Treatment Strategy for Unruptured Intracranial Aneurysm in Elderly Patients: Coiling, Clipping, or Conservative?

Abstract

An increasing number of unruptured intracranial aneurysms (UIAs) has been discovered in elderly patients in recent years, but the optimal treatment strategy for these patients remains controversial. We report our six-year experience treating UIAs in elderly patients (≥ 70 years old). A retrospective review was conducted of elderly patients who harbored UIAs treated by conservative observation, microsurgical clipping, or endovascular coiling between January 2009 and December 2014. The patients’ clinical and imaging information was recorded. Treating methods, procedure-related complications, imaging results, and clinical outcomes were analyzed. A total of 141 consecutive elderly patients with 166 UIAs were enrolled in our study. In all, 64 patients with 79 aneurysms were treated with coiling, and 14 patients with 14 aneurysms were treated with clipping. The remaining 63 patients with 73 aneurysms were placed under conservative observation. The average modified Rankin scale was 0.99 (range 0–6) in the full cohort after a mean follow-up of 50.4 months (range 0–70 months). There was no significant difference of modified Rankin scale in patients with UIAs treated by different methods. Multivariate analysis showed that age ( p=0.030) and aneurysm size ( p=0.011) were independent risk factors for unfavorable outcome of UIAs in the elderly. Patient age ( p=0.010) and aneurysm size ( p=0.020) were also significantly associated with unfavorable outcome of UIAs managed with observation initially. Our results indicated that endovascular coil embolization and clipping were both safe and effective treatment methods for UIAs in the elderly. Aggressive treatment for UIAs in elderly patients with risk factors of aneurysm rupture should be considered positively.

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

“…Similar to our results, Yang et al reported that there was no significant difference in symptomatic complication and clinical outcome between the two groups. 20) Jang et al also reported that the morbidity rate was higher in coiling group (4%) than in clipping group (1.78%). 9) Some previous reports revealed that surgery for elderly patients is more invasive and has significant high morbidity and mortality than coiling.…”

“…Yang et al also reported that general complications including heart dysfunction and pneumonia occurred significantly higher in surgery group (21.4%) than in EVT group (4.69%, p=0.033). 20) We thought that invasiveness of surgery and longer operation and anesthesia time might be associated to these results. In addition, the rate of good functional outcome at 3 months was lower in clipping group (90.9%) than in coiling group (97.7%) even though there was no statistical significance (p=0.154).…”

“… 10) It is still controversy that which method (surgery, endovascular treatment (EVT), or observation and follow-up) is optimal for these patients. 20) Aging process changes patient’s physiologic conditions including decreased life expectancy, increased co-morbidity, increased surgical risk due to its invasiveness and longer operation time, and increased EVT risk due to vascular tortuosity and atherosclerosis. 2) 6) 8) 14) Therefore, for almost extremely elderly patients with more than 75 years, observation and follow-up is mainly chosen for fear of procedure-related or unrelated complications.…”

“… 2) 6) 8) 14) Therefore, for almost extremely elderly patients with more than 75 years, observation and follow-up is mainly chosen for fear of procedure-related or unrelated complications. 6) 20) However, in some UIA cases, treatment should be needed even in extremely elderly patients. In this study, we introduced our experience treating UIA with extremely elderly patients and compared treatment outcome between surgery and EVT.…”

Analysis of the surgical outcome of unruptured intracranial saccular aneurysms in octogenarians (80–89 Years)

“…Aggressive treatment for UCAs in elderly patients with risk factors of aneurysm rupture should be considered positively. [ 8 ]…”