fisher 3 or 4. The distribution of the Fisher strata was different between groups (p=0.0002) (Figure 1).
Hunt Hess classification
Twenty nine patients (40%) in group 1 presented with Hunt Hess of 4 or 5, and 43 patients (60%) presented with HH of 1, 2 or 3. In group 2, 48 patients (15%) were HH 4 or 5 and 269 (85%) were HH 1, 2 or 3. The distribution of the Fisher strata was different between groups (p<0.0001) (Figure 2).
Treatment modality
The majority of patients in our sample (90.7%) was submitted to surgical treatment, while few cases underwent endovascular management (9.3%) (Table 1).
Outcome in SAH
In group 1, 58 out of 72 patients (80.5%) developed GOS of 1, 2 or 3 and 14 patients 4 or 5 (19.5%). In group 2, 124 (39%) developed GOS 1, 2 or 3 and 193 (61%) 4 or five (p<0.0001) (Figure 3).
One hundred and three patients (26.5%) were discharged in GOS 1, 2 and 3. Two hundred and eighty six (73.5%) were discharged in GOS 4 or 5. Forty patients (38.8%) discharged with GOS 1, 2 and 3 presented initially with HH of 1, 2 or 3 and 63 patients (62.2%) with 4 or 5. Among patients discharged with GOS 4 or 5, 275 (96%) presented initially with HH 1, 2 or 3 and 11 patients (4%) with HH of 4 or 5 (p<0.0001).
In group 1, 50 patients (69.5%) were discharged in GOS 1, 2 or 3 and 22 (30.5%) in GOS 4 or 5. Among GOS 1, 2 or 3 group, 22 (44%) were HH 1, 2 or 3 and 28 (56%) were HH 4 or 5. Among GOS 4 or 5 group, 21 (95.5%) were HH 1, 2 or 3 and 1 (4.5%) was HH 4. The distribution of the Fisher strata was different between groups (p<0.0001).
In group 2, 51 patients (16%) were discharged in GOS 1, 2 or 3 and 264 (84%) in GOS 4 or 5. Among GOS 1, 2 or 3 group, 18 (35%) were HH 1, 2 or 3 and 35 (65%) were HH 4 or 5. Among GOS 4 or 5 group, 254 (96%) were HH 1, 2 or 3 and 10 (4%) was HH 4 (p<0.0001).
Patients submitted to surgical treatment presented with better GOS (p<0.05). Two hundred and fifty four patients submitted to surgery (72%) were discharged in GOS 4 or 5. 28% were discharged in GOS 1, 2 or 3. In endovascular group, 81% (29 patients) were discharged in GOS 1, 2 or 3 and 19% in GOS 4 or 5.
Female patients were 74% of the sample. There was no difference in GOS according to gender. When evaluating all variates together in multiple regression analysis, age, Fisher, Hunt Hess and treatment modality were associated with worse outcome. Age and Hunt Hess revealed the strongest association with worse GOS (Table 2).
DISCUSSION
Our sample illustrates the strong association between age and poor outcomes when treating ruptured intracranial aneurysms. In summary, there was statistically significant association of age with impaired clinical and radiological presentation in cases of SAH and outcomes were worse in SAH patients. When age was analysed together with initial HH as an outcome predictor, age presented stronger impact with statistical significance.
Although most of our patients were female, there was no association of gender with clinical, radiological and/or outcome. Other factors like clinical comorbidities, may indeed interfere with presentation and outcomes.
The incidence of intracranial aneurysms rises with age, and the same behavior is true
regarding SAH11 . Connolly ES Jr, Rabinstein AA, Carhuapoma JR, American Heart
Association Stroke Council, Council on Cardiovascular Radiology and
Intervention, Council on Cardiovascular Nursing et al. Guidelines for the
management of aneurismal subarachnoid hemorrhage: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association.
Stroke. 2012;43(6):1711-37. http://dx.doi.org/10.1161/str.0b013e3182587839
https://doi.org/10.1161/str.0b013e318258...
,22 . International Study of Unruptured Aneurysms Investigators.
Unruptured intracranial aneurysms: risk of rupture and risk of neurosurgical
intervetion. N Eng J Med. 1998;339(24):1725-33.
http://dx.doi.org/10.1056/NEJM199812103392401
https://doi.org/10.1056/NEJM199812103392...
,33 . Wiebers DO, International Study of Unruptured Intracranial
Aneurysms Investigators. Unruptured intracranial aneurysms: natural history,
clinical outcome, and risks of surgical and endovascular treatment. Lancet.
