- Department of Neurosurgery, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku ku, Tokyo 160-0023, Japan
- Department of Neurosurgery, Social Insurance Chuo General Hospital, 3-22-1 Hyakunintyo, Shinjuku-ku, Tokyo 169-0073, Japan
- Department of Neurosurgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Amimachi Chuou, Inagi-gun, Ibaraki 300-0395, Japan
Department of Neurosurgery, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku ku, Tokyo 160-0023, Japan
DOI:10.4103/2152-7806.136090Copyright: © 2013 Watanabe D 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: Watanabe D, Hashimoto T, Koyama S, Ohashi HT, Okada H, Ichimasu N, Kohno M. Endovascular treatment of ruptured intracranial aneurysms in patients 70 years of age and older. Surg Neurol Int 05-Jul-2014;5:104
How to cite this URL: Watanabe D, Hashimoto T, Koyama S, Ohashi HT, Okada H, Ichimasu N, Kohno M. Endovascular treatment of ruptured intracranial aneurysms in patients 70 years of age and older. Surg Neurol Int 05-Jul-2014;5:104. Available from: http://sni.wpengine.com/surgicalint_articles/endovascular-treatment-of-ruptured-intracranial-aneurysms-in-patients-70-years-of-age-and-older/
Background:An increasing number of elderly patients present with intracranial aneurysms. In addition to female gender, an older age is associated with a higher risk of developing a subarachnoid hemorrhage (SAH), and these patients often fare poorly in terms of long-term outcome. It is often thought that elderly patients would especially benefit from endovascular aneurysm treatment. We assessed the clinical outcomes in elderly patients with ruptured intracranial aneurysms (RIAs) who were treated by endovascular procedures.
Methods:We performed a retrospective review of a prospective database of elderly patients treated with coil embolization for RIAs. The clinical outcomes were assessed using the modified Glasgow Outcome Scale. The rates of procedural complications and adverse events were also recorded.
Results:During a period of 5 years, 162 patients with 183 intracranial aneurysms were treated in our hospital by means of an endovascular approach. Among them, 51 patients (31.5%) with a ruptured aneurysm were aged 70 years or older. These patients aged 70-91 years (mean age, 74 years) were treated by coil embolization for RIAs. Among them, seven had a Hunt and Hess (HH) grade of I or II, 42 had an HH grade of III or IV, and 2 had an HH grade of V. Endovascular treatment resulted in 32 complete occlusions (62.7%), 15 neck remnants (22%), and 4 body fillings (7.9%). Procedural complications occurred in five patients (9.8%). The outcomes were good or excellent in 17 patients (33.3%). Three patients (5.8%) who died had an HH grade of IV or V. Rebleeding occurred during follow-up in one patient (1.9%).
Conclusions:Coil embolization of intracranial aneurysms is safe and effective in the elderly. However, the morbidity and mortality rates are higher in patients with high HH grades. This finding suggests that the timing of treatment should be based on the patient's initial clinical status.
Keywords: Coil embolization, elderly, intracranial aneurysm, ruptured
With the increase in elderly population, we can expect more elderly patients to present with intracranial aneurysms. In addition to female gender, an older age is associated with a higher risk of developing a subarachnoid hemorrhage (SAH), and these patients often fare poorly in terms of ong-term outcome.[
In a long-term follow-up of patients treated in the International Subarachnoid Aneurysm Trial (ISAT), younger patients (<40 years of age) treated by coil embolization, despite showing good initial results, had a greater risk for late rebleeding, compared with patients treated with clipping.[
It seems possible that a less-invasive approach, particularly in those patients with multiple comorbidities who are poor surgical candidates, may be reasonable. The risk of rebleeding and recanalization, which are prominent in younger patients, may be less important in elderly patients. Coupled with the fact that older patients have a higher risk of adverse outcomes with surgical treatment compared with endovascular treatment,[
Between April 2006 and December 2010, 162 patients with 183 intracranial aneurysms were treated in our hospital by means of an endovascular approach. Among them, 51 patients (31.5%) with a ruptured aneurysm were aged 70 years or older. These included 34 females (67%) and 17 males (33%), with a mean age of 74 years (range, 70-91 years).
All patients presented with SAH and were classified according to the Hunt and Hess (HH) scale . Seven patients (14%) were assigned to grade I or II, 30 (58%) to grade III, 12 to (24%) grade IV, and 2 (4%) to grade V [
Therapeutic alternatives were discussed by the neurosurgical and neurointerventional teams. The indications for endovascular therapy in our patient group mainly concerned the anticipated surgical difficulties due to the age of the patients and/or the location of their aneurysms. In all patients, embolization was performed within 72 after initial bleeding.
