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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58:M520-M524 (2003)
© 2003 The Gerontological Society of America

REVIEW ARTICLE

Review Article. Intracerebral Aneurysms: A Review With Special Attention to Geriatric Aspects

Thomas Vogel1,2, René Verreault2,3, Jean-François Turcotte4, Michèle Kiesmann1 and Marc Berthel1

1 Centre de Gérontologie, Hôpital de la Robertsau, Strasbourg, France.
2 Unité de Recherche en Gériatrie de l'Université Laval
3 Département des Sciences Neurologiques, Centre Hospitalier Affilié Universitaire de Québec, Canada.
4 Département de Médecine Sociale et Préventive, Université Laval, Québec, Canada.


   Abstract
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 Abstract
Epidemiology and Physiopathology
 Diagnosis
 Clinical Presentation
 Management
 Specific Management in the...
 References
 
Rupture of an intracranial aneurysm (ICA) remains a devastating complication associated with a high degree of morbidity and mortality. In the past 2 decades, older people were often excluded from active treatment on the unique basis of their chronological age. Recent developments of less-invasive techniques for the diagnosis and treatment of ruptured and unruptured ICAs suggest that this fatalistic attitude toward older patients should be reconsidered. Furthermore, taking into account the heterogeneity of the elderly population, the use of a comprehensive geriatric assessment approach, based on a multidisciplinary evaluation, appears particularly helpful in proposing the optimal treatment strategy for each older patient. This article reviews the geriatric features of epidemiological, physiopathological, as well as clinical and therapeutic aspects of ruptured and unruptured ICAs.

THE rupture of an intracranial aneurysm (ICA) is a devastating event, and is still associated with a relatively poor outcome. Twenty years ago, older people were considered to have such a poor prognosis that they were frequently excluded from active treatment on the unique basis of their advanced age. However, new approaches in the management of ICAs have been developed over the last 2 decades, including early surgery, neurointensive care, interventional neuroradiology, and more aggressive rehabilitation programs. Recent reports suggest that the prognosis of ICA has globally improved in recent years (1), and that carefully selected older patients may benefit from these new treatments for ICA, suggesting that the classical fatalist attitude associated with age and ICA should be reconsidered.


   EPIDEMIOLOGY AND PHYSIOPATHOLOGY
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 Epidemiology and Physiopathology
Diagnosis
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 Management
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The prevalence of ICA varies considerably, ranging between 3.6% and 6% (2,3), and 80% to 85% of ICAs are located in the anterior circulation. The major complication is subarachnoid hemorrhage (SAH) due to rupture. The annual risk of aneurysm rupture has been stable over the last 3 decades, estimated at 1% to 2%, with a range of 0.05% to 4% (3–5). Incidence of SAH due to ICA rupture seems to increase with advancing age (6). Some studies reported a steady increase in incidence rate with age (7–11), while others reported an increase in incidence up to 50–70 years of age, followed by a decline thereafter (12–16). In the Canadian Collaborative Study Group of Stroke Hospitalizations, the incidence of SAH increased with age for both sexes, and reached a plateau of 16.2 per 100,000 between 55 and 59 years for men, and a plateau of 24.4 per 100,000 between ages 69 and 74 years for women (17). Some studies suggested that in patients older than 60 years, SAH occurred predominantly in women, whereas in those younger than 60 years, there was a preponderance of men (8,13,14). Several longitudinal studies reported an increase in incidence of ruptured and unruptured ICAs in recent years among older people (18,19), suggesting a potential change in attitudes as to the diagnosis and treatment of ICA in the elderly population.

Mechanisms involved in ICA development remain controversial. Pathogenesis of ICA involves genetic predisposition and environmental factors, probably in interaction (20–23). Potential acquired risk factors include smoking, alcohol, and, to a lesser extent, hypertension (24,25), although specific impact on the risk of formation or rupture has been difficult to individualize (26). Once the ICA is present, factors associated with the risk of rupture include the size of the aneurysm, a location in the posterior circulation, and a previous history of aneurysmal SAH (4,27). The relationship between age and risk of aneurysm rupture remains unclear. The International Study of Unruptured Intracranial Aneurysms (ISUIA) found no association with age (4), while a recent review reported a higher risk of rupture in older age groups (3).


