Nonsurgical Aneurysm Treatment May Be Most Beneficial for Older Adults

Newswise — As alternatives to surgery, endovascular treatments for unruptured brain aneurysms appear most advantageous in elderly patients, suggests an analysis of national data published in the January issue of Neurosurgery.

Dr. Fred G. Barker II and colleagues of Harvard Medical School analyzed the results of aneurysm treatment in over 3,900 patients, identified through a representative database of patients treated at U.S. hospitals from 1996 to 2000. All patients were treated before their aneurysm ruptured, a serious complication that can cause stroke from bleeding into the brain.

Eighty-nine percent of the patients underwent conventional surgery, or "clipping," to seal the aneurysm off from the rest of the blood circulation. The remaining eleven percent were treated by newer, endovascular techniques. In these nonsurgical procedures, a catheter is threaded through the patients' blood vessels and miniature coils are placed to block off the aneurysm.

Rates of the worst treatment outcomes were similar between endovascular treatment and surgery. The risk of death was 2.1 percent after surgery and 1.7 percent after endovascular treatment. The rate of discharge to a long-term care facility (for example, a nursing home) was also similar: 2.4 and 3.3 percent.

However, patients undergoing surgery were significantly more likely to be sent from the hospital to a short-term rehabilitation facility: 13 percent, compared with 5 percent in the endovascular group. Counting these patients, the overall risk of adverse outcomes was twice as high after surgery compared with endovascular treatment.

The difference was mainly apparent for people over age 65, suggesting that elderly patients derive the greatest benefit from endovascular aneurysm treatment. The outcome differences became greater from 1996 to 2000, as experience was gained with endovascular techniques.

Neurological complications were about twice as common after surgery as endovascular treatment. Patients stayed in the hospital an average of five days after surgery, compared with two days in the endovascular group. This contributed to a significant difference in average cost between the two treatment approaches: $22,000 for surgery vs $13,000 for endovascular treatment.

There is ongoing debate over the results of surgery vs endovascular treatment for aneurysms. Some studies suggest lower death and complication rates with the nonsurgical approach. Until a formal randomized trial is performed, large databases like the one used in the new study can provide useful insights.

Overall, the results suggest similarly low rates of adverse outcomes for patients undergoing surgery or endovascular treatment for unruptured aneurysms. However—especially for elderly patients—endovascular treatment has an important advantage in reducing the need for short-term rehabilitation. Although more study is needed and other factors may need to be considered, Dr. Barker and colleagues suggest that endovascular aneurysm therapy may be especially appropriate for elderly patients, and for patients with medical conditions that might increase the risks of surgery.

"Age-Dependent Differences in Short-Term Outcome After Surgical or Endovascular Treatment of Unruptured intracranial Aneurysms in the United States, 1996-2000" by Fred G. Barker II, MD, et. al.NeurosurgeryVol. 54, No. 1, Pg. 18January 2004