Endovascular Treatment: Part Two

The number of elderly patients admitted with diagnosis of cerebral aneurysms is markedly increasing worldwide. Treatment in this group of patients is certainly more difficult than in the young subjects and not many reports deal with their management.Many factors must be considered deciding if to pursue treatment. Patients admitted after bleeding (subarachnoid haemorrhage, SAH) have a different prognosis from young subjects and those harboring unruptured vascular malformations.We have analyzed the literature on the basis of this distinction.La gestione degli aneurismi cerebrali nei pazienti anziani Analisi della letteratura RIASSUNTO -Il numero di pazienti anziani ricoverati con diagnosi di aneurismi cerebrali è marcatamente aumentato in tutto il mondo. Il trattamento di questo tipo di pazienti è certamente più difficile che non nei soggetti giovani, solo pochi articoli sono dedicati a questo problema.Molti fattori vanno presi in considerazione nel decidere se proseguire nel trattamento. I pazienti ricoverati dopo un'emorragia subaracnoidea hanno una prognosi differente dai giovani e da coloro che presentano malformazioni vascolari non rotte.Abbiamo analizzato la letteratura sulla base di questa distinzione.Ricevuto il 06.08.2002 Management of Cerebral Aneurysms in Elderly PatientsF. Griva 598 more likely to have occurred and elevated blood pressure seems to be related to the severity of age 9 .As an adjunctive consideration it is important to notice that basic mechanisms responsible for the damage to the aged brain are not completely understood. Lanzino et Al 16 describe the possibility of a cellular time-dependent loss of structure and function, an impairment in mRNA translation, a decrease of the number of mitochondria with age and a lowered reactive synaptogenesis in response to any neuronal insult. According to cerebral vasospasm, other aspects can be described. After SAH the entity of blood in the first CT scan is related to the subsequent development of vasospasm 7 .In elderly patients, in spite of the usually thicker clot on CT, the incidence of angiographic vasospasm is lower than expected. Even if vascular narrowing in angiography is less frequently encountered in elderly patients, the incidence of symptomatic vasospasm is similar to that described in younger subjects. Lanzino et Al 16 described an increase in clinical vaospasm in elderly patients. In their series, patients older than 70 years were more likely to suffer permanent neuological morbidity from vasospasm. This can be considered a consequence of the decreased cerebral blood flow with advancing age 24,25 . After SAH an impairment of cerebrovascular reactivity is known to occur. In older individuals, the ischemic threshold can be easily reached with immediate clinical consequences.The results of treatment in the past have been less favorable in older than in younger patients 23,34 . Mc Kissock et Al 23 reported an operative mortality rate of 44% for patients between 60 and 70 years old and Martindale et Al 22 suggested that no patients older tha...

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“…Indeed, increasingly experience in the endovascular technique is very promising in the treatment of these patients 37,38 .…”

Section: Discussionmentioning

confidence: 99%

Management of Cerebral Aneurysms in Elderly Patients

Griva¹,

Tartara²,

Longo³

et al. 2002

Rivista di Neuroradiologia

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“…Our opinion is that the best results are obtained not by a contrast between coiling and clipping, but by their integration in a protocol that is flexible, and open to the continuous introduction of technical improvements particularly on the endovascular side [4][5][6] .…”

Section: Discussionmentioning

confidence: 99%

Coiling or Clipping?

Ducati

Pasquini

2002

Rivista di Neuroradiologia

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The introduction of endovascular coiling for aneurysm occlusion has significantly improved the global outcome in a homogeneous population of SAH patients with AcoA aneurysm rupture observed in the Ancona area in a three year period. Mortality was 15,3%, Good Recovery 64.7%. Moreover, at neuropsychological testing more than 50% of the entire population appeared to be normal or slightly impaired. The group of patients that benefit most from this treatment is the one with intermediate risk, while patients with all bad predictors and patients with all good predictors behave in the same way either with coiling or clipping."Coiling" o "clipping".Una esperienza su una popolazione omogenea RIASSUNTO -L'introduzione dell'embolizzazione con spirali per l'occlusione degli aneurismi ha significativamente migliorato i risultati terapeutici globali in una popolazione omogenea di pazienti affetti da emorragia subaracnoidea da rottura di aneurisma della comunicante anteriore nell'area di Ancona in un periodo di tre anni.La mortalità è stata del 15,3%; buon recupero nel 64,7%. Inoltre i test neurofisiologici hanno dimostrato la normalità o il lievissimo deficit nel 50% dell'intero gruppo.I pazienti che beneficiano di più di questo trattamento sono quelli a livello medio di rischio, mentre i pazienti considerati ad alto o a basso rischio hanno avuto risultati identici con terapia endovascolare o neurochirurgica.

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“…The endovascular treatment is now an accepted method, alternative to surgery in many cases. In particular, in patients in poor clinical condition the less invasive endovascular approach is increasingly used in the Neuroscience Department of Torino 7,11,49 .…”

Section: /3 Operated Upon Within Sah-day 4-7; 2/3 Sah-day 8-14 or Latermentioning

confidence: 99%

“…Since its introduction in our department in 1994, it has become the method of first choice for aneurysms in the posterior circulation independently from the clinical condition 7,11,49 .…”

Section: Posterior Fossa Aneurysmsmentioning

confidence: 99%

Surgery for Bleeding Aneurysms

Fontanella

Pagni

2002

Rivista di Neuroradiologia

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The comparison between the overall results in series treated with late surgery and those obtained with early surgery demonstrates a marked reduction of mortality and an increase in good results in the series treated with early surgery. In many series in which a protocol of late surgery was employed no less than 10-15% percent of the patients died waiting for the operation.The advantage of early surgery is much more evident if the results are analysed on the basis of the Hunt-Hess grade on admission. In the past, some of the surgeons who considered early surgery an useful weapon for patients in Hunt-Hess I-II, thought that early surgery was too risky in Hunt-Hess III, and that grade IV and V patients should not undergo surgery.In Hunt-Hess III operative mortality and morbidity were respectively 15-30% and 10-25% with delayed surgery, but the overall mortality is up to 40% mainly due to the rebleeding rate. Operative result and overall outcome in Hunt-Hess III is much better in series treated in early surgery with Nimodipine, ventricular drainage and intracranial pressure control. In the past, the approach to Grade IV and V patient was usually nonoperative.This has changed today, since early surgical treatment is increasingly done also in these groups of patients. In our experience, the endovascular approach can be a good alternative in many cases. Such considerations are valid also for those patients, usually in severe clinical condition, with an intracerebral haematoma. Posterior circulation aneurysms have usually been operated on in late surgery.In these cases a careful selection of patients, the surgical approach and improvement in neurointensive care techniques to obtain more operating space and to minimize retraction, allow satisfactory results also with early surgery. Only a few series reported the results of early surgery in giant aneurysms. On the basis of those papers it can safely be affirmed that if the sac is clippable with the usual surgical technique, an early approach can be attempted. If temporary prolonged arterial occlusion or by-pass seem to be necessary, it is better to postpone surgery.

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Endovascular Treatment: Part Two

Cited by 6 publications

References 30 publications

Management of Cerebral Aneurysms in Elderly Patients

Management of Cerebral Aneurysms in Elderly Patients

Coiling or Clipping?

Surgery for Bleeding Aneurysms

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