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Treatment of octogenarians and nonagenarians with aneurysmal subarachnoid hemorrhage: a 17-year institutional analysis

  • Original Article -Vascular Neurosurgery - Aneurysm
  • Published:
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Abstract

Background

Outcomes for octogenarians and nonagenarians after an aneurysmal subarachnoid hemorrhage (aSAH) are particularly ominous, with mortality rates well above 50%. The present analysis examines the neurologic outcomes of patients ≥ 80 years of age treated for aSAH.

Method

A retrospective review was performed of all aSAH patients treated at Barrow Neurological Institute from January 1, 2003, to July 31, 2019. Patients were placed in 2 groups by age, < 80 vs ≥ 80 years. The ≥ 80-year-old group of octogenarians and nonagenarians was subsequently analyzed to compare treatment modalities. Poor neurologic outcome was defined as a modified Rankin Scale (mRS) score of > 2.

Results

During the study period, 1418 patients were treated for aSAH. The mean (standard deviation) age was 55.1 (13.6) years, the mean follow-up was 24.6 (40.0) months, and the rate of functional independence (mRS 0–2) at follow-up was 54% (751/1395). Logistic regression analysis found increasing age strongly associated with declining functional independence (R2 = 0.929, p < 0.001). Forty-three patients ≥ 80 years old were significantly more likely to be managed endovascularly than with open microsurgery (67% [n = 29] vs 33% [n = 14], p < 0.001). Compared with younger patients, those ≥ 80 years old had an increased risk of mortality and poor neurologic outcomes at follow-up. In the ≥ 80-year-old group, only 4 patients had good outcomes; none of the 4 had preexisting comorbidities, and all 4 were treated endovascularly.

Conclusions

Age is a significant prognostic indicator of functional outcomes and mortality after aSAH. Most octogenarians and nonagenarians with aSAH will become severely disabled or die.

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Abbreviations

aSAH:

Aneurysmal subarachnoid hemorrhage

BRAT:

Barrow Ruptured Aneurysm Trial

CCI:

Charlson Comorbidity Index

DCI:

Delayed cerebral ischemia

HH:

Hunt and Hess

mRS:

Modified Rankin Scale

PBRAT:

Post-Barrow Ruptured Aneurysm Trial

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Acknowledgements

We thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.

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Authors and Affiliations

  1. Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA

    Joshua S. Catapano, Kavelin Rumalla, Visish M. Srinivasan, Mohamed A. Labib, Candice L. Nguyen, Jacob F. Baranoski, Tyler S. Cole, Caleb Rutledge, Redi Rahmani, Joseph M. Zabramski, Ashutosh P. Jadhav, Andrew F. Ducruet, Felipe C. Albuquerque & Michael T. Lawton

Authors
  1. Joshua S. Catapano
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  2. Kavelin Rumalla
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  3. Visish M. Srinivasan
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  4. Mohamed A. Labib
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  5. Candice L. Nguyen
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  6. Jacob F. Baranoski
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  7. Tyler S. Cole
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  12. Andrew F. Ducruet
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  13. Felipe C. Albuquerque
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  14. Michael T. Lawton
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Contributions

Joshua S. Catapano, MD—manuscript writing; Kavelin Rumalla, MD—stats; Visish M. Srinivasan, MD—edits; Mohamed A. Labib, MD, CM—edits; Candice L. Nguyen, BS—data collection; Jacob F. Baranoski, MD—edits; Tyler S. Cole, MD—stats; Caleb Rutledge, MD—edits; Redi Rahmani, MD—edits; Joseph M. Zabramski, MD—final edits; Ashutosh P. Jadhav, MD—final edits; Andrew F. Ducruet, MD—final edits; Felipe C. Albuquerque, MD—final edits; and Michael T. Lawton, MD—final edits and approval.

Corresponding author

Correspondence to Michael T. Lawton.

Ethics declarations

Ethics approval

The St. Joseph’s Hospital and Medical Center Institutional Review Board approved this observational study.

Informed consent

The need for informed consent was waived by the institutional review board due to the retrospective nature of the study and the minimal risk of patient identification.

Conflict of interest

The authors declare no competing interests.

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Comments

The authors present a retrospective analysis of octo- and nonagenarians presenting with aneurysmal subarachnoid hemorrhage treated at the Barrow Neurological Institute from 2003 to 2019. A total of 1418 patients presented with aneurysmal subarachnoid hemorrhage during the study period, with 43 patients ≥ 80 years old. Logistic regression analysis demonstrated that increasing age was significantly associated with declining functional independence as measured by modified Rankin scores (mRS) at last follow-up. Increased age likely acts as a surrogate for the presence of comorbidities, worse baseline mRS, and diminished capacity for recovery after subarachnoid hemorrhage.

In addition, patients in the elderly age group were significantly more likely to undergo endovascular treatment, had lower rates of angiographic vasospasm, and similar rates of delayed cerebral ischemia as compared to younger patients. 91% of the elderly patients were not functionally independent, compared to 36% of the non-elderly patients at their final follow-up. It is unclear why elderly patients, other than their age, were more likely to undergo endovascular treatment since there were no significant differences in comorbidities, Hunt and Hess (HH) grades, and Fisher grades between elderly patients receiving endovascular or microsurgical treatments. The mRS scores and long-term mortality were not significantly different between the treatment types in elderly patients. The inclusion of patients from 2003 to 2007 that were enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) in this current study may not fully reflect practice patterns based on clinical and patient factors since patients as a part of BRAT were randomized to microsurgical or endovascular treatments. It is unclear how much that may have altered the overall proportions of the respective treatment groups in this study.

Only 4 patients in the elderly cohort (9%) demonstrated functional independence at their final follow-up. Interestingly, these 4 patients all were treated endovascularly, had no significant comorbidities, no symptomatic vasospasm, no hydrocephalus, and had lower mean HH and Fisher grades compared to those with worse outcomes. As acknowledged by the authors, the small sample size of elderly patients with positive functional outcomes prevents statistical analysis in order to adequately evaluate variables that may result in functional recovery. These findings suggest that the presence of comorbidities, HH and Fisher grades remain important prognostic factors in elderly patients.

In this study, an overwhelming number of patients ≥ 80 years old with aneurysmal subarachnoid hemorrhage were unable to achieve functional independence regardless of treatment modality. This is a difficult group to study due to their small population, but future studies in conjunction with this data will help provide a valuable framework for discussions with families and patients regarding the prognosis of elderly patients with aneurysmal subarachnoid hemorrhage.

Eric T. Quach,

Christopher M. Loftus

Philadelphia, Pennsylvania, USA

This article is part of the Topical Collection on Vascular Neurosurgery—Aneurysm

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Catapano, J.S., Rumalla, K., Srinivasan, V.M. et al. Treatment of octogenarians and nonagenarians with aneurysmal subarachnoid hemorrhage: a 17-year institutional analysis. Acta Neurochir 163, 2941–2946 (2021). https://doi.org/10.1007/s00701-021-04985-y

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  • DOI: https://doi.org/10.1007/s00701-021-04985-y

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