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International Subarachnoid Aneurysm Trial of neurosurgical clipping versus endovascular coiling: Subgroup analysis of 278 elderly patients
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Nuffield Dept Surgery, Radcliff, University of Oxford, UK.
Neurovasc Res Unit, Radcliff, University of Oxford, UK.
2008 (English)In: Stroke, Vol. 39, no 10, 2720-2726 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND PURPOSE: It is often thought that elderly patients in particular would benefit from endovascular aneurysm treatment. The aim of this analysis was therefore to compare the efficacy and safety of endovascular coiling (EVT) with neurosurgical clipping (NST) in the subgroup of elderly SAH patients in the International Subarachnoid Aneurysm Trial (ISAT). METHODS: In the ISAT cohort 278 SAH patients, 65 years or older, were enrolled. The patients were randomly allocated EVT (n=138) or NST (n=140). The primary outcome was the proportion of patients with a modified Rankin scale score of 0 to 2 (independent survival) at 1 year after the SAH. The rates of procedural complications and adverse events were also recorded. RESULTS: 83 of 138 (60.1%) patients allocated EVT were independent compared to 78 of 140 (56.1%) allocated NST (N.S.). 36 of 50 (72.0%) patients with internal carotid and posterior communicating artery aneurysms allocated EVT were independent compared to 26 of 50 (52.0%) allocated NST (P<0.05). 10 of 22 (45.5%) patients with middle cerebral artery aneurysms allocated EVT were independent compared to 13 of 15 (86.7%) allocated NST (P<0.05). The epilepsy frequency was 0.7% in the EVT group compared to 12.9% in the NST group (P<0.001). CONCLUSIONS: In good grade elderly SAH patients with small anterior circulation aneurysms, EVT should probably be the favored treatment for ruptured internal carotid and posterior communicating artery aneurysms, whereas elderly patients with ruptured middle cerebral artery aneurysms appear to benefit from NST. EVT resulted in a lower epilepsy frequency than NST.

Place, publisher, year, edition, pages
2008. Vol. 39, no 10, 2720-2726 p.
Keyword [en]
subarachnoid hemorrhage, intracranial aneurysm, aged, endovascular treatment, neurosurgery, clinical trial
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-97923DOI: 10.1161/STROKEAHA.107.506030ISI: 000259648700008PubMedID: 18669898OAI: oai:DiVA.org:uu-97923DiVA: diva2:173043
Available from: 2008-12-19 Created: 2008-12-19 Last updated: 2016-05-02Bibliographically approved
In thesis
1. Subarachnoid Hemorrhage in the Elderly
Open this publication in new window or tab >>Subarachnoid Hemorrhage in the Elderly
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Subarachnoid hemorrhage (SAH) is a disease with high risk of mortality and morbidity. Elderly patients have an even higher risk of poor outcome. The incidence of SAH increases with age and the elderly constitute a substantial and increasing proportion of the population. Thus, the management of elderly SAH patients is an imminent clinical challenge. Time trends in clinical management and outcome were investigated in 281 SAH patients aged ≥65 years admitted over an 18-year period. The volume of elderly patients, especially patients ≥70 years and patients in worse clinical condition increased over time. The proportion of patients with favorable outcome increased over time, without an increase in severely disabled patients. Technical results and clinical outcome of endovascular aneurysm treatment (EVT) was investigated in 62 elderly SAH patients. EVT can be performed in elderly SAH patients with high technical success, acceptable aneurysm occlusion degree, acceptable procedural complication rate, and fair outcome results. EVT was compared to neurosurgical clipping (NST) in 278 elderly SAH patients in the International Subarachnoid Aneurysm Trial. In good grade elderly SAH patients, EVT should probably be the favored treatment for internal carotid and posterior communicating artery aneurysms, while elderly patients with middle cerebral artery aneurysms appear to benefit from NST. Occurrence of secondary insults and their impact on clinical deterioration were studied in 99 patients with severe SAH. High intracranial pressure increased and high cerebral perfusion pressure decreased the risk of clinical deterioration. Elderly patients had less intracranial hypertension insults and more hypertensive, hypotensive and hypoxemic insults. Good outcome was achieved in 24% of elderly patients with severe SAH, and the proportion of severe disability was similar to that of younger patients. Patient age was not a significant predictor for vasospasm in 413 SAH patients when admission and treatment variables were adjusted for with multiple logistic regression.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2009. 106 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 407
Keyword
subarachnoid hemorrhage, intracranial aneurysm, elderly, outcome, endovascular coiling, neurosurgical clipping, secondary insult, cerebral vasospasm
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-9504 (URN)978-91-554-7375-4 (ISBN)
Public defence
2009-01-09, Enghoffsalen, Akademiska sjukhuset, ing 50, Uppsala, 09:15
Opponent
Supervisors
Available from: 2008-12-19 Created: 2008-12-19 Last updated: 2011-01-12Bibliographically approved

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