Elderly, aneurysms

Q1 A stroke involves significant reduction in blood flow to a part of the brain. It can be caused either (i) by an embolus or by intravascular clotting, which blocks blood flow to an area (approximately 85% of strokes), or (ii) by haemorrhage from a ruptured blood vessel, which compresses the brain tissue (approximately 15% of strokes). Patients with extensive atherosclerosis are at risk of intravascular coagulation and blockage of cerebral blood flow, but a vessel can be blocked by a thrombus originating in another part of the circulation. This cause of stroke is common in elderly patients >60 years of age. Aneurysms which rupture suddenly are a more common cause of stroke in younger patients. 

Phenylephrine should be used cautiously in elderly people and in patients with hypertension, coronary heart disease, aneurysms, and diabetic autonomic neuropathy (SEDA-21, 487). 

Atherosclerotic vascular disease is more frequent in elderly patients and may be associated with more tortuous vessel anatomy. Superselective catheterizations of distal cerebral vessels might thus become technically more difficult. Atherosclerotic carotid bifurcation disease is frequently associated in patients with advanced age and might increase the risk of thromboembolic complications. In selected cases, a combined approach, first stenting of the carotid artery stenosis and subsequently coil embolization of the ruptured aneurysm might be a therapeutic option. 

Ellenbogen BK (1970) Subarachnoid haemorrhage in the elderly. Gerontol Clin 12 115-120 Elliott JP, Le Roux PD (1998) Subarachnoid hemorrhage and cerebral aneurysms in the elderly. Neurosurg Clin North Am 9 587-594... 

Inagawa T, Hada H, Katoh Y (1992) Unruptured intracranial aneurysms in elderly patients. Surg Neurol 38 364-370 Inci S, Erbengi A, Ozgen T (1998) Aneurysms of the distal anterior cerebral artery report of 14 cases and a review of the literature. Surg Neurol 50 130-139 discussion 139-140... 

Sugiu K, Tokunaga K, Watanabe K, Sasahara W, Tagawa M, Tamesa N, Ono S, Onoda K, Date I (2005) Endovascular treatment for elderly patients with ruptured aneurysm. Acta Neurochir Suppl 94 7-9... 

Taylor CL, Yuan Z, Selman WR, Ratcheson RA, Rimm AA (1995) Cerebral arterial aneurysm formation and rupture in 20,767 elderly patients hypertension and other risk factors. J Neurosurg 83 812-819 Teunissen LL, Rinkel GJ, Algra A, van Gijn J (1996) Risk factors for subarachnoid hemorrhage a systematic review. Stroke 27 544-549... 

Renal artery aneurysms can also be seen in patients with angiomyolipomas (AMLs) (Fig. 8.2). Classically, AMLs occur in elderly females and patients with tuberous sclerosis. The entire lesion can often be embolized in addition to coiling the aneurysms. A combination of coils and PVA or simply ethanol infusion with a balloon occlusion catheter can be performed as definitive treatment or if surgical resection is anticipated. 

In The Netherlands, we already have experience with a professional safety board for the endovascular treatment of the abdominal aortic aneurysm (de Mol, 2000). The aneurysm, in this case a dilated part of the abdominal aorta, often needs to be removed because of the risk of rupture, especially when its diameter continues to increase. Removal used to involve major abdominal surgery, with a mortality rate of approximately 5 percent. This mortality rate applies to a selected group of patients. Many patients with such an aneurysm do not qualify for this treatment, because they are elderly and often not fit enough for major surgery. 

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