75歳以上高齢者無症候性未破裂脳動脈瘤は治療すべきか？─単一施設の動脈瘤治療成績からの解析─

抄録

Background: The decision to treat unruptured aneurysms (uANs) includes an analysis of the natural history, risks of treatment, and potential benefits of a lifelong cure for each patient. With the increase in average life expectancy and widespread use of magnetic resonance imaging (MRI), it is estimated that the number of uANs diagnosed in elderly patients will increase. However, outcomes associated with surgical and endovascular treatments for uANs in elderly patients remain unclear.
Objective: The aim of this study was to assess the outcomes in elderly patients with asymptomatic uANs who underwent either clipping or coiling.
Methods: In this retrospective study, 17 consecutive elderly patients (age ≧ 75 years) with asymptomatic uANs underwent clipping or coiling at our institution between April 2010 and March 2015. The clinical (Glasgow Outcome Scale at discharge) and postoperative radiological results in this group were compared with a group of younger patients with uANs (< 75 years, n=93), and with consecutive patients with concurrent subarachnoid hemorrhage (SAH) due to ruptured aneurysms: ≧ 75 years (n = 18) and < 75 years of age (n = 101).
Results: A total of 17 patients ≧ 75 years of age (average: 79.8 years, range 75-85) with a total of 20 asymptomatic uANs were treated with either surgical (n=10) or endovascular procedures (n=8).
In contrast with the overall results in patients with SAH (older patients fare worse than their younger counterparts: good recovery, 22% vs. 56%, respectively), posttreatment neurological deficits in patient with uANs were more common in the younger group (< 75 years old, 5%) than in the older group (≧ 75 years old, 0%); however, there was no statistical difference. On the contrary, the posttreatment occurrence of chronic subdural hematoma in the elderly (16.7%) was more common than in the younger group (1%), and the difference was significant.
Surgically treated elderly patients with uANs had a significantly longer hospital stay than elderly patients who underwent endovascular treatment (25.7 days vs. 5.3 days).
Moreover, among all surgically treated patients with a good neurological outcome, increased age was associated with an increased length of hospital stay. In contrast to the surgically treated group, the length of hospital stay in the endovascular treatment group did not vary with age.
Conclusion: Endovascular and surgical treatments for uAN in patients ≧ 75 years old appear to be feasible and safe.
With regard to safety and length of hospital stay, coiling is a better method than clipping for elderly patients with uAN.