2003;362(9378):103-10.
http://dx.doi.org/10.1016/S0140-6736(03)13860-3
https://doi.org/10.1016/S0140-6736(03)13...
,44 . Collice M, D'Aliberti G, Arena O, Fontana RA, Bizzozero L,
Solaini C et al. Multidisciplinary (surgical and endovascular) approach to
intracranial aneurysms. J Neurosurg Sci. 1998;42(1 Suppl
1):S131-40.,55 . Rooij NK, Linn FH, Plas JA, Algra A, Rinkel GJ. Incidence of
subarachnoid haemorrhage: a systematic review with emphasis on region, age,
gender and time trends. J Neurol Neurosurg Psychiatr. 2007;78912):1365-72.
http://dx.doi.org/10.1136/jnnp.2007.117655
https://doi.org/10.1136/jnnp.2007.117655...
. As a general rule, unruptured aneurysms have a 1% per year
probability of bleeding. Thus, unruptured aneurysms greater than 10 mm should be
treated at any age, due to risk of rupture. Aneurysms between 5-10 mm should be
considered in a particular basis, once age and clinical morbidities may interfere
with treatment22 . International Study of Unruptured Aneurysms Investigators.
Unruptured intracranial aneurysms: risk of rupture and risk of neurosurgical
intervetion. N Eng J Med. 1998;339(24):1725-33.
http://dx.doi.org/10.1056/NEJM199812103392401
https://doi.org/10.1056/NEJM199812103392...
,33 . Wiebers DO, International Study of Unruptured Intracranial
Aneurysms Investigators. Unruptured intracranial aneurysms: natural history,
clinical outcome, and risks of surgical and endovascular treatment. Lancet.
2003;362(9378):103-10.
http://dx.doi.org/10.1016/S0140-6736(03)13860-3
https://doi.org/10.1016/S0140-6736(03)13...
. Below 5 mm, a more conservative
approach is usually advocated. When SAH is present, these rationales are abandoned
and prompt treatment must be achieved independently of aneurysm size11 . Connolly ES Jr, Rabinstein AA, Carhuapoma JR, American Heart
Association Stroke Council, Council on Cardiovascular Radiology and
Intervention, Council on Cardiovascular Nursing et al. Guidelines for the
management of aneurismal subarachnoid hemorrhage: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association.
Stroke. 2012;43(6):1711-37. http://dx.doi.org/10.1161/str.0b013e3182587839
https://doi.org/10.1161/str.0b013e318258...
.
Several factors impact evaluation, treatment strategies and outcomes in intracranial
aneurysmal disease. Aging probably is one of the most significant independent
factors. It impairs several physiologic patterns related to cerebrovascular
hemodynamics and homeostasis66 . Proust F, Ge'rardin E, Derrey S, Lesvèque S, Ramos S,
Langlois O et al. Interdisciplinary treatment of ruptured cerebral aneurysms in
elderly patients. J Neurosurg 2010;112(6):1200-7.
http://dx.doi.org/10.3171/2009.10.JNS08754
https://doi.org/10.3171/2009.10.JNS08754...
,77 . Karamanakos PN, Koivisto T, Vanninen R, Khallaf M, Ronkainen A,
Parviainen I et al. The impact of endovascular management on the outcome of
aneurysmal subarachnoid hemorrhage in the elderly in Eastern Finland. Acta
Neurochir (Wien). 2010;152(9):1493-1502.
http://dx.doi.org/10.1007/s00701-010-0714-6
https://doi.org/10.1007/s00701-010-0714-...
,88 . Cai Y, Spelle L, Wang H, Piotin M, Mounayer C, Vanzin JR et al.
Endovascular treatment of intracranial aneurysms in the elderly: singlecenter
experience in 63 consecutive patients. Neurosurgery. 2005;57(6):1096-102.
http://dx.doi.org/10.1227/01.neu.0000185583.25420.df
https://doi.org/10.1227/01.neu.000018558...
,99 . Nieuwkamp DJ, Setz LE, Algra A, Linn FH, Rooij NK, Rinkel GJ.
Changes in case fatality of aneurysmal subarachnoid haemorrhage over time,
according to age, sex, and region: a meta-analysis. Lancet Neurol.
2009;897):635-42.
http://dx.doi.org/10.1016/S1474-4422(09)70126-7
https://doi.org/10.1016/S1474-4422(09)70...
