Endovascular Coiling versus Neurosurgical Clipping in the Management of Aneurysmal Subarachnoid Haemorrhage in the Elderly: A Multicenter Cohort Study

Endovascular Coiling versus Neurosurgical Clipping in the Management of Aneurysmal Subarachnoid Haemorrhage in the Elderly: A Multicenter Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Endovascular Coiling versus Neurosurgical Clipping in the Management of Aneurysmal Subarachnoid Haemorrhage in the Elderly: A Multicenter Cohort Study Keng Siang Lee, Isabel Siow, Lily Yang, Aaron Foo, John Zhang, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3835086/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Mar, 2024 Read the published version in Neurosurgical Review → Version 1 posted 7 You are reading this latest preprint version Abstract Introduction The comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH). Methods Data were obtained from all patients with aSAH aged ≥60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality. Results Of the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0–2 at 3 months (OR = 2.45 [95%CI:11.16–5.20];p = 0.018), and a lower incidence of in-hospital mortality (OR = 0.31 [95%CI:0.10–0.91];p = 0.026). The benefit of coiling over clipping in terms of good mRS score at 6 months showed a trend towards statistical significance (OR = 1.98 [95%CI:0.97–4.04];p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR = 0.32 [95%CI:0.12–0.90];p = 0.025). Age, admission WFNS score I–III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I–III remained significant predictors of good functional outcomes at 6 months. Conclusions Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores. Aneurysm subarachnoid hemorrhage elderly geriatric endovascular clipping cohort study Figures Figure 1 Introduction Longer life expectancies are leading to aging populations and rising incidence of aneurysmal subarachnoid haemorrhage (aSAH).[ 1 – 3 ] The advent of minimally invasive aneurysm securing technique has encouraged a gradual shift in treatment paradigm for this age group to encompass early treatment comprising microsurgical clipping, endovascular coiling and neurointensive care.[ 4 , 5 ] As a result, clinical practice has also changed and more elderly aSAH patients are being referred to neurosurgical centers. Treatment of elderly patients with aSAH however still remains a clinical challenge,[ 3 , 5 – 7 ] largely owing to their higher rate of poor clinical grade on admission, severe aSAH on initial computed tomography (CT) scan, and general complications.[ 8 , 9 ] Older age within this cohort has also been associated with poor outcomes.[ 5 ] The literature reporting outcomes for elderly patients with aSAH is scarce and optimal management of this condition in the elderly remains unclear.[ 4 , 7 , 8 , 10 – 13 ] Whilst the recommendation for endovascular coiling over surgical clipping for SAH in general is relatively well established, 14,15,16 the International Subarachnoid Aneurysm Trial (ISAT) has been the only large, multicenter, RCT that compared neurosurgical clipping with detachable platinum coils in patients with ruptured intracranial aneurysms, who were considered to be suitable for either treatment. 15 However, results of ISAT have continued to generate some criticism, mainly because of its selection bias. For example, vast majority of the enrolled patients, had a favourable grade at the time of enrolment, 95% of the aneurysms were in the anterior cerebral circulation, and 90% were smaller than 10 mm. This makes it difficult for clinicians to generalise the results to their own practice. Hence whether the superiority of coillingstill prevails in the elderly subgroup remains unconfirmed. Therefore, our study aims to explore the outcomes of coiling and clipping in a unique cohort of elderly patients with aSAH. Methods Data collection Ethics approval was obtained from the institutional review board before commencement of the study. Data were obtained retrospectively from the National University Health System (NUHS) cluster in Singapore which included the National University Hospital, Khoo Teck Puat Hospital and Ng Teng Fong General Hospital, over a period of six years from 2014 to 2019. Electronic medical records were reviewed for all for elderly patients (aged 60 years and above) who had undergone treatment for aSAH at our institutions. The definition of 'elderly' may vary according to chronological, biological, psychological, and social aspects. In this study patients aged 60 years and above were classified in the elderly age group in line with the definition established by the World Health Organisation (WHO) and United Nations (UN).[ 10 , 14 ] Diagnosis of aSAH was confirmed with a head computed tomography scan or a lumbar puncture. Evidence of aSAH was verified by a neuroradiologist on computed tomography angiography or digital subtraction angiography. Patients with no aneurysmal SAH, or those who did not undergo treatment were excluded from the analysis. The collected patient variables included: age, gender, smoking history, and comorbidities (hypertension, hyperlipidaemia, diabetes mellitus, and ischaemic heart disease), and World Federation of Neurosurgical Societies (WFNS) score on admission, dichotomized as good (Grades I – III) and poor (Grades IV – V). The following information about aSAH features was extracted: number of aneurysms, size of aneurysms, and location of subarachnoid haemorrhages. Additionally, information on the treatment modality (coiling or clipping) was obtained. The following information about patient complications was also extracted: aneurysm re-rupture, delayed hydrocephalus, delayed ischaemic neurological deficit, large infarct requiring decompressive craniectomy, and venous thromboembolism. Outcome measures The primary outcome measure was functional outcome defined by the modified Rankin Scale (mRS) at 3 months and 6 months after aSAH. Furthermore, the outcome was dichotomized as favorable (mRS score of 0–2) or unfavorable (mRS score of 3–6). The secondary outcome was in-hospital mortality. Statistical analysis Numerical variables were described as median (interquartile range [IQR]) for non-normal distributions. Normality of data was tested for using the Shapiro-Wilk test. Age was either analyzed as a categorical or a continuous variable. Patients were separated into 3 age groups: 60–69, 70–79, and ≥80 years. If age was analyzed as a categorical variable, odd ratios (ORs) were compared with the reference category 60–69 years (OR = 1.0).[ 10 ] Comparisons of non-normal numerical data were conducted using the Mann-Whitney U test and comparisons of categorical variables were performed using the Pearson chi-squared test. Stepwise multivariable logistic regression was used to identify associations identify independent predictors for categorical outcome measures. Data were collated in Microsoft Excel (Microsoft, Redmond, WA, USA). All statistical analyses were performed using R software version 4.2.1 (R Foundation for Statistical Computing, 2022). P-values less than 0.05 were considered statistically significant. Results Baseline characteristics A total of 134 patients were included in our analysis (Fig. 1 ). Median age of these patients was 68.5 years (IQR 64–74). There were 104 females (77.6%) and 30 males (22.4%), with only six patients (4.5%) having a history of smoking. Eighty-seven patients (64.9%) exhibited at least one comorbidity. The most common comorbidities were hypertension in 75 patients (56.0%), hyperlipidaemia in 58 (43.3%), diabetes mellitus in 18 (13.4%) and ischaemic heart disease in 17 patients (12.7%). On admission, 70 patients (52.2%) had good admission WFNS grade (I – III). Eighty-four patients (62.7%) underwent coiling whilst 50 patients (37.3%) underwent clipping. Twenty seven (20.1%) patients had multiple aneurysms, 24 (17.9%) with two aneurysms and three (2.2%) with three aneurysms. Ninety one patients (67.9%) had aneurysm < 7mm in size, with 103 (76.9%) located anteriorly. Table 1 compares the baseline patient and aneurysm characteristics, between the coiling and clipping groups which demonstrates no significant difference. Table 1 Baseline characteristics of the study population Endovascular coiling (n = 84) Neurosurgical clipping (n = 50) P-value Age (years) 68 (64–74) 69 (65–74) 0.770 Gender Male Female 21 (25.0) 63 (75.0) 9 (18.0) 41 (82.0) 0.347 Smoking 4 (4.8) 2 (4.0) 0.837 Comorbidities Hypertension Hyperlipidaemia Diabetes Mellitus Ischemic heart disease 44 (52.4) 32 (38.1) 10 (11.9) 12 (14.3) 31 (62.0) 26 (52.0) 8 (16.0) 5 (10.0) 0.278 0.116 0.501 