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Table of Contents    
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 101-107

The Outcome of Aneurysm Clipping in Septuagenarians – A Retrospective Analysis in a Basic Neurovascular Unit

1 Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
2 Department of Community Medicine and Government Medical College, Thiruvananthapuram, Kerala, India

Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Jyothish L Sivanandapanicker
Department of Neurosurgery, Government Medical College, Thiruvananthapuram - 695 011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.279659

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 » Abstract 

Introduction: The management of aneurysmal subarachnoid hemorrhage (SAH) in the elderly is challenging. Clipping as the definitive treatment is less well tolerated by the elderly population. The outcome is anticipated to be more glimmer in poor grade SAH and in a setup which lacks modern neurovascular gadgets. We present our experience of surgical clipping in elderly patients in such a basic neurovascular unit.
Materials and Methods: A retrospective analysis of hospital records of elderly patients between 70 and 79 of age who underwent surgical clipping of intracranial aneurysms between 2015 and 2017 was done. The patients' characteristics, comorbidities, aneurysm characteristics, intraoperative complications, and postoperative complications were studied to determine the factors influencing an unfavorable outcome. All information was entered into a database (Microsoft Excel) and analyzed using SPSS trial version 16. Outcomes were grouped into a favorable outomce which included Glasgow Outcome Scale scores of 4 and 5, whereas an unfavorable outcome which included Glasgow Outcome Scale scores of 1, 2, and 3.
Results: There were 21 patients with aneurysms located either in the anterior or posterior circulation or both. All underwent standard craniotomy and clipping pertaining to that particular type of aneurysm. A favorable outcome was achieved in 48% of the patients and 52% had an unfavorable outcome. The duration of surgery, number of days on ventilator, and presence of hydrocephalus were the factors found to be statistically significantly associated with unfavorable outcomes.
Conclusion: A team approach consisting of a neuroanaesthetist, neurosurgeons, and critical care personnel can have a huge impact on the postoperative outcome.

Keywords: Aneurysm, clipping, septuagenarians, subarachnoid hemorrhage
Key Messages: The incidence of aneurysmal subarachnoid hemorrhage is on the rise in the aging population. Age is a strong predictor of outcome following surgical clipping of intracranial aneurysm. The elderly population should not be denied surgery citing age as the only reason and they should be offered a fair chance to life with clipping of aneurysm explaining the risks and benefits of the procedure to the family.

How to cite this article:
Kutty RK, Sivanandapanicker JL, Sreemathyamma SB, Prabhakar RB, Peethambaran A, Libu GK. The Outcome of Aneurysm Clipping in Septuagenarians – A Retrospective Analysis in a Basic Neurovascular Unit. Neurol India 2020;68:101-7

How to cite this URL:
Kutty RK, Sivanandapanicker JL, Sreemathyamma SB, Prabhakar RB, Peethambaran A, Libu GK. The Outcome of Aneurysm Clipping in Septuagenarians – A Retrospective Analysis in a Basic Neurovascular Unit. Neurol India [serial online] 2020 [cited 2020 Apr 7];68:101-7. Available from:

Aging is inevitable. The health hazards associated with aging are difficult to manage. The neurosurgical diseases associated with aging are usually perilous and need sophisticated care. The state of Kerala in India is aging faster than the rest of India with an average geriatric population of 12.8%, compared to the national average of 8%.[1] The incidence of aneurysmal subarachnoid hemorrhage (aSAH) is hence on the rise in this age group. Worldwide trends suggest that the incidence of aneurysms in the age group >70 years is around 7.8/100,000 population.[2] There are dilemmas with regards to the best modality for treatment of aSAH in the elderly population. Many researchers favor coiling[2],[3],[4] to have superior outcomes in this cohort, while some scholars propose that surgery is a viable option for them.[5],[6],[7] Since our department is a basic neurovascular unit which does not have the facility for endovascular coiling, we resort to clipping as the only option in the management of aSAH. In this article, we present the results of outcome in our patients in the age group between 70 and 79 years who underwent clipping after rupture of aneurysms. This is the first study from India which examines the outcome of clipping exclusively in the septuagenarian population.

 » Materials and Methods Top

All patients in the age group between 70 and 79 years who underwent clipping after subarachnoid hemorrhage were included in the study. Case records were retrieved from the department library and data were entered into analytical software SPSS trial version. Patients who died prior to clipping were excluded from the study. The study was approved by the institutional review board and ethics committee.