   DIAGNOSIS
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 Diagnosis
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Unruptured ICA
The gold standard for the diagnosis of unruptured ICAs remains the intraarterial digital subtractions angiography (DSA). It has the highest spatial resolution and allows visualization of the entire cerebral arterial vasculature (28). DSA, however, carries risk of complication, with an occurrence of permanent neurological injury of approximately 0.07% and a mortality rate of less than 0.1% (29). Higher risk of complications and death after DSA in older patients has been consistently reported. Some studies reported a lower risk of neurological complications when DSA is performed for SAH or ICA, compared with transient ischemic attack or stroke (30–32).

In the last few years, new noninvasive procedures have been developed, including computed tomography helical angiography (CTA), magnetic resonance angiography (MRA), and transcranial Doppler ultrasonography. Compared with DSA, MRA and CTA depicted ICA with a similar accuracy of about 90%, although the sensitivity of detection appears slightly lower for ICAs of small size (33–36).

Subarachnoid Hemorrhage
Computed tomography scanning appears as the investigation of choice in patients with suspected SAH. Its sensitivity reaches 90% to 95% if it is performed within 24 hours, and decreases with time, falling to 70% at 3 days, and approaching 0% at 3 weeks (5). Conventional MRI seems to be relatively insensitive in SAH detection, but new MR sequences appear to have potential advantages to CT scanning, especially in the subacute period (37). Lumbar puncture remains the cornerstone investigation if clinical suspicion is strong and if imaging investigations are negative. The lumbar puncture can, however, falsely suggest a diagnosis of SAH in patients with intracerebral hematoma or traumatic tap, and these pathologies are not uncommon in geriatric medicine. Nevertheless, taking into account the frequency of neuroimaging and focal neurological signs in these patients, this remains improbable in modern practice.


   CLINICAL PRESENTATION
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Unruptured ICAs are usually silent. They occasionally produce classical signs of a mass effect, including headache with neurological manifestations according to ICA location. One of the most frequently described sign is palsy of the third cranial nerve, caused by an ICA located at the junction of the carotid and the posterior communicating arteries or at the upper end of the basilar artery. Other uncommon manifestations of unruptured ICAs include small infarcts or transient ischemia due to distal embolization (38). Specific presentations of unruptured ICAs in older people have not been greatly examined. Classical symptoms and signs may be more difficult to recognize in older patients with concomitant cerebrovascular or neurodegenerative diseases.

Rupture of an ICA usually produces an SAH, but can also cause an intracerebral hemorrhage, an intraventricular hemorrhage, or a subdural hematoma. Signs and symptoms of aneurysmal SAH typically include acute severe headache, signs of meningeal irritation, altered consciousness, various degrees of neurological deficits, and presence of retinal hemorrhages at fundoscopy. Up to 60% of patients with SAH report an episode of sudden severe headache, days to weeks before rupture, often considered as a "warning leak." Despite this classical clinical presentation, up to 25% of patients with SAH are initially misdiagnosed (39–41).


   MANAGEMENT
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General Considerations
Treatment strategies differ radically whether the ICA is ruptured or not. In an unruptured ICA, especially if the ICA is asymptomatic, decisions must balance the risk of intervention with the risk of rupture while considering concurrent patient conditions and life expectancy. A comprehensive geriatric assessment remains a crucial preliminary step to better estimate these individual risks. This multidisciplinary geriatric approach includes an evaluation of the medical, functional, as well as neuropsychological and social conditions (42–44). Consideration of chronological age alone appears indisputably insufficient, inducing a potential loss of chance for the older patients. Once rupture has occurred, SAH is a life-threatening disease, and management must first focus on stabilization of the patient as well as prevention and treatment of complications. Secondarily, indication of the specific aneurysmal repair treatment that prevents rebleeding should be discussed. The benefit–risk ratio of this curative option should be weighed against a palliative or a symptomatic approach, taking into account, again, the overall condition of the patient.

For both ruptured and unruptured ICAs, the two procedures currently available for aneurysmal sac repair include surgical clipping and endovascular coiling. Neurosurgical clipping of the neck of the ICA has been the standard approach in ICA treatment for more than 40 years. The risk associated with clipping of an unruptured ICA has been well studied. In a recent meta-analysis, Raaymakers and colleagues reported a mortality of 2.6% and a morbidity of 10.9% (45). The long-term safety of surgical clipping is generally considered as good, with an annual risk of SAH of 1% to 2% (46).

