(Stroke. 1996;27:276-281.)
© 1996 American Heart Association, Inc.
Articles |
Craniotomy for Intracranial Aneurysm and Subarachnoid Hemorrhage
Is Course, Cost, or Outcome Affected by Age?
Presented in part at the Congress of Neurological Surgeons, San Francisco, Calif, October 14-19, 1995.
From the Departments of Anesthesiology (J.B.S., A.J.L., T.J.G.), Medicine (A.J.L.), Neurosurgery (J.B.S., A.L.D.), and Surgery (T.J.G., A.J.L.), University of Florida College of Medicine (Gainesville).
Correspondence to Editorial Office, A.J. Layon, MD, Department of Anesthesiology, University of Florida College of Medicine, Box 100254, Gainesville, FL 32610-0254. E-mail edit.anest2@wpo.health.ufl.edu.
 |
Abstract |
|---|
 Top Abstract IntroductionSubjects and Methods Results Discussion References |
|---|
Background and Purpose Age may influence cost or effectiveness of treatment for subarachnoid hemorrhage (SAH). This study examined the effect of age on both.
Methods Patients (n=219) who underwent
craniotomy for intracranial aneurysm and SAH
over 6 years at one tertiary care center were divided in two ways by
age: single advanced age (<65 years and 
65 years) and decade of age
(23 to 39, 40 to 49, 50 to 59, 60 to 69, and 70 to 81 years). Data
recorded for each patient included numbers of procedures and
complications in the surgical intensive care unit (SICU), number of
days in the SICU and the hospital, costs for SICU and ward care, total
cost (SICU plus ward costs), and the Acute Physiology and Chronic
Health Evaluation (APACHE) II score at admission and discharge, the
Hunt-Hess grade at admission and immediately preoperatively, and
quality of life score, a measure of outcome. Mortality rates by age
group were calculated.
Results The only variable significantly affected by
decade of age was mortality rate, which increased as decade of age
increased (3% to 17%). With the 65-year comparison, mortality rate,
cost, APACHE II score at admission and discharge, days before
operation, and days in the SICU were significantly higher for age 65
years.
Conclusions Whereas mortality is higher for the older age group, quality of life scores appear acceptable for those who survive. Even though the hospital costs of treating elderly patients for SAH may be higher than those for younger patients, this should not be used to justify withholding care from the elderly.
Key Words: aged • craniectomy • costs and cost analysis • quality of life • subarachnoid hemorrhage
|
Introduction |
|---|
|
TopAbstractIntroductionSubjects and Methods Results Discussion References |
|---|
The International Cooperative Study on the Timing of Aneurysm Surgery1 suggested that multiple factors contribute to mortality from SAH, including location of the aneurysm (eg, basilar aneurysm), thickness of the subarachnoid clot on CT, level of consciousness, high blood pressure, coexisting illness, and increased age. The importance of many of these factors has come under debate with recent advances in microneurosurgery and perioperative intensive care. In particular, disagreement exists as to the effect of age on ultimate outcome.1 2 3 4 5 6 Age is a substantial issue because the elderly represent an increasing proportion of the population and therefore may account for a greater proportion of total healthcare costs than do patients of other ages. Thus, we studied whether age significantly affects the course, cost, or final outcome of craniotomy for intracranial aneurysm and SAH.
|
Subjects and Methods |
|---|
|
TopAbstractIntroductionSubjects and Methods Results Discussion References |
|---|
Patients (n=219) with SAH from a ruptured intracranial aneurysm who underwent craniotomy and clipping of the aneurysm between February 1989 and December 1994 were grouped by age in two ways: (1) a single older age, <65 years of age (AGE<65) and those
65 years
(AGE65); and (2) decade of age, 23 to 39
years of age (AGE<40), 40 to 49 years (AGE40),
50 to 59 years (AGE50), 60 to 69 years (AGE60),
and 70 to 81 years (AGE70). The study
consisted of a combined prospective/retrospective analysis.
Contemporaneously collected data were age, sex, race, diagnoses on
admission to the hospital and SICU, sequential APACHE II scores,
discharge status, and numbers of complications, procedures, and days in
the SICU. Retrospectively collected data were location of
aneurysm, incidence of ventriculotomy-dependent
hydrocephalus, and costs of SICU and non-SICU care and combined cost.