The patients' characteristics, World Federation of Neurological Surgeons (WFNS) grade[8] [Figure 1] at presentation, aneurysm characteristics, type of surgery, side of approach, intraoperative rupture, time from ictus to surgery, presence of hydrocephalus, influence of comorbidities, duration of surgery, presence of complications, and number of days on ventilator were the factors evaluated for the outcome using the Glasgow Coma Scale[9] [Figure 2]. The outcome was grouped into a favorable outcome which comprised Glasgow Outcome Scale (GOS) scores of 4 and 5 and an unfavorable outcome, which consisted of GOS scores of 1, 2, and 3.
Figure 1: Chart showing World Federation of Neurosurgical Society (WFNS) grades

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Figure 2: Chart showing Glasgow Outcome Scale (GOS)

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 » Results Top

There were 21 patients included in the study. The majority of the study population consisted of females who outnumbered males, 20:1. The WFNS grade of the patients is given in [Figure 3]. There were 10 patients in grade 1, 5 patients in grade 2, 2 patients in grade 3, 4 patients in grade 4, and 0 patients in grade 5. There were 8 (32%) patients with diabetes and 17 (68%) patients were hypertensive. There were seven patients who were suffering from both hypertension and diabetes. There were no smokers in this cohort. There were both anterior and posterior circulation aneurysms in this study. The most common location of the aneurysm was the internal carotid artery aneurysm [10 (47.6%)], followed by the middle cerebral artery [4 (19%)], followed by the anterior communicated artery [3 (14%)]. The aneurysmal characteristics are given in [Figure 4]a and [Figure 4]b. The other aneurysms encountered in this series were located on the distal anterior cerebral artery, and a combination of aneurysms involving basilar, Internal Carotid, middle cerebral and posterior communicating arteries. The mean duration from ictus to surgery was 9.57 ± 4. 05 days. The mean duration of surgery was 5.2 ± 1.5 hours. The mean duration from surgery to discharge was 9.7 ± 2.6 days. The mean duration of hospitalization in the deceased was 43.2 ± 39.8 days. Among all the patients, 11 (52.38%) patients had an unfavorable outcome and 10 (47.61%) patients had a favorable outcome. In the unfavorable outcome group, eight (38%) patients died and three (14%) were severely disabled. None was in the persistent vegetative state. In the favorable group, seven (34%) had good recovery and three (14%) were moderately disabled [Figure 5]. Among the factors evaluated for poor outcome, the duration of surgery [Figure 6], presence of hydrocephalus, and the number of days spent of the ventilator [Figure 7] were found to be statistically significant upon analysis using Chi-square test. Complications occurred in patients in both outcome groups. Complications were more frequently seen in patients who had an unfavorable outcome (79%) than in patients with favorable outcomes (21%). Upon statistical analysis by the Chi-square test, this difference did not reach a statistical significance. The most common complication was hyponatremia (57.14%), followed by chest infection (28.57%) and hydrocephalus (14.28%). The remaining complications that occurred in the descending order were hemiplegia, meningitis, ischemic infarcts, deep vein thrombosis leading to pulmonary embolism, and sudden cardiac arrest. The overall complications are charted in [Figure 8]. The WFNS grade had a negative correlation with outcome. Pearson's coefficient of correlation was 2.5 [Figure 9].
Figure 3: Chart representing the number of patients in various World Federation of Neurosurgical Society grades

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Figure 4: (a) Chart representing the distribution of aneurysm types in patients who underwent clipping. Most common location of aneurysm was in the internal carotid artery. There were three cases of multiple aneurysms. (b) Chart representing distribution of aneurysm location in the internal cerebral artery and the middle cerebral artery

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Figure 5: Chart representing the outcome in patients who underwent clipping. The right half with darker shade represents unfavorable outcome and the left half in lighter shade represents favorable outcome

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Figure 6: Box plot representing unfavorable outcome in patients who underwent long duration of surgery against short operating time

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Figure 7: Box plot representing unfavorable outcome in patients who were ventilated against patients who were not ventilated postoperatively

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Figure 8: Graph representing the complications that occurred in patients

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Figure 9: Graph representing the negative correlation between higher WFNS grades and Glasgow Outcome Scale

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 » Discussion Top

The outcome of elderly patients with aSAH is poor. Surgery is always on a second thought, at least in this part of the world. The incidence of this disease has shown to be on the rise in the age group of >70 years in various studies.[10],[11] The mortality associated with aSAH in this age group is very high. Age has been shown to be an independent risk factor in the management of aSAH in various studies.[12],[13],[14],[15],[16],[17],[18],[19] Similar to previously reported studies involving aSAH in the elderly,[17],[20],[21],[22],[23],[24] females outnumbered males in our study. Lifestyle disease such as hypertension which is an important factor in the development of aSAH[25],[26],[27] was present in 17 patients. Although it did not turn out to be statistically significant, 10 (58.8%) patients who were hypertensive had an unfavorable outcome. Because of the social stigma of smoking and alcohol imposed on females in this part of the world, none of the study participants was smoker or consumed alcohol. The WFNS grades inversely correlated with the outcome. Although poor grades fared worse in this study, most patients in the study had good WFNS scores. Of the 10 patients in grade 1, 4 patients had an unfavorable outcome. In grade 2, two out of five patients had an unfavorable outcome. In grade 3, one patient among two had an unfavorable outcome, and in grade 4 all four patients had an unfavorable outcome.