A less-invasive endovascular approach using detachable coils, introduced by Guglielmi in 1991, revolutionized the treatment of ICA (47,48). Several recent clinical studies suggest that coiling carries similar or even lower risk of complications than open surgery, especially for ICAs arising from the posterior circulation (49–56). However, these findings, for the most part, come from small-scale nonrandomized clinical studies with relatively short-term follow-up. No data from large randomized prospective trials comparing the long-term advantages of surgical clipping with endovascular coiling are yet available, so that, although promising, the long-term efficacy of coiling remains unclear. A large prospective multicenter trial (the International Subarachnoid Aneurysm Trial) comparing the cost and outcome between the endovascular and neurosurgical procedures is nevertheless under way.

Currently, the choice of clipping or coiling mainly depends on the characteristics of the ICA, presence of neurological complications, coexisting medical conditions, and experience of the surgical team (57).


   SPECIFIC MANAGEMENT IN THE ELDERLY POPULATION
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Unruptured ICA
Management of unruptured ICAs remains controversial in older patients since no large studies have been specifically conducted in this population. The prognostic impact of age after clipping or coiling remains unclear. In Raaymakers' meta-analysis, no clear association between age and surgical outcome was found, while in the ISUIA, older age was the only independent predictor of poor outcome after neurosurgery. Similarly, in a series of 172 cases of unruptured ICAs, Khanna and colleagues found an association between increasing age and poor outcome after surgery (58). Conversely, Chung and colleagues reported, in a small study that included 40 patients aged 70 years or older, a good outcome at 6 months among 85% of the patients, and a mortality rate of 2.5% (59).

Balancing life expectancy with risk of rupture appears crucial in determining potential benefits of treatment of unruptured ICAs in older patients. In order to estimate the number of life-years saved by surgical treatment, recent studies have reported results of actuarial risk analysis. Although the results remain controversial, they suggest that, assuming that the risk of rupture is constant over time, benefits of treatment in terms of life expectancy is expected to decrease with increasing age at diagnosis and to be lowest for patients in the oldest age groups (60,61). It has been suggested, however, that the risk of rupture could change over time, and that estimation of that risk could be much more complex, especially for older patients. Consequently, the choice of optimal treatment strategy remains particularly difficult in elderly patients, as individual life expectancy, risk of surgery, and risk of ICA rupture are extremely difficult to predict. These risk–benefit analyses are made even more complex by multiple comorbidities frequently observed in these populations. In addition, decisions need to be weighed against the wishes of patients and their quality of life.

Ruptured ICA
Prognosis of aneurysmal SAH remains poor with a mortality rate of 25–50%, while 10–20% of patients will remain severely disabled (62). In the study by Chung and colleagues, 45% of the 89 older patients with a ruptured ICA died after 6 months (59). Prognostic factors include location of the ICA, clinical grade at admission, age, coexisting illnesses, systemic and neurological complications, timing of surgery, and experience of the surgical team (63,64). A poorer prognosis with increasing age has been largely documented (65–76). Advanced age has been associated with a high rate of mortality, morbidity, and cognitive impairment (77). Whether this worsening in prognosis could be explained by age itself or by concomitant prognostic factors associated with age remains unclear. Potential age-associated factors include less-aggressive management (78), poorer clinical grade, more frequent comorbidities (79), and higher rates of neurological (71,80) and other complications (66,80,81). Some studies found an association between older age and poor outcome after SAH, independent of other prognostic factors (18,68), while others failed to observe any association between age and mortality (13), or sequelae after SAH (82). Finally, occurrence of cerebral vasospasm, one of the most severe neurological complications after SAH, appeared to be less frequent in older age groups in several studies (81–83), but these findings remain questionable. Recent studies suggested that some elderly patients might have a particularly favorable outcome after an aneurysmal SAH, especially those with good clinical condition prior to rupture (84). Johansson and colleagues studied 281 older subjects, and 85% of those with good neurological conditions at admission (Hunt and Hess I and II) had a favorable outcome (19). In a study by Fridriksson and colleagues, 25 of 76 patients aged 70 to 74 years who were treated with surgery returned to independent living with good cognition (85). In addition, Stachniak and colleagues reported using a small sample of older subjects (n = 47); despite a high mortality rate, elderly patients who survived had a good quality of life (64).

Potential benefits of the newer endovascular procedures in older patients have not been specifically studied. Endovascular coiling is a far less invasive approach than craniotomy with open surgery. It could offer definite advantages for older patients, in particular, by reducing the risk of complications such as pneumonia and anemia (54,86,87). Moreover, the theoretical advantage of the cisternal washing during open surgery to prevent vasospasm is reduced since incidence of vasospasm appears lower in older patients. In addition, the controversial problem of long-term consequences of occasional incomplete aneurysm occlusion after coiling appears less crucial in older people with shorter life expectancy. Finally, it has been suggested that endovascular coiling, by minimizing structural brain damage, may result in less-frequent cognitive impairment than surgery (88).