Each patient's condition and outcome were scored in three ways. Two
measures of morbidity were used. For severity of illness, APACHE II
scores at admission and at discharge from the SICU were
recorded.7 For severity of neurological insult, HH
grade8 at admission and immediately before operation was
recorded as follows: grade 0, no hemorrhage,
asymptomatic aneurysm; grade 1, SAH with no
neurological deficit, possible nuchal rigidity and headache; grade 2,
moderate to severe headache, nuchal rigidity, no neurological deficit
other than cranial nerve palsy; grade 3, drowsiness, confusion, or mild
focal deficit; grade 4, stupor, moderate to severe hemiparesis, and
possibly early decerebrate rigidity and vegetative
disturbances; and grade 5, coma, decerebrate rigidity, and
moribund appearance. Outcome was assessed by QOL score as follows: grade 1, normal lifestyle or a return to that before SAH; grade 2, minor neurological dysfunction but activities of daily living can be performed without help; grade 3, needs help with some activities of daily living; grade 4, unable to perform activities of daily living and requires full-time care, eg, in a rehabilitation center; and grade 5, death.
Mortality rate was calculated for each age group.
With a computerized statistical analysis system (SigmaStat
version 1.01, Jandel Corp), all data were evaluated for normality of
distribution. Continuous data not normally distributed were
analyzed by Mann-Whitney rank sum, Wilcoxon signed
rank, and Kruskal-Wallis tests. Normally distributed data were
analyzed by the unpaired t test. APACHE II and HH
scores on admission, before operation, and at discharge were evaluated
with ANOVA. All costs and durations of care were treated as
non–repeated measures in each population and were analyzed
with the Mann-Whitney rank sum test. Proportional data, such as QOL
score, were analyzed with either the 
2 or
the Fisher's exact test. Multiple regression analysis was used
to determine which variable or group of variables most closely
correlated with QOL score. Statistical significance was set at
P
.05.
|
Results |
|---|
|
TopAbstractIntroductionSubjects and Methods Results Discussion References |
|---|
Of the 219 patients studied, women outnumbered men and the predominate races were white and African American (Table 1
),
but QOL score did not differ by sex or race. The
slightly smaller number of posterior communicating artery
aneurysms and the larger number of basilar aneurysms
were likely due to the referral pattern for our tertiary care center.
QOL score also did not differ significantly by location of
aneurysm (Table 2). There was a trend, however,
suggesting that posterior circulation and ophthalmic segment artery
aneurysms (many of which were giant) were associated with a
slightly higher QOL score. For all ages, the most common complication
was hypertension, followed by cerebral vasospasm (Table 3).
Patients with ventriculostomy-dependent
hydrocephalus had a slightly higher median QOL score9 than
those without hydrocephalus,10 but the difference was not
significant.
|
|
|
Duration of SICU care, which ranged from 4 to 10.5 days, did not differ
by decade of age; however, with the 65-year-based division,
AGE65 had significantly more SICU days than
AGE<65 (Table 4). Number of
days in the SICU before surgery was significantly higher in
AGE60 than the two youngest groups and than the oldest
group (5 versus 2 days). This difference in SICU days before surgery
also occurred in the 65-year-based groups (2 versus 3 days,
P=.017). Number of procedures and complications in the SICU
did not differ by age group (Table 4). Cost was significantly
greater
for AGE65 (Table 4); costs tended to increase
as decade of age increased, but this did not achieve statistical
significance.
|
Morbidity and Outcome
APACHE II scores were significantly
higher in most older groups
compared with younger groups at admission and discharge (Table
4
); this
was true for both the decade and 65-year comparisons. On admission and
immediately before surgery, HH grade did not differ significantly by
age (Table 4). Compared with AGE<65, the
AGE65 group had a significantly higher
mortality (13% versus 4.6%) and QOL score (2 versus 1) (Table
4).
Mortality by decade ranged from 3% to 17%, the only significant
difference occurring between AGE50 and
AGE70 (Table 4).
Power analysis suggested
that each group contained a sufficient
number of patients to show differences in outcome if they existed.
Although analysis showed that mortality rate increased with
AGE70, both mean and median morbidity
statistics failed to differ between any age groups except
AGE50 and AGE70 (Table 4). The
final HH grade–weighted QOL showed that higher HH grade at
admission, regardless of age, was significantly associated with higher
QOL score (P.05).
