1. Baseline characteristics
A total of 2730 patients with IAs were treated in our hospital from January 2016 to January 2020; among them, 290 elderly patients (≥70 years old on admission) (10.6%) were analysed in the current study. The mean age of the patients was 74.0±4.7 years (range 70 to 95 years old); a total of 220 (75.9%) patients were female. Patient demographic information and history of previous illness are shown in Table 1. Compared with patients in the unruptured group (n=114, 39.3%), patients in the ruptured group (n=176, 60.7%) were significantly older (P<0.001) and had a significantly higher percentage of patients with hypoproteinaemia (P<0.001), anaemia (P<0.001), diabetes mellitus (P<0.001), electrolyte disturbance (P=0.001), pulmonary infection (P=0.001), coronary disease (P=0.005), brain atrophy (P=0.032) and ischaemic stroke (P=0.009). The unruptured group had a significantly higher percentage of patients receiving routine treatment for hypertension than the ruptured group (P=0.024).
Table 1 Baseline information of elderly patients with intracranial aneurysms
Characteristics
|
All combined (n=290)
|
Ruptured (n=176)
|
Unruptured (n=114)
|
P value
|
Age (SD)/years old
|
74.0±4.7
|
74.5±4.8
|
73.3±4.3
|
0.023
|
Female patients, (%)
|
220/290 (75.9)
|
132/176 (75.0)
|
88/114 (77.2)
|
0.670
|
Smoking, (%)
|
25/290 (8.6)
|
15/176 (8.5)
|
10/114 (8.8)
|
0.941
|
Alcohol consumption, (%)
|
15/290 (5.2)
|
6/176 (3.4)
|
9/114 (7.9)
|
0.158
|
Hypertension, (%)
|
228/290 (78.6)
|
144/176 (81.8)
|
84/114 (73.7)
|
0.133
|
Regular treatment of hypertension, (%)
|
198/228 (86.8)
|
119/144 (82.6)
|
79/84 (94.0)
|
0.024
|
Hypoproteinaemia, (%)
|
171/290 (59.0)
|
130/176 (73.9)
|
41/114 (36.0)
|
<0.001
|
Anaemia, (%)
|
152/290 (52.4)
|
119/176 (67.6)
|
33/114 (28.8)
|
<0.001
|
Diabetes mellitus, (%)
|
156/290 (53.8)
|
133/176 (75.6)
|
23/114 (20.2)
|
<0.001
|
Electrolyte disturbance, (%)
|
143/290 (49.3)
|
113/176 (64.2)
|
30/114 (26.3)
|
<0.001
|
Hyperlipidaemia, (%)
|
36/290 (12.4)
|
17/176 (9.7)
|
19/114 (16.7)
|
0.113
|
Pulmonary infection, (%)
|
110/290 (37.9)
|
80/176 (45.5)
|
30/114 (26.3)
|
0.001
|
Coronary disease, (%)
|
38/290 (13.1)
|
31/176 (17.6)
|
7/114 (6.1)
|
0.005
|
Brain atrophy, (%)
|
32/290 (11.0)
|
25/176 (14.2)
|
7/114 (6.1)
|
0.032
|
Ischaemic stroke, (%)
|
98/290 (33.8)
|
72/176 (40.9)
|
26/114 (22.8)
|
0.009
|
Haemorrhagic stroke, (%)
|
8/290 (2.8)
|
6/176 (3.4)
|
2/114 (1.8)
|
0.636
|
Elderly patients: age ≥70 years old; SD: standard deviation;
2. Clinical presentation
Elderly patients with ruptured aneurysms
For the 176 (60.7%) patients who had ruptured aneurysms, the attacks commonly occurred in the morning after waking (n=49, 27.8%). Common inducements included straining during defecation (n=24, 13.6%), emotional fluctuation (n=15, 8.5%) and sneezing (n=8, 4.5%). Presentations included headache (n=148, 84.1%), vomiting (n=118, 67.0%), loss of consciousness (n=64, 36.4%), dizziness (n=22, 12.5%) and hemiparesis (n=20, 11.4%), while only 4 patients (2.3%) presented with seizures. Meningeal irritation (n=68, 38.6%) was the most common sign, followed by cranial nerve deficits (n=22, 12.5%). Slow, progressive development of initial symptoms was documented in 86 (48.9%) patients rather than the typical pattern of sudden onset. Consequently, the mean delay from ictus to admission was prolonged to 264.2±914.0 hours. On admission, a total of 130 patients (73.9%) had good clinical performance (Hunt-Hess grade I-III) (Table 2).
