J Korean Med Sci.  2021 Jul;36(26):e178. 10.3346/jkms.2021.36.e178.

Clinical Outcomes of Clipping and Coiling in Elderly Patients with Unruptured Cerebral Aneurysms: a National Cohort Study in Korea

• Lee SH
• Lee SU
• Kwon OK
• Bang JS
• Ban SP
• Kim T
• Kim YD
• Byoun HS
• Oh CW

• KMID: 2518156
• DOI: http://doi.org/10.3346/jkms.2021.36.e178

Abstract

Background
We aimed to analyze outcomes of clipping and coiling in treating unruptured intracranial aneurysms (UIAs) in elderly patients and to identify the age at which perioperative risk increases based on national cohort data in South Korea.
Methods
The incidence of perioperative intracranial hemorrhage (ICRH), perioperative cerebral infarction (CI), mortality, and moderate to severe disability data of the patients who underwent coiling or clipping for UIAs were retrieved. Estimated breakpoint (EBP) was calculated to identify the age at which the risk of treatment increases.
Results
A total of 38,207 patients were treated for UIAs. Among these, 22,093 (57.8%) patients underwent coiling and 16,114 (42.2%) patients underwent clipping. The incidence of ICRH, requiring a secondary operation, within 3 months in patients ≥ 65 years that underwent coiling and clipping was 1.13% and 4.81%, respectively, and that of both groups assessed were significantly higher in patients ≥ 75 years (coiling, P = 0.013, relative risk (RR) 1.81; clipping, P = 0.015) than younger patients. The incidence of CI within 3 months in patients aged ≥ 65 was 13.90% and 9.19% in the coiling and clipping groups, respectively. The incidence of CI after coiling in patients aged ≥ 75 years (P < 0.001, RR 1.96) and after clipping in patients aged ≥ 70 years (P < 0.001, RR 1.76) was significantly higher than that in younger patients. The mortality rates within 1 year in patients with perioperative ICRH or CI were 2.41% and 3.39% for coiling and clipping groups, respectively, in patients ≥ 65. These rates increased significantly at age 70 in the coiling group and at age 75 for the clipping group (P = 0.012 and P < 0.001, respectively).
Conclusion
The risk of treatment increases with age, and this risk increases dramatically in patients aged ≥ 70 years. Therefore, the treatment decisions in patients aged ≥ 70 years should be made with utmost care.

Keyword

Cerebral Infarction; Intracranial Aneurysm; Intracranial Hemorrhages

Figure

• 

  Fig. 1 The EBP of the incidence of ICRH in patients that underwent clipping was 75 years, and the incidence of ICRH significantly increased in patients aged ≥ 75 years (P = 0.015; B). However, there was no significant EBP determined for patients of the coiling group (P = 0.079; A).EBP = estimated breakpoint, ICRH = intracranial hemorrhage.

• 

  Fig. 2 The estimated breakpoint of cerebral infarction incidence was determined to be 75 years old (P = 0.105; A) in patients who underwent coiling and 70 years old (P = 0.134; B) in patients who underwent clipping; however, the value was not statistically significant.

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  Fig. 3 Estimated breakpoint analysis for disability revealed elevated values in patients who underwent coiling among those aged 70 years or older (P = 0.012; A). The same type of analysis revealed elevated values in patients who underwent clipping among those aged 75 years or older (P < 0.001; B).

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