The rate of complications was higher in the unfavorable group but did not reach a statistical significance. Chest infection was the most common cause of mortality in our patients. Advanced age has been cited as a predisposing factor for the development of chest infection by many authors[28],[29] and more so has been cited as a leading cause of mortality in elderly with subarachnoid hemorrhage.[30] This is because of the fact that all patients were primarily under non-neurosurgical care and were transferred to such facility only when the presence of aneurysm was confirmed by a computed tomography (CT) angiogram. This practice might have caused considerable delay in providing a proper surgical cure to some patients. Meanwhile, during this period such patients might have had microaspirations leading to frank chest infection at a later stage. The additional risk factor of a prolonged surgery which has proved to be a statistically significant factor might have added to chest infection in the background of microaspirations. The age-related decline in the pulmonary function combined with postoperative pulmonary pathophysiologic changes result in higher respiratory complications in elderly.[31] Underlying comorbidity, malnourishment, and decreased immune response increase the risk and mortality of pneumonia in elderly patients. In a review by Beliveauand Multach, patients above 70 years of age had an higher risk of respiratory complications compared with younger patients.[32] Savardekar et al. examined the factors responsible for development of postoperative pneumonia in their series of 103 patients undergoing microsurgical clipping of aneurysms.[33] Among other factors that significantly contributed toward the development of postoperative pneumonia, advanced age (>50 years) and duration of surgery >3 hours were statistically significant. Postoperative ventilation has also been cited as a factor for the development of postoperative pneumonia.[33] In our patients, the number of days spent on ventilation significantly contributed toward mortality on statistical analysis. There were 12 patients who were ventilated, out of which 6 developed pneumonia resulting in a fatal outcome. Advanced age patients when compared with young patients have decreased chest wall compliance and show a blunted response to hypoxia and hypercapnia and thus decreased respiratory drive.[34] These factors contribute to the difficult weaning off from the ventilator. The mean duration of surgery in our patients was 5.2 ± 1.5 hours. The shortest surgery lasted 3 hours, while the longest duration was 10 hours. This long variable duration was partly due to the fact that a fair number of cases in the cohort having multiple aneurysms needing additional dissection and clipping. Also, the variable differences in level of expertise and experience of the operating surgeons contributed to the duration of surgery. Only in one case were there bilateral aneurysms needing a bilateral craniotomy and clipping resulting in a prolonged surgery. This case involved rupture of posterior communicating artery along with a nonruptured 22-mm aneurysm of the middle cerebral artery. A right-sided approach was undertaken to clip the posterior communicating aneurysm; in addition, an attempt was made to locate the contralateral aneurysm of the middle cerebral artery. But since the brain was not adequately lax, sequalae to the subarachnoid hemorrhage and considering the longer length of the M1 portion of the middle cerebral artery in this patient, it was thought that this maneuver would do more harm. Hence, a contralateral craniotomy and clipping of the middle cerebral artery was done in the same sitting. Such one session contralateral craniotomies for clipping of unruptured aneurysms have been described by many authors in the literature.[35],[36],[37],[38],[39]

The occurrence of intraoperative rupture has been considered to affect the outcome adversely in elderly population.[40] We had only one case of intraoperative rupture involving an aneurysm of the communicating segment of the internal carotid artery in this series. This patient survived but had an unfavorable outcome.

Hyponatremia was the most common complications in our study. It has been regarded as the most common electrolyte abnormality following aSAH.[41],[42],[43],[44] The management of hyponatremia in the elderly population is challenging. The cause of hyponatremia has to be elucidated accurately as management differs between the most common syndrome of inappropriate syndrome of inappropriate anti-diuretic hormone (SIADH) secretion and cerebral salt wasting syndrome. Treatment was administered only to patients who were clinically symptomatic with serum sodium levels of <131 mmol/L according to the newly classified guidelines of hyponatremia by Rahman and Friedman.[45] The treatment mostly instituted at our center was 3% saline under strict observation as the chance of pontine myelinolysis is high while rapidly correcting in elderly individuals. In only refractory cases, a small dose of steroid (0.1 mg/day fludrocortisone) was sometimes administered. Such small doses have been shown to be effective in maintaining sodium balance as reported in the management of hyponatremia in cerebral salt wasting syndrome following trauma.[46]

