Early Surgical Treatment for the Elderly with Severe SAH: Surgical Indication Based on Glasgow Coma Scale

To determine the indication for early surgery of aneurysmal subarachnoid hemorrhage (SAH) in the elderly, we retrospectively correlated surgical outcome with Glasgow Coma Scale (GCS) score. Between Jan. 1989 and Dec. 2000, 1,885 of 3,447 patients admitted within 48 hours after SAH underwent clipping of aneurysms between Day 0 and Day 3. The incidence of severe SAH (GCS 3 to 6) on admission inversely correlated with age: 38.2% for patients aged ≥80 years, 27.4% for patients aged 70-79 years, 24.2% for those aged 60-69 years, and 20.6% for those aged <60 years. The rate of early surgery was 87 of 272 patients (32.0%) for those aged ≥80 years, 386 of 738 patients (52.3%) for those aged 70-79 years, 578 of 996 patients (58.0%) for those aged 60-69 years, and 834 of 1441 patients (57.9%) for those aged <60 years. At the 3-month evaluation, the overall incidence of favorable outcome (Good recovery and moderate disability) was 23.0% for those aged ≥80 years, 43.2% for those aged 70-79 years, 59.4% for those aged 60-69 years, and 74.9% for those aged <60 years. Among patients aged ≥80 years, the incidence of favorable outcome was 47.4% in GCS 15, 31.0% in GCS 13+14, 33.3% in GCS 11+12, and 0% in GCS≤10. For patients aged 70-79 years, the incidence of favorable outcome was 61.9% in GCS 15, 40-50% between GCS 7 and GCS 14, and less than 10% between GCS 4 and 6. Initial bleeding and systemic complications were the major risk factors for poor prognosis in the elderly. We concluded that lower limitation of GCS score for early surgery was 11 for patients aged ≥80 years, and 7 for those aged 70-79 years.