0.471 Acute hydrocephalus requiring EVD 59 (70.2) 42 (84.0) 0.074 Admission WFNS I – III IV – V 42 (50.0) 42 (50.0) 28 (56.0) 22 (44.0) 0.501 Aneurysm number Single Multiple 69 (82.1) 15 (17.9) 38 (76.0) 12 (24.0) 0.391 Aneurysm location Anterior circulation Posterior circulation 60 (71.4) 24 (28.6) 43 (86.0) 7 (14.0) 0.053 Aneurysm size < 7mm ≥ 7mm 61 (72.6) 23 (27.4) 30 (60.0) 20 (40.0) 0.130 All categorical data presented as n (%) and all numerical data presented as median (interquartile range). EVD = External Ventricular Drain; WFNS = World Federation of Neurosurgical Societies Clinical outcomes of endovascular versus clipping Fifty-five (41.0%) patients had a good functional outcome (mRS score 0–2) at 3 months follow-up, whilst 65 (48.5%) patients had good functional outcome at 6 months follow-up. There were 16 in-hospital mortalities (11.9%) in our cohort of elderly patients. The clinical outcomes and complications sustained between the coiling and clipping groups are presented in Table 2 . Table 2 Comparison of outcomes between endovascular and neurosurgical treatment Outcome Endovascular coiling (n = 84) Neurosurgical clipping (n = 50) OR (95% CI) p-value mRS 0–2 at 3 months 41 (48.8) 14 (28.0) 2.45 (1.16–5.20) 0.018 mRS 0–2 at 6 months 46 (54.8) 19 (38.0) 1.98 (0.97–4.04) 0.060 Aneurysm rebleed 4 (4.8) 3 (6.0) 0.78 (0.17–3.65) 0.755 Delayed hydrocephalus requiring ventriculoperitoneal shunt 23 (27.4) 20 (40.0) 0.57 (0.27–1.19) 0.130 Delayed ischemic neurological deficit 14 (16.7) 4 (8.0) 2.30 (0.71–7.41) 0.155 Large infarct requiring decompressive craniectomy 7 (8.3) 11 (22.0) 0.32 (0.12–0.90) 0.025 Venous thromboembolism 4 (4.8) 1 (2.0) 2.45 (0.27–22.73) 0.415 In-hospital mortality 6 (7.1) 10 (20.0) 0.31 (0.10–0.91) 0.026 All categorical data presented as n (%). mRS = modified Rankin Scale Neurosurgical clipping group is used as the reference group The endovascular group showed a higher incidence of good mRS score at 3 months (48.8% in coiling group vs. 28.8% in clipping group; OR = 2.45 [95% CI: 11.16–5.20]; p = 0.018), and a lower incidence of in-hospital mortality (7.1% in coiling group vs. 20.0% in clipping group; OR = 0.31 [95%CI: 0.10–0.91]; p = 0.026). The benefit of coiling over clipping in terms of good mRS score at 6 months showed a trend towards statistical significance (54.8% in coiling group vs. 38.0% in clipping group; OR = 1.98 [95% CI: 0.97–4.04]; p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (8.3% in coiling group vs 22.0% in clipping group; OR = 0.32 [95% CI: 0.12–0.90]; p = 0.025). Predictors of clinical outcomes Independent predictors of clinical outcomes and their effect sizes are presented in Table 3 . Table 3 Multivariate logistic regression for predictors of poor clinical outcome Univariate analysis Multivariate analysis Outcome Predictor OR (95% CI) p-value OR (95% CI) p-value mRS score 0–2 at 3 months Age* 0.42 (0.24–0.743) 0.003 0.32 (0.17–0.61) < 0.001 Admission WFNS score I – III † 3.28 (1.59–6.79) 0.001 3.81 (1.47–9.88) 0.009 Acute hydrocephalus requiring EVD 0.24 (0.11–0.56) < 0.001 0.50 (0.18–1.43) 0.197 Endovascular coiling ‡ 2.45 (1.15–5.20) 0.018 3.31 (1.36–8.02) 0.012 mRS score 0–2 at 6 months Age* 0.52 (0.31–0.87) 0.013 0.46 (0.26–0.79) 0.005 Admission WFNS score I – III † 3.47 (1.70–7.06) < 0.001 3.31 (1.42–7.67.0) 0.005 Acute hydrocephalus requiring EVD 0.31 (0.13–0.72) 0.005 1.64 (0.66–4.72) 0.253 Mortality in hospital Admission WFNS score I – III † 0.18 (0.05–0.65) 0.004 0.15 (0.04–0.62) 0.008 Aneurysm size ≥7 mm § 3.17 (1.10–9.17) 0.043 0.69 (0.19–2.5`) 0.577 Endovascular coiling ‡ 0.31 (0.10–0.91) 0.026 0.28 (0.08–0.95) 0.041 Large infarct requiring decompressive craniectomy 3.68 (1.10–12.20) 0.026 4.23 (0.87–20.833) 0.075 Delayed hydrocephalus requiring ventriculoperitoneal shunt 0.12 (0.02–0.95) 0.018 0.07 (0.01–0.63) 0.018 *Age category 60–69 years is used as the reference group † WFNS Grades IV – V is used as the reference group ‡ Neurosurgical clipping group is used as the reference group WFNS Grades IV – V is used as the reference group § Aneurysm size < 7mm is used as the reference group EVD = External Ventricular Drain; WFNS = World Federation of Neurosurgical Societies On univariate analyses, age (p = 0.003), admission WFNS score I – III (p = 0.001), presence of acute hydrocephalus (p < 0.001) and coiling (p = 0.018), were found to be significant predictors of good functional outcomes mRS scores 0–2, at 3 months. On multivariate analysis, only age (p < 0.001), admission WFNS score I – III (p = 0.009), and coiling (p = 0.012) remained statistically significant predictors of good functional outcomes mRS scores 0–2, at 3 months On univariate analyses, age (p = 0.013), admission WFNS score I – III (p < 0.001), and presence of acute hydrocephalus (p = 0.005) were found to be significant predictors of good functional outcomes mRS scores 0–2, at 6 months. On multivariate analysis, only age (p = 0.005) and admission WFNS score I – III (p = 0.005) remained statistically significant predictors of good functional outcomes mRS scores 0–2, at 6 months. On univariate analyses, admission WFNS score (p = 0.004), aneurysm size ≥7 mm (p = 0.043), treatment modality (p = 0.026), large infarct requiring decompressive craniectomy (p = 0.026), and delayed hydrocephalus requiring ventriculoperitoneal shunt (p = 0.018) were found to be significant predictors of in-hospital mortality. On multivariate analysis, admission WFNS score (p = 0.008), treatment modality (p = 0.041), and delayed hydrocephalus requiring ventriculoperitoneal shunt (p = 0.018) remained statistically significant predictors of in-hospital mortality. Subgroup analysis Within the WFNS score IV – V subgroup, the beneficial effect of coiling over neurosurgical clipping in terms of good mRS scores at 3-month (p = 0.090) and 6-month (p = 0.214) and in-hospital mortality (p = 0.098) diminished. Within the age 60–69 subgroup, the beneficial effect of coiling over neurosurgical clipping in terms of good mRS scores at 3-month was retained (p = 0.038), but lost for good mRS scores at 6-month (p = 0.175) and in-hospital mortality (p = 0.509). Discussion Our findings demonstrate that coiling compared with neurosurgical clipping was associated with higher incidences of good functional outcomes and lower incidences of in-hospital mortality, with no significant differences in the incidence of complications, in terms of aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism. However, more patients in the clipping group developed large infarcts requiring decompressive craniectomy. A lower age, favorable admission WFNS scores and endovascular treatment were consistently identified as independent predictors of good functional outcomes in elderly patients with aSAH, whilst the latter two factors were also independent predictors of in-hospital mortality. Our study avoided preselection by including patients who, because of their clinical status, did not receive treatment of the ruptured aneurysm. Numerous studies have reported reasonable outcomes for elderly aSAH patients, but older and poor-grade patients are often underrepresented in these analyses,[ 4 , 8 , 9 , 12 , 13 ] as they are shown to be predictive of unfavorable outcomes and mortality.[ 5 , 10 , 13 , 15 ] An important consideration in the controversial debate around treatment of elderly patients with poor-grade aSAH is the possibility of increasing the number of dependent patients.[ 1 – 3 ] The elderly are a heterogenous population with the hexegenarians differing clinically from the octogenarian subgroup. A consensus for an age cap for maximal aneurysm treatment remains to be achieved for aSAH. The clinical implications of this are that maximal active aneurysm treatment should be recommended strongly to the young (aged 60–79) elderly subgroup, especially if they are alert at the time of presentation, given the likelihood of positive short term outcomes at three months. Indeed this is supported by Goldberg et al. who showed that despite its high initial mortality, maximal treatment of aSAH in the elderly resulted in a reasonable proportion of favorable outcomes.[ 10 ] Such a trend is also reflective of improvements in coiling technology and technical know-how which underpin the improvements in patient outcomes. This is further reinforced by an observed increase in the percentage of aSAH cases treated with coiling at our institution from 42% in 2009, to 63% in 2019, reflecting a gradual shift in treatment paradigm in favor of coiling.[ 16 ] Notwithstanding, the better patient outcomes after coiling compared with clipping could also be partly explained by the selection bias our included patients were inevitably subjected to.