Key-words:
Aneurysm - clipping - octogenarian - unruptured intracranial aneurysms
Introduction
The number of elderly patients with unruptured cerebral aneurysms (UCAs) is increasing
with time in aging populations. The choice of the proper treatment method remains
inconclusive. Kwinta et al. did a study to evaluate the possible complications and
treatment outcome among 139 elderly patients of >65 years with UCAs. The mean age
was 69.01 years ± 3.60 standard deviation (SD). The most common aneurysm location
was the middle cerebral artery (MCA). The mean dome size was 8.36 ± 4.24 mm. Seventy-two
patients (55.97%) underwent aneurysm clipping and 39 (27.04%) coiling. Eighteen patients
(11.90%) required stent-assisted coiling and 4 (5.00%) had a single stent placement.
A total of 133 patients (95.71%) had good treatment outcomes (modified Rankin Scale
score 0–3, surgical 0.32 ± 1.03 vs. endovascular group 0.40 ± 1.12, P = 0.65). The
occlusion rate of aneurysms was evaluated based on digital subtraction angiogram (endovascular
group) or computed tomography (CT) angiogram (microsurgical group) results. Complete
or near-complete occlusion in the endovascular group was achieved in 83% directly
after treatment and in 89% at 6–12 months after procedure. The microsurgical group
presented 100% occlusion at follow-up. A total of 95.71% of patients presented a good
outcome in early observation and 94.96% in late follow-up. In clipping group, one
patient died 3 months after MCA aneurysm clipping and another patient presented with
motor aphasia after left MCA aneurysm clipping. These complications occurred as a
consequence of cerebral infarction. Despite the high prevalence of comorbidities in
the age group >65 years, the vast majority of patients in this series treated invasively
for UCAs presented with good treatment outcomes. Among elderly patients, modern microsurgical
as well as endovascular management of brain aneurysms in a high-volume center seems
to be a safe and effective method of treatment.[[1]]
Patients and Methods
A retrospective study was conducted involving all the cases of unruptured intracranial
saccular aneurysms operated surgically in elderly patients aged between 80 and 89
years. All the patients operated in Fujita Health University Bantane Hospital, Nagoya,
Aichi, Japan, between January 2017 and October 2019 were selected. The preoperative
neurological status was assessed using the Glasgow Coma Scale (GCS). The preoperative
diagnosis of the aneurysm was done using cerebral CT angiogram. The size of the aneurysm
was defined by the maximum diameter of the aneurysm. The risk factors and comorbidities
of the patients were noted. Patients underwent surgical clipping or bypass surgery
of aneurysms. Postoperative neurological status was assessed by postoperative GCS
score and by the presence or absence of the motor weakness of limbs.
Parameters analyzed
Age, sex, preoperative GCS score, history of hypertension, diabetes mellitus, smoking,
history of alcoholism, previous history of treatment for aneurysm, family history
of subarachnoid hemorrhage (SAH) or aneurysm in first-degree relatives, intake of
antiplatelet/anticoagulant medication, history of other comorbid diseases, number
of aneurysms, aneurysm location, aneurysm size, use of motor evoked potential (MEP),
postoperative GCS score, presence or absence of postoperative motor weakness of limbs,
postoperative complications occurring during the hospital stay, and duration of stay.
Statistical analysis
Data were collected in the Microsoft Excel sheet. Statistical analysis was done using
Epi Info software (Centers for Disease Control and Prevention, Atlanta, Georgia, United
States).
Results
Thirty-three unruptured intracranial saccular aneurysms were operated in 27 patients.
Two patients were operated two times at separate occasions for different aneurysms
during the study period and hence making a total of 29 surgeries. The age range was
80–88 years, with a mean of 82.4 years ± 2.64 SD, and there were 7 (24.1%) males and
22 (75.86%) females. All the patients had a preoperative GCS score of 15/15 without
any focal neurological deficit. The mean size (mm) of the aneurysms was 6.57 ± 4.04
SD, and the locations of the aneurysms are given in [[Table 1]]. There were 31 (93.94%) aneurysms in the anterior circulation and 2 (6.06%) aneurysms
in the posterior circulation. The comorbidities and risk factors are given in [[Table 2]]. Age, sex, risk factors, and comorbid diseases did not influence the outcome of
unruptured saccular aneurysm surgery in octogenarians.