Table 2 Clinical presentations of elderly patients with ruptured intracranial aneurysms
Characteristics
|
All combined
|
%
|
Ruptured patients
|
176/290
|
60.7
|
Symptoms slow development
|
86/176
|
48,9
|
Headache
|
148/176
|
84.1
|
Unconsciousness
|
64/176
|
36.4
|
Vomiting
|
118/176
|
67.0
|
Dizziness
|
22/176
|
12.5
|
Hemiparesis
|
20/176
|
11.4
|
Seizure
|
4/176
|
2.3
|
Meningeal irritation
|
68/176
|
38.6
|
Cranial nerve deficit
|
22/176
|
12.5
|
Admission delay (SD)/hours
|
264.2±914.0
|
-
|
GCS(SD)
|
11.9±4.1
|
-
|
Good clinical presentation
|
130/176
|
73.9
|
Elderly patients: age≥70 years old; SD: standard deviation; GCS: Glasgow Coma Score; Good clinical presentation: Hunt-Hess grade (I-III);
Elderly patients with unruptured aneurysms
Among the remaining 114 (39.3%) patients with unruptured aneurysms, dizziness was the most common symptom (n=42, 36.8%), followed by headache (n=24, 21.1%), limb weakness (n=14, 12.3%) and vomiting (n=6, 5.3%). The most common sign was cranial nerve deficits (n=28, 24.6%) (Table 3).
Table 3 Clinical presentations of elderly patients with unruptured intracranial aneurysms
Characteristics
|
All combined
|
%
|
Unruptured patients
|
114/290
|
39.3
|
Dizziness
|
42/114
|
36.8
|
Headache
|
24/114
|
21.1
|
Limb weakness
|
14/114
|
12.3
|
Vomiting
|
6/114
|
5.3
|
Cranial nerve deficit
|
28/114
|
24.6
|
Elderly patients: age ≥70 years old; SD: standard deviation;
3. Radiological characteristics
Other radiological characteristics of the patients are shown in Table 4. The distribution of modified Fisher grade for the 176 ruptured cases (60.7%) showed that grades 3 and 4 accounted for 60.8% (n=107) of all ruptured cases. Multiple aneurysms were diagnosed in 88 patients (30.3%). The mean size of the aneurysms (largest diameter) was 5.8±4.6 mm. Notably, of the 176 patients with ruptured lesions, 109 (61.9%) had lesions with a largest diameter of less than 5 mm. In addition, 103 (35.5%) patients had irregular lesions with daughter sacs. Furthermore, CAS, brain atrophy and FTP were recorded in 159 (54.8%), 32 (11.0%) and 39 (13.4%) patients, respectively.
Compared with the unruptured group, the ruptured group had significantly higher percentages of patients with irregular aneurysms (P<0.001), CAS (P<0.001), and FTP (P=0.001). In addition, the mean lesion diameter in the ruptured group was significantly smaller (P<0.001), and the percentage of patients with small aneurysms was significantly higher than that in the unruptured group (P<0.001).