Conclusion
The number of older people presenting with an ICA will undoubtedly increase over the next decades in developed countries due to the rapid aging process. Prognosis after aneurysmal SAH seems to have improved over the last 20 years, especially for older patients (89). New approaches in treatment and better neurointensive care units have certainly contributed to this improvement. Although the sole consideration of chronological age for choosing between a conservative or a more aggressive treatment now appears no longer justified, optimal management of ruptured as well as unruptured ICAs among older patients remains a matter of debate. The use of a comprehensive geriatric assessment approach, based on multidisciplinary evaluation, should prove particularly helpful in screening potential suitable candidates for invasive procedures after thorough evaluation of medical, functional, psychological, and social conditions. Nevertheless, large-scale clinical studies are clearly needed to better understand the patterns of prognosis after an ICA in the elderly population and to determine the best management strategies, which could reduce mortality, morbidity, and disability while maximizing quality of life.


   Acknowledgments
 
Dr. Thomas Vogel was responsible for the initial literature review and analysis, the initial text draft, and subsequent revisions to the text. Dr. René Verreault contributed substantially to the conception, design, and revisions to the text. Dr. Jean-François Turcotte revised the manuscript critically for important intellectual content. Dr. Michèle Kiesmann and Dr. Marc Berthel contributed to the revising of the article. All authors take full responsibility for the manuscript and its conclusions.

Address correspondence to Dr. Thomas Vogel, Centre de Gérontologie, Hôpitaux Universitaires de Strasbourg, Hôpital de la Robertsau, Pavillon Schutzenberger, 83 Rue Himmerich, 67091 Strasbourg, Cedex, France. E-mail: vogelthomas{at}wanadoo.fr

Received October 7, 2002

Accepted December 11, 2002


   References
Top
 Abstract
 Epidemiology and Physiopathology
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 Clinical Presentation
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 Specific Management in the...
 References
 