,1010 . Lanzino G, Kassell NF, Germanson TP, Kongable GL, Truskowski LL,
Torner JC et al. Age and outcome after aneurysmal subarachnoid hemorrhage: why
do older patients fare worse? J Neurosurg. 1996;85(3):410-8.
http://dx.doi.org/10.3171/jns.1996.85.3.0410
https://doi.org/10.3171/jns.1996.85.3.04...
,1111 . Molyneux AJ, Kerr RS, Yu L-M, Clarke M, Sneade M, Yarnold JA et
al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping
versus endovascular coiling in 2143 patients with ruptured intracranial
aneurysms: a randomised comparison of effects on survival, dependency, seizures,
rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366(9488):809-17.
http://dx.doi.org/10.1016/s0140-6736(05)67214-5
https://doi.org/10.1016/s0140-6736(05)67...
,1212 . Bakker NA, Metzemaekers JD, Groen RJ, Mooij JJ, Van Dijk JM.
International subarachnoid aneurysm trial 2009: endovascular coiling of ruptured
intracranial aneurysms has no significant advantage over neurosurgical clipping.
Neurosurgery 2010;66(5):961-2.
http://dx.doi.org/10.1227/01.NEU.0000368152.67151.73
https://doi.org/10.1227/01.NEU.000036815...
.
There is a decline in cerebral blood flow velocity with age, which may be associated
with certain changes as: decreased cerebral blood flow (CBF) or metabolic demands;
vessel changes like progressive kinking, calcifications (Figure 4), elongation, stenosis and lower cardiac output11 . Connolly ES Jr, Rabinstein AA, Carhuapoma JR, American Heart
Association Stroke Council, Council on Cardiovascular Radiology and
Intervention, Council on Cardiovascular Nursing et al. Guidelines for the
management of aneurismal subarachnoid hemorrhage: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association.
Stroke. 2012;43(6):1711-37. http://dx.doi.org/10.1161/str.0b013e3182587839
https://doi.org/10.1161/str.0b013e318258...
,22 . International Study of Unruptured Aneurysms Investigators.
Unruptured intracranial aneurysms: risk of rupture and risk of neurosurgical
intervetion. N Eng J Med. 1998;339(24):1725-33.
http://dx.doi.org/10.1056/NEJM199812103392401
https://doi.org/10.1056/NEJM199812103392...
,33 . Wiebers DO, International Study of Unruptured Intracranial
Aneurysms Investigators. Unruptured intracranial aneurysms: natural history,
clinical outcome, and risks of surgical and endovascular treatment. Lancet.
2003;362(9378):103-10.
http://dx.doi.org/10.1016/S0140-6736(03)13860-3
https://doi.org/10.1016/S0140-6736(03)13...
,1111 . Molyneux AJ, Kerr RS, Yu L-M, Clarke M, Sneade M, Yarnold JA et
al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping
versus endovascular coiling in 2143 patients with ruptured intracranial
aneurysms: a randomised comparison of effects on survival, dependency, seizures,
rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366(9488):809-17.
http://dx.doi.org/10.1016/s0140-6736(05)67214-5
https://doi.org/10.1016/s0140-6736(05)67...
,1313 . Ryttlefors M, Enblad P, Ronne-Engström E, Persson L, Ilodigwe
D, Macdonald RL. Patient age and vasospasm after subarachnoid hemorrhage.
Neurosurgery. 2010;67(4):911-7.
http://dx.doi.org/10.1227/neu.0b013e3181ed11ab
https://doi.org/10.1227/neu.0b013e3181ed...
,1414 . Macdonald RL, Higashida RT, Keller E, Mayer SA, Molyneux A, Raabe
A et al. Randomised trial of clazosentan, an endothelin receptor antagonist, in
patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping
(CONSCIOUS-2). Acta Neurochir. 2013;115(Suppl):S27-31.
http://dx.doi.org/10.1007/978-3-7091-1192-5_7
https://doi.org/10.1007/978-3-7091-1192-...
,1515 . Torbey MT, Hauser T-K, Bhardwaj A, Williams MA, Ulatowski JA,
Mirski MA et al. Effect of age on cerebral blood flow velocity and incidence of
vasospasm after aneurysmal subarachnoid hemorrhage. Stroke. 2001;32(9):2005-211.
http://dx.doi.org/10.1161/hs0901.094622
https://doi.org/10.1161/hs0901.094622 ...