Table 1: The locations of the unruptured intracranial aneurysms in octogenarians
Table 2: Comorbidities and risk factors in octogenarians with unruptured intracranial aneurysms
MEP was used in 14 cases. Clipping was done in 32 aneurysms. One case of posterior
inferior cerebellar artery (PICA) aneurysm underwent occipital artery to PICA bypass
surgery. In postoperative period, seven patients developed chronic subdural hematoma
(CSDH), all of which were irrigated. One case of ophthalmic artery aneurysm developed
extradural hematoma (EDH) in postoperative day 1 and underwent EDH evacuation. One
case of MCA aneurysm developed meningitis which was managed conservatively. One case
of PICA aneurysm developed lower cranial nerve palsy following occipital artery-PICA
bypass, which was recovered in postoperative period. All the patients were discharged
with GCS 15/15 without motor weakness of the limbs. Although detailed Mini-Mental
State Examination (MMSE) was not done, a patient's gross cognitive function remained
the same as that of the preoperative status. The mean duration of stay was 16.62 days
± 9.98 SD.
Discussion
Sorenson et al., in their study on UCAs, found that patients over 80 years had a significantly
higher incidence of hypertension and a significantly lower incidence of smoking history
and familial aneurysm history. UCAs >7 mm carry a nonnegligible risk of rupture of
3.2% per patient-year in patients over the age of 80 years.[[2]]
Ikawa et al. did a study to clarify the risk factors of treatment for UCAs in elderly
patients by comparing the morbidity at discharge between surgical clipping and endovascular
coiling in nonelderly (<65 years) and elderly (≥65 years) patients based on a national
database in Japan. Risk factors for morbidity at discharge were basilar artery aneurysm
compared with internal carotid artery (ICA), diabetes mellitus, antiplatelet drug,
and anticoagulation drug; however, the highest hospital volume compared with lowest
was an inverse risk factor in both age groups. Anterior communicating artery (Acom)
aneurysm and MCA aneurysm compared with ICA were significantly inverse risks in the
elderly group.[[3]]
Juvela et al. investigated the long-term natural history of UCAs and risk factors
predictive of subsequent rupture. A total of 142 patients with 181 UCAs diagnosed
between 1956 and 1978, when these were not treated, were followed up until death or
SAH or until 2011–2012. They concluded that cigarette smoking, Acom aneurysm, patient's
age inversely, and aneurysm diameter ≥7 mm independently predicted the subsequent
aneurysm rupture.[[4]]
The comparative effectiveness of clipping and coiling for UCAs remains an issue of
debate and has not been studied in clinical trials. Bekelis et al. performed a cohort
study for elderly patients who had treatment for UCAs between 2007 and 2012. During
the study period, 8705 patients underwent treatment for UCAs. Of these patients, 29.7%
had surgical clipping and 70.3% had endovascular coiling. Instrumental variable analysis
demonstrated no difference between coiling and clipping in 1-year postoperative mortality
or 90-day readmission rate. Clipping was associated with a higher rate of discharge
to a rehabilitation facility and a longer length of stay.[[5]]
Mori et al. compared the complications and outcomes after keyhole clipping between
nonfrail elderly patients (≥70 years) and nonelderly patients. Keyhole clipping (either
supraorbital or pterional) was performed to treat 260 cases of relatively small (≤10
mm) anterior circulation UCAs. There were 62 cases in the nonfrail elderly group (mean
age: 72.9 ± 2.6 years SD) and 198 cases in the nonelderly group (mean age: 59.5 ±
7.6 years). The incidence of CSDH was not significantly higher in the elderly group
than in the nonelderly group (8.1% vs. 4.5%, P = 0.332); rates of other complications
including stroke and epilepsy were not significantly different. Lacunar infarction
occurred in 3.2% of the elderly group and 3.0% of the nonelderly group. No patient
in the elderly group required retreatment or demonstrated the recurrence of clipped
aneurysms. The MMSE score at 3 months significantly improved in the nonelderly group
but did not change in the elderly group. The Beck Depression Inventory and Hamilton
Rating Scale for Depression at 3 months were significantly improved in both the groups.
