超高齢者のくも膜下出血治療のあり方―１１２例の経験から―

Abstract

With a globally aging population, it is imperative to develop specific treatment strategies for subarachnoid hemorrhage (SAH) in the elderly. However, the optimal management of SAH in the elderly remains controversial, especially for patients over 80 years of age. Therefore, we retrospectively evaluated the long-term outcomes measured in 112 consecutive patients aged over 80 years and treated at our single-institution. We conducted a retrospective review to evaluate the medical records and imaging studies of 112 patients treated with clipping or conservative therapy between January 1992 and August 2006. The neurological status was evaluated according to Hunt & Kosnik (HK 20 were men. Thirty-two patients underwent clipping procedures, and 80 patients were under conservative therapy. Overall results evaluated as GOS at discharge were: good recovery (GR), 21 (18.8%); moderate disability (MD), 10 (8.9%); severe disability (SD), 9 (8.0%); vegetative state (V), 4 (3.6%); and death (D), 68 (60.7%). This outcome was in accordance with the “best” H&K grade during pre-surgical treatment, not with H&K grade on admission. The outcome of the “best” H&K Grade 1 and 2 groups was significantly better than that of the “best” H&K Grade 3, 4 and 5 groups. Twenty of 28 patients waiting for chronic operation died due to re-rupture, vasospasm, and pneumonia before the operation. The overall outcome of patients with acute operation (GR12, MD4, SD5, V1 and D2) was significantly better than that of patients waiting for chronic operation (GR4, MD3, SD1, V0 and D20). Long-term follow-up showed the median survival periods after discharge of patients surviving in MD, SD, and V were 10 months, 4 months, and 2 months, respectively. Especially in the case of extremely aged patients, the long-term survival was rare even in MD condition. The leading cause of MD condition at discharge was the induction of dementia by long-term lying in bed. The “best” H&K Grade during pre-surgical treatment, not that on admission is a useful and practical tool for the selection of elderly patients affected by SAH as surgical candidates. Many patients planned for chronic operation could not survive until the operation period because of deterioration of general condition. Therefore, acute operation was recommended if the patient's “best” H&K Grade comes up to 1 or 2. All grades of GOS other than GR are a bad prognostic factor for survival after discharge. To prevent the induction of dementia and to achieve good functional condition, rehabilitation soon after surgery should be considered.