Multiple linear regression was performed on the following variables to evaluate their impact on QOL outcome and thus their impact on outcome: age, number of days between hemorrhage and surgery, HH grade on admission and just before surgery, APACHE II score on admission and discharge, non-SICU and SICU costs, and days and number of complications and procedures in the SICU. Only about 35% of the variation in outcome could be accounted for by these variables (r=.592, r2=.35).
|
Discussion |
|---|
|
TopAbstractIntroductionSubjects and Methods Results Discussion References |
|---|
SAH, most commonly secondary to aneurysmal rupture, is a subcategory of cerebrovascular accident, the third leading cause of death in the United States.8 Epidemiological studies suggest that SAH causes 8% to 10% of cerebrovascular accidents and 4% to 5% of related deaths.5 Of approximately 28 000 people who suffer SAH yearly in North America, 18 000 will die or be disabled11 ; 8% to 15% die before receiving medical care, 35% within the first 8 hours, 20% to 37% within 48 hours, and 42% to 61% within the first month.12 Overall mortality ranges from 6% to 52%.1 4 9 12 13 Furthermore, autopsy studies suggest that at least 1% of adults harbor unruptured aneurysms and approximately 0.01% to 0.02% suffer SAH14 ; thus, unruptured aneurysms outnumber ruptured aneurysms. Which unruptured saccular aneurysms should be surgically treated is a matter of debate among neurosurgeons and neurologists.14 15 16 17 The International Cooperative Study on aneurysms suggested that the following factors relate significantly to mortality: thickness of the subarachnoid clot on CT, basilar aneurysm, coexisting medical illness, level of consciousness, increased blood pressure, and advanced age.1 Progress in microneurosurgery and perioperative intensive care may have mitigated some of these factors, in particular age.3 10 12 15 18 19
Studies have reported that the incidence of SAH increases with
age.6 20 Even before those studies, however, it
seemed
intuitive that older patients must necessarily have a worse outcome
secondary to comorbidity. If this were true, then what age group has
the greatest surgical risk or at what age does risk begin to become
"greater"? Several large studies have compared patients by age in
an attempt to answer this question (Table 5). In
general, patients with higher HH grade and significant underlying
medical problems do worse than those without these risk factors. Even
though early
studies1 4 5 15 19
suggested that age was an
independent risk factor for worse outcome, better data now
available2 6 18 21 indicate
that surgical outcome for
elderly patients is not necessarily poor. Functional status at 6 months
to 1 year does appear to worsen with HH grade and age.
|
As several other investigators have
done,1 2 4 6 15 18 21
we also examined the effect of clinical grade in the present study.
Although scoring systems have flaws11 when used for
predictive purposes, as has occurred with the APACHE II system, these
systems can provide an objective barometer of the degree of
comorbidity. Clinical grade as represented by HH score did
not differ by age, which suggests that the severity of the SAH was a
more important determinant than age. APACHE II scores, however, did
vary by age: they were higher both at admission and at discharge with
AGE65 and were higher for the two older
decade groups compared with the two younger decade groups. Therefore,
it was surprising that number of complications or duration of
hospitalization did not differ by age. This emphasizes that, while risk
related to comorbidity can be greater for the elderly, this is not a
given.
With the onset of managed care, concern with cost-effectiveness in
health care has increased.12 We wanted to determine
whether our elderly patients were in fact more expensive to treat and
whether outcome was significantly worse. Cost was, indeed,
significantly higher in every area of care for
AGE65 than AGE<65 (Table 4);
when evaluated by decade, however, there were no significant cost
differences.
In the comparison by decade of age, mortality was increased in a
clinically significant manner only with the oldest age group and in the
overall comparison (Table 4). Outcome also worsened with age;
however,
this difference is unlikely to be clinically significant. All of the
older patients remained independent and able to continue to perform the
activities of daily living.
Although mortality in our study was low and outcome generally excellent compared with the results reported in many previous studies, neurosurgeons may nonetheless need to reassess their understanding of a "good" outcome. Previous studies have primarily based evaluation of surgical results on mortality and some determinant of functional status, such as the Glasgow Coma Scale or QOL. Recently, more sophisticated neuropsychological testing has shown that patients previously considered to have had a good outcome in fact have significant impairment of cognitive function.22 23 For example, nonverbal memory deficits can be frequent, severe, and persistent, with 47% of patients having moderate-to-severe impairment 1 year after craniotomy for aneurysmal SAH.23 Problems with speed of response and visuospatial and frontal lobe abilities occurred and were more profound in the elderly, which suggests that they suffered greater long-term effects from SAH. These data, combined with the fact that fewer than 50% of those who suffer SAH return to work, suggest that tremendous work remains to be done in the treatment and rehabilitation of persons who suffer SAH.