Endovascular treatment was performed under general anesthesia and with systemic heparinization. The adequacy of systemic anticoagulation was monitored by frequent measurements of the activated clotting time (ACT). A baseline ACT was obtained before a bolus administration of heparin (50 IU/kg body weight) and hourly thereafter. The bolus was followed by a continuous infusion (1000 IU/h) with the purpose of doubling the baseline ACT. In most cases, systemic heparinization was prolonged for 24 hafter the procedure. One patient demonstrated an aneurysm perforation for which heparinization was immediately reversed with protamine sulfate. All patients were treated by selective embolization with detachable coils. In six cases (12%) with an unfavorable neck-to-sac ratio, the adjunctive techniques[
Patients underwent angiography to document aneurysm obliteration. The angiographic results were classified as complete occlusion (no contrast material filling the aneurysmal sac), neck remnant (residual contrast material filling the aneurysmal neck), and body filling (residual contrast material filling the aneurysmal body). A senior neurointerventionalist recorded the clinical course, including worsening of symptoms and death. The clinical outcome was graded according to a modified Glasgow Outcome Scale (GOS)[
Selective embolization was successful in all patients and resulted in 32 (62.7%) complete occlusions, 15 (29.4%) neck remnants, and 4 (7.9%) body fillings [
For patients with SAH who underwent surgery, there were trends toward decreases in the case fatality rate and in the incidence of permanent symptomatic vasospasm. Since their introduction, endovascular technologies have evolved into one of the most important management options for intracranial aneurysms, and the techniques have been shown to be generally safe and effective.[
The largest prospective clinical trial to date comparing coiling and surgical clipping was the ISAT.[
Other series of coil embolization studies in elderly patients in the literature have included 68 patients reported by Lubicz et al.,[
By regrading the re-rupture risk, Cai et al.[
The procedure used for the endovascular coiling of intracranial aneurysm has been described in the literature. However, specific situations may be encountered in elderly people. The tortuosity or stenosis of the femoral and/or supra-aortic vessels may limit intracranial arterial access. In our series, four patients (7.8%) could not be treated successfully via the femoral approach: The carotid and/or the femoral artery had a tortuous course that prevented safe catheterization of the aneurysm with a microcatheter. Common carotid artery punctures were performed to allow for better catheter pushability and stability. Endovascular treatment was performed with heparinization, and the common carotid artery was compressed for 15 min at the end of the puncture to prevent any local complications at the puncture site.
Procedural complications may occur during endovascular coiling of intracranial aneurysms, and are mostly of thromboembolic and hemorrhagic origin. Sedat et al.[
Sedat et al.[
Although early embolization of patients with low HH grades (I-III) is now generally accepted, the optimal care of those with high HH grades (IV and V) remains controversial. An endovascular series in patients of any age with HH grades of IV of V had a mortality rate of 59%.[
Endovascular treatment of ruptured intracranial aneurysms has been accepted as an alternative to surgical clipping, but information about its feasibility and long-term results in the elderly patients is limited. Coil embolization of ruptured intracranial aneurysms in patients 70 years of age or older is effective and presents rebleeding. However, the morbidity and mortality rates are higher in patients with high HH grades. This finding suggests that the timing of treatment should be based on the patient's initial clinical status.
