Endovascular management of elderly subarachnoid hemorrhage patients: A UK experience
Khalid Mohmoud, Nithish Jayakumar, Nicholas Ross

Department of Neurosurgery, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, United Kingdom

Purpose
Subarachnoid hemorrhage (SAH) in the elderly is a grave illness with high morbidity and mortality [1].  However, as the population grows older in most high-income countries, the incidence of elderly patients with SAH is bound to increase too. 
Endovascular treatment has become the mainstay of treatment for aneurysmal SAH in the United Kingdom (UK) and its advantages are well-recognised [2]. Endovascular treatment in elderly SAH patients, however, has not shown any significant benefit compared to surgical clipping [3]. 
The purpose of this study was to describe the experience of managing SAH in elderly (>75 years old) patients at a tertiary neurosciences centre in the UK.

Materials and Methods
A retrospective cohort study of all patients with SAH admitted to our institution, aged 75 years and above, between the years 2014-2019 was performed. Clinical notes and imaging of eligible patients were reviewed independently by the authors. 
Data items collected include patient demographics, WFNS grade, aneurysm location, the presence of hydrocephalus, and pre-morbid ASA grade. Functional outcomes were assessed through the Modified Rankin Scale (MRS) – at discharge and 6-month follow-up. Clinical outcomes included SAH complications (hyponatraemia, rebleed), medical complications (pneumonia, stroke, etc), hospital length of stay, need for ITU admission, and procedural complications. 
Statistical analyses were performed on SPSS (IBM).

Results
Fifty-three patients were included. Median age was 78 (range = 75-91) and 84.9% were females. Over 80% of aneurysms were in the anterior circulation. Two-thirds (67.9%) presented with a good grade (WFNS I-II) while 22.6% had a poor grade (WFNS IV-V). Forty-seven (88.7%) were treated by endovascular therapy. The majority (91.7%) were treated within 48 hours of the ictus. 
More than half (56.3%) required CSF diversion for hydrocephalus on admission. Nearly half (45.3%) had one or more medical complications. 
The overall mortality rate was 17.0%. Less than half (46.9%) were discharged with a good functional outcome (MRS 0-2). At 6-month follow-up, almost two-thirds (64.9%) were functionally independent (MRS 0-2). 
Predictors of a good functional outcome were WFNS grade, pre-morbid ASA, absence of hydrocephalus, and being discharged home directly. 

Conclusion
The majority of elderly SAH patients were treated with endovascular therapy at our institution. Although the mortality and morbidity remain high, two-thirds of patients achieved a good functional outcome at 6-months. 
Our results confirm prior findings that WFNS grade is a predictor of good outcome while patient co-morbidities and hydrocephalus are also important to consider in this cohort. Endovascular treatment, therefore, is a good treatment option even in the elderly SAH patient.

References
1.	Ohkuma, H., Shimamura, N., Naraoka, M., & Katagai, T. (2017). Aneurysmal Subarachnoid Hemorrhage in the Elderly over Age 75: A Systematic Review. Neurologia medico-chirurgica, 57(11), 575–583. doi:10.2176/nmc.ra.2017-0057
2.	Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomised trial. Lancet. 2002;360:1267–74
3.	F. Proust, S. Bracard, J.-P. Lejeune, L. Thines, X. Leclerc, G. Penchet, J. Bergé, X. Morandi, J.-Y. Gauvrit, K. Mourier, F. Ricolfi, M. Lonjon, J. Sedat, B. Bataille, J. Droineau, T. Civit, E. Magro, I. Pelissou-Guyotat, H. Cebula, K. Lallouche, P. David, E. Emery, P. Courthéoux, J.-R. Vignes, J. Bénichou, N. Aghakani, P.-H. Roche, E. Gay, P. Bessou, J. Guabrillargues, B. Irthum, for the FASHE investigators, A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid haemorrhage. Neurochirurgie. 2018 Dec;64(6):395-400. doi: 10.1016/j.neuchi.2018.08.004

Endovascular management of elderly subarachnoid hemorrhage patients: A UK experience

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