We think that the results from our study combined with other recent findings18 suggest that elderly patients, certainly those older than 65 years, can benefit from aggressive treatment. Although mortality is worse for older patients, outcome of patients who survive is acceptable (data on cognitive impairment23 notwithstanding). Many of these patients will require rehabilitation but can, with aggressive postoperative care, continue to lead useful and productive lives. Thus, the analysis of data from our institution indicates that aggressive treatment of the elderly is appropriate unless and until the patient or family/surrogate determines that, for nonmedical reasons, nonsurgical treatment is preferred. Finally, even though the hospital costs for treating SAH may be higher in elderly patients, whether access to care should be based on the cost of care provision is a moral and ethical question and is not answerable strictly by accounting principles.
|
Selected Abbreviations and Acronyms |
|---|
|
|
Acknowledgments |
|---|
Special thanks to B.E. George and Brenda Hamby for their help in data collection and Lynn Dirk for editorial assistance.
Received September 1, 1995; revision received November 1, 1995; accepted November 1, 1995.
|
References |
|---|
|
TopAbstractIntroductionSubjects and Methods Results Discussion References |
|---|
1. Kassell NF, Torner JC, Haley EC, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery, I: overall management results. J Neurosurg. 1990;73:18-36. [Medline] [Order article via Infotrieve]
2. Inagawa T. Cerebral vasospasm in elderly patients treated by early operation for ruptured intracranial aneurysms. Acta Neurochir (Wien). 1992;115:79-85. [Medline] [Order article via Infotrieve]
3. Inagawa T. Timing of admission and management outcome in patients with subarachnoid hemorrhage. Surg Neurol. 1994;41:268-276. [Medline] [Order article via Infotrieve]
4. Inagawa T, Yamamoto M, Kamiya K, Ogasawara H. Management of elderly patients with aneurysmal subarachnoid hemorrhage. J Neurosurg. 1988;69:332-339. [Medline] [Order article via Infotrieve]
5. Martindale B, Garfield J. Subarachnoid haemorrhage above the age of 59: are intracranial investigations justified? Br Med J. 1978;25:465-466.
6.
Sacco RL, Wolf PA, Bharucha NE, Meeks SL, Kannel WB,
Charette LJ, McNamara PM, Palmer EP, D'Agostino R.
Subarachnoid and intracerebral
hemorrhage: natural history, prognosis, and precursive factors
in the Framingham study. Neurology. 1984;34:847-854.
7. Knaus W, Draper E, Wagner D, Zimmerman J. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818-829. [Medline] [Order article via Infotrieve]
8. Hunt W, Hess R. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28:14-20. [Medline] [Order article via Infotrieve]
9. Camarata PJ, Heros RC, Latchaw RE. `Brain attack': the rationale for treating stroke as a medical emergency. Neurosurgery. 1994;34:144-158. [Medline] [Order article via Infotrieve]
10. Amacher AL, Ferguson GG, Drake CG, Girvin JP, Barr HWK. How old people tolerate intracranial surgery for aneurysm. Neurosurgery. 1977;1:242-244. [Medline] [Order article via Infotrieve]
11. Civetta J, Kirby R. Prediction and definition of outcome. In: Stoelting RK, Barash P, Gallagher TJ, eds. Advances in Anesthesia. St Louis, Mo: Mosby-Year Book; 1992:137-194.
12. Kilner J. Age as a basis for allocating lifesaving medical resources: an ethical analysis. J Health Polit Policy Law. 1988;13:405-423.
13. Levinsky N. Age as a criterion for rationing health care. N Engl J Med. 1990;322:1813-1815. [Medline] [Order article via Infotrieve]
14. Ellenbogen BK. Subarachnoid hemorrhage in the elderly. Gerontol Clin (Basel). 1970;12:115-120. [Medline] [Order article via Infotrieve]
15.
Hijdra A, Braackman R, van Gijn J, Vermeulen M, van
Crevel H. Aneurysmal subarachnoid
hemorrhage complications and outcome in a hospital
population. Stroke. 1987;18:1061-1067.