  1. Cesarini KG, Hardemark HG, Persson L. Improved survival after aneurysmal subarachnoid hemorrhage: review of case management during a 12-year period. J Neurosurg.. 1999;90:664-672.[Medline]
  2. Winn HR, Jane JA, Sr, Taylor J, Kaiser D, Britz GW. Prevalence of asymptomatic incidental aneurysms: review of 4568 arteriograms. J Neurosurg.. 2002;96:43-49.[Medline]
  3. Rinkel GJ, Djibuti M, Van Gijn J. Prevalence and risk of rupture of intracranial aneurysms: a systematic review. Stroke.. 1998;29:251-256.[Abstract/Free Full Text]
  4. The International Study of Unrupted Intracranial Aneurysms Investigators. unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. N Engl J Med.. 1998;339:1725-1733.[Abstract/Free Full Text]
  5. Linn FHH, Rinkel GJE, Agra A, van Gijn J. Incidence of subarachnoid hemorrhage. Role of region, year, and rate of computed tomography: a meta-analysis. Stroke.. 1996;27:625-629.[Abstract/Free Full Text]
  6. Ingall T, Asplund K, Mähönen M. Bonita A, for the WHO MONICA Project. A multinational comparison of subarachnoid hemorrhage epidemiology in the WHO MONICA Study. Stroke.. 2000;31:1054-1061.[Abstract/Free Full Text]
  7. Fogelholm R. Subarachnoid hemorrhage in middle Finland: incidence, early prognosis and indications for neurosurgical treatment. Stroke.. 1981;12:296-301.[Abstract/Free Full Text]
  8. Sacco RL, Wolf PA, Bharucha NE, et al. Subarachnoid and intracerebral hemorrhage: natural history, prognosis, and precursive factors in the Framingham Study. Neurology.. 1984;34:847-854.[Abstract/Free Full Text]
  9. Kiyohara Y, Ueda K, Hasuo Y, et al. Incidence and prognosis of subarachnoid hemorrhage in a Japanese rural community. Stroke.. 1989;20:1150-1155.[Abstract/Free Full Text]
  10. Phillips LH, 2nd, Whisnant JP, O'Fallon WM, Sundt TM, Jr. The unchanging pattern of subarachnoid hemorrhage in a community. Neurology.. 1980;30:1034-1040.[Abstract/Free Full Text]
  11. Epidemiology of aneurysmal subarachnoid hemorrhage in Australia and New Zealand: incidence and case fatality from the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS). Stroke.. 2000;31:1843-1850.[Abstract/Free Full Text]
  12. Bonita R, Beaglehole R, North JDK. Subarachnoid hemorrhage in New Zealand: an epidemiological study. Stroke.. 1983;14:342-347.[Abstract/Free Full Text]
  13. Inagawa T, Tokuda Y, Ohbayashi N, Takaya M, Moritake K. Study of aneurysmal subarachnoid hemorrhage in Izumo city, Japan. Stroke.. 1995;26:761-766.[Abstract/Free Full Text]
  14. Pakarinen S. Incidence, aetiology, and prognosis of primary subarachnoid haemorrhage: a study based on 589 cases diagnosed in a defined urban population during a defined period. Acta Neurol Scand.. 1967;43:(suppl 29): 1-128.
  15. Ohkuma H, Fujita S, Suzuki S. Incidence of aneurysmal subarachnoid hemorrhage in Shimokita, Japan, from 1989 to 1998. Stroke.. 2002;33:195-199.[Abstract/Free Full Text]
  16. Nilsson OG, Lindgren A, Stahl N, Brandt L, Säveland H. Incidence of intracerebral and subarachnoid in southern Sweden. J Neurol Neurosurg Psychiatr.. 2000;69:601-607.[Abstract/Free Full Text]
  17. Ostbye T, Levy AR, Mayo NE. Hospitalization and case-fatality rates for subarachnoid hemorrhage in Canada from 1982 through 1991. The Canadian Collaborative Study Group of Stroke Hospitalizations. Stroke.. 1997;28:793-798.[Abstract/Free Full Text]
  18. Yamashita K, Kashiwagi S, Kato S, Takasago T, Ito H. Cerebral aneurysms in the elderly in Yamaguchi, Japan. Analysis of the Yamaguchi Data Bank of Cerebral Aneurysm From 1985 to 1995. Stroke.. 1997;28:1926-1931.[Abstract/Free Full Text]
  19. Johansson M, Cesarini KG, Contant CF, Persson L, Enblad P. Changes in intervention and outcome in elderly patients with subarachnoid hemorrhage. Stroke.. 2001;32:2845-2849.[Abstract/Free Full Text]
  20. Schievink WI. Intracranial aneurysms. N Engl J Med.. 1997;336:28-40.[Free Full Text]
  21. Warlaw J, White PM. The detection and management of unruptured intracranial aneurysms. Brain.. 2000;123:205-221.[Abstract/Free Full Text]
  22. Bannerman RM, Ingall GB, Graf CJ. The familial occurrence of intracranial aneurysms. Neurology.. 1970;20:283-292.[Free Full Text]
  23. Gaist D, Vaeth M, Tsiropoulos I, et al. Risk of subarachnoid haemorrhage in first-degree relatives of patients with subarachnoid haemorrhage: follow up study based on national registries in Denmark. BMJ.. 2000;320:141-145.[Abstract/Free Full Text]
  24. Teunissen LL, Rinkel GJ, Algra A, Van Gijn J. Risk factors for subarachnoid hemorrhage: a systematic review. Stroke.. 1996;27:544-547.[Abstract/Free Full Text]
  25. Juvela S, Hillbom M, Nummissen H, Koskinen P. Cigarette smoking and alcohol consumption as risk factors for aneurysmal subarachnoid hemorrhage. Stroke.. 1993;24:639-646.[Abstract/Free Full Text]
  26. Juvela S, Poussa K, Porras M. Factors affecting formation and growth of intracranial aneurysms. A long-term follow-up study. Stroke.. 2001;32:485-491.[Abstract/Free Full Text]
  27. Wiebers DO, Whisnant JP, O'Fallon WM. The natural history of unruptured intracranial aneurysms. N Engl J Med.. 1981;304:696-698.[Abstract]
  28. White PM, Wardlaw JM, Easton V. Can noninvasive imaging accurately depict intracranial aneurysms? A systematic review. Radiology.. 2000;217:361-370.[Abstract/Free Full Text]
  29. Dion JE, Gates PC, Fox AJ, Barnett HJM, Blom RJ. Clinical events following neuroangiography: a prospective study. Stroke.. 1987;18:997-1004.[Abstract/Free Full Text]
  30. Cloft HJ, Joseph GJ, Dion JE. Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation. A meta-analysis. Stroke.. 1999;30:317-320.[Abstract/Free Full Text]
  31. Heiserman JE, Dean BL, Hodak JA, et al. Neurologic complications of cerebral angiography. Am J Neuroradiol.. 1994;15:1408-1411.
  32. Earnest F, Forbes G, Sandok BA, et al. Complications of cerebral angiography: prospective assessment of risk. Am J Roentgenol.. 1984;142:247-253.[Abstract/Free Full Text]
  33. Preda L, Gaetani P, Rodriguez YBR, et al. Spiral CT angiography and surgical correlations in the evaluation of intracranial aneurysms. Eur Radiol.. 1998;8:739-745.[Medline]
  34. Huston J, 3rd, Nichols DA, Luetmer PH, et al. Blinded prospective evaluation of sensitivity of MR angiography to known intracranial aneurysms: importance of aneurysm size. Am J Neuroradiol.. 1994;15:1607-1614.[Abstract]
  35. White PM, Teasdale EM, Wardlaw JM, Easton V. Intracranial aneurysms: CT angiography and MR angiography for detection—prospective blinded comparison in a large patient cohort. Radiology.. 2001;219:739-749.[Abstract/Free Full Text]
  36. White PM, Wardlaw JM, Teasdale E, Sloss S, Cannon J, Easton V. Power transcranial doppler ultrasound in the detection of intracranial aneurysms. Stroke.. 2001;32:1291-1297.[Abstract/Free Full Text]
  37. Wilkinson PMID, Hoggard N, Paley MNJ, et al. Detection of subarachnoid haemorrhage with magnetic resonance imaging. J Neurol Neurosurg Psychiatr.. 2001;70:205-211.[Abstract/Free Full Text]
  38. Brownlee RD, Tranmer BI, Sevick RJ, Karmy G, Curry BJ. Spontaneous thrombosis of an unruptured anterior artery aneurysm. Stroke.. 1995;26:1945-1949.[Abstract/Free Full Text]
  39. Linn FHH, Rinkel GJE, Algra A, van Gijn J. The notion of "warning leak" in subarachnoid haemorrhage: are such patients in fact admitted with a rebleed. J Neurol Neurosurg Psychiatr.. 2000;68:332-336.[Abstract/Free Full Text]
  40. Mayer PL, Awad IA, Todor R, et al. Misdiagnosis of symptomatic cerebral aneurysm. Prevalence and correlation with outcome at four institutions. Stroke.. 1996;27:1558-1563.[Abstract/Free Full Text]
  41. Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med.. 2000;342:29-36.[Free Full Text]
  42. Applegate WB, Miller ST, Graney MJ, Elam JT, Burns R, Akins DE. A randomized, controlled trial of a geriatric assessment unit in a community rehabilitation hospital. N Engl J Med.. 1990;322:1572-1578.[Abstract]
  43. Nikolaus T, Specht-Leible N, Bach M, Oster P, Schlierf G. A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients. Age Ageing.. 1999;28:543-550.[Abstract/Free Full Text]
  44. Andrews GR. Promoting health and function in an ageing population. BMJ.. 2001;322:728-729.[Free Full Text]
  45. Raaymakers TWM, Rinkel GJE, Limburg M, Algra A. Mortality and morbidity of surgery for unruptured intracranial aneurysms. A meta-analysis. Stroke.. 1998;29:1531-1538.[Abstract/Free Full Text]
  46. Tsutsumi K, Ueki K, Morita A, Usui M, Kirino T. Risk of aneurysm recurrence in patients with clipped cerebral aneurysms. Results of long-term follow-up angiography. Stroke.. 2001;32:1191-1194.[Abstract/Free Full Text]
  47. Guglielmi G, Vinuela F, Sepetka I, Macellari V. Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: electrochemical basis, technique, and experimental results. J Neurosurg.. 1991;75:1-7.[Medline]
  48. Guglielmi G, Vinuela F, Dion J, Duckwiller G. Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: preliminary clinical experience. J Neurosurg.. 1991;75:8-14.[Medline]
  49. Johnston SC, Wilson CB, Halbach VV, et al. Endovascular and surgical treatment of unruptured cerebral aneurysms: comparison of risks. Ann Neurol.. 2000;48:11-19.[Medline]
  50. Koivisto T, Vanninen R, Hurskainen H, Saari T, Hernesniemi J, Vapalahti M. Outcomes of early endovascular versus surgical treatment of ruptured cerebral aneurysms. A prospective randomized study. Stroke.. 2000;31:2369-2377.[Abstract/Free Full Text]
  51. Johnston SC, Zhao S, Dudley RA, Berman MF, Gress DR. Treatment of unruptured cerebral aneurysms in California. Stroke.. 2001;32:597-605.[Abstract/Free Full Text]
  52. Brilstra EH, Rinkel JE, Van der Graf Y, Van Rooij WJJ, Algra A. Treatment of intracranial aneuryms by embolization with coils. A systematic review. Stroke.. 1999;30:470-476.[Abstract/Free Full Text]
  53. Roy D, Milot G, Raymond J. Endovascular treatment of unruptured aneurysms. Stroke.. 2001;32:1998-2004.[Abstract/Free Full Text]
  54. Cognard C, Weill A, Spelle L, et al. Long-term angiographic follow-up of 169 intracranial berry aneurysms occluded with detachable coils. Radiography.. 1999;212:348-356.
  55. Thornton J, Debrun GM, Aletich VA, Bashir Q, Charbel FT, Ausman J. Follow-up angiography of intracranial aneurysms treated with endovascular placement of Guglielmi detachable coils. Neurosurgery.. 2002;50:239-249.[Medline]
  56. Khangure MS, Phatouros CC, Bynevelt M, ApSimon H, McAuliffe W. Endovascular treatment of intracranial aneurysms with Gugliemi detachable coils. Stroke.. 2002;33:210-217.[Abstract/Free Full Text]
  57. Versati PP, Cenzato, Tartara F, et al. Introduction of GDC embolization in the clinical practice as treatment synergical to surgery: impact on overall outcome of patients with subarachnoid hemorrhage. Acta Neurochir.. 2000;142:677-684.
  58. Khanna RK, Malik GM, Qureshi N. Predicting outcome following surgical treatment of unruptured intracranial aneurysms: a proposed grading system. J Neurosurg.. 1996;84:49-54.[Medline]
  59. Chung RY, Carter BS, Norbash A, Budzik R, Putnam C, Ogilvy CS. Management outcomes for ruptured and unruptured aneurysms in the elderly. Neurosurg.. 2000;47:827-832.
  60. Eskesen V, Rosenorn J, Schimidt K. The influence of unruptured intracranial aneurysms on life expectancy in relation to their size at the time of detection and to age. Br J Neurosurg.. 1988;2:379-384.[Medline]
  61. Mitchell P, Jakubowski J. Risk analysis of treatment of unruptured aneurysms. J Neurol Neurosurg Psychiatr.. 2000;68:577-580.[Abstract/Free Full Text]
  62. Hop JW, Rinkel GJE, Algra A, van Gijn J. Case-fatality rates and functional outcome after subarachnoid hemorrhage. A systematic review. Stroke.. 1997;28:660-664.[Abstract/Free Full Text]
  63. Kassell NF, Torner JC, Haley EC, Jr, Jane DA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: overall management results. J Neurosurg.. 1990;73:18-36.[Medline]
  64. Kassel NF, Torner JC, Jane JA, Haley EC, Jr, Adams HP. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: surgical results. J Neurosurg.. 1990;73:37-47.[Medline]
  65. Stachniak JB, Layon AJ, Day AL, Gallagher J. Craniotomy for intracranial aneurysm and subarachnoid hemorrhage. Is course, cost, or outcome affected by age? Stroke.. 1996;27:276-281.[Abstract/Free Full Text]
  66. Lanzino G, Kassell NF, Germanson TP, et al. Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse? J Neurosurg.. 1996;85:410-418.[Medline]
  67. Collice M. [Subarachnoid hemorrhage from ruptured aneurysms in elderly patients]. [In Italian]. Minerva Anestesiol.. 1998;64:163-165.[Medline]
  68. Yamashita K, Kashiwagi S, Kato S. Trend in outcome of cerebral aneurysmal rupture since 1995: a proposal for future treatment [Letter]. Stroke.. 1999;30:1730-1731.[Free Full Text]
  69. Inagawa T. Trends in incidence and case fatality rates of aneurysmal subarachnoid hemorrhage in Izumo city, Japan, between 1980–1989 and 1990–1998. Stroke.. 2001;32:1499-1507.[Abstract/Free Full Text]
  70. Pobereskin LH. Incidence and outcome of subarachnoid haemorrhage: a retrospective study. J Neurol Neurosurg Psychiatr.. 2001;70:340-343.[Abstract/Free Full Text]
  71. Muizelaar JP, Vermeulen M, van Crevel H, et al. Outcome of aneurysmal subarachnoid hemorrhage in patients 66 years of age and older. Clin Neurol Neurosurg.. 1988;90:203-207.[Medline]
  72. Fortuny LA, Adams CB, Briggs M. Surgical mortality in an aneurysm population: effects of age, blood pressure and preoperative neurological state. Clin Neurol Neurosurg.. 1980;43:879-882.
  73. Ross N, Hutchinson PJ, Seeley H, Kirkpatrick PJ. Timing of surgery for supratentorial aneurysmal subarachnoid haemorrhage: report of a prospective study. J Neurol Neurosurg Psychiatr.. 2002;72:480-484.[Abstract/Free Full Text]
  74. Inagawa T, Shibukawa M, Inokuchi F, Tokuda Y, Okada Y, Okada K. Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II: management and surgical outcome. J Neurosurg.. 2000;93:967-975.[Medline]
  75. Jomin M, Lesoin F, Lozes G. Prognosis with 500 ruptured and operated intracranial arterial aneurysms. Surg Neurol.. 1984;21:13-18.[Medline]
  76. Hernesniemi J, Vapalahti M, Niskanen M, et al. One-year outcome in early aneurysm surgery: a 14 years experience. Acta Neurochir.. 1993;122:1-10.
  77. Kreiter KT, Copeland D, Bernardini GL, et al. Predictors of cognitive dysfunction after subarachnoid hemorrhage. Stroke.. 2002;33:200-209.[Abstract/Free Full Text]
  78. O'Sullivan MG, Dorward N, Whittle IR, Steers AJ, Miller JD. Management and long-term outcome following subarachnoid haemorrhage and intracranial aneurysm surgery in elderly patients: an audit of 199 consecutive cases. Br J Neurosurg.. 1994;8:23-30.[Medline]
  79. Sakaki S, Ohta S, Ohue S, Kohno K, Matsuoka K. Outcome in elderly patients with ruptured intracranial aneurysm. Clin Neurol Neurosurg.. 1989;91:21-27.[Medline]
  80. Lan Q, Ikeda H, Jimbo H, Izumiyama H, Matsumoto K. Considerations on surgical treatment for elderly patients with intracranial aneurysms. Surg Neurol.. 2000;53:231-238.[Medline]
  81. Yoshimoto Y, Kwak S. Age-related multifactorial causes of neurological deterioration after early surgery for aneurysmal subarachnoid hemorrhage. J Neurosurg.. 1995;83:984-988.[Medline]
  82. Charpentier C, Audibert G, Guillemin F, et al. Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage. Stroke.. 1999;30:1402-1408.[Abstract/Free Full Text]
  83. Rabb CH, Tang G, Chin LS. A statistical analysis of factors related to symptomatic cerebral vasospasm. Acta Neurochir.. 1992;115:79-85.
  84. Inagawa T. Management outcome in the elderly patient following subarachnoid hemorrhage. J Neurosurg.. 1993;78:554-561.[Medline]
  85. Fridriksson SM, Hillman J, Saveland H, Brandt L. Intracranial aneurysm surgery in the 8th and 9th decades of life: impact on population-based management outcome. Neurosurgery.. 1995;37:627-631.[Medline]
  86. Rowe JG, Molyneux AJ, Byrne JV, Renowden S, Aziz TZ. Endovascular treatment of intracranial aneurysms: a minimally invasive approach with advantages for elderly patients. Age Ageing.. 1996;25:372-376.[Abstract/Free Full Text]
  87. Kremer C, Groden C, Hansen HC, Grzyska U, Zeumer H. Outcome after endovascular treatment of Hunt and Hess Grade IV or V aneurysms. Comparison of anterior versus posterior circulation. Stroke.. 1999;30:2617-2622.[Abstract/Free Full Text]
  88. Hadjivassiliou M, Tooth CL, Romanowski CAJ, et al. Aneurysmal SAH. Cognitive outcome and structural damage after clipping or coiling. Neurology.. 2001;56:1672-1677.[Abstract/Free Full Text]
  89. Truelsen T, Bonita R, Duncan J, Anderson NE, Mee E. Changes in subarachnoid hemorrhage mortality, incidence, and case fatality in New Zealand between 1981–1983 and 1991–1993. Stroke.. 1998;29:2298-2303.[Abstract/Free Full Text]




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