Rationale and Objectives
The incidence of aneurysmal subarachnoid hemorrhage is increasing in the elderly as life expectancy increases. The purpose of this study was to analyze whether ultra-early coiling of ruptured intracranial aneurysms improves clinical outcomes in elderly patients.
Materials and Methods
Records of patients (aged ≥ 70 years) with aneurysmal subarachnoid hemorrhage treated with endovascular coiling were retrieved. Patients were classified into two groups: group A (patients coiled within 24 hours of subarachnoid hemorrhage) and group B (patients coiled ≥24 hours after subarachnoid hemorrhage). For each group, patient demographics, World Federation of Neurological Surgeons clinical grade, Fisher computed tomographic grade, aneurysm characteristics, and clinical outcomes were recorded. Outcomes were measured using the Modified Rankin Scale at 6 months.
Results
Fifty-six patients were coiled within 24 hours of subarachnoid hemorrhage (group A) and 40 patients at ≥24 hours after subarachnoid hemorrhage (group B). Groups A and B had similar clinical and angiographic characteristics. Clinical outcomes showed that a total of 87.5% of patient (49 of 56) in group A were independent (Modified Rankin Scale score 0–2) compared with 70.0% of patients (28 of 40) in group B ( P = .034). In multivariate logistic regression analysis, ultra-early coiling (odds ratio, 3.860; 95% confidence interval, 1.125–13.249; P = .032) proved to be an independent predictor of better clinical outcome (Modified Rankin Scale score 0–2).
Conclusions
Ultra-early (<24 hours after subarachnoid hemorrhage) coiling of ruptured aneurysms was marginally associated with improved clinical outcomes compared to coiling at ≥24 hours in elderly patients. Larger, prospective studies are required to adequately assess outcome differences between these two groups.
Subarachnoid hemorrhage (SAH) is the most common presentation of intracranial aneurysms. Brain aneurysms occur at a rate of 7.8 per 100,000 among people aged ≥ 70 years, and epidemiologic studies have shown a frequency of SAH threefold to fourfold higher in elderly patients, and as life expectancy increases, the incidence of SAH continues to increase . The role of endovascular therapy in the treatment of intracranial aneurysms has evolved rapidly, initially as an alternative to surgical treatment for patients in poor general health or with unclippable aneurysms but more recently as first-line treatment . Retrospective analyses have shown evidence that coiling is associated with less risk for poor outcomes, shorter hospital stays, and shorter recovery periods compared to surgery . Coiling is also efficient because of the significantly reduced procedure time and reduced stay in the intensive care unit .
Older age, combined with a higher frequency of comorbidities, makes many of these patients poor surgical candidates. Medical complications that can occur with anesthesia and surgical treatment can lead to worse outcomes in patients harboring intracranial aneurysms. Endovascular coil embolization represents a generally better tolerated alternative to surgical clipping .
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Materials and methods
Patients
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Diagnosis and Definitions
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Endovascular Procedures
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Data Collection
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Missing Data
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Statistical Analysis
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Results
Patients and Aneurysms
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Table 1
Clinical and Angiographic Characteristics, Treatment Modality, and Clinical Outcomes in Patients with SAH
Variable Group A ∗ Group B † P ( n = 56) ( n = 40) Sex .652 Female 32 (57.1%) 21 (52.5%) Male 24 (42.9%) 19 (47.5%) Age (y) 74.5 (70–85) 75.7 (70–89) .195 WFNS clinical grade .504 1–3 40 (71.4%) 31 (77.5%) 4 or 5 16 (28.6%) 9 (22.5%) Fisher CT grade .752 1 or 2 34 (60.7%) 23 (57.5%) 3 or 4 22 (39.3%) 17 (42.5%) Location of aneurysm .625 Anterior circulation 47 (83.9%) 35 (87.5%) Posterior circulation 9 (16.1%) 5 (12.5%) Aneurysm size (mm) 9.5 ± 3.6 10.3 ± 3.1 .145 Modality of treatment .625 Coiling alone 43 (76.8%) 28 (70.0%) Stent-assisted coiling 6 (10.7%) 7 (17.5%) Remodeling 7 (12.5%) 5 (12.5%) Clinical outcome at 6 mo .034 mRS score 0–2 49 (87.5%) 28 (70.0%) mRS score 3–6 7 (12.5%) 12 (30.0%)
CT, computed tomographic; mRS, Modified Rankin Scale; SAH, subarachnoid hemorrhage; WFNS, World Federation of Neurological Surgeons.
Data are expressed as number (percentage), as mean (range), or as mean ± standard deviation.
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Modalities of Endovascular Treatment
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Comparability of the Study Groups
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Effects of Clinical Variables on Clinical Outcomes (mRS Score) at 6 Months
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Table 2
Univariate Statistical Models Testing the Effects of Clinical Variables on Clinical Outcomes
Variable mRS Score 0–2 mRS Score 3–6P ( n = 77) ( n = 19) Age (y) 74.3 77.8 .009 ∗ Sex .196 † Female 40 (75.5%) 13 (24.5%) Male 37 (86.0%) 6 (14.0%) WFNS clinical grade .007 ‡ 1–3 62 (87.3%) 9 (12.7%) 4 or 5 15 (60.0%) 10 (40.0%) Fisher CT grade .006 † 1 or 2 51 (89.5%) 6 (10.5%) 3 or 4 26 (66.7%) 13 (33.3%) Aneurysm size (mm) 9.7 ± 3.3 10.2 ± 3.7 .701 § Location .143 ‡ Anterior circulation 68 (82.9%) 14 (17.1%) Posterior circulation 9 (64.3%) 5 (35.7%) Modality of treatment .772 ‡ Coiling alone 56 (78.9%) 15 (21.1%) Stent-assisted coiling and remodeling 21 (84.0%) 4 (16.0%) Treatment timing (h) .034 † <24 49 (87.5%) 7 (12.5%) ≥24 28 (70.0%) 12 (30.0%)
CT, computed tomographic; mRS, Modified Rankin Scale; WFNS, World Federation of Neurological Surgeons.
Data are expressed as mean ± standard deviation or as number (percentage).
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Multivariate Analysis
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Table 3
Multivariate Logistic Regression Model Testing Independent Variables Associated with Good Clinical Outcome (Modified Rankin Scale Score 0 to 2)
Variable Odds Ratio 95% Confidence Interval_P_ Age 1.215 1.056–1.398 .006 Low WFNS clinical grade (1–3) 6.218 1.784–21.668 .004 Ultra-early treatment (<24 h after SAH) 3.860 1.125–13.249 .032
SAH, subarachnoid hemorrhage; WFNS, World Federation of Neurological Surgeons.
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Discussion
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Conclusions
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