Hydrocephalus has been shown to be a negative prognostic factor in patients with aSAH in various studies especially in the elderly population.[15],[47],[48] There were five (23.8%) cases of hydrocephalus in our series which is much lower than in earlier studies. The incidence of elderly patients with aSAH developing hydrocephalus quoted in the literature is around 37%–44%.[15],[49],[50] All our patients with hydrocephalus were managed with external ventricular drain along with surgery. Out of these five external ventricular drains, only two could be converted to a permanent ventriculoperitoneal shunt. All patients in our series who developed hydrocephalus had an unfavorable outcome. In a review by Degos et al., hydrocephalus in elderly patients was shown to be a poor prognostic marker of outcome in patients with subarachnoid hemorrhage at 1 year.[48]

The other complications that occurred in our series were hemiplegia, infarct, pulmonary embolism, and sudden cardiac arrest, all of which are more commonly seen in elderly population. The detection of the complication rate in the elderly is usually late compared with younger individuals. The occurrence of infarct is possibly due to vasospasm. As we do not have a facility for digital subtraction angiography or transcranial Doppler, our detection rate of such complications is very low and mostly late when neurologic manifestations have already occurred. We rely mainly on clinical examination and follow the clinical criteria for detection of symptomatic vasospasm as defined by Shirao et al.[19] Accordingly, vasospasm was suspected whenever there was (a) new onset neurological decline or a focal motor deficit within 14 days of aSAH, (b) negative findings on CT scan to preclude rebleeding or hydrocephalus, and (c) when no other causes of neurological deterioration like seizures, electrolyte imbalance, or metabolic disturbances were identified. The incidence of vasospasm reported in the elderly population with aSAH is variable.[47],[51] Studies have shown that the incidence of asymptomatic angiographic vasospasm in elderly population is much less compared to adults;[4],[52],[53] however, the incidence of symptomatic vasospasm has been the same.[51] This is due to the fact that older patients have more rigid arteries that have become less sensitive to the spasmogenic properties of the accumulated blood products of aneurysmal bleed.[47] Nevertheless, in elderly patients, symptomatic vasospasm has been associated with increased mortality.[19],[47],[54]

The high occurrence of cardiac complications has been noted in various studies involving clipping of aneurysms in the elderly population. This complication is more prevalent in a background of preexisting cardiac illness of the patient undergoing surgery for aneurysm clipping. The minor cardiac events like rhythm abnormalities more common in elderly patients were not included for analysis. Only major events culminating in mortality were recorded. This was observed in a patient who underwent basilar top aneurysm clipping and was recovering well in the postoperative period. The occurrence of sudden death in the recovery period of aneurysm clipping has been shown to occur more in elderly patients compared to younger population.[24] The occurrence of deep vein thrombosis was noted in another patient in the postoperative period. This patient ultimately succumbed to pulmonary embolism in spite of aggressive management. The incidence of DVT is well described in the literature among poor grade patients who undergo clipping of aneurysm. In a study by Gupta et al., this complication was found to be 3%.[55]

The importance of the perioperative care in the elderly patients after clipping of aneurysms cannot be emphasized more. The wide range of complications that an elderly patient develop sequalae to subarachnoid hemorrhage mandate a specialized neurocritical care. The early detection of complications and its management have profound implications. Unlike younger patients, the elderly patients with frailty and declining physiologic reserve who once decompensate in the wake of complications have fewer chances to recoup.

The outcome of elderly patients undergoing clipping have been variable in the literature. The general consensus that patients in good grade have good outcomes and poor grade have poor outcome reflects in the series involving both elderly and young patients. However, the percentage of patients with good outcome proportionately decreases with age.[47] The incidence of an unfavorable outcome in elderly patients in a similar age group who underwent clipping was 52.6%,[5] 53.5%,[17] and 30%.[56] In another series by Schöller et al. involving septuagenarians, poor GOS was observed in 50% and mortality rate was 23%.[4] The mortality rate in our series was 38% (8 patients) and the incidence of sever disability was 14% (3 patients). There were no patients in the vegetative state. Hence, the number of patients with unfavorable outcome was 11 (52%). This is in fact due to lack of poor patient selection, lack of state-of-art postoperative care, and delay in detection of complications.

 » Conclusion Top

Clipping of ruptured aneurysms in elderly patients has a dismal prognosis. Short surgical time and aggressive postoperative management and intensive monitoring may reduce morbidity and mortality associated with aSAH. However, patients in poor grade WFNS are more likely to end up with an unfavorable outcome given surgical intervention.

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