[ 17 ] At our institution, all aSAH patients are first considered for coiling, and only proceeds to clipping if not amendable to endovascular means. Hence, the general pool of clipped aneurysms were more complex with poorer grades at admission to begin with, predisposing to postoperative complications.[ 18 , 19 ] However, these were accounted for in our regression and subgroup analyses. However, we should note the possibility of coiling losing its advantage over conventional clipping in the long term. Our results showed that elderly aSAH patients who were treated endovascularly had superior functional outcomes compared to those treated neurosurgically in the short term at 3 months post discharge, but there was no statistical significance in outcomes between these two groups by 6 months post discharge. This could indicate the possibility of coiling and clipping yielding comparable outcomes in the long-term, beyond our 6-month follow-up period. Long-term follow-up of the ISAT trial lends some support to this view, reporting a comparable rate of dependency in the coiling and clipping groups in the long run.[ 18 , 19 ] Moving forward, there is a need for larger prospective trials to shed light on current evidence on this important clinical topic.[ 20 ] With increasing evidence supporting the safety and effectiveness of maximal treatment in elderly patients with aSAH,[ 4 , 8 , 10 , 19 , 21 , 22 ] there may finally be sufficient clinical equipoise to warrant a randomized prospective trial that could help to address the question at hand.[ 23 ] Limitations The limitations of our study stem from its retrospective nature. First, being a retrospective review, non-standardized documentation of medical records could have resulted in bias in the collected data. This limitation was mitigated by the few numbers of patients lost to follow-up, minimising attrition bias. Secondly, the majority of patients had complete documentation of information during their hospital stay, resulting in few patients having to be excluded from final analysis. Nonetheless, the moderate sample size in our cohort limited further subgroup analyses to delineate the benefits of coiling over neurosurgical clipping. Finally, our study was conducted using data from three tertiary institutions, with several different surgeons attending to the patients. There may have been slight differences in management despite a largely standardized protocol at our institutions. However, this is reflective of real-world practice and hence enhances the applicability of our findings to the general cohort of elderly patients with aSAH. Conclusion Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH but its benefits diminishes at 6 months. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores. Declarations Author Contribution Keng Siang, Lee: Methodology, validation, formal analysis, investigation, writing - original draft, writing - review & editing, visualisationIsabel Siow: Methodology, validation, investigation, data curation, writing - review & editingLily Yang: Methodology, validation, investigation, data curation, writing - review & editingAaron SC, Foo: Methodology, validation, investigation, writing - review & editingJohn J. Y., Zhang: Methodology, validation, investigation, data curation, writing - review & editing Ian Mathews: Methodology, validation, writing - review & editingChun Peng Goh: Methodology, validation, writing - review & editingColin Teo: Methodology, validation, writing - review & editingBolem, Nagarjun: Methodology, validation, writing - review & editingVanessa Chen: Methodology, validation, investigation, writing - review & editingSein Lwin: Methodology, validation, writing - review & editingKejia Teo: Methodology, validation, writing - review & editingShiong Wen Low: Methodology, validation, writing - review & editingIra SY Sun: Methodology, validation, writing - review & editingBoon Chuan Pang: Methodology, validation, writing - review & editingEugene WR Yang: Methodology, validation, writing - review & editingCunli Yang: Methodology, validation, writing - review & editingAnil Gopinathan: Methodology, validation, investigation, writing - review & editing, visualisationTseng Tsai Yeo: Methodology, validation, investigation, writing - review & editing, visualisation, supervisionVincent DW Nga: Conceptualization, methodology, validation, investigation, writing - review & editing, visualisation, supervision The authors report no conflict of interest. Ethical approval Not applicable. Funding None. Availability of data and materials Not applicable. Disclosure of interest The authors report no conflict of interest. References Kontis, V., et al., Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble. Lancet, 2017. 389 (10076): p. 1323-1335. de Rooij, N.K., et al., Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry, 2007. 78 (12): p. 1365-72. Lee, K.S., et al., Radiological surveillance of small unruptured intracranial aneurysms: a systematic review, meta-analysis, and meta-regression of 8428 aneurysms. Neurosurg Rev, 2021. 44 (4): p. 2013-2023. Ryttlefors, M., et al., Neurointensive care is justified in elderly patients with severe subarachnoid hemorrhage--an outcome and secondary insults study. Acta Neurochir (Wien), 2010. 152 (2): p. 241-9; discussion 249. Proust, F., et al., Interdisciplinary treatment of ruptured cerebral aneurysms in elderly patients. J Neurosurg, 2010. 112 (6): p. 1200-7. Hoh, B.L., et al., 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke, 2023. Johansson, M., et al., Changes in intervention and outcome in elderly patients with subarachnoid hemorrhage. Stroke, 2001. 32 (12): p. 2845-949. Lanzino, G., et al., Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse? J Neurosurg, 1996. 85 (3): p. 410-8. Nieuwkamp, D.J., et al., Subarachnoid haemorrhage in patients > or = 75 years: clinical course, treatment and outcome. J Neurol Neurosurg Psychiatry, 2006. 77 (8): p. 933-7. Goldberg, J., et al., Survival and Outcome After Poor-Grade Aneurysmal Subarachnoid Hemorrhage in Elderly Patients. Stroke, 2018. 49 (12): p. 2883-2889. Pavelka, M., et al., Vasospasm risk following aneurysmal subarachnoid hemorrhage in older adults. J Neurosurg, 2023: p. 1-9. Suzuki, Y., et al., Results of Clipping Surgery for Aneurysmal Subarachnoid Hemorrhage in Elderly Patients Aged 90 or Older. Acta Neurochir Suppl, 2016. 123 : p. 13-6. Hironaka, K., et al., Outcomes in Elderly Japanese Patients Treated for Aneurysmal Subarachnoid Hemorrhage: A Retrospective Nationwide Study. J Stroke Cerebrovasc Dis, 2020. 29 (6): p. 104795. Organization, W.H. Ageing . 13 June 2023]; Available from: https://www.who.int/health-topics/ageing#tab=tab_1. Park, J., et al., Critical age affecting 1-year functional outcome in elderly patients aged ≥ 70 years with aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien), 2014. 156 (9): p. 1655-61. Koh, K.M., et al., Management of ruptured intracranial aneurysms in the post-ISAT era: outcome of surgical clipping versus endovascular coiling in a Singapore tertiary institution. Singapore Med J, 2013. 54 (6): p. 332-8. Lee, K.S., et al., The evolution of intracranial aneurysm treatment techniques and future directions. Neurosurg Rev, 2022. 45 (1): p. 1-25. Molyneux, A.J., et al., The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT). Lancet, 2015. 385 (9969): p. 691-7. Ryttlefors, M., et al., International subarachnoid aneurysm trial of neurosurgical clipping versus endovascular coiling: subgroup analysis of 278 elderly patients. Stroke, 2008. 39 (10): p. 2720-6. Lee, K.S., et al., Antiplatelet therapy in aneurysmal subarachnoid hemorrhage: an updated meta-analysis. Neurosurg Rev, 2023. 46 (1): p. 221. Braun, V., et al., Treatment and outcome of aneurysmal subarachnoid haemorrhage in the elderly patient. Neuroradiology, 2005. 47 (3): p. 215-21. Koffijberg, H., E. Buskens, and G.J. Rinkel, Aneurysm occlusion in elderly patients with aneurysmal subarachnoid haemorrhage: a cost-utility analysis. J Neurol Neurosurg Psychiatry, 2011. 82 (7): p. 718-27. Zumofen, D.W., et al., Factors associated with clinical and radiological status on admission in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev, 2018. 41 (4): p. 1059-1069. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3835086","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":265929265,"identity":"333f08ef-9f3f-449c-a09c-ac921902888b","order_by":0,"name":"Keng Siang 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System","correspondingAuthor":false,"prefix":"","firstName":"Isabel","middleName":"","lastName":"Siow","suffix":""},{"id":265929267,"identity":"fcad9c87-47f0-4c6e-8f4e-414d33b3ba66","order_by":2,"name":"Lily Yang","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Lily","middleName":"","lastName":"Yang","suffix":""},{"id":265929268,"identity":"cfbd62f7-cc54-4d4d-b393-32e2d61daec9","order_by":3,"name":"Aaron Foo","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Aaron","middleName":"","lastName":"Foo","suffix":""},{"id":265929269,"identity":"4038757c-8abf-40df-8ff6-dde5f715876b","order_by":4,"name":"John Zhang","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"","lastName":"Zhang","suffix":""},{"id":265929270,"identity":"2ebacbc0-3ade-40ba-ae93-328e8d9eec50","order_by":5,"name":"Ian Matthews","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Ian","middleName":"","lastName":"Matthews","suffix":""},{"id":265929271,"identity":"91925fb0-4166-4571-9de7-f8df69e8dc1d","order_by":6,"name":"Chun Peng Goh","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Chun","middleName":"Peng","lastName":"Goh","suffix":""},{"id":265929272,"identity":"72135859-61a6-4e57-8e43-df8c126c21b2","order_by":7,"name":"Colin Teo","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Colin","middleName":"","lastName":"Teo","suffix":""},{"id":265929273,"identity":"230f8cfb-326d-4571-b08f-8b59acf4d86d","order_by":8,"name":"Bolem Nagarjun","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Bolem","middleName":"","lastName":"Nagarjun","suffix":""},{"id":265929274,"identity":"c6e891a7-532f-408c-9399-909a1a52886c","order_by":9,"name":"Vanessa Chen","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Vanessa","middleName":"","lastName":"Chen","suffix":""},{"id":265929275,"identity":"d0a7ab65-fe05-4270-89ff-63afec618042","order_by":10,"name":"Sein Lwin","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Sein","middleName":"","lastName":"Lwin","suffix":""},{"id":265929276,"identity":"860cbcf4-3ee0-45dc-8fc5-bb5cf4496a91","order_by":11,"name":"Kejia Teo","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Kejia","middleName":"","lastName":"Teo","suffix":""},{"id":265929277,"identity":"3223afb8-a419-441a-8af8-ba495feb734b","order_by":12,"name":"Shiong Wen Low","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Shiong","middleName":"Wen","lastName":"Low","suffix":""},{"id":265929278,"identity":"8c260a90-444a-4fe5-9911-a70ca7ac97d3","order_by":13,"name":"Ira Sun","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Ira","middleName":"","lastName":"Sun","suffix":""},{"id":265929279,"identity":"448bfe25-55b9-46ed-b6dc-973531d823a1","order_by":14,"name":"Boon Chuan Pang","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Boon","middleName":"Chuan","lastName":"Pang","suffix":""},{"id":265929280,"identity":"0ef50b29-5005-4345-9ca7-26f03dfdce2e","order_by":15,"name":"Eugene Yang","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Eugene","middleName":"","lastName":"Yang","suffix":""},{"id":265929281,"identity":"53738687-7435-4840-9eb8-a1033de9fb4a","order_by":16,"name":"Cunli Yang","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Cunli","middleName":"","lastName":"Yang","suffix":""},{"id":265929282,"identity":"6180fde1-7a82-467f-9c31-ee7e8a337447","order_by":17,"name":"Anil Gopinathan","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Anil","middleName":"","lastName":"Gopinathan","suffix":""},{"id":265929283,"identity":"e8163595-9368-40cd-8953-cfe77db7f95b","order_by":18,"name":"Tseng Tsai Yeo","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Tseng","middleName":"Tsai","lastName":"Yeo","suffix":""},{"id":265929284,"identity":"c1175bc3-d796-465c-95c7-f8e6b4bd7654","order_by":19,"name":"Vincent Nga","email":"","orcid":"","institution":"National University Health System","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"Nga","suffix":""}],"badges":[],"createdAt":"2024-01-04 17:29:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3835086/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3835086/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10143-024-02325-z","type":"published","date":"2024-03-01T15:02:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":49440218,"identity":"a588dd8a-4e55-4252-8438-320d79de04ca","added_by":"auto","created_at":"2024-01-10 21:53:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":316086,"visible":true,"origin":"","legend":"\u003cp\u003eStrengthening the Reporting of Observational Studies in Epidemiology (STROBE) flow chart demonstrating inclusion/exclusion of patients identified across the National University Health System (NUHS) cluster in Singapore from 2014 to 2019\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3835086/v1/9a6e8ce10dcb5f4de4d0f6f6.png"},{"id":51958374,"identity":"bd8501ae-1bb0-43dd-ade9-d144392f43c7","added_by":"auto","created_at":"2024-03-04 15:15:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":515506,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3835086/v1/31ac0378-eec0-49fb-a2b5-defe68d502dc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endovascular Coiling versus Neurosurgical Clipping in the Management of Aneurysmal Subarachnoid Haemorrhage in the Elderly: A Multicenter Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLonger life expectancies are leading to aging populations and rising incidence of aneurysmal subarachnoid haemorrhage (aSAH).[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The advent of minimally invasive aneurysm securing technique has encouraged a gradual shift in treatment paradigm for this age group to encompass early treatment comprising microsurgical clipping, endovascular coiling and neurointensive care.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] As a result, clinical practice has also changed and more elderly aSAH patients are being referred to neurosurgical centers.\u003c/p\u003e \u003cp\u003eTreatment of elderly patients with aSAH however still remains a clinical challenge,[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] largely owing to their higher rate of poor clinical grade on admission, severe aSAH on initial computed tomography (CT) scan, and general complications.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Older age within this cohort has also been associated with poor outcomes.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The literature reporting outcomes for elderly patients with aSAH is scarce and optimal management of this condition in the elderly remains unclear.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWhilst the recommendation for endovascular coiling over surgical clipping for SAH in general is relatively well established,\u003csup\u003e14,15,16\u003c/sup\u003e the International Subarachnoid Aneurysm Trial (ISAT) has been the only large, multicenter, RCT that compared neurosurgical clipping with detachable platinum coils in patients with ruptured intracranial aneurysms, who were considered to be suitable for either treatment.\u003csup\u003e15\u003c/sup\u003e However, results of ISAT have continued to generate some criticism, mainly because of its selection bias. For example, vast majority of the enrolled patients, had a favourable grade at the time of enrolment, 95% of the aneurysms were in the anterior cerebral circulation, and 90% were smaller than 10 mm. This makes it difficult for clinicians to generalise the results to their own practice. Hence whether the superiority of coillingstill prevails in the elderly subgroup remains unconfirmed. Therefore, our study aims to explore the outcomes of coiling and clipping in a unique cohort of elderly patients with aSAH.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eData collection\u003c/h2\u003e\n \u003cp\u003eEthics approval was obtained from the institutional review board before commencement of the study. Data were obtained retrospectively from the National University Health System (NUHS) cluster in Singapore which included the National University Hospital, Khoo Teck Puat Hospital and Ng Teng Fong General Hospital, over a period of six years from 2014 to 2019. Electronic medical records were reviewed for all for elderly patients (aged 60 years and above) who had undergone treatment for aSAH at our institutions. The definition of \u0026apos;elderly\u0026apos; may vary according to chronological, biological, psychological, and social aspects. In this study patients aged 60 years and above were classified in the elderly age group in line with the definition established by the World Health Organisation (WHO) and United Nations (UN).