An Official publication of The Asian Congress of Neurological Surgeons (AsianCNS)

Search Article
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Advertise Subscribe Contacts Login  Facebook Tweeter
  Users Online: 794 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  

   Table of Contents      
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 730-736

Surgical management of unruptured cerebral aneurysms in the elderly: An institution experience


1 Department of Neurosurgery, Ali Ait Idir Hospital and Medical School of Algiers - Algiers University 1, Algiers, Algeria
2 Department of Neurosurgery, Institute of Neurosurgery, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
3 Department of Neurosurgery, Banbutane Hotkukai Hospital, Fujita Health University, Toyoake, Nagoya, Aichi Prefecture, Japan

Date of Web Publication2-Aug-2019

Correspondence Address:
Abderrahmane Cheikh
Department of Neurosurgery, Ali Ait Idir Hospital, Algiers
Algeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajns.AJNS_233_18

Rights and Permissions
  Abstract 


Background and Purpose: The elderly population is increasing in the world, especially in developed countries. The gain in life expectancy is remarkable in Japan, consequently incidence of aneurysms increases in this population. The purpose of this study is to evaluate the surgical treatment and outcome of patients aged more than 75 years treated for unruptured intracranial aneurysms. Patients and Methods: We conducted a retrospective study for unruptured cerebral aneurysms operated between September 2014 and August 31, 2018, in Fujita Health University, Banbuntane Hotokukai Hospital, for people aged more than 75 years. A demographic study was done. We also studied aneurysm location, aneurysm size, outcome, duration of stay, and complications. Results: About 61 patients aged more than 75 years were operated in 4 years, comprising 12 males and 45 females. The mean age was 79.32 ± 3.29 years. Mean size of the aneurysm was 6.22 ± 3.28. Aneurysm location (P = 0.0037), associated risk factors (P = 0.006), and association of hypertension and diabetes (P = 0.0362) influence outcome. Length of stay is directly correlated with outcome (P = 0.009). Conclusions: Elder patients with hypertension and diabetes or associated risk factors having a posterior circulation aneurysm have a poor diagnosis.

Keywords: Elderly, outcome, surgical treatment, unruptured cerebral aneurysms


How to cite this article:
Cheikh A, Kasinathan S, Yasuhiro Y, Kawase T, Kato Y. Surgical management of unruptured cerebral aneurysms in the elderly: An institution experience. Asian J Neurosurg 2019;14:730-6

How to cite this URL:
Cheikh A, Kasinathan S, Yasuhiro Y, Kawase T, Kato Y. Surgical management of unruptured cerebral aneurysms in the elderly: An institution experience. Asian J Neurosurg [serial online] 2019 [cited 2019 Nov 15];14:730-6. Available from: http://www.asianjns.org/text.asp?2019/14/3/730/252950




  Introduction Top


The remarkable gain of life expectancy in developed countries is one of the most important accomplishments in the 20th century.[1] Most babies born since 2000 in France, Germany, Italy, the UK, the USA, Canada, and Japan will celebrate their 100th anniversary.[1]

This is expected to change the epidemiological aspect of many diseases, including their incidences.

[2] Aneurysm incidence is high in Japan, and the management and outcome of aneurysms have improved as a consequence of the development of surgery and multimodality treatment. Unruptured intracranial aneurysms carry a risk of rupture which can lead to intracranial stroke, subarachnoid hemorrhage, coma, or death.[3] Elder age is considered as one of the poor prognosis factors for the management of intracranial aneurysms.[3] Management of unruptured intracranial aneurysms in the elderly remains controversial and challenging in cerebrovascular disease because of greater rigidity and turtosity of the arteries, concomitant disease and life expectancy.[4] Management strategies include surgery, endovascular of conservative management with periodic imaging.[5],[6],[7]

No consensus has been established till now for the geriatric population; the aim of this study is to show the safety of surgical treatment for Unruptured cerebral aneurysms (UCA) in the elderly.