Table 4 Radiological characteristics of elderly patients with intracranial aneurysms
Characteristics
|
All combined (n=290)
|
Ruptured (n=176)
|
Unruptured (n=114)
|
P value
|
SAH+ICH, (%)
|
-
|
29/176 (16.5)
|
-
|
-
|
Modified Fisher grade I-II, (%)
|
-
|
69/176 (39.2)
|
-
|
-
|
Modified Fisher grade III-IV, (%)
|
-
|
107/176 (60.8)
|
-
|
-
|
With irregular aneurysms, (%)
|
103/290 (35.5)
|
88/176 (50.0)
|
15/114 (13.2)
|
<0.001
|
CAS, (%)
|
159/290 (54.8)
|
121/176 (68.8)
|
38/114 (33.3)
|
<0.001
|
FTP, (%)
|
39/290 (13.4)
|
33/176 (18.8)
|
6/114 (5.3)
|
0.001
|
With multiple aneurysms, (%)
|
88/290 (30.3)
|
51/176 (29.0)
|
37/114 (32.5)
|
0.529
|
Dissecting aneurysms, (%)
|
12/290 (4.1)
|
7/176 (4.0)
|
5/114 (4.4)
|
0.896
|
Lesion diameter (SD)/mm
|
5.8±4.6
|
5.1±3.3
|
6.8±6.0
|
<0.001
|
Small-size aneurysm, (%)
|
158/290 (54.5)
|
113/176 (64.2)
|
45/114 (39.5)
|
<0.001
|
Anterior circulation, (%)
|
280/290 (96.6)
|
172/176 (97.7)
|
108/114 (94.7)
|
0.301
|
ICA, (%)
|
204/290 (70.3)
|
124/176 (70.5)
|
80/114 (70.2)
|
0.959
|
MCA, (%)
|
58/290 (20.0)
|
38/176 (21.6)
|
20/114 (17.5)
|
0.400
|
ACA, (%)
|
24/290 (8.3)
|
18/176 (10.2)
|
6/114 (5.3)
|
0.134
|
Acom, (%)
|
32/290 (11.0)
|
18/176 (10.2)
|
14/114 (12.3)
|
0.586
|
Posterior circulation, (%)
|
24/290 (8.3)
|
10/176 (5.7)
|
14/114 (12.3)
|
0.076
|
PCA, (%)
|
4/290 (1.4)
|
2/176 (1.1)
|
2/114 (1.8)
|
0.940
|
PICA, (%)
|
2/290 (0.7)
|
2/176 (1.1)
|
0/114 (0)
|
0.678
|
VA, (%)
|
14/290 (4.8)
|
5/176 (2.8)
|
9/114 (7.9)
|
0.093
|
BA, (%)
|
4/290 (1.4)
|
1/176 (0.6)
|
3/114 (2.6)
|
0.339
|
Elderly patients: age≥70 years old; SAH: subarachnoid haemorrhage; ICH: intracerebral haemorrhage; CAS: cerebrovascular atherosclerotic stenosis; FTP: foetal-type posterior cerebral artery; SD: standard deviation; ICA: internal carotid artery; MCA: middle cerebral artery; ACA: anterior cerebral artery; Acom: anterior communicating artery; PCA: posterior cerebral artery; PICA: posterior inferior cerebellar artery; VA: vertebral artery; BA: basilar artery;
4. Treatment and complications during hospitalization
The patients’ treatment modalities and incidence of complications are shown in Table 5. A total of 181 patients (62.4%) were treated by surgical intervention, including 91 (31.4%) with craniotomy clipping and 90 (31.0%) with an endovascular approach; the remaining 109 patients (37.6%) received conservative treatment. Pulmonary infection (n=138, 47.6%), hydrocephalus (n=72, 24.8%), and thrombosis (n=35, 12.1%) were common complications during hospitalization. Notably, some commonly seen complications in other age groups, such as seizures (1.7%) and vasospasm (2.8%), were not obvious in our series.
For the comparison between the two groups, the ruptured group had significantly higher percentages of patients who underwent craniotomy surgery (P<0.001), while the unruptured group had a significantly higher ratio of cases undergoing the endovascular approach (P<0.001). Regarding complications, the ruptured group had a significantly higher percentage of patients with thrombosis than the unruptured group (P=0.031).
Table 5 Treatment, complications and prognosis of elderly patients with intracranial aneurysms
Characteristics
|
All combined (n=290)
|
Ruptured (n=176)
|
Unruptured (n=114)
|
P value
|
Craniotomy, (%)
|
91/290 (31.4)
|
75/176 (42.6)
|
16/114 (14.0)
|
<0.001
|
Endovascular, (%)
|
90/290 (31.0)
|
33/176 (18.8)
|
57/114 (50.0)
|
<0.001
|
Conservative, (%)
|
109/290 (37.6)
|
68/176 (38.6)
|
41/114 (36.0)
|
0.646
|
Pulmonary infection, (%)
|
138/290 (47.6)
|
83/176 (47.2)
|
55/114 (48.2)
|
0.856
|
Hydrocephalus, (%)
|
72/290 (24.8)
|
43/176 (24.4)
|
29/114 (25.4)
|
0.846
|
Thrombosis, (%)
|
24/290 (12.1)
|
20/176 (11.4)
|
4/114 (3.5)
|
0.031
|
Rebleeding, (%)
|
23/290 (7.9)
|
14/176 (8.0)
|
9/114 (7.9)
|
0.985
|
Gastrointestinal bleeding, (%)
|
16/290 (5.5)
|
8/176 (4.5)
|
8/114 (7.0)
|
0.368
|
Seizure, (%)
|
5/290 (1.7)
|
2/176 (1.1)
|
3/114 (2.6)
|
0.622
|
Blood vasospasm, (%)
|
8/290 (2.8)
|
4/176 (2.3)
|
4/114 (3.5)
|
0.794
|
Intracranial infection, (%)
|
15/290 (5.2)
|
9/176 (5.1)
|
6/114 (5.3)
|
0.955
|
Elderly patients: age ≥70 years old;
5. Clinical outcomes
Patient clinical outcomes are shown in Table 6. The mean length of hospital stay was 9.5±10.7 days, ranging from 1 to 74 days. By the time of discharge, favourable clinical outcomes (GCS score≥13) were seen in 199 (68.6%) patients. A total of 35 patients (12.1%) died during their stay in the hospital. By the end of the 1-year follow-up, 158 patients (54.5%) demonstrated favourable outcomes (mRS score 0–2), while 33 additional patients had died, resulting in a total mortality rate of 23.4% (n=68). The remaining 64 (22.1%) patients demonstrated unfavourable outcomes (mRS score 3–5).
The clinical outcomes showed significant differences between the ruptured and unruptured groups. Patients in the ruptured group had a significantly longer length of hospital stay than those in the unruptured group (P=0.037). Additionally, the ruptured group had significantly better clinical outcomes at different follow-up time points, presenting as significantly higher percentages of unfavourable outcomes (P<0.05) and death (P<0.05) and significantly lower rates of patients who had favourable outcomes (P<0.001).
Table 6 Clinical outcomes of elderly patients with intracranial aneurysms
Characteristics
|
All combined (n=290)
|
Ruptured (n=176)
|
Unruptured (n=114)
|
P value
|
Mean length of stay (SD)/day
|
9.5±10.7
|
10.5±11.1
|
7.8±9.9
|
0.037
|
Discharge
|
Favourable, (%)
|
199/290 (68.6)
|
97/176 (55.1)
|
102/114 (89.5)
|
<0.001
|
Unfavourable, (%)
|
56/290 (19.3)
|
49/176 (27.8)
|
7/114 (6.1)
|
<0.001
|
Death, (%)
|
35/290 (12.1)
|
30/176 (17.0)
|
5/114 (4.4)
|
0.002
|
3 month
|
Favourable, (%)
|
187/290 (64.5)
|
87/176 (49.4)
|
100/114 (87.7)
|
<0.001
|
Unfavourable, (%)
|
61/290 (21.0)
|
53/176 (30.1)
|
8/114 (7.0)
|
<0.001
|
Death, (%)
|
42/290 (14.5)
|
36/176 (20.5)
|
6/114 (5.3)
|
<0.001
|
6 month
|
Favourable, (%)
|
164/290 (56.6)
|
75/176 (42.6)
|
89/114 (78.1)
|
<0.001
|
Unfavourable, (%)
|
71/290 (24.5)
|
56/176 (31.8)
|
15/114 (13.2)
|
<0.001
|
Death, (%)
|
55/290 (19.0)
|
45/176 (25.6)
|
10/114 (8.8)
|
<0.001
|
1-year follow-up
|
Favourable, (%) outcomes
|
158/290 (54.5)
|
72/176 (40.9)
|
86/114 (75.4)
|
<0.001
|
Unfavourable, (%)
|
64/290 (22.1)
|
46/176 (26.1)
|
18/114 (15.8)
|
0.038
|
Death, (%)
|
68/290 (23.4)
|
58/176 (33.0)
|
10/114 (8.8)
|
<0.001
|
Elderly patients: age≥70 years old; SD: standard deviation; GCS: Glasgow Coma Score; Favourable outcomes: GCS score≥13 at discharge and Modified Rankin Scale of 0–2 during follow-up; Unfavourable outcomes: GCS score <13 at discharge and Modified Rankin Scale of 3-6 during follow-up;