[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e] Diagnosis of aSAH was confirmed with a head computed tomography scan or a lumbar puncture. Evidence of aSAH was verified by a neuroradiologist on computed tomography angiography or digital subtraction angiography. Patients with no aneurysmal SAH, or those who did not undergo treatment were excluded from the analysis.\u003c/p\u003e\n \u003cp\u003eThe collected patient variables included: age, gender, smoking history, and comorbidities (hypertension, hyperlipidaemia, diabetes mellitus, and ischaemic heart disease), and World Federation of Neurosurgical Societies (WFNS) score on admission, dichotomized as good (Grades I \u0026ndash; III) and poor (Grades IV \u0026ndash; V). The following information about aSAH features was extracted: number of aneurysms, size of aneurysms, and location of subarachnoid haemorrhages. Additionally, information on the treatment modality (coiling or clipping) was obtained. The following information about patient complications was also extracted: aneurysm re-rupture, delayed hydrocephalus, delayed ischaemic neurological deficit, large infarct requiring decompressive craniectomy, and venous thromboembolism.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eOutcome measures\u003c/h2\u003e\n \u003cp\u003eThe primary outcome measure was functional outcome defined by the modified Rankin Scale (mRS) at 3 months and 6 months after aSAH. Furthermore, the outcome was dichotomized as favorable (mRS score of 0\u0026ndash;2) or unfavorable (mRS score of 3\u0026ndash;6). The secondary outcome was in-hospital mortality.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cp\u003eNumerical variables were described as median (interquartile range [IQR]) for non-normal distributions. Normality of data was tested for using the Shapiro-Wilk test. Age was either analyzed as a categorical or a continuous variable. Patients were separated into 3 age groups: 60\u0026ndash;69, 70\u0026ndash;79, and \u0026ge;80 years. If age was analyzed as a categorical variable, odd ratios (ORs) were compared with the reference category 60\u0026ndash;69 years (OR\u0026thinsp;=\u0026thinsp;1.0).[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e] Comparisons of non-normal numerical data were conducted using the Mann-Whitney U test and comparisons of categorical variables were performed using the Pearson chi-squared test. Stepwise multivariable logistic regression was used to identify associations identify independent predictors for categorical outcome measures.\u003c/p\u003e\n \u003cp\u003eData were collated in Microsoft Excel (Microsoft, Redmond, WA, USA). All statistical analyses were performed using R software version 4.2.1 (R Foundation for Statistical Computing, 2022). P-values less than 0.05 were considered statistically significant.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eA total of 134 patients were included in our analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Median age of these patients was 68.5 years (IQR 64\u0026ndash;74). There were 104 females (77.6%) and 30 males (22.4%), with only six patients (4.5%) having a history of smoking. Eighty-seven patients (64.9%) exhibited at least one comorbidity. The most common comorbidities were hypertension in 75 patients (56.0%), hyperlipidaemia in 58 (43.3%), diabetes mellitus in 18 (13.4%) and ischaemic heart disease in 17 patients (12.7%). On admission, 70 patients (52.2%) had good admission WFNS grade (I \u0026ndash; III).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eEighty-four patients (62.7%) underwent coiling whilst 50 patients (37.3%) underwent clipping. Twenty seven (20.1%) patients had multiple aneurysms, 24 (17.9%) with two aneurysms and three (2.2%) with three aneurysms. Ninety one patients (67.9%) had aneurysm\u0026thinsp;\u0026lt;\u0026thinsp;7mm in size, with 103 (76.9%) located anteriorly. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e compares the baseline patient and aneurysm characteristics, between the coiling and clipping groups which demonstrates no significant difference.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndovascular coiling\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeurosurgical clipping\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (64\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69 (65\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.770\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (25.0)\u003c/p\u003e \u003cp\u003e63 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (18.0)\u003c/p\u003e \u003cp\u003e41 (82.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.347\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.837\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003cp\u003eHyperlipidaemia\u003c/p\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003cp\u003eIschemic heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (52.4)\u003c/p\u003e \u003cp\u003e32 (38.1)\u003c/p\u003e \u003cp\u003e10 (11.9)\u003c/p\u003e \u003cp\u003e12 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (62.0)\u003c/p\u003e \u003cp\u003e26 (52.0)\u003c/p\u003e \u003cp\u003e8 (16.0)\u003c/p\u003e \u003cp\u003e5 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003cp\u003e0.116\u003c/p\u003e \u003cp\u003e0.501\u003c/p\u003e \u003cp\u003e0.471\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute hydrocephalus requiring EVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (70.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (84.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmission WFNS\u003c/p\u003e \u003cp\u003eI \u0026ndash; III\u003c/p\u003e \u003cp\u003eIV \u0026ndash; V\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (50.0)\u003c/p\u003e \u003cp\u003e42 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (56.0)\u003c/p\u003e \u003cp\u003e22 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.501\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAneurysm number\u003c/p\u003e \u003cp\u003eSingle\u003c/p\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (82.1)\u003c/p\u003e \u003cp\u003e15 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (76.0)\u003c/p\u003e \u003cp\u003e12 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.391\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAneurysm location\u003c/p\u003e \u003cp\u003eAnterior circulation\u003c/p\u003e \u003cp\u003ePosterior circulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (71.4)\u003c/p\u003e \u003cp\u003e24 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (86.0)\u003c/p\u003e \u003cp\u003e7 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAneurysm size\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7mm\u003c/p\u003e \u003cp\u003e\u0026ge;\u0026thinsp;7mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (72.6)\u003c/p\u003e \u003cp\u003e23 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (60.0)\u003c/p\u003e \u003cp\u003e20 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.130\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAll categorical data presented as n (%) and all numerical data presented as median (interquartile range). EVD\u0026thinsp;=\u0026thinsp;External Ventricular Drain; WFNS\u0026thinsp;=\u0026thinsp;World Federation of Neurosurgical Societies\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical outcomes of endovascular versus clipping\u003c/h2\u003e \u003cp\u003eFifty-five (41.0%) patients had a good functional outcome (mRS score 0\u0026ndash;2) at 3 months follow-up, whilst 65 (48.5%) patients had good functional outcome at 6 months follow-up. There were 16 in-hospital mortalities (11.9%) in our cohort of elderly patients. The clinical outcomes and complications sustained between the coiling and clipping groups are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of outcomes between endovascular and neurosurgical treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndovascular coiling\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeurosurgical clipping\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS 0\u0026ndash;2 at 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.45 (1.16\u0026ndash;5.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS 0\u0026ndash;2 at 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (54.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (38.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.98 (0.97\u0026ndash;4.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAneurysm rebleed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78 (0.17\u0026ndash;3.