1. Barker FG, Amin-Hanjani S, Butler WE, Hoh BL, Rabinov JD, Pryor JC. Age-dependent differences in short-term outcome after surgical endovascular treatment of unruptured intracranial aneurysms in the United States, 1996-2000. Neurosurgery. 2004. 54: 18-30
2. Benitez RP, Silva MT, Klem J, Veznedaroglu E, Rosenwasser RH. Endovascular occlusion of wide-necked aneurysms with a new intracranial microstent (Neuroform) and detachable coils. Neurosurgery. 2004. 54: 1359-68
3. Cai Y, Spelle L, Wang H, Piotin M, Mounayer C, Vanzin JR. Endovascular treatment of intracranial aneurysms in the elderly: Single-center experience in 63 consecutive patients. Neurosurgery. 2005. 57: 1096-102
4. Camp A, Ramzi N, Molneux AJ, Summers PE, Kerr RS, Sneade M. Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT). Stroke. 2007. 38: 1538-44
5. Cottier JP1, Pasco A, Gallas S, Gabrillargues J, Cognard C, Drouineau J. Utility of balloon-assisted Guglielimi detachable coiling in the treatment of 49 cerebral aneurysms: A retrospective, multicenter stury. AJNR Am J Neuroradiol. 2001. 51:
6. Gonzalez N, Murayama Y, Nien YL, Martin N, Frazee J, Duckwiler G. Treatment of unruptured aneurysms with GDCs: Clinical experience with 247 aneurysms. AJNR Am J Neuroradiol. 25: 577-83
7. Guglielmi G, Vinuela F, Duckwiler G, Dion J, Lylyk P, Berenstein A. Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically deachable coils. J Neurosurg. 1992. 77: 515-24
8. Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975. 1: 480-4
9. Kaminogo M, Yonekura M, Shibata S. Incidence and outcome of multiple intracranial aneurysms in a defined population. Stroke. 2003. 34: 16-21
10. Kassell NF1, Torner JC, Haley EC, Jane JA, Adams HP, Kongable GL. The international cooperative study on the timing of aneurysm surgery, I: Overall management resuts. J Neurosurg. 1990. 73: 18-36
11. Kazumata K, Kamiyama H, Ishikawa T. Reference table predicting the outcome of subarachnoid hemorrhage in the elderly, stratified by age. J Stroke Cerebrovasc Dis. 2006. 15: 14-7
12. Lanzino G1, Kassell NF, Germanson TP, Kongable GL, Truskowski LL, Torner JC. Age and outcome after aneurysmal subarachnoid hemorrhage: Why do older patients fare worst?. J Neurosurg. 1996. 85: 410-8
13. Lubicz B, Leclerc X, Gauvrit JY, Lejeune JP, Pruvo JP. Endovascular treatment of ruptured intracranial aneurysms in elderly people. AJNR Am J Neuroradiol. 2004. 25: 592-5
14. Lylyk P, Ferrario A, Pasbon B, Miranda C, Doroszuk G. Buenos Aires experience with the Neuroform self-expanding stent for the treatment of tntracranial aneurysms. J Neurosurg. 2005. 102: 235-41
15. Mitchell P, Kerr R, Mendelow AD, Molyneux A. Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the International Subarachnoid Aneurysm Trial?. J Neurosurg. 2008. 108: 437-42
16. Molyneux A1, Kerr R, Stratton I, Sandercock P, Clarke M. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomized trial. J Stroke Cerebrovasc Dis. 2002. 11: 304-14
17. Molyneux A1, Kerr R, Stratton I, Sandercock P, Clarke M. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomized trial. Lancet. 2002. 360: 1267-74
18. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical slipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomized comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005. 366: 809-17
19. Moret J, Cognard C, Weill A, Castaings L, Rey A. The remodeling technique in the treatment of wide neck intracranial aneurysms: Angiographic results and clinical follow-up in 56 cases. Interv Neuroradiol. 1997. 3: 21-35
20. Murayama Y, Nien YL, Duckwiler G, Gobin YP, Jahan R, Frazee J. Guglielmi detachable coil embolization of cerebral aneurysms: 11 years’ experience. J Neurosurg. 2003. 98: 959-66
21. Sedat J, Dib M, Lonjon M, Litrico S, Von Langsdorf D, Fontaine D. Endovascular treatment of ruptured intracranial aneurysms in patients aged 65 years and older: Follow-up of 52 patients after 1 year. Stroke. 2002. 33: 2620-5
22. Stachniak JB, Layon AJ, Day AL, Gallagher TJ. Craniotomy for intracranial aneurysm and subarachnoid hemorrhage. Stroke. 1996. 27: 276-81
23. Taschner CA, Leclerc X, Rachdi H, Barros AM, Pruvo JP. Matrix detachable coils for the endovascular treatment of intracranial aneurysms: Analysis of early angiographic and clinical outcomes. Stroke. 2005. 36: 2176-80
24. Weir RU, Marcellus ML, Do HM, Steinberg GK, Marks MP. Aneurysmal subarachnoid hemorrhage in patients with Hunt and Hess grade 4 or 5: Treatment using Guglielmi detachable coil system. AJNR Am J Neuroradiol. 2003. 24: 585-90
25. Wiebers DO, Whisnant JP, Huston J, Meissner I, Brown RD, Piepgras DG. International study of Unruptured Intracranial Aneurysms Investigators. Unruputured intracranial aneurysms: Natural history, clinical outcome, and risk of surgical and endovascular treatment. Lancet. 2003. 362: 103-10
26. Yamashita K, Kashiwagi S, Kato S, Takasago T, Ito H. Cerebral aneurysms in the elderly in Yamaguchi, Japan: Analysis of the Yamaguchi Data Bank of cerebral aneurysm from 1985 to 1995. Stroke. 1998. 28: 1926-31