No patient died in either group. The morbidity at 3 months and 1 year in the elderly
group (1.6% and 4.8%, respectively) was not significantly different from that in the
nonelderly group (2.0% and 1.5%, respectively). They concluded that keyhole clipping
for nonfrail elderly patients (≥70 years) with relatively small anterior circulation
UCAs did not significantly increase the complication, mortality, or morbidity rate;
hospitalization period; or aneurysm recurrence compared with nonelderly patients,
and it was associated with improvement in anxiety and depression.[[6]]
Silva et al. did a study to analyze the outcomes of UCAs in elderly patients (≥65
years of age) after coiling or clipping. These patients had a significantly higher
prevalence of various comorbidities and incidence of complications. Elderly patients
who received clipping experienced a 10.3% incidence rate of perioperative stroke,
whereas their coiling counterparts experienced this complication at a rate of 3.5%.
Elderly patients treated with clipping had greater odds of perioperative acute renal
failure, whereas their coiling counterparts had greater odds of perioperative deep
venous thrombosis and pulmonary embolism.[[7]]
An increasing number of UCAs have been discovered in elderly patients in recent years,
but the optimal treatment strategy for these patients remains controversial. Yang
et al. did a retrospective review in elderly patients (≥70 years old) who harbored
UCAs and treated by conservative observation, microsurgical clipping, or endovascular
coiling between January 2009 and December 2014. A total of 141 consecutive elderly
patients with 166 UCAs were enrolled in the study. Seventy-nine aneurysms were treated
with coiling, and 14 aneurysms were treated with clipping. The remaining 73 aneurysms
were placed under conservative observation. There was no significant difference of
the modified Rankin Scale in patients with UCAs treated by different methods. Multivariate
analysis showed that age and aneurysm size are independent risk factors for unfavorable
outcome of UCAs in the elderly. Patient age and aneurysm size were also significantly
associated with unfavorable outcome of UCAs managed with observation initially. Their
results indicated that endovascular coil embolization and clipping were both safe
and effective treatment methods for UCAs in the elderly. Aggressive treatment for
UCAs in elderly patients with risk factors of aneurysm rupture should be considered
positively.[[8]]
Brinjikji et al. applied the United States National Inpatient Sample data from 2001
to 2008 to determine and compare outcomes of coiling and clipping of UCAs in the elderly.
They found that 140 (0.5%) patients aged 80 years or older underwent clipping of UCAs.
33.5% (47/140) of clipped patients were discharged to long-term facilities. The mortality
rate was 21.4% (30/140), and the mean length of stay was 12.7 (SD, 23.0) days.[[9]]
Ansari et al. did a retrospective analysis of all patients with UCAs operated between
September 2014 and December 2016. A total of 247 patients underwent craniotomies for
clipping of aneurysms. CSDH developed in 22 (8.9%) patients in the postoperative period.[[10]] In an author's cases also, CSDH is the most common complication. It is mainly due
to the atrophy of the brain.
Hoh et al. obtained the Nationwide Inpatient Sample from the Healthcare Cost and Utilization
Project, Agency for Healthcare Research and Quality. Hospitalizations for clipping
or coiling of ruptured and UCA from 2002 to 2006 were identified. There were 4513
patients who underwent clipping of UCAs. Their mean age was 53.3 years ± 11.6 SD,
and the length of hospital stay was 1–182 days (9.0 days ± 10.4 SD). For unruptured
aneurysm patients, after adjusting for patient-specific and hospital-specific factors,
clipping compared to coiling was associated with significantly longer length of stay
(P < 0.0001).[[11]] In our study, the mean age was 82.4 years ± 2.64 SD, and the mean duration of stay
was 16.62 days ± 9.98 SD. The length of stay in octogenarians of an author's study
is more than the general population.
In an author's study, all the patients were recovered with a GCS score of 15/15 without
weakness of limbs. The main reason for the good clinical outcome is that these cases
are nonfrail octogenarians and are operated in a high-volume tertiary care neurovascular
center in Japan. The small number of cases and lack of long-term follow-up are the
limitations of the study. The authors recommend that the advanced age alone should
not be considered for preferring coiling against clipping in octogenarians, who are
otherwise fit to undergo surgery.
Conclusion
Although octogenarians are at risk for open surgery for intracranial aneurysm, unruptured
saccular aneurysms have got a good result in the tertiary care neurovascular center
in Japan. Hence, advanced age alone should not be considered for preferring coiling
against clipping. Octogenarians are more prone to developing postoperative CSDH due
to atrophy of the brain.