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.755\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed hydrocephalus requiring ventriculoperitoneal shunt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.57 (0.27\u0026ndash;1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.130\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed ischemic neurological deficit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.30 (0.71\u0026ndash;7.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge infarct requiring decompressive craniectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.32 (0.12\u0026ndash;0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenous thromboembolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.45 (0.27\u0026ndash;22.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.415\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.31 (0.10\u0026ndash;0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAll categorical data presented as n (%). mRS\u0026thinsp;=\u0026thinsp;modified Rankin Scale\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNeurosurgical clipping group is used as the reference group\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe endovascular group showed a higher incidence of good mRS score at 3 months (48.8% in coiling group vs. 28.8% in clipping group; OR\u0026thinsp;=\u0026thinsp;2.45 [95% CI: 11.16\u0026ndash;5.20]; p\u0026thinsp;=\u0026thinsp;0.018), and a lower incidence of in-hospital mortality (7.1% in coiling group vs. 20.0% in clipping group; OR\u0026thinsp;=\u0026thinsp;0.31 [95%CI: 0.10\u0026ndash;0.91]; p\u0026thinsp;=\u0026thinsp;0.026). The benefit of coiling over clipping in terms of good mRS score at 6 months showed a trend towards statistical significance (54.8% in coiling group vs. 38.0% in clipping group; OR\u0026thinsp;=\u0026thinsp;1.98 [95% CI: 0.97\u0026ndash;4.04]; p\u0026thinsp;=\u0026thinsp;0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (8.3% in coiling group vs 22.0% in clipping group; OR\u0026thinsp;=\u0026thinsp;0.32 [95% CI: 0.12\u0026ndash;0.90]; p\u0026thinsp;=\u0026thinsp;0.025).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePredictors of clinical outcomes\u003c/h2\u003e \u003cp\u003eIndependent predictors of clinical outcomes and their effect sizes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression for predictors of poor clinical outcome\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMultivariate analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003emRS score\u003c/p\u003e \u003cp\u003e0\u0026ndash;2 at 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.42 (0.24\u0026ndash;0.743)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.32 (0.17\u0026ndash;0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdmission WFNS score I \u0026ndash; III\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.28 (1.59\u0026ndash;6.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.81 (1.47\u0026ndash;9.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcute hydrocephalus requiring EVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.24 (0.11\u0026ndash;0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.50 (0.18\u0026ndash;1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.197\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndovascular coiling\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.45 (1.15\u0026ndash;5.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.31 (1.36\u0026ndash;8.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003emRS score\u003c/p\u003e \u003cp\u003e0\u0026ndash;2 at 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.52 (0.31\u0026ndash;0.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.46 (0.26\u0026ndash;0.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdmission WFNS score I \u0026ndash; III\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.47 (1.70\u0026ndash;7.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.31 (1.42\u0026ndash;7.67.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcute hydrocephalus requiring EVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31 (0.13\u0026ndash;0.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.64 (0.66\u0026ndash;4.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eMortality in hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdmission WFNS score I \u0026ndash; III\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.18 (0.05\u0026ndash;0.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15 (0.04\u0026ndash;0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAneurysm size \u0026ge;7 mm\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.17 (1.10\u0026ndash;9.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.69 (0.19\u0026ndash;2.5`)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.577\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndovascular coiling\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31 (0.10\u0026ndash;0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28 (0.08\u0026ndash;0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLarge infarct requiring decompressive craniectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.68 (1.10\u0026ndash;12.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.23 (0.87\u0026ndash;20.833)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelayed hydrocephalus requiring ventriculoperitoneal shunt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.12 (0.02\u0026ndash;0.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07 (0.01\u0026ndash;0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Age category 60\u0026ndash;69 years is used as the reference group\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eWFNS Grades IV \u0026ndash; V is used as the reference group\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u0026Dagger;\u003c/sup\u003eNeurosurgical clipping group is used as the reference group WFNS Grades IV \u0026ndash; V is used as the reference group\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u0026sect;\u003c/sup\u003eAneurysm size\u0026thinsp;\u0026lt;\u0026thinsp;7mm is used as the reference group\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eEVD\u0026thinsp;=\u0026thinsp;External Ventricular Drain; WFNS\u0026thinsp;=\u0026thinsp;World Federation of Neurosurgical Societies\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn univariate analyses, age (p\u0026thinsp;=\u0026thinsp;0.003), admission WFNS score I \u0026ndash; III (p\u0026thinsp;=\u0026thinsp;0.001), presence of acute hydrocephalus (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and coiling (p\u0026thinsp;=\u0026thinsp;0.018), were found to be significant predictors of good functional outcomes mRS scores 0\u0026ndash;2, at 3 months. On multivariate analysis, only age (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), admission WFNS score I \u0026ndash; III (p\u0026thinsp;=\u0026thinsp;0.009), and coiling (p\u0026thinsp;=\u0026thinsp;0.012) remained statistically significant predictors of good functional outcomes mRS scores 0\u0026ndash;2, at 3 months\u003c/p\u003e \u003cp\u003eOn univariate analyses, age (p\u0026thinsp;=\u0026thinsp;0.013), admission WFNS score I \u0026ndash; III (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and presence of acute hydrocephalus (p\u0026thinsp;=\u0026thinsp;0.005) were found to be significant predictors of good functional outcomes mRS scores 0\u0026ndash;2, at 6 months. On multivariate analysis, only age (p\u0026thinsp;=\u0026thinsp;0.005) and admission WFNS score I \u0026ndash; III (p\u0026thinsp;=\u0026thinsp;0.005) remained statistically significant predictors of good functional outcomes mRS scores 0\u0026ndash;2, at 6 months.\u003c/p\u003e \u003cp\u003eOn univariate analyses, admission WFNS score (p\u0026thinsp;=\u0026thinsp;0.004), aneurysm size \u0026ge;7 mm (p\u0026thinsp;=\u0026thinsp;0.043), treatment modality (p\u0026thinsp;=\u0026thinsp;0.026), large infarct requiring decompressive craniectomy (p\u0026thinsp;=\u0026thinsp;0.026), and delayed hydrocephalus requiring ventriculoperitoneal shunt (p\u0026thinsp;=\u0026thinsp;0.018) were found to be significant predictors of in-hospital mortality. On multivariate analysis, admission WFNS score (p\u0026thinsp;=\u0026thinsp;0.008), treatment modality (p\u0026thinsp;=\u0026thinsp;0.041), and delayed hydrocephalus requiring ventriculoperitoneal shunt (p\u0026thinsp;=\u0026thinsp;0.018) remained statistically significant predictors of in-hospital mortality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSubgroup analysis\u003c/h2\u003e \u003cp\u003eWithin the WFNS score IV \u0026ndash; V subgroup, the beneficial effect of coiling over neurosurgical clipping in terms of good mRS scores at 3-month (p\u0026thinsp;=\u0026thinsp;0.090) and 6-month (p\u0026thinsp;=\u0026thinsp;0.214) and in-hospital mortality (p\u0026thinsp;=\u0026thinsp;0.098) diminished. Within the age 60\u0026ndash;69 subgroup, the beneficial effect of coiling over neurosurgical clipping in terms of good mRS scores at 3-month was retained (p\u0026thinsp;=\u0026thinsp;0.038), but lost for good mRS scores at 6-month (p\u0026thinsp;=\u0026thinsp;0.175) and in-hospital mortality (p\u0026thinsp;=\u0026thinsp;0.509).