Romanian Neurosurgery (Mar 2007)
Cerebral vasospasm in elderly patients with ruptured intracranial aneurysms
Abstract
Spontaneous subarachnoid hemorrhage (SAH) is often a devastating condition and a significant cause of worldwide morbidity and mortality. Because the percentage of senior citizens is increasing in many countries and because of the increased incidence of SAH in elderly patients, ruptured intracranial aneurysm is an increasingly frequent pathology in all countries. The number of elderly patients with cerebral aneurysms has markedly increased since 1991, and in 2000 approximately 32% of all patients with cerebral aneurysms were elderly. Twenty years ago, older people were considered to have such a poor prognosis that they were frequently excluded from active treatment on the unique basis of their advanced age. Improving results published in recent studies showed that the classic fatalistic attitude associated with age and intracranial aneurysm (IA) should be reconsidered. Therefore, because of improvements in surgical results and neuro-intensive care, and more aggressive rehabilitation programs, the management of ruptured intracranial aneurysms in the elderly is changing. This paper aims to emphasize the specific aspects of the disease in the elderly, and present the current management of SAH in an elderly population. Cerebral vasospasm in elderly patients who were operated on the acute stage after subarachnoid hemorrhage was studied under strict criteria. We analyzed a number of 180 cases admitted between January 2000- June 2006, with subarachnoid hemorrhage secondary to an aneurismal rupture, diagnosed on CT scan and DSA angiography. The 180 patients were classified into two age groups: 59 years or younger (group A: 123 cases), 60 to 79 years (group B: 57 cases). Severity of both the subarachnoid hemorrhages on computed tomography scan and the angiographic vasospasms was graded. The angiographic vasospasms were analyzed at the internal carotid artery, M1 segments of the middle cerebral artery, and A2 segments of the anterior cerebral. Clinical vasospasm was appreciated in direct relation with the neurological deficits. In all the relationships among the subarachnoid hemorrhage grades, and the operative approaches to the angiographic vasospasm grade, there was a tendency for the angiographic vasospasm grades to be lower with increasing age in both the internal carotid artery and the M1 segment of the middle cerebral artery. Despite the literature reports of the incidence rate of symptomatic cerebral vasospasm and rebleeding is the same in both groups of age, in our series elderly patients presents a lower incidence of clinical and angiographic vasospasm, because of higher atherosclerosis incidence and cerebral atrophy. The surgical morbidity and mortality rates were 26.31 % (15 cases) and 5.26 % (3 cases), respectively. These rates were non-significantly higher than those for younger patients. CONCLUSION: Prognosis of surgical treatment in aneurismal subarachnoid hemorrhage in elderly patients is not directly related to the severity of hemorrhage or vasospasm but with the associated diseases age related.
