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Neurointensive care is justified in elderly patients with severe subarachnoid hemorrhage—an outcome and secondary insults study

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Abstract

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.

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Acknowledgments

This study was supported by the Erik, Karin, and Gösta Selander’s Foundation (Mats Ryttlefors) and the Swedish Research Council (Per Enblad).

Conflict of interests

None of the authors have disclosed any conflict of interest.

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Authors and Affiliations

  1. Section of Neurosurgery, Department of Neuroscience, Uppsala University Hospital, 751 85, Uppsala, Sweden

    Mats Ryttlefors, Tim Howells, Elisabeth Ronne-Engström, Pelle Nilsson & Per Enblad

Authors
  1. Mats Ryttlefors
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  2. Tim Howells
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  3. Elisabeth Ronne-Engström
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  4. Pelle Nilsson
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  5. Per Enblad
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Corresponding author

Correspondence to Mats Ryttlefors.

Additional information

Comment

The information in this paper is interesting and worthwhile to be published. The authors use an automated data collecting system for their ICU monitoring which gives them an advanced means for providing quite “complete” data on their patients. The problem they attack with this study is very sensibly and honestly put forward: Is it justified to treat all SAH patients with the same intensity and means irrespective of their age? For many years, based on the known poor outcome in elderly patients, there has been hesitation among neurosurgeons to do so. Since endovascular treatment became available, the resistance to actively treat elder patients has decreased, because of the presumed “ease” of that intervention compared to surgery. In fact, it is not the surgery itself that is dangerous for the elderly but the overall insult by the SAH and its sequelae. Therefore, data such as provided here are necessary in order to balance the pros and cons of active treatment of older SAH patients irrespective of coiling or clipping. The study focuses on the ICU aspects, the measured events, the outcome, and the correlations between the various parameters.

J.J.A. Mooij

Groningen, The Netherlands

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Ryttlefors, M., Howells, T., Ronne-Engström, E. et al. Neurointensive care is justified in elderly patients with severe subarachnoid hemorrhage—an outcome and secondary insults study. Acta Neurochir 152, 241–249 (2010). https://doi.org/10.1007/s00701-009-0496-x

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  • DOI: https://doi.org/10.1007/s00701-009-0496-x

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