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings demonstrate that coiling compared with neurosurgical clipping was associated with higher incidences of good functional outcomes and lower incidences of in-hospital mortality, with no significant differences in the incidence of complications, in terms of aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism. However, more patients in the clipping group developed large infarcts requiring decompressive craniectomy. A lower age, favorable admission WFNS scores and endovascular treatment were consistently identified as independent predictors of good functional outcomes in elderly patients with aSAH, whilst the latter two factors were also independent predictors of in-hospital mortality.\u003c/p\u003e \u003cp\u003eOur study avoided preselection by including patients who, because of their clinical status, did not receive treatment of the ruptured aneurysm. Numerous studies have reported reasonable outcomes for elderly aSAH patients, but older and poor-grade patients are often underrepresented in these analyses,[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] as they are shown to be predictive of unfavorable outcomes and mortality.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] An important consideration in the controversial debate around treatment of elderly patients with poor-grade aSAH is the possibility of increasing the number of dependent patients.[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The elderly are a heterogenous population with the hexegenarians differing clinically from the octogenarian subgroup. A consensus for an age cap for maximal aneurysm treatment remains to be achieved for aSAH. The clinical implications of this are that maximal active aneurysm treatment should be recommended strongly to the young (aged 60\u0026ndash;79) elderly subgroup, especially if they are alert at the time of presentation, given the likelihood of positive short term outcomes at three months. Indeed this is supported by Goldberg et al. who showed that despite its high initial mortality, maximal treatment of aSAH in the elderly resulted in a reasonable proportion of favorable outcomes.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Such a trend is also reflective of improvements in coiling technology and technical know-how which underpin the improvements in patient outcomes. This is further reinforced by an observed increase in the percentage of aSAH cases treated with coiling at our institution from 42% in 2009, to 63% in 2019, reflecting a gradual shift in treatment paradigm in favor of coiling.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Notwithstanding, the better patient outcomes after coiling compared with clipping could also be partly explained by the selection bias our included patients were inevitably subjected to.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] At our institution, all aSAH patients are first considered for coiling, and only proceeds to clipping if not amendable to endovascular means. Hence, the general pool of clipped aneurysms were more complex with poorer grades at admission to begin with, predisposing to postoperative complications.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] However, these were accounted for in our regression and subgroup analyses.\u003c/p\u003e \u003cp\u003eHowever, we should note the possibility of coiling losing its advantage over conventional clipping in the long term. Our results showed that elderly aSAH patients who were treated endovascularly had superior functional outcomes compared to those treated neurosurgically in the short term at 3 months post discharge, but there was no statistical significance in outcomes between these two groups by 6 months post discharge. This could indicate the possibility of coiling and clipping yielding comparable outcomes in the long-term, beyond our 6-month follow-up period. Long-term follow-up of the ISAT trial lends some support to this view, reporting a comparable rate of dependency in the coiling and clipping groups in the long run.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Moving forward, there is a need for larger prospective trials to shed light on current evidence on this important clinical topic.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] With increasing evidence supporting the safety and effectiveness of maximal treatment in elderly patients with aSAH,[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] there may finally be sufficient clinical equipoise to warrant a randomized prospective trial that could help to address the question at hand.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe limitations of our study stem from its retrospective nature. First, being a retrospective review, non-standardized documentation of medical records could have resulted in bias in the collected data. This limitation was mitigated by the few numbers of patients lost to follow-up, minimising attrition bias. Secondly, the majority of patients had complete documentation of information during their hospital stay, resulting in few patients having to be excluded from final analysis. Nonetheless, the moderate sample size in our cohort limited further subgroup analyses to delineate the benefits of coiling over neurosurgical clipping. Finally, our study was conducted using data from three tertiary institutions, with several different surgeons attending to the patients. There may have been slight differences in management despite a largely standardized protocol at our institutions. However, this is reflective of real-world practice and hence enhances the applicability of our findings to the general cohort of elderly patients with aSAH.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEndovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH but its benefits diminishes at 6 months. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKeng Siang, Lee: Methodology, validation, formal analysis, investigation, writing - original draft, writing - review \u0026amp; editing, visualisationIsabel Siow: Methodology, validation, investigation, data curation, writing - review \u0026amp; editingLily Yang: Methodology, validation, investigation, data curation, writing - review \u0026amp; editingAaron SC, Foo: Methodology, validation, investigation, writing - review \u0026amp; editingJohn J. Y., Zhang: Methodology, validation, investigation, data curation, writing - review \u0026amp; editing Ian Mathews: Methodology, validation, writing - review \u0026amp; editingChun Peng Goh: Methodology, validation, writing - review \u0026amp; editingColin Teo: Methodology, validation, writing - review \u0026amp; editingBolem, Nagarjun: Methodology, validation, writing - review \u0026amp; editingVanessa Chen: Methodology, validation, investigation, writing - review \u0026amp; editingSein Lwin: Methodology, validation, writing - review \u0026amp; editingKejia Teo: Methodology, validation, writing - review \u0026amp; editingShiong Wen Low: Methodology, validation, writing - review \u0026amp; editingIra SY Sun: Methodology, validation, writing - review \u0026amp; editingBoon Chuan Pang: Methodology, validation, writing - review \u0026amp; editingEugene WR Yang: Methodology, validation, writing - review \u0026amp; editingCunli Yang: Methodology, validation, writing - review \u0026amp; editingAnil Gopinathan: Methodology, validation, investigation, writing - review \u0026amp; editing, visualisationTseng Tsai Yeo: Methodology, validation, investigation, writing - review \u0026amp; editing, visualisation, supervisionVincent DW Nga: Conceptualization, methodology, validation, investigation, writing - review \u0026amp; editing, visualisation, supervision\u003c/p\u003e\u003cp\u003eThe authors report no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKontis, V., et al., \u003cem\u003eFuture life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble.\u003c/em\u003e Lancet, 2017. \u003cstrong\u003e389\u003c/strong\u003e(10076): p. 1323-1335.