. It is also associated with a 20% to 30% decrease in
CBF in healthy individuals between the ages of 20 and 80 years and with dilatation
of major extracranial arteries and reduction of flow within parenchymal vessels11 . Connolly ES Jr, Rabinstein AA, Carhuapoma JR, American Heart
Association Stroke Council, Council on Cardiovascular Radiology and
Intervention, Council on Cardiovascular Nursing et al. Guidelines for the
management of aneurismal subarachnoid hemorrhage: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association.
Stroke. 2012;43(6):1711-37. http://dx.doi.org/10.1161/str.0b013e3182587839
https://doi.org/10.1161/str.0b013e318258...
,1313 . Ryttlefors M, Enblad P, Ronne-Engström E, Persson L, Ilodigwe
D, Macdonald RL. Patient age and vasospasm after subarachnoid hemorrhage.
Neurosurgery. 2010;67(4):911-7.
http://dx.doi.org/10.1227/neu.0b013e3181ed11ab
https://doi.org/10.1227/neu.0b013e3181ed...
,1414 . Macdonald RL, Higashida RT, Keller E, Mayer SA, Molyneux A, Raabe
A et al. Randomised trial of clazosentan, an endothelin receptor antagonist, in
patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping
(CONSCIOUS-2). Acta Neurochir. 2013;115(Suppl):S27-31.
http://dx.doi.org/10.1007/978-3-7091-1192-5_7
https://doi.org/10.1007/978-3-7091-1192-...
,1515 . Torbey MT, Hauser T-K, Bhardwaj A, Williams MA, Ulatowski JA,
Mirski MA et al. Effect of age on cerebral blood flow velocity and incidence of
vasospasm after aneurysmal subarachnoid hemorrhage. Stroke. 2001;32(9):2005-211.
http://dx.doi.org/10.1161/hs0901.094622
https://doi.org/10.1161/hs0901.094622 ...
.
All those statements justify that elderly usually present with more severe SAH than
younger patients, characterized by higher Fisher and Hunt Hess grades. After
treatment, elderly are also prone to face severe neurological and systemic
complications, like vasospasm, hydrocephalus, brain and heart ischemic insults and
others66 . Proust F, Ge'rardin E, Derrey S, Lesvèque S, Ramos S,
Langlois O et al. Interdisciplinary treatment of ruptured cerebral aneurysms in
elderly patients. J Neurosurg 2010;112(6):1200-7.
http://dx.doi.org/10.3171/2009.10.JNS08754
https://doi.org/10.3171/2009.10.JNS08754...
,77 . Karamanakos PN, Koivisto T, Vanninen R, Khallaf M, Ronkainen A,
Parviainen I et al. The impact of endovascular management on the outcome of
aneurysmal subarachnoid hemorrhage in the elderly in Eastern Finland. Acta
Neurochir (Wien). 2010;152(9):1493-1502.
http://dx.doi.org/10.1007/s00701-010-0714-6
https://doi.org/10.1007/s00701-010-0714-...
,88 . Cai Y, Spelle L, Wang H, Piotin M, Mounayer C, Vanzin JR et al.
Endovascular treatment of intracranial aneurysms in the elderly: singlecenter
experience in 63 consecutive patients. Neurosurgery. 2005;57(6):1096-102.
http://dx.doi.org/10.1227/01.neu.0000185583.25420.df
https://doi.org/10.1227/01.neu.000018558...
,99 . Nieuwkamp DJ, Setz LE, Algra A, Linn FH, Rooij NK, Rinkel GJ.
Changes in case fatality of aneurysmal subarachnoid haemorrhage over time,
according to age, sex, and region: a meta-analysis. Lancet Neurol.
2009;897):635-42.
http://dx.doi.org/10.1016/S1474-4422(09)70126-7
https://doi.org/10.1016/S1474-4422(09)70...
,1010 . Lanzino G, Kassell NF, Germanson TP, Kongable GL, Truskowski LL,
Torner JC et al. Age and outcome after aneurysmal subarachnoid hemorrhage: why
do older patients fare worse? J Neurosurg. 1996;85(3):410-8.
http://dx.doi.org/10.3171/jns.1996.85.3.0410
https://doi.org/10.3171/jns.1996.85.3.04...
.
Cerebral vasospasm (VSP) is the major complication associated with aneurysmal SAH
that results in delayed ischemic deficits in up to 25% of all cases. Although it is
associated with hypercholesterolemia, chronic hypertension and atherosclerosis,
there is lower incidence of VSP in older patients, probably secondary to the
age-related impairment of contractility and elasticity of the muscle wall of small
arteries and arterioles. However, the severity of VSP in such patients is pronounced
as the margin between adequate CBF and the ischemic threshold may become especially
narrow1313 . Ryttlefors M, Enblad P, Ronne-Engström E, Persson L, Ilodigwe
D, Macdonald RL. Patient age and vasospasm after subarachnoid hemorrhage.
Neurosurgery. 2010;67(4):911-7.
http://dx.doi.org/10.1227/neu.0b013e3181ed11ab
https://doi.org/10.1227/neu.0b013e3181ed...
,1414 . Macdonald RL, Higashida RT, Keller E, Mayer SA, Molyneux A, Raabe
A et al. Randomised trial of clazosentan, an endothelin receptor antagonist, in
patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping
(CONSCIOUS-2). Acta Neurochir. 2013;115(Suppl):S27-31.
http://dx.doi.org/10.1007/978-3-7091-1192-5_7
https://doi.org/10.1007/978-3-7091-1192-...
,1515 . Torbey MT, Hauser T-K, Bhardwaj A, Williams MA, Ulatowski JA,
Mirski MA et al. Effect of age on cerebral blood flow velocity and incidence of
vasospasm after aneurysmal subarachnoid hemorrhage. Stroke. 2001;32(9):2005-211.
http://dx.doi.org/10.1161/hs0901.094622
https://doi.org/10.1161/hs0901.094622 ...
.
Several limitations should be pointed out. Our report was a simplified analysis of outcome related to the age of patients and restricted to general classification according to Fisher and Hunt Hess scores and GOS. The association between age and adverse outcome is almost a constant in any disease. This is why most investigations adjust for age, but do not primarily investigate its effects. This fact may bias but not invalidate our analysis.
Then, discharge outcomes are biased because the follow-up times are highly variable between patients and post-discharge outcomes were not assessed. Additionally, the age of 70 years old was chosen because it is a landmark in the most important trials in literature, above what management strategies are substantially changed towards endovascular approaches.
We did not disclose important details like associated clinical morbidities, Glasgow Coma Scale, aneurysm topography, size, shape and presence of aneurysmal calcifications. We also did not discuss presence of hydrocephalus and vasospasm in our sample.
Our endovascular sample was biased, once patients submitted to endovascular treatment were already in worse clinical conditions, changing outcomes. Randomization of surgical and endovascular groups would potentially disclose different results. All those factors may surely bias our findings and interfere with inferences from the study, but not invalidate it.
Therefore, solid experimental and clinical evidence already points to similar
findings and corroborate the need of evaluating aneurysmal disease in elderly with
caution. A special issue that must be addressed is the increasing application of
endovascular treatment in elderly, due to lower perioperative risk, similar
treatment results and potential better outcomes11 . Connolly ES Jr, Rabinstein AA, Carhuapoma JR, American Heart
Association Stroke Council, Council on Cardiovascular Radiology and
Intervention, Council on Cardiovascular Nursing et al. Guidelines for the
management of aneurismal subarachnoid hemorrhage: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association.
Stroke. 2012;43(6):1711-37. http://dx.doi.org/10.1161/str.0b013e3182587839
https://doi.org/10.1161/str.0b013e318258...
,22 . International Study of Unruptured Aneurysms Investigators.
Unruptured intracranial aneurysms: risk of rupture and risk of neurosurgical
intervetion. N Eng J Med. 1998;339(24):1725-33.
http://dx.doi.org/10.1056/NEJM199812103392401
https://doi.org/10.1056/NEJM199812103392...
.
References
-
1Connolly ES Jr, Rabinstein AA, Carhuapoma JR, American Heart Association Stroke Council, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular Nursing et al. Guidelines for the management of aneurismal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(6):1711-37. http://dx.doi.org/10.1161/str.0b013e3182587839
» https://doi.org/10.1161/str.0b013e3182587839 -
2International Study of Unruptured Aneurysms Investigators. Unruptured intracranial aneurysms: risk of rupture and risk of neurosurgical intervetion. N Eng J Med. 1998;339(24):1725-33. http://dx.doi.org/10.1056/NEJM199812103392401
» https://doi.org/10.1056/NEJM199812103392401 -
3Wiebers DO, International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362(9378):103-10. http://dx.doi.org/10.1016/S0140-6736(03)13860-3
» https://doi.org/10.1016/S0140-6736(03)13860-3 -
4Collice M, D'Aliberti G, Arena O, Fontana RA, Bizzozero L, Solaini C et al. Multidisciplinary (surgical and endovascular) approach to intracranial aneurysms. J Neurosurg Sci. 1998;42(1 Suppl 1):S131-40.
