- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Ube, Japan
- Department of Public Health, Yamaguchi University School of Medicine, Ube, Japan
Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Ube, Japan
DOI:10.4103/2152-7806.103886Copyright: © 2012 Shirao S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Shirao S, Yoneda H, Kunitsugu I, Suehiro E, Koizumi H, Suzuki M. Age limit for surgical treatment of poor-grade patients with subarachnoid hemorrhage: A project of the Chugoku-Shikoku division of the Japan neurosurgical society. Surg Neurol Int 27-Nov-2012;3:143
How to cite this URL: Shirao S, Yoneda H, Kunitsugu I, Suehiro E, Koizumi H, Suzuki M. Age limit for surgical treatment of poor-grade patients with subarachnoid hemorrhage: A project of the Chugoku-Shikoku division of the Japan neurosurgical society. Surg Neurol Int 27-Nov-2012;3:143. Available from: http://sni.wpengine.com/surgicalint_articles/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 P = 0.02), Fisher grade (P P 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.
Keywords: Aneurysm, elderly, poor grade, subarachnoid hemorrhage
Patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) of World Federation of Neurosurgical Societies (WFNS) Grades IV and V have high mortality and morbidity, and the majority are treated conservatively.[
The annual incidence rate of aneurysmal SAH increases with age[
This study was performed retrospectively in a cohort with poor-grade SAH (WFNS Grades IV and V). The patients were recruited from January to December 2003 from 66 medical centers in Chugoku and Shikoku, Japan.[
The inclusion criteria for the study were patients with poor-grade SAH (WFNS Grades IV and V) who were undergoing surgical treatment of surgical clipping or GDC embolization. WFNS grades of patients were obtained at admission by the neurosurgeon before resuscitation, treatment of intracranial hypertension, and intracranial pressure control. Patients treated with other types of coils for endovascular treatment were excluded from the study. SAH was confirmed in all patients by head CT scans and classified based on the Fisher grade: Group 1, no blood detected; Group 2, a diffuse deposition or thin layer with all vertical layers of blood (interhemispheric fissure, insular cistern, ambient cistern) <1 mm thick; Group 3, localized clots and/or vertical layers of blood ≥1 mm in thickness; and Group 4, diffuse or no subarachnoid blood, but with intracerebral or intraventricular clots.[
Age, sex, WFNS grade, improvement of WFNS grade, Fisher grade, aneurysm location, rebleeding, treatment modality (surgical clipping and GDC embolization), and time to intervention (≤24 h, 24-72 h, >72 h) were recorded as baseline characteristics. The outcome measures were symptomatic vasospasm, LDA associated with vasospasm on CT, shunt-dependent hydrocephalus, length of hospital stay, clinical outcome at discharge, and mortality. Symptomatic vasospasm was as previously defined based on clinical criteria of (1) onset of new neurological deficits such as confusion, disorientation, drowsiness, or focal motor deficit on days 4 to 14 after onset of SAH; (2) negative findings on CT scans obtained to rule out other causes of neurological deterioration, such as surgery, hydrocephalus, or intracranial rebleeding; and (3) no other identifiable cause of neurological deterioration, such as seizure, infection, electrolyte imbalance, or metabolic disturbances.[
A χ2 test and Student t test were used to compare variables between patients with favorable and poor outcomes. Factors found to be significantly associated with outcome were further examined by multivariate analysis (Statistical Analysis System, SAS Institute, Cary, NC). These factors included demographic information (age and sex), SAH-related variables (WFNS Grade at admission, improvement of WFNS Grade within 72 h, Fisher grade, aneurysm location, rebleeding, time to intervention, treatment modality, symptomatic vasospasm, LDA on CT, and shunt-dependent hydrocephalus), GOS at discharge, and mortality. Data are shown as means ± standard deviation. A P value less than 0.05 was considered significant in all analyses.
The mean age of the 283 patients was 64.8 years old, 65.7% of the patients were female, 127 (44.9%) were <65 years old (mean age: 53.2 years old), and 156 (55.1%) were ≥65 years old (mean age: 74.5 years). The characteristics of the patients are given for all patients and for the two age groups in
Factors associated with outcome
Factors with a potential association with clinical outcomes at discharge (age, sex, WFNS Grade at admission, improvement of WFNS Grade within 72 h, Fisher grade, aneurysm location, rebleeding, treatment modality, symptomatic vasospasm, LDA on CT, shunt- dependent hydrocephalus, and time to intervention) in the 156 patients aged ≥65 years old were examined by univariate analysis [
Factors associated with treatment modality
The treatment modality (surgical clipping or GDC embolization) in the 156 patients aged ≥65 years old was examined by univariate analysis [
Multivariate analysis and outcome prediction
The four factors with a significant effect on outcome identified in univariate analysis in patients aged ≥65 years old (age, Fisher grade, improvement of WFNS Grade, LDA on CT) and a factor with a significant effect on outcome identified in univariate analysis in patients of all ages (WFNS grade at admission)[
Independent prognostic factors of a poor outcome at discharge for patients aged ≥65 years old based on multivariate analysis of age, Fisher grade, World Federation of Neurosurgical Societies grade, improvement of World Federation of Neurosurgical Societies grade, and low density area on computed tomography
In this report, we describe a retrospective study of 283 patients with poor-grade SAH who underwent surgical obliteration of the aneurysm at 66 medical centers in Chugoku and Shikoku, Japan. Of these patients, 156 were ≥65 years old. The crude annual incidence of SAH (WFNS Grades I-V) and the age and sex-adjusted incidence of poor-grade SAH (WFNS Grades IV and V) in this study indicated that most patients with SAH in Chugoku and Shikoku were included, and thus an accurate assessment of outcome for poor-grade SAH in these regions is provided in this one-year study.[
Several studies have suggested that advanced age is associated with a poor outcome in patients with poor- grade SAH,[
LeRoux et al.[
LeRoux et al.[
GDC embolization has been applied to poor-grade SAH patients in previous studies[
Several studies have found that early surgery for poor- grade SAH is associated with a favorable outcome,[
Our analysis demonstrates that advanced age (≥75 years old), Fisher group 4, and a new LDA associated with vasospasm on CT are independent predictors of outcome in elderly patients with poor- grade SAH. WFNS Grade V at admission may also be an independent predictor of outcome in this patient population. Improvement of WFNS Grade was identified as a predictor of a favorable outcome in univariate analysis, but did not show an independent correlation with outcome in multivariate analysis. The rate of a favorable outcome in elderly patients with poor-grade SAH treated with GDC embolization was higher than that with surgical clipping, but with no significant difference. Early aneurysm surgery was not found to be an independent predictor of outcome in elderly patients with poor-grade aneurysm. The results of this study should not be taken as proof of preoperative prediction of outcome in elderly patients with poor-grade SAH, since we only looked at patients who received surgical treatment and excluded those who were not treated. Proof of preoperative prediction of outcome in elderly patients with poor-grade SAH can only be accomplished in a randomized controlled trial in a large number of patients at multiple centers. However, our results do confirm previously identified trends for outcome in elderly patients with poor-grade SAH.
We thank the members of the Chugoku-Shikoku Division of the Japan Neurosurgical Society who made the project possible: Isao Date, M.D., Kaoru Kurisu, M.D., Keiji Shimizu, M.D., Masaaki Uno, M.D., Shinji Nagahiro, M.D., Takanori Ohnishi, M.D., Takashi Tamiya, M.D., Takashi Watanabe, M.D., and Yasuhiko Akiyama, M.D. We also thank the members of the project of the Chugoku-Shikoku Division of the Japan Neurosurgical Society for providing data.
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