\u003c/li\u003e\n\u003cli\u003ede Rooij, N.K., et al., \u003cem\u003eIncidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends.\u003c/em\u003e J Neurol Neurosurg Psychiatry, 2007. \u003cstrong\u003e78\u003c/strong\u003e(12): p. 1365-72.\u003c/li\u003e\n\u003cli\u003eLee, K.S., et al., \u003cem\u003eRadiological surveillance of small unruptured intracranial aneurysms: a systematic review, meta-analysis, and meta-regression of 8428 aneurysms.\u003c/em\u003e Neurosurg Rev, 2021. \u003cstrong\u003e44\u003c/strong\u003e(4): p. 2013-2023.\u003c/li\u003e\n\u003cli\u003eRyttlefors, M., et al., \u003cem\u003eNeurointensive care is justified in elderly patients with severe subarachnoid hemorrhage--an outcome and secondary insults study.\u003c/em\u003e Acta Neurochir (Wien), 2010. \u003cstrong\u003e152\u003c/strong\u003e(2): p. 241-9; discussion 249.\u003c/li\u003e\n\u003cli\u003eProust, F., et al., \u003cem\u003eInterdisciplinary treatment of ruptured cerebral aneurysms in elderly patients.\u003c/em\u003e J Neurosurg, 2010. \u003cstrong\u003e112\u003c/strong\u003e(6): p. 1200-7.\u003c/li\u003e\n\u003cli\u003eHoh, B.L., et al., \u003cem\u003e2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association.\u003c/em\u003e Stroke, 2023.\u003c/li\u003e\n\u003cli\u003eJohansson, M., et al., \u003cem\u003eChanges in intervention and outcome in elderly patients with subarachnoid hemorrhage.\u003c/em\u003e Stroke, 2001. \u003cstrong\u003e32\u003c/strong\u003e(12): p. 2845-949.\u003c/li\u003e\n\u003cli\u003eLanzino, G., et al., \u003cem\u003eAge and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse?\u003c/em\u003e J Neurosurg, 1996. \u003cstrong\u003e85\u003c/strong\u003e(3): p. 410-8.\u003c/li\u003e\n\u003cli\u003eNieuwkamp, D.J., et al., \u003cem\u003eSubarachnoid haemorrhage in patients \u0026gt; or = 75 years: clinical course, treatment and outcome.\u003c/em\u003e J Neurol Neurosurg Psychiatry, 2006. \u003cstrong\u003e77\u003c/strong\u003e(8): p. 933-7.\u003c/li\u003e\n\u003cli\u003eGoldberg, J., et al., \u003cem\u003eSurvival and Outcome After Poor-Grade Aneurysmal Subarachnoid Hemorrhage in Elderly Patients.\u003c/em\u003e Stroke, 2018. \u003cstrong\u003e49\u003c/strong\u003e(12): p. 2883-2889.\u003c/li\u003e\n\u003cli\u003ePavelka, M., et al., \u003cem\u003eVasospasm risk following aneurysmal subarachnoid hemorrhage in older adults.\u003c/em\u003e J Neurosurg, 2023: p. 1-9.\u003c/li\u003e\n\u003cli\u003eSuzuki, Y., et al., \u003cem\u003eResults of Clipping Surgery for Aneurysmal Subarachnoid Hemorrhage in Elderly Patients Aged 90 or Older.\u003c/em\u003e Acta Neurochir Suppl, 2016. \u003cstrong\u003e123\u003c/strong\u003e: p. 13-6.\u003c/li\u003e\n\u003cli\u003eHironaka, K., et al., \u003cem\u003eOutcomes in Elderly Japanese Patients Treated for Aneurysmal Subarachnoid Hemorrhage: A Retrospective Nationwide Study.\u003c/em\u003e J Stroke Cerebrovasc Dis, 2020. \u003cstrong\u003e29\u003c/strong\u003e(6): p. 104795.\u003c/li\u003e\n\u003cli\u003eOrganization, W.H. \u003cem\u003eAgeing\u003c/em\u003e. 13 June 2023]; Available from: https://www.who.int/health-topics/ageing#tab=tab_1.\u003c/li\u003e\n\u003cli\u003ePark, J., et al., \u003cem\u003eCritical age affecting 1-year functional outcome in elderly patients aged \u003c/em\u003e\u003cem\u003e\u0026ge; 70 years with aneurysmal subarachnoid hemorrhage.\u003c/em\u003e Acta Neurochir (Wien), 2014. \u003cstrong\u003e156\u003c/strong\u003e(9): p. 1655-61.\u003c/li\u003e\n\u003cli\u003eKoh, K.M., et al., \u003cem\u003eManagement of ruptured intracranial aneurysms in the post-ISAT era: outcome of surgical clipping versus endovascular coiling in a Singapore tertiary institution.\u003c/em\u003e Singapore Med J, 2013. \u003cstrong\u003e54\u003c/strong\u003e(6): p. 332-8.\u003c/li\u003e\n\u003cli\u003eLee, K.S., et al., \u003cem\u003eThe evolution of intracranial aneurysm treatment techniques and future directions.\u003c/em\u003e Neurosurg Rev, 2022. \u003cstrong\u003e45\u003c/strong\u003e(1): p. 1-25.\u003c/li\u003e\n\u003cli\u003eMolyneux, A.J., et al., \u003cem\u003eThe durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT).\u003c/em\u003e Lancet, 2015. \u003cstrong\u003e385\u003c/strong\u003e(9969): p. 691-7.\u003c/li\u003e\n\u003cli\u003eRyttlefors, M., et al., \u003cem\u003eInternational subarachnoid aneurysm trial of neurosurgical clipping versus endovascular coiling: subgroup analysis of 278 elderly patients.\u003c/em\u003e Stroke, 2008. \u003cstrong\u003e39\u003c/strong\u003e(10): p. 2720-6.\u003c/li\u003e\n\u003cli\u003eLee, K.S., et al., \u003cem\u003eAntiplatelet therapy in aneurysmal subarachnoid hemorrhage: an updated meta-analysis.\u003c/em\u003e Neurosurg Rev, 2023. \u003cstrong\u003e46\u003c/strong\u003e(1): p. 221.\u003c/li\u003e\n\u003cli\u003eBraun, V., et al., \u003cem\u003eTreatment and outcome of aneurysmal subarachnoid haemorrhage in the elderly patient.\u003c/em\u003e Neuroradiology, 2005. \u003cstrong\u003e47\u003c/strong\u003e(3): p. 215-21.\u003c/li\u003e\n\u003cli\u003eKoffijberg, H., E. Buskens, and G.J. Rinkel, \u003cem\u003eAneurysm occlusion in elderly patients with aneurysmal subarachnoid haemorrhage: a cost-utility analysis.\u003c/em\u003e J Neurol Neurosurg Psychiatry, 2011. \u003cstrong\u003e82\u003c/strong\u003e(7): p. 718-27.\u003c/li\u003e\n\u003cli\u003eZumofen, D.W., et al., \u003cem\u003eFactors associated with clinical and radiological status on admission in patients with aneurysmal subarachnoid hemorrhage.\u003c/em\u003e Neurosurg Rev, 2018. \u003cstrong\u003e41\u003c/strong\u003e(4): p. 1059-1069.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Aneurysm, subarachnoid hemorrhage, elderly, geriatric, endovascular, clipping cohort study","lastPublishedDoi":"10.21203/rs.3.rs-3835086/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3835086/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eThe comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData were obtained from all patients with aSAH aged \u0026ge;60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0\u0026ndash;2 at 3 months (OR\u0026thinsp;=\u0026thinsp;2.45 [95%CI:11.16\u0026ndash;5.20];p\u0026thinsp;=\u0026thinsp;0.018), and a lower incidence of in-hospital mortality (OR\u0026thinsp;=\u0026thinsp;0.31 [95%CI:0.10\u0026ndash;0.91];p\u0026thinsp;=\u0026thinsp;0.026). The benefit of coiling over clipping in terms of good mRS score at 6 months showed a trend towards statistical significance (OR\u0026thinsp;=\u0026thinsp;1.98 [95%CI:0.97\u0026ndash;4.04];p\u0026thinsp;=\u0026thinsp;0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR\u0026thinsp;=\u0026thinsp;0.32 [95%CI:0.12\u0026ndash;0.90];p\u0026thinsp;=\u0026thinsp;0.025). Age, admission WFNS score I\u0026ndash;III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I\u0026ndash;III remained significant predictors of good functional outcomes at 6 months.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eEndovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.\u003c/p\u003e","manuscriptTitle":"Endovascular Coiling versus Neurosurgical Clipping in the Management of Aneurysmal Subarachnoid Haemorrhage in the Elderly: A Multicenter Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-10 21:53:00","doi":"10.21203/rs.3.rs-3835086/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-01-24T03:20:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-01-16T01:08:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b6894660-69a6-4b48-9243-87b60f66b8c9","date":"2024-01-15T21:23:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-01-15T18:15:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-15T18:13:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-08T16:22:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2024-01-04T17:21:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7c233996-0bb3-4a31-8e05-15fbb7a1f257","owner":[],"postedDate":"January 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-03-04T15:09:17+00:00","versionOfRecord":{"articleIdentity":"rs-3835086","link":"https://doi.org/10.1007/s10143-024-02325-z","journal":{"identity":"neurosurgical-review","isVorOnly":false,"title":"Neurosurgical Review"},"publishedOn":"2024-03-01 15:02:00","publishedOnDateReadable":"March 1st, 2024"},"versionCreatedAt":"2024-01-10 21:53:00","video":"","vorDoi":"10.1007/s10143-024-02325-z","vorDoiUrl":"https://doi.org/10.1007/s10143-024-02325-z","workflowStages":[]},"version":"v1","identity":"rs-3835086","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3835086","identity":"rs-3835086","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}