Meta-Analysis: Endovascular Therapy Suitable for Intracranial Aneurysms in Selected Elderly

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Endovascular coiling to treat ruptured and unruptured intracranial aneurysms offers high long-term occlusion rates in elderly patients, according to a meta-analysis published in the July 2013 issue of Stroke. However, the risks of mortality and morbidity warrant careful patient selection, especially in those with unruptured aneurysms.

Investigators led by Giuseppe Lanzino, MD, of the Mayo Clinic College of Medicine (Rochester, MN), looked 1,511 patients aged 65 years or older who underwent endovascular coiling for ruptured or unruptured intracranial aneurysms in 21 studies conducted between 1995 and 2012. All were case series, and 18 were retrospective.

The majority of patients (89%) underwent coiling alone. Balloon-assisted coiling was used in 5% of the procedures, while stent-assisted coiling and secondary clipping were each required in 3%.

Ruptured Aneurysms Pose Greater Risk

Endovascular therapy resulted in a similarly high 87% rate of total/near total occlusion beyond 12 months for both the ruptured and unruptured groups (P = NS). But patients with ruptured aneurysms saw higher rates of intraoperative rupture and perioperative mortality and a trend toward greater perioperative morbidity (table 1).

Table. Complications and Outcomes

Other perioperative complications including parent artery occlusion, transient ischemic attack, vasospasm, and stroke were equivalent irrespective of rupture, as was the development of procedure-related new permanent neurological deficit.

At 1-year post-procedure, 78% of patients were classified as having achieved good recovery or moderate disability (93.0% for unruptured vs. 66.0% for ruptured aneurysms).

Limited Lessons for Practice

Like any meta-analysis, the main limitation of the study is that its validity depends upon the quality of the literature on which it is based, Dr. Lanzino told TCTMD in an e-mail communication. Importantly, he said, “there is no way to know the selection process which went into the choice of the patients included in these single center reports.”

In addition, Christopher J. Moran, MD, of Washington University School of Medicine (St. Louis, MO), pointed out that the meta-analysis did not include many studies reviewing adjunctive techniques.

“Most of the studies were just coiling without balloon-assisted or stent-assisted coiling, both of which have somewhat higher complication rates but are capable of treating aneurysms that you could not otherwise treat,” Dr. Moran told TCTMD in a telephone interview. 

Surgery the Only Alternative to Coiling 

Currently, the only alternative to endovascular coiling is surgical clipping.

“There is greater morbidity associated with clipping and probably a slightly higher mortality, and as patients age, the procedure takes more out of them,” Dr. Moran said. Although the older patient population continues to be studied, surgery and endovascular therapy outcomes are coming closer together, he commented.

According to Dr. Lanzino, the risks of hemorrhage from brain contusion and seizure, both of which may occur after open surgery in the elderly, are also reduced with the endovascular approach. However, he added that endovascular treatment is not without its own complications, including ischemic stroke arising from manipulation of the vessel. 

Patient Selection Key

Because of the risks associated with endovascular treatment, Drs. Moran and Lanzino agreed that appropriate patient selection is important. Physicians must balance the characteristics of the patient, the geometry of the aneurysm, and their proficiency at the procedure.

“This is particularly true in the case of unruptured intracranial aneurysms, which often do not need any treatment at all, especially in elderly individuals,” Dr. Lanzino said. “The ideal patient [is one] with a brain aneurysm at high risk for rupture—because of size, ruptured status, location, and the presence of symptoms—and who has a low risk from the recommended treatment.”

 

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Source:
Sturiale CL, Brinjikji W, Murad MH, Lanzino G. Endovascular treatment of intracranial aneurysms in elderly patients: A systematic review and meta-analysis. Stroke. 2013;44:1897-1902.

 

 

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