Michael Chen, MD
Recently, I took care of a woman in her mid-80s who was found to have a large brain aneurysm discovered by accident after she tripped, fell and hit her head. Fortunately, her scan did not reveal any blood, or any other serious injury for that matter. But what we were left with was this finding that looked to be a concern because of its size. She was an otherwise healthy appearing older woman who was carrying on quite well in her life. She had a large family. Her 11th great grandchild was on the way next week she told me.
This unique type of medical decision-making is becoming increasingly common as people live longer and more medical imaging is being performed. Besides the typical issues that are included in the decision to treat unruptured brain aneurysms, when caring for much older patients, the imprecise and awkward estimation needs to be made as to life expectancy and quality of life.
We rather quickly covered the more customary concerns, such as the aneurysm diameter, which was 8mm and at the internal carotid artery bifurcation. According to the literature, this anatomic information would qualify as high risk for future rupture. But because this aneurysm was discovered by accident, and she was in her mid eighties, there was the distinct possibility that she had lived with this aneurysm for quite some time, perhaps even a decade or so.
The technical aspects of the procedure were reviewed, and fortunately, it appeared to be a relatively straightforward procedure. She had no active medical issues, good cardiac function, no significant vascular tortuosity on imaging, and an aneurysm neck that was relatively narrow, making for a potential embolization procedure consisting of coil placement alone.
The real question really boiled down to whether our current notions of how concerning or dangerous the aneurysm was, based on its size and anatomy, needed to be adjusted in any way because of the patient’s age. The information we oftentimes have is frustratingly limited. There are no reliable warning signs on the neurologic examination, bloodwork, or imaging that reliably helps us predict if something harmful is truly imminent. She is already past the average life expectancy of a woman in the North America. She is quite active on a daily basis and her personality is one of someone who deeply cares for her family and their activities. She is not aware of any active medical issues that currently occupy her attention. One of her children is a physician. I asked him to make his best estimate as to her life expectancy at this point. Given how she has living, we all generally agreed that she could very well live at least another five years.
We took our time. We allowed time for the patient and family to deliberate on the issues we brought up. Certain questions were repeated. We showed pictures. We talked about our prior experience. We talked about published case series looking at outcomes from elective preventative aneurysm treatment in patients older than 70 years old.
Fortunately, the procedