Key result
Open microsurgical clipping was associated with a reduced likelihood of returning home compared to endovascular coiling among octogenarians with subarachnoid hemorrhage (aHR 0.67; 95% CI 0.54-0.81).
Why the study?
Does endovascular coiling compared to microsurgical clipping improve long-term survival and return to home in octogenarians with aneurysmal subarachnoid hemorrhage?
Cohort (n=1,298)
Yes
Does endovascular coiling compared to microsurgical clipping improve long-term survival and return to home in octogenarians with aneurysmal subarachnoid hemorrhage?
Hazard Ratio: 0.67 (95% CI 0.54–0.81)
In octogenarians with aneurysmal subarachnoid hemorrhage, endovascular coiling is associated with a higher likelihood of returning home compared to microsurgical clipping, despite high overall mortality.
Supports endovascular coiling for home discharge in octogenarian SAH; hypothesis-generating and requires randomized confirmation before practice change.
OBJECTIVE: Data evaluating the long-term outcomes, particularly with regard to treatment modality, of aneurysmal subarachnoid hemorrhage (SAH) in octogenarians are limited. The primary objectives were to evaluate the disposition (living at home vs institutional settings) and analyze the predictors of long-term survival and return to home for octogenarians after SAH. METHODS: Data pertaining to patients age 80 and older who underwent microsurgical clipping or endovascular coiling for SAH were extracted from 100% nationwide Medicare inpatient claims and linked with the Minimum Data Set (2008-2011). Patient disposition was tracked for 2 years after index SAH admission. Multivariable logistic regression stratified by aneurysm treatment modality, and adjusted for patient factors including SAH severity, evaluated predictors of return to home at 60 and 365 days after SAH. Survival 365 days after SAH was analyzed with a multivariable Cox proportional hazards model. RESULTS: A total of 1298 cases were included in the analysis. One year following SAH, 56% of the patients had died or were in hospice care, 8% were in an institutional post-acute care setting, and 36% had returned home. Open microsurgical clipping (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.54-0.81), male sex (aHR 0.70, 95% CI 0.57-0.87), tracheostomy (aHR 0.63, 95% CI 0.47-0.85), gastrostomy (aHR 0.60, 95% CI 0.48-0.76), and worse SAH severity (aHR 0.94, 95% CI 0.92-0.97) were associated with reduced likelihood of patients ever returning home. Older age (aHR 1.09, 95% CI 1.05-1.13), tracheostomy (aHR 2.06, 95% CI 1.46-2.91), gastrostomy (aHR 1.55, 95% CI 1.14-2.10), male sex (aHR 1.66, 95% CI 1.20-2.23), and worse SAH severity 1.51 (95% CI 1.04-2.18) were associated with reduced survival. CONCLUSIONS: In this national analysis, 56% of octogenarians with SAH died, and 36% returned home within 1 year of SAH. Coil embolization predicted returning to home, which may suggest a benefit to endovascular treatment in this patient population.
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Dasenbrock et al. (2018) conducted a cohort in aneurysmal subarachnoid hemorrhage (n=1,298). Open microsurgical clipping vs. Endovascular coiling was evaluated on Return to home (aHR 0.67, 95% CI 0.54-0.81). Open microsurgical clipping was associated with a reduced likelihood of returning home compared to endovascular coiling among octogenarians with subarachnoid hemorrhage (aHR 0.67; 95% CI 0.54-0.81).
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