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Endovascular Treatment of Intracranial Aneurysms in Elderly Patients

목 적:고령에서의 뇌동맥류 출혈로 인한 외지주막하 출혈이 증가추세에 있다. 나이가 증가함에 따른 혈관수술 위험성도 높아진다. 이 연구의 목적은 혈관내 코일색전술을로 치료한 고령의 뇌지주막하출혈환자 에게서 시술적 및 임상적 결과를 평가함에 있다. 방 법:2004년 9월부터 2008년 8월까지 본원에서 혈관내 코일색전술을로 치료한 65세 이상의 고령의 뇌지주막하출혈환자 45명을 연구의 대상으로 삼았다. 이 연구의 모든 환자에게서 혈관내 코일색전술을 일 차적인 치료를 하였다. 임상적 변수, 시술과정에서의 기술적 문제에 대한 정보, 시술합병증, 그리고, 임상적 결과를 평가하였다, 결 과:입원시의 임상적 등급이 Hunt & Hess I-II인 경우가 58%, H & H III인 경우가 29%, 그리고, H & H III인 경우가 15%이였다. 후순환동맥류의 빈도는 전체의 8.8%이였다. 코일색전술은 전체의 95%에 서 성공적으로 시술되었다(2명의 환자의 경우는 시술을 시도 하였으나 성공하지 못 하였다). 치료한 뇌동맥 류의 패색정도는 67%에서 완전히 폐색되었고, 16%에서는 뇌동맥류 기시부 부분이 잔존하였고, 13%에서 는 뇌동맥류의 일부 잔류부분에 있었고, 4명의 환자는 치료가 시도되지 못 하였다. 시술합병증의 비율은 8%이였고, 6개월 후 결과는 65%에서 성공적이었고, 27%에서는 심한 장애가 있었고, 9%에서는 부정적인 결과를 보였다. 결 론:65세 이상의 고령의 뇌지주막하출혈환자에서의 혈관내 코일색전술 치료는 재출혈 방지에 효과 적 이었고, 일부 선택된 환자에게서는 개두술보다 작은 유병률 및 치사율로 대체치료법으로 대변된다. 본 연구의 결과에서 보듯이 혈관내 수술치료법이 대부분의 경우 성공적인 결과를 보이기 떄문에 고령의 환 자에게서는 일차적인 치료법이 될 수 있을 것으로 사료된다.


Introduction
The definition of an elderly person is debateable； however, age is a recognised negative prognostic factor for outcome after subarachnoid haemorrhage, and the age cut-off of 65 years is accepted to define a high risk population. As a result of the aging population in the west and the increased incidence of SAH in elderly patients, ruptured intracranial aneurysm is an increas-ingly frequent pathology in elderly people 3)4)6)12)13)15)19)21)23)27) .
Endovascular treatment of intracranial aneurysms has made remarkable progress over the last 10 years and become widely used 5)8)16)24)28) . Moreover, selective embolization with detachable coils has been accepted as an alternative to surgical clipping, with lower morbidity and mortality rates in select cases. Because embolization is less invasive than surgery, it allows us to treat more patients, including elderly individuals, in whom surgical clipping is considered risky. Endovascular treatment is now recognized as an alternative to surgical treatment, especially for patients in poor general health and for lesions of the posterior circulation 1)2)9)17)20) 25) . Nevertheless, no study assessing the results of endovascular treatment in relation to age have been undertaken, and the effectiveness of embolization in elderly patients is yet to be determined.
However, little information is available about its feasibility and effectiveness in elderly patients. We assessed clinical outcomes and results with ruptured intracranial aneurysms treated with selective embolization. And, we compared endovascular therapy results with previous published data.
The goal of this article is to access the outcome in this precise population of patients that underwent endovascular treatment after aneurysm rupture.

Patients and Methods
The selection criteria for this study were：1) spontaneous SAH between September 2004 and August 2008, 2) age 65 years or older at time of SAH, 3) aneurysm rupture as the cause of SAH, 4) endovascular aneurysm treatment chosen as the first line of treatment, and 5) that aneurysm repair treatment was given at the acute stage after hemorrhage(within 3 weeks of aneurysm rupture) 6) Patients with fusiform, traumatic, or mycotic aneurysm were excluded from the study. All patients underwent conventional angiography of both carotid arteries and vertebral arteries. Table 2. shows the location of the aneurysms, 92% of which were in the anterior circulation and 8% of which were in the posterior circulation. Multiple aneurysms were seen in 8 patients(17.6%), but only those responsible for the SA-H were treated. The clinical state of all patients treated by embolization was assessed 6 months after treatment with the use of the Glasgow Outcome Scale(GOS). We define the good recovery(GOS score 5) and moderate disability(GOS score 4) as a 'favorable', severe disability(GOS score 3) and persistent vegetative state(GOS score 2) as a 'severe disability' and death(GOS score 1) as a 'poor outcome'.

Endovascular Embolization Procedure
Coiling of aneurysms was performed on a biplane angiographic unit(Integris BN 3,000；Phillips Medical Systems, Best, the Netherlands). Embolization was performed after induction of general anesthesia and systemic heparinization(3,000 IU bolus, followed by continuous intraarterial infusion of heparin at 1,000 IU/hour) and maintenance of an activated coagulation time more than twice the control value. Aneurysms were embolized using size 10 soft GDCs(Guglielmi detachable coils, Boston Scientific, Boston, USA) 2 or 3mm in diameter.
After road mapping was performed using clear magnified images, a microcatheter(Excelsior SL-10；Boston Scientific, Boston, USA or Prowler 14；Cordis, Miami, USA) was carefully inserted into the aneurysm over the guidewire, and coils were then introduced. The aim of coiling was obtain an attenuated packing of the aneurysm, until not a single coil could be placed. In the occurrence of aneurysm perforation during coiling, heparin was re- Among them, 45 patients(32%) with a ruptured aneurysm were aged 65 years or older. They included 38 women(84%) and 7 men(16%) with a mean age of 71 years(range, 65-82 years)( Table 1). All patients presented with subarachnoid hemorrhage(SAH) and were classified according to the Hunt and Hess(H-H) scale (Table 4). Twenty-six patients(58%) were assigned grade I or II；13(29%), grade III；6, and grade IV-V(13%). In 45 patients, 38 patients for embolization was performed within 24 hours after initial bleeding. The   (Fig. 1, 2, 3), 7 neck remnants(16%), 6 residual filling and attempted cases(4%). Procedural com-   plications occurred in four patients(4%) (Fig. 4, 5, 6).
Outcomes were good or excellent in 29 patients(64%), including the two treated 3-weeks after initial bleeding.
A severe disability or poor outcome was observed in 16   The results of endovascular aneurysm treatment in elderly patients in particular remain to be evaluated in a large series of patients. It is desirable to evaluate the tolerance and benefit of endovascular aneurysm treatment specifically in elderly SAH patients.

Complications
The procedure of endovascular coiling of intracranial aneurysm has been described in the literature 2)16) . However, specific situations may be encountered in elderly people. Tortuosity or stenosis of the femoral and/or supraaortic vessels may limit intracranial arterial access. Common carotid artery puncture were performed to allow better catheter pushability and stability. Endovascular treatment was performed with heparinization, and the common carotid artery was compressed for 15 minutes at the end of the procedure to prevent any local complication at the puncture site.
Sedat et al 25) showed that thromboembolic events during embolization of a ruptured aneurysm are more frequent in elderly people than in younger patients(13%

Risk & Benefit
The main reason for partial occlusion is probably that the goal in this age group was to prevent the ruptured aneurysm from rebleeding without running too great a