  Patients and Methods Top


This study constitutes a retrospective study and analysis for the outcome of patients aged more than 75 years operated for unruptured intracranial aneurysms in Fujita Health University, Banbuntane Hotokukai Hospital, between September 2014 and August 31, 2018. In all cases, the aneurysm was diagnosed by intra-arterial or computed tomography angiography.

Criteria for exclusion were when patients were 75 years old or less.

From a total of 458 patient operated in the same period, 61 patients (13%) were older than 75 years. Five patients of them presented multiple aneurysms.

All the patients of our study underwent open surgery.

The outcome was evaluated in the postoperative period using the modified Rankin Scale (mRS).

We collected and analyzed the following variables:

  • The demographic data such as sex and age. Patients were divided into three groups regarding their age (76–80, 81–85, and >85 years)
  • Risk factors such as hypertension, diabetes mellitus, kidney disease, smoking, chronic cardiac disease, and kidney disease
  • Aneurysm characteristics such as size and location where also studied. For a better analysis, three groups were established for aneurysms size: <7 mm, 7-9 mm, 10-25 mm.
  • Complications using the mRS.


Statistical study was performed using Epi Info 7 software (Centers for Disease Control and Prevention CDC, Atlanta, Georgia, US); Continuous variables were presented as mean ± standard deviation. All variables were statistically compared with the outcome which is represented by mRS. The univariate and multivariate analysis was done using the same software.

P < 0.05 was considered statistically significant.

Clinical data and outcome results were provided by the senior author.


  Results Top


Demographic study

A total of 61 patients older than 75 years operated for unruptured intracranial aneurysms were 49 females and 12 males. They were aged between 76 and 88 years. Mean age was 79.32 ± 3.29 years [Table 1].
Table 1: Demographic analysis of our series

Click here to view


Risk factors

Hypertension was the main risk factors in our study, it was seen in 46 cases followed by diabetes mellitus in 7 cases, and chronic cardiac disease was seen in 6 cases and kidney disease in 2 cases.

Only one patient in our current study was a smoker.

In several cases, more than one risk factor has been seen.

Out of 61 patients, 34 patients had only one risk factor (hypertension, diabetes, chronic kidney disease, cardiac disease, and smoking) [Chart 1]. Eleven patients had two risk factors and only two patients had three risk factors.



Aneurysm study

Location

Fifty-six patients (91.80%) had anterior circulation aneurysms, while 6 patients only (9.67%) presented aneurysms in the posterior circulation.

Five patients presented multiple aneurysms in anterior circulation.

The most common site for anterior circulation aneurysms was the middle cerebral artery (MCA) (25 cases, 40.98%), followed by the internal carotid artery (IC) (22 cases, 36.06%), the anterior communicating artery (Acom) (7 cases, 11.47%), and anterior cerebral artery (6 cases, 9.83%).

Posterior circulation aneurysms were in Vertebral Artery (VA) - Posterior Inferior Cerebellar Artery (PICA) Junction (VA-PICA) in 4 cases. Two patients presented a basilar top aneurysm [Chart 2].



Size of aneurysms

Size of aneurysms ranges from 2 to 20 mm. Mean size was 6.22 ± 3.28 mm. Out of 66 aneurysms for the 61 patients, 43 aneurysms were <7 mm, 15 aneurysms had a size between 7 and 9 mm, and 8 aneurysms were more than 10 mm [Chart 3].



Multiple aneurysms

Multiple aneurysms were as follows:

  • Double MCA aneurysm
  • IC tip aneurysm associated with an MCA aneurysm
  • An ICPCom Aneurysm was associated with an IC-anterior choroidal artery (IC-Ach) junction aneurysm
  • Acom aneurysm was associated to other localization in two cases: One case of IC-Ach, and one other case of ICPC.