-
5Rooij NK, Linn FH, Plas JA, Algra A, Rinkel GJ. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatr. 2007;78912):1365-72. http://dx.doi.org/10.1136/jnnp.2007.117655
» https://doi.org/10.1136/jnnp.2007.117655 -
6Proust F, Ge'rardin E, Derrey S, Lesvèque S, Ramos S, Langlois O et al. Interdisciplinary treatment of ruptured cerebral aneurysms in elderly patients. J Neurosurg 2010;112(6):1200-7. http://dx.doi.org/10.3171/2009.10.JNS08754
» https://doi.org/10.3171/2009.10.JNS08754 -
7Karamanakos PN, Koivisto T, Vanninen R, Khallaf M, Ronkainen A, Parviainen I et al. The impact of endovascular management on the outcome of aneurysmal subarachnoid hemorrhage in the elderly in Eastern Finland. Acta Neurochir (Wien). 2010;152(9):1493-1502. http://dx.doi.org/10.1007/s00701-010-0714-6
» https://doi.org/10.1007/s00701-010-0714-6 -
8Cai Y, Spelle L, Wang H, Piotin M, Mounayer C, Vanzin JR et al. Endovascular treatment of intracranial aneurysms in the elderly: singlecenter experience in 63 consecutive patients. Neurosurgery. 2005;57(6):1096-102. http://dx.doi.org/10.1227/01.neu.0000185583.25420.df
» https://doi.org/10.1227/01.neu.0000185583.25420.df -
9Nieuwkamp DJ, Setz LE, Algra A, Linn FH, Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol. 2009;897):635-42. http://dx.doi.org/10.1016/S1474-4422(09)70126-7
» https://doi.org/10.1016/S1474-4422(09)70126-7 -
10Lanzino G, Kassell NF, Germanson TP, Kongable GL, Truskowski LL, Torner JC et al. Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse? J Neurosurg. 1996;85(3):410-8. http://dx.doi.org/10.3171/jns.1996.85.3.0410
» https://doi.org/10.3171/jns.1996.85.3.0410 -
11Molyneux AJ, Kerr RS, Yu L-M, Clarke M, Sneade M, Yarnold JA et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366(9488):809-17. http://dx.doi.org/10.1016/s0140-6736(05)67214-5
» https://doi.org/10.1016/s0140-6736(05)67214-5 -
12Bakker NA, Metzemaekers JD, Groen RJ, Mooij JJ, Van Dijk JM. International subarachnoid aneurysm trial 2009: endovascular coiling of ruptured intracranial aneurysms has no significant advantage over neurosurgical clipping. Neurosurgery 2010;66(5):961-2. http://dx.doi.org/10.1227/01.NEU.0000368152.67151.73
» https://doi.org/10.1227/01.NEU.0000368152.67151.73 -
13Ryttlefors M, Enblad P, Ronne-Engström E, Persson L, Ilodigwe D, Macdonald RL. Patient age and vasospasm after subarachnoid hemorrhage. Neurosurgery. 2010;67(4):911-7. http://dx.doi.org/10.1227/neu.0b013e3181ed11ab
» https://doi.org/10.1227/neu.0b013e3181ed11ab -
14Macdonald RL, Higashida RT, Keller E, Mayer SA, Molyneux A, Raabe A et al. Randomised trial of clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping (CONSCIOUS-2). Acta Neurochir. 2013;115(Suppl):S27-31. http://dx.doi.org/10.1007/978-3-7091-1192-5_7
» https://doi.org/10.1007/978-3-7091-1192-5_7 -
15Torbey MT, Hauser T-K, Bhardwaj A, Williams MA, Ulatowski JA, Mirski MA et al. Effect of age on cerebral blood flow velocity and incidence of vasospasm after aneurysmal subarachnoid hemorrhage. Stroke. 2001;32(9):2005-211. http://dx.doi.org/10.1161/hs0901.094622
» https://doi.org/10.1161/hs0901.094622
Publication Dates
-
Publication in this collection
Nov 2014
History
-
Received
10 July 2014 -
Reviewed
20 July 2014 -
Accepted
08 Aug 2014