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Neurointensive care is justified in elderly patients with severe subarachnoid hemorrhage--an outcome and secondary insults study
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.
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.
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2010 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 152, no 2, 241-249 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: The aim was to study the outcome and the occurrence of secondary brain insults in elderly patients with severe subarachnoid hemorrhage (SAH) in comparison to younger patients. METHODS: Ninety-nine patients with severe SAH requiring a ventriculostomy and management at the neurointensive care unit with at least 120 h of multimodality monitoring data during the first 240 h following SAH were included. Data were continuously recorded for intracranial pressure (ICP), cerebral perfusion pressure, blood pressure, oxygen saturation, and temperature. Secondary insult levels were defined and quantified as percent of good monitoring time at insult level. Outcome according to the Glasgow Outcome Scale was evaluated at 6 months after the SAH. Age-dependent differences in occurrence of secondary insults and clinical characteristics were analyzed with multiple regression analysis. RESULTS: Good recovery or moderate disability was achieved in 24.1% of the elderly and in 42.9% of the younger patients. The frequency of severe disability was 41.4% in the elderly and 37.1% in the younger patients. The occurrence of ICP insults was lower and the occurrence of hypertensive, hypotensive, and hypoxemic insults were higher in the elderly patients. CONCLUSIONS: An independent outcome was achieved in a substantial proportion of the elderly with severe SAH, and the proportion of severe disability was not greater than among the younger patients, which justifies neurointensive care also in elderly patients. The occurrence of secondary insults was age dependent. Future studies of multimodality monitoring may provide age-specific secondary insult levels necessary for a tailored neurointensive care specific for elderly patients with severe SAH.

Place, publisher, year, edition, pages
2010. Vol. 152, no 2, 241-249 p.
Keyword [en]
Subarachnoid hemorrhage, Aneurysm, Elderly, Neurointensive care, Outcome, Secondary cerebral ischemia
National Category
Medical and Health Sciences
Research subject
Neurosurgery
Identifiers
URN: urn:nbn:se:uu:diva-123070DOI: 10.1007/s00701-009-0496-xISI: 000274199900008PubMedID: 19707714OAI: oai:DiVA.org:uu-123070DiVA: diva2:311771
Available from: 2010-04-23 Created: 2010-04-23 Last updated: 2017-12-12
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
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Available from: 2008-12-19 Created: 2008-12-19 Last updated: 2011-01-12Bibliographically approved

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