Management strategies

All the patients of our series underwent direct surgery. Two aneurysms were wrapped, one patient had occipital artery-posterior inferior cerebellar artery bypass. All the other aneurysms (63) were treated by microsurgical clipping.

Motor evoked potential (MEP) was used for 22 patients; only one patient had modification of wave amplitude but without any symptoms.

Outcome-modified Rankin Scale

The outcome was excellent for most of the patients. mRS at 0 in 98.36% (60 cases) signifies that there is no complication. Only one patient had a mRS at 3. This patient who was operated for a basilar artery top aneurysm presented a postoperative hydrocephalus treated by shunt.

No other patient had a complication in our series.

Length of stay

The duration of stay for the patients of our series ranges from 7 to 98 days, with a mean period of duration of 12.91 days with a standard deviation of 12.32 days.

Twenty-nine patients (47.54%) spent between 10 and 15 days after surgery, 21 patients (34.42%) <10 days, and 8 patients (13.11%) have been in the hospital for a period between 15 and 20 days after surgery.

Only 3 patients (4.91%) have been for more than 20 days in the hospital after surgery [Chart 4].



Statistical analysis [Table 2]
Table 2: Statistical analysis of our series

Click here to view


Analysis of various parameters with outcome was not statistically significant for each variable individually. The association of all variables influences the outcome; the study was statistically significant with a P = 0.0377.

Linear regression studying the location of the aneurysm with the outcome compared with other input variables was statistically significant (P = 0.0037).

Risk factors are not individually affecting the outcome. Associated risk factors affect the outcome. Multianalysis of variables for risk factors associated with the outcome is significant (P = 0.006).

The association of hypertension and diabetes mellitus influences the outcome in elderly patients (P = 0.0362).

Length of stay in hospital is directly correlated with the outcome (P = 0.009). Statistical analysis is shown in [Table 2].


  Discussion Top


Life expectancy is lengthening almost linearly in most developed countries, with no sign of deceleration. The probability of dying for men aged 80 years in the early 1950s was about 14%. Actually, the probability of surviving from 80 to 90 exceeds 50% for women in Japan which is the country with the best chances of survival. Large improvements in life expectancy were also reported in Spain, the USA, Italy, and Finland. The increase of the geriatric population implies the change of the epidemiologic data notably the incidence of all the pathologies.[1],[8]

Consequently, the incidence of cerebrovascular disease and intracranial aneurysms is increasing in elderly population which constitutes to us neurosurgeons a real challenge.

Arai et al. reported that of the total Japanese population, the percentage of people aged ≥65 years reached 25% and those aged ≥75 years accounted for 12.3% as of 2013, and this is expected to reach 26.9% in 2060.[9]

The definition of the elderly population is not universal; it changes from one population to another, the reason for which we find in the literature different ages defining the elderly population. Thus, in previous publications, the elderly population was defined as aged more than 60,[7],[10] 65,[3],[4],[11],[12] 70[13],[14] or 75[15] depending on the author and the country of the study.

In our current study, all patients are elder than 75 years, with a mean age of 79.32 ± 3.29 years [Table 3].
Table 3: Summary of the literature review for elderly patients with unruptured cerebral aneurysms

Click here to view


This population represents 13% from all the patients operated for intracerebral aneurysms Department of Neurosurgery, Banbutane Hotkukai Hospital, Fujita Health University, Toyoake, Nagoya, during the same period, and this percentage is similar to the literature findings; in Japan, approximately 13% of the population is older than 75 years.[9]

The natural history of unruptured cranial aneurysms was reported in several publications,[11],[16],[17] the International Study of Unruptured Intracranial Aneurysms defined the size (7 mm or larger) and location (tip of basilar arteries and IC-posterior communicating arteries [IC-PComA]) as significant risk factors for rupture.[18] Unruptured cranial aneurysm study in Japan showed that the annual rate of rupture was 0.95%.[16]

Warmer et al. reported that age older than 60, female gender, and Japanese or Finnish descent are important risk factors of rupture. In addition, smoking increased the risk of rupture.[19]

