J Cerebrovasc Endovasc Neurosurg.  2020 Jun;22(2):78-84. 10.7461/jcen.2020.22.2.78.

Treatment outcome after coiling or clipping for elderly patients with unruptured intracranial aneurysms

• Cho WC
• Shin YS
• Kim Bs
• Choi JH

• KMID: 2503820
• DOI: http://doi.org/10.7461/jcen.2020.22.2.78

Abstract

Objective
The purpose of this study was to analyze treatment outcomes according to treatment modality for elderly patients over 75 years with unruptured intracranial aneurysm.
Methods
Fifty-four elderly patients treated in a single tertiary institute between January 2010 and December 2018 were retrospectively reviewed. We compared clinical outcome, radiological results, and complications between the coiling and clipping groups.
Results
A total of 55 procedures were performed in 54 patients. Of 55 aneurysms, 44 were treated endovascularly and 11 were treated surgically. There was no significant difference in patient baseline characteristics including mean age, sex, and preexisting co-morbidity between the two groups. Even though there was no significant difference (p=0.373), procedure-related symptomatic complication occurred only in coiling group (3 out of 44 patients, 6.6%). Mortality rate was significantly higher in clipping group (1 out of 11 patients, 9.1%) than in coiling group (0%, p=0.044). Good clinical outcome (modified Rankin Scale 0-2) at 90 days was achieved in 43 cases treated with coiling (97.7%), and 10 cases with clipping (90.9%, p=0.154).
Conclusions
Clipping is more invasive procedure and takes longer operation time, which might lead to unpredictable mortality in elderly patients. Coiling might have high procedure-related stroke rate due to tortuous vessels with atherosclerosis. Therefore, aggressive treatment of elderly patients should be carefully considered based on patient’s medical condition and angiographic findings.

Keyword

Elderly; Cerebral; Aneurysm; Coiling; Clipping

Reference

1. International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms--risk of rupture and risks of surgical intervention. N Engl J Med. 1998; Dec. 339(24):1725–33.

2. Barker FG 2nd, Amin-Hanjani S, Butler WE, Hoh BL, Rabinov JD, Pryor JC, et al. Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the United States, 1996–2000. Neurosurgery. 2004; Jan. 54(1):18–28. discussion 28–30.

3. 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; Mar. 126(3):811–8.

4. Brinjikji W, Rabinstein AA, Lanzino G, Kallmes DF, Cloft HJ. Effect of age on outcomes of treatment of unruptured cerebral aneurysms: a study of the National Inpatient Sample 2001–2008. Stroke. 2011; May. 42(5):1320–4.

5. Brinjikji W, Rabinstein AA, Nasr DM, Lanzino G, Kallmes DF, Cloft HJ. Better outcomes with treatment by coiling relative to clipping of unruptured intracranial aneurysms in the United States, 2001–2008. AJNR Am J Neuroradiol. 2011; Jun–Jul. 32(6):1071–5.

6. Ellenbogen BK. Subarachnoid haemorrhage in the elderly. Gerontol Clin (Basel). 1970; 12(2):115–20.

7. Greving JP, Wermer MJ, Brown RD Jr, Morita A, Juvela S, Yonekura M, et al. Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies. Lancet Neurol. 2014; Jan. 13(1):59–66.

8. Hishikawa T, Takasugi Y, Shimizu T, Haruma J, Hiramatsu M, Tokunaga K, et al. Cerebral vasospasm in patients over 80 years treated by coil embolization for ruptured cerebral aneurysms. Biomed Res Int. 2014; 2014:253867.

9. Jang EW, Jung JY, Hong CK, Joo JY. Benefits of surgical treatment for unruptured intracranial aneurysms in elderly patients. J Korean Neurosurg Soc. 2011; Jan. 49(1):20–5.

10. Kawada T, Hishikawa T, Date I, Tominari S, Morita A. Risk of rupture of unruptured cerebral aneurysms in elderly patients. Neurology. 2016; Apr. 86(17):1650.

11. Lunenfeld B, Stratton P. The clinical consequences of an ageing world and preventive strategies. Best Pract Res Clin Obstet Gynaecol. 2013; Oct. 27(5):643–59.

12. Mahaney KB, Brown RD Jr, Meissner I, Piepgras DG, Huston J 3rd, Zhang J, et al. Age-related differences in unruptured intracranial aneurysms: 1-year outcomes. J Neurosurg. 2014; Nov. 121(5):1024–38.

13. Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, Hashimoto N, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med. 2012; Jun. 366(26):2474–82.

14. Ryttlefors M, Enblad P, Kerr RSC, Molyneux AJ. International subarachnoid aneurysm trial of neurosurgical clipping versus endovascular coiling: subgroup analysis of 278 elderly patients. Stroke. 2008; Oct. 39(10):2720–6.

15. Song J, Lang L, Zhu W, Gu Y, Xu B, Cai J, et al. Application of intraoperative motor evoked potential monitoring during giant internal carotid artery aneurysm surgery using prolonged temporary occlusion. Acta Neurochir (Wien). 2015; Nov. 157(11):1833–40.

16. Sturiale CL, Brinjikji W, Murad MH, Lanzino G. Endovascular treatment of intracranial aneurysms in elderly patients: a systematic review and meta-analysis. Stroke. 2013; Jul. 44(7):1897–902.

17. Thirumala PD, Udesh R, Muralidharan A, Thiagarajan K, Crammond DJ, Chang YF, et al. Diagnostic Value of Somatosensory-Evoked Potential Monitoring During Cerebral Aneurysm Clipping: A Systematic Review. World Neurosurg. 2016; May. 89:672–80.

18. Wermer MJH, van der Schaaf IC, Algra A, Rinkel GJE. Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics: an updated meta-analysis. Stroke. 2007; Apr. 38(4):1404–10.

19. Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003; Jul. 362(9378):103–10.

20. Yang H, Jiang H, Ni W, Leng B, Bin X, Chen G, et al. Treatment strategy for unruptured intracranial aneurysm in elderly patients: coiling, clipping, or conservative? Cell Transplant. 2019; Jun. 28(6):767–74.