16. Hugosson R. Intracranial arterial aneurysms: considerations on the upper age limit for surgical treatment. Acta Neurochir (Wien). 1973;28:157-164. [Medline] [Order article via Infotrieve]
17. Saveland H, Hillman J, Brandt L, Jakobsson K, Edner G, Algers G. Causes of morbidity and mortality, with special reference to surgical complications, after early aneurysm operation: a prospective, one year study from neurosurgical units in Sweden. Acta Neurol Scand. 1993;88:254-258. [Medline] [Order article via Infotrieve]
18. Inagawa T. Management outcome in the elderly patient following subarachnoid hemorrhage. J Neurosurg. 1993;78:554-561. [Medline] [Order article via Infotrieve]
19.
Inagawa T, Takahashi M, Aoki H, Ishikawa S, Yoshimoto
H. Aneurysmal subarachnoid hemorrhage in
Izumo City and Shimane prefecture of Japan outcome.
Stroke. 1987;19:176-180.
20.
Ingall TJ, Whisnant JP, Weibers DO, O'Fallon
WM. Has there been a decline in subarachnoid
hemorrhage mortality? Stroke. 1989;20:718-724.
21. Ljunggren B, Saveland H, Brandt L. Causes of unfavorable outcome after early aneurysm operation. Neurosurgery. 1983;13:629-633. [Medline] [Order article via Infotrieve]
22. McKissock W, Paine KWE, Walsh LS. An analysis of the results of treatment of ruptured intracranial aneurysms: report of 772 consecutive cases. J Neurosurg. 1960;17:762-776.
23. Ogden JA, Mee EW, Henning M. A prospective study of impairment of cognition and memory and recovery after subarachnoid hemorrhage. Neurosurgery. 1993;33:572-587.[Medline] [Order article via Infotrieve]
This article has been cited by other articles:
 |
|
 |
|
  R. Luengo-Fernandez, A. M. Gray, and P. M. Rothwell Costs of Stroke Using Patient-Level Data: A Critical Review of the Literature Stroke, February 1, 2009; 40(2): e18 - e23. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D J Nieuwkamp, G J E Rinkel, R Silva, P Greebe, D A Schokking, and J M Ferro Subarachnoid haemorrhage in patients >=75 years: clinical course, treatment and outcome J. Neurol. Neurosurg. Psychiatry, August 1, 2006; 77(8): 933 - 937. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Lubicz, X. Leclerc, J.-Y. Gauvrit, J.-P. Lejeune, and J.-P. Pruvo Endovascular Treatment of Ruptured Intracranial Aneurysms in Elderly People AJNR Am. J. Neuroradiol., April 1, 2004; 25(4): 592 - 595. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Vogel, R. Verreault, J.-F. Turcotte, M. Kiesmann, and M. Berthel Review Article. Intracerebral Aneurysms: A Review With Special Attention to Geriatric Aspects J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2003; 58(6): M520 - 524. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Sedat, M. Dib, M. Lonjon, S. Litrico, D. Von Langsdorf, D. Fontaine, and P. Paquis Endovascular Treatment of Ruptured Intracranial Aneurysms in Patients Aged 65 Years and Older: Follow-Up of 52 Patients After 1 Year Stroke, November 1, 2002; 33(11): 2620 - 2625. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Johansson, K. G. Cesarini, C. F. Contant, L. Persson, and P. Enblad Changes in Intervention and Outcome in Elderly Patients With Subarachnoid Hemorrhage Stroke, December 1, 2001; 32(12): 2845 - 2949. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. D. Reed, D. K. Blough, K. Meyer, and J. G. Jarvik Inpatient costs, length of stay, and mortality for cerebrovascular events in community hospitals Neurology, July 24, 2001; 57(2): 305 - 314. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. E. Lempert, A. M. Malek, V. V. Halbach, C. C. Phatouros, P. M. Meyers, C. F. Dowd, and R. T. Higashida Endovascular Treatment of Ruptured Posterior Circulation Cerebral Aneurysms : Clinical and Angiographic Outcomes Stroke, January 1, 2000; 31(1): 100 - 110. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. C. Johnston, D. R. Gress, and J. G. Kahn Which unruptured cerebral aneurysms should be treated?: A cost-utility analysis Neurology, June 1, 1999; 52(9): 1806 - 1806. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||