Several studies compared the endovascular treatment with microsurgical clipping for elderly patients in ruptured intracranial aneurysms, but there are conflicting opinions on when there is appropriate to operate by direct surgery and endovascular surgery rather than continuing conservative management with observation for unruptured intracranial aneurysms after taking in consideration risk factors of rupture.[19],[20],[12]

Nevertheless, the therapeutic attitude varies from a country to another according to the educational and economic findings. Differences in the management of cerebral aneurysms globally are significant. North Americans and Europeans show similar ratios of coiling to clipping, whereas the rest of the world shows preponderance for clipping.[21] Patients may decrease their quality of life if knowing they are living with an unruptured aneurysm.[22]

Bekelis et al., in a cohort study which compared 8705 Medicare patients who underwent treatment for UCA for which 2585 (29.7%) underwent surgical clipping and 6120 (70.3%) underwent endovascular coiling, concluded that there was only a little difference in 1-year survival between patients undergoing elective coiling or clipping of UCA.[12] Length of stay and cost of treatment for microsurgical management are higher than endovascular procedures.[12]

In our actual study, length of stay was directly correlated with outcome (P = 0.009); the mean duration of stay was 12.91 ± 12.32 days.

Factors influencing the outcome in our series are aneurysm location and association of risk factors. Aged patients with posterior circulation aneurysm having hypertension and diabetes mellitus have a poor prognosis.

Patients with poor outcome spend more time in the rehabilitation department.[12]

Indication for treatment of unruptured cranial aneurysms in the elderly should be taken individually with consideration of comorbidities and a good knowledge about the natural history of unruptured intracranial aneurysms.

In our series, we report a very low rate of complication which is of 1.67% (only one patient) for the whole series, with an excellent outcome for all the other patients.


  Conclusions Top


Accelerating aging of the population in developed countries has a great impact on the incidence and prevalence of several pathologies. Elder age is an important risk factor for rupture of UCA. In our current study, associated risk factors, the association of hypertension and diabetes mellitus, and posterior circulation aneurysms are poor prognosis factors for surgical management in the elderly. Length of stay after microsurgical clipping is directly correlated with the outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: The challenges ahead. Lancet 2009;374:1196-208.  Back to cited text no. 1
    
2.
Ohkuma H, Shimamura N, Naraoka M, Katagai T. Aneurysmal subarachnoid hemorrhage in the elderly over age 75: A systematic review. Neurol Med Chir (Tokyo) 2017;57:575-83.  Back to cited text no. 2
    
3.
Silva NA, Shao B, Sylvester MJ, Eloy JA, Gandhi CD. Unruptured aneurysms in the elderly: Perioperative outcomes and cost analysis of endovascular coiling and surgical clipping. Neurosurg Focus 2018;44:E4.  Back to cited text no. 3
    
4.
Ma X, Yang Y, Zhou Y, Jia W. Endovascular treatment of ruptured intracranial aneurysms in elderly patients: Clinical features and treatment outcome. Neurosurg Rev 2018. Available from: https://doi.org/10.1007/s10143-018-1031-4.  Back to cited text no. 4
    
5.
Xin C, Zhang J, Li Z, Xiong Z, Yang B, Wu X, et al. Treatment of giant cavernous aneurysm in an elderly patient via extracranial-intracranial saphenous vein bypass graft in a hybrid operating room: A case report. Medicine (Baltimore) 2018;97:e0295.  Back to cited text no. 5
    
6.
Crobeddu E, Panciani PP, Garbossa D, Pilloni G, Fornaro R, Ronchetti G, et al. Cerebrovascular diseases in the elderly: The challenge of multiple aneurysms. Int J Neurosci 2014;124:573-6.  Back to cited text no. 6
    
