Abstract
Purpose
Patients over the age of 80 years when diagnosed with an unruptured intracranial aneurysm (UIA) pose unique decision-making challenges due to shortened life-expectancy and increased risk of treatment. Thus, we investigated the risk of rupture and survival of a consecutive series of patients who were diagnosed with an UIA after the age of 80 years.
Methods
Data of consecutive patients with an UIA were reviewed, and patients were included in our study if they were first evaluated for a UIA by the senior author during their ninth decade of life. Outcomes were aneurysm rupture and overall survival after diagnosis. Survival was estimated from a Kaplan-Meier survival curve. Incidence of risk factors was compared to a population of patients less than 65 years who were seen by the senior author over the same time period.
Results
Eighty-three patients who were over 80 years when diagnosed with a UIA were included in this study. In our population, there is a risk of rupture of 3.2% per patient-year. One-, three-, and five-year survival rates for our population were estimated to be 92, 64, and 35%, respectively. When compared to patients under 65 years diagnosed with a UIA, “over 80” patients had a significantly higher incidence of hypertension, and a significantly lower incidence of smoking history and familial aneurysm history.
Conclusions
In our study population, UIAs greater than 7 mm carry a non-negligible risk of rupture of 3.2% per patient-year, and further studies investigating the risk-to-benefit ratio of treatment in this population are warranted.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required. All included patients agreed to be included in our aneurysm research database.
This article does not contain any studies with animals performed by any of the authors.
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All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
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As we consider this manuscript, let us remember our first principles. Unruptured aneurysms are dangerous and represent a material risk to the patient. Subarachnoid hemorrhage from a known UIA is a dangerous and often lethal disease. Anything we can do, safely, to prevent SAH from UIA is worthwhile. This particular study addresses the question of UIA in patients 80 years of age or older. As clinicians, we deal with this issue frequently. The author’s own words are poignant: “A UIA diagnosed in our population of patients over 80 years carries an annual rate of rupture of 3.2% per patient with a 100% rupture-related mortality rate.” It is important for us to recognize that all ruptured aneurysms in this study were 7 mm or greater, curiously mirroring the ISUIA data, which comes from the same institution. To me, the answer is simple, if we can treat UIA 7 mm or greater with a morbidity/mortality less than 3.2%, treatment should be offered, no matter what the age, presuming that no life-threatening co-morbidities (like terminal malignancy) are present. The problem of course, is that this simple answer leaves us still in doubt about elderly, healthy patients with lesions less than 7 mm in size. Do we treat them too, or is this unjustified based on the risk? Do we follow them for enlargement, and if so how often, and what change would then justify proceeding to treatment? These questions are not addressed in this manuscript, and experienced clinicians must still follow their own internal guidance here as they counsel UIA patients in this age group.
Christopher M. Loftus
PA, USA
This article is part of the Topical Collection on Vascular Neurosurgery-Aneurysm
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Sorenson, T.J., Vine, R. & Lanzino, G. Unruptured intracranial aneurysms in patients over 80 years: natural history and management implications. Acta Neurochir 160, 1773–1777 (2018). https://doi.org/10.1007/s00701-018-3590-0
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DOI: https://doi.org/10.1007/s00701-018-3590-0