Subarachnoid hemorrhage in the elderly
Chr. TSONIDIS, Ph. TSITSOPOULOS
Most of the patients with spontaneous intracerebral hemorrhage are between 50-80 years old, which means that elderly patients who have suffered a stroke are quite involved. Chronic hypertension constitutes the main risk factor, and in a number of these cases of intracerebral hemorrhage, surgical treatment by means of clot removal is indicated. Other causes, such as cerebral aneurysms and AVMs, are more strictly neurosurgically oriented. Despite the poor results found in the literature, especially in cases of aneurysm surgery in the elderly, more aggressive management seems to lead to better results, with lower morbidity and mortality rates.
Eighteen cases of elderly patients (over 65 years old) with spontaneous intracranial haemorrhage, viz. 10 males and 8 females, aged between 65 and 89 out of a total of 123 patients with spontaneous intracranial hemorrhage, were reviewed in this study. According to W.F.N.S. subarachnoid grading scale at the day of admission, 1 patient was in grade I, 5 patients in grade II, 1 patient in grade III, 7 patients in grade IV and 4 patients in grade V.
Clinical and neuroradiological investigation disclosed subarachnoid haemorrhage, combined with intracerebral haemorrhage in 4 cases, intraventricular haemorrhage in 1 case, and subdural haemorrhage in 1 case. All of these patients underwent CT Scan. In 10 cases the investigation completed by angiograms, which were positive for vascular abnormalities in 8 cases. In 1 patient cerebral vessels studied by MRA. Three patients underwent operation, 1 for basilar tip aneurysm clipping and CSF shunting, 1 for P-com aneurysm clipping, and 1 with post-haemorrhagic hydrocephalus, for CSF shunting. From the remaining 6 patients with angiographic findings, 1 with opthalmic artery aneurysm deteriorated due to gastrointesinal track compilations, septicemia and aneurysm rebleeding, 1 patients with a small ICA aneurysm was scheduled for a new angiography, 1 patient with ICA ectasia was treated conservatively, 1 patient with MCA aneurysm was excluded from surgery due to a large celebral infact and poor general condition, 1 patient with a giant, thrombosed MCA aneurysm, ectasia of the ICA and MCA and celebral infarct, was treated conservatily,while patient with ICA aneurysms was not considered to be a candidate for surgical treatment due to age and an infarct disclosed in CT.
2 out of 3 surgically treated patients (GOS-Glascow Outcome Scale), and GOS 3, for P-com and Basilar tip aneurysm respectively), as well as the patient with hydrocephalus and shunt procedure (GOS 1) improved after surgery. 6 out of 15 patients who were managed conservatively, also improved(GOS 1 and 2), 4 were discharged in the same condition (GOS 2 and 3), while 5 died (GOS 5), 3 due to the initial haemorrhage (W.F.N.S.V.), and 2 after severe complications.
Our results lead to the conclusion that the more aggressive the management of these cases greater the benefits for elderly patients with spontaneous intracranial haemorrhage. Improvements in intensive care, new neuroradiological moralities and established microneurosurgical techniques allow us, nowadays, to manage these cases more effectively.
Key words: Subarachnoid hemorrhage, intracelebral hemorrhage, intraventricular hemorrhage, AVMs, old age.