7.
Zheng K, Zhao B, Tan XX, Li ZQ, Xiong Y, Zhong M, et al. Comparison of aggressive surgical treatment and palliative treatment in elderly patients with poor-grade intracranial aneurysmal subarachnoid hemorrhage. Biomed Res Int 2018;2018:5818937.  Back to cited text no. 7
    
8.
Lunenfeld B, Stratton P. The clinical consequences of an ageing world and preventive strategies. Best Pract Res Clin Obstet Gynaecol 2013;27:643-59.  Back to cited text no. 8
    
9.
Arai H, Ouchi Y, Toba K, Endo T, Shimokado K, Tsubota K, et al. Japan as the front-runner of super-aged societies: Perspectives from medicine and medical care in Japan. Geriatr Gerontol Int 2015;15:673-87.  Back to cited text no. 9
    
10.
Zhang QR, Zhang X, Wu Q, Shi JX, Wang HD, Hang CH, et al. The impact of microsurgical clipping and endovascular coiling on the outcome of cerebral aneurysms in patients over 60 years of age. J Clin Neurosci 2012;19:1115-8.  Back to cited text no. 10
    
11.
Ryttlefors M, Enblad P, Kerr RS, Molyneux AJ. International subarachnoid aneurysm trial of neurosurgical clipping versus endovascular coiling: Subgroup analysis of 278 elderly patients. Stroke 2008;39:2720-6.  Back to cited text no. 11
    
12.
Bekelis K, Gottlieb DJ, Su Y, O'Malley AJ, Labropoulos N, Goodney P, et al. Comparison of clipping and coiling in elderly patients with unruptured cerebral aneurysms. J Neurosurg 2017;126:811-8.  Back to cited text no. 12
    
13.
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 1997;28:1926-31.  Back to cited text no. 13
    
14.
Hishikawa T, Date I, Tokunaga K, Tominari S, Nozaki K, Shiokawa Y, et al. Risk of rupture of unruptured cerebral aneurysms in elderly patients. Neurology 2015;85:1879-85.  Back to cited text no. 14
    
15.
Horiuchi T, Hongo K. Clipping surgery for aneurysmal subarachnoid hemorrhage in patients aged 75 years or older. Neurol Res 2011;33:853-7.  Back to cited text no. 15
    
16.
Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomised trial. Lancet 2002;360:1267-74.  Back to cited text no. 16
    
17.
Chung RY, Carter BS, Norbash A, Budzik R, Putnam C, Ogilvy CS, et al. Management outcomes for ruptured and unruptured aneurysms in the elderly. Neurosurgery 2000;47:827-32.  Back to cited text no. 17
    
18.
Hishikawa T, Date I. Unruptured cerebral aneurysms in elderly patients. Neurol Med Chir (Tokyo) 2017;57:247-52.  Back to cited text no. 18
    
19.
Warmer MJ, van der Schaarf IC, Agra A, Rinke GJ. Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics: An updated meta-analysis. Stroke 2007;38:1404-10.  Back to cited text no. 19
    
20.
Derrey S, Curey S, Hannequin P, Castel H, Langlois O, Tollard E, et al. Elderly patients with aneurysmal subarachnoid hemorrhage: Coils but also clips. Neurochirurgie 2012;58:140-5.  Back to cited text no. 20
    
21.
Alshafai N, Cusimano MD, Falenchuk O. Global differences in the present and future management of cerebral aneurysms. World Neurosurg 2013;80:717-22.  Back to cited text no. 21
    
22.
Yasui T, Sakamoto H, Kishi H, Komiyama M, Iwai Y, Yamanaka K, et al. Management of elderly patients with incidentally discovered unruptured aneurysms. No Shinkei Geka 1998;26:679-84.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
<
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
  Introduction
  Patients and Methods
  Results
  Discussion
  Conclusions
   References
   Article Tables

 Article Access Statistics
    Viewed383    
    Printed33    
    Emailed0    
    PDF Downloaded50    
    Comments [Add]    

Recommend this journal