Improvements in microsurgical and neuroanesthesiological have resulted in an increasing number of operation for aneurysm clipping in elderly patients. It is the purpose of this article to evaluate surgical outcome of elderly patients(stand point of three groups), considering neurologic grade on admission, amount of subarachnoid hemorrhage(SAH) on computerized tomography(CT) findings and timing of surgery.

The subjects of the present study are 34 patients who were admitted to department of neurosurgery and treated surgically between 1991 and 1997 in Mok-Dong and Tongdaemun hospital. All the patients in this study were verified as having aneurysmal SAH on CT scanning followed b cerebral argiography. The patients were classified by age into three groups : 65 to 70 years(24 cases), 76 years(7 cases) and 76 years or older(3 cases). On admission, the clinical condition of patients was graded according to the scals of Hunt and Hess and the amounts of SAH was graded according to grading system of Fisher. The day 7 SAH was defined as Day O. the timing of operation was divided into three. 1-3 days ; 3-7 days; 8-days.

The surgical mortality according to the different age groups, Hunt-hess grade, grading system of Fisher and timing of operation was analised.

Overall, 11 of the 34 patients died, for a mortality rate 32%. The mortality rate by age groups was 21% for 65 to 70 years, 57% for 71 to 75 years and 20% for 76 years of older. The mortality rate by Hunt-Hess grade was 35%, in I-II, 33% in III and 20% in IV-V, and the mortality rate as related to grading system of Fisher was 0% in 1, 36% in 2, 36% in 3 and 25% in IV. The mortality rate according to timing of operation was 31% in 1-3 days, 25% in 3-7 days and 25% in over days.

In recent years, with improvement in surgical technique and neuroanesthesia, the number of operation for ruptured aneurysm have increased in elderly patient. A more aggressive treatment in elderly patients is justified.

Chronic hydrocephalus is a frequent occurrence after aneurysmal subarachnoid hemorrhage. 14 patients with chronic hydrocephalus and treating with shunting procedure were retrospectively reviewed. Chronic hydrocephalus after aneurysmal subarachnoid hemorrhage was usually recognized when gradual deterioratsm of consciousnes, unexplanied aggrvation of occuring neurologic defists, especially urinary incontinence.

Two-hundred consecutive patients with aneurysmal SAH were admitted to the neuro-surgical department Ewha Womans university Mok-Dong Hospital between fanuary 1994 and fanuary 2001, in all the patients aneurysms clipping was carried out. Among then 14 patient to chronic hydrocephalus following aneurysmal SAH and treating with shunting procedure were reviewed according to consionsnes level(Hunt-Hess classification), amonts of SAH(grading system of Fisher), sites and incidence. The chronic hydrocephalus was diagnosed CT findings in the clinical findings ; deterioration of level of consiousness, aggravation of neurologic deficits and urinary incontinence.

The average age of patients was 51 and predominant in women(man : woman=4 : 10). The incidence of chronic hydrocephalus was 7% and the aneurysmal sites were followings : posterior communicating artery(7), anterior communicating artery(4), and internal carotid artery bifuncation, middle cerebral artery and superior cerebellar artery were 1 respectiviy. According Hunt-Hess Grades were following ; grade I, II, III and IV=1, 6, 3 and 4. The number of patients according to Fisher's grading system were following ; grade 2, 3, and 4=6, 7, and 1. The outcomes by Glasgow assessment were the followings ; Score 5 and 4=9 and 5.

The response to shunting procedure in symptomatic patients of Chronic hydrocephalus following aneurysmal SAH. good in all patients.

Despite of recent advances in pharmacological treatment and improvement surgical and anesthetic techniques, subarachnoid hemorrhage(SHA) from ruptured intracranial aneurysms with poor clinical grades still carries unacceptably high morbidity and mortality rates. Recently surgery for aneurysmal SAH with poor clinical grade has increased interest.

The authors experienced 57 patients with poor clinical grade (Hunt and Hess grade IV-V) after ancurysmal SAH. Among them 25 patients were treated with immediate CSF drainage via ventriculostomy, blood pressure control, early angiography(except 3 patients) and surgery within 12 hour of admission.

The outcomes of patients were categorized using a four-tiered scale :

1) independent and working

2) impaired but independent

3) severly impaired and dependent

4) dead

The average age was 48(13-75) and the male to female ratio was 7:18 in surgical group. The average time to admission and surgery was 12 hours or less among the 25 patients. Among them 9 cases were dead, 2 cases were severly impaired and dependent, 3 cases were impaired but dependent, and 11 cases were independent and working. In this patient all cases, exception one could be ligated with a clip.

The above results suggest that the acute aggressive surgery based on appropriate selection in poor aneurysmal SAH patients can reduce of the mortality.