Surgical management of ruptured aneurysms in the eighth and ninth decades

The surgical management of elderly patients with aneurysmal subarachnoid haemorrhage (SAH) is controversial. The present study was performed to more clearly define issues facing elderly SAH patients undergoing surgical repair of their aneurysms.

Between 1990 and 2000, 100 patients, aged 70 years or older, were managed consecutively with aneurysmal surgical repair at Verona City Hospital. Ninety-seven of these were analysed with regard to age, clinical grade on admission, radiological features, and specific management components (3 patients were excluded from further analysis because of inadequate follow up data). Surviving patients were followed up for a minimum of 6 months and clinical outcome was assessed.

Hydrocephalus requiring permanent CSF diversion occurred in 44% of cases surviving beyond 10 days from their SAH. The development of hydrocephalus requiring shunting was delayed more than 6 weeks in 7% of these cases. Medical complications occurred in 22% of cases. Clinical grade of haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.03) were significantly associated with poor outcome. Clinical vasospasm was not a major determinant of outcome in this group. The need for permanent CSF diversion was significantly associated with increasing age (p=0.03), intraventricular haemorrhage (p<0.001), early hydrocephalus requiring ventriculostomy (p=0.003) and the development of medical complications (p=0.05).

Elderly patients experience a different range of complications following aneurysmal subarachnoid haemorrhage than their younger counterparts. Clinicians should remain alert to the development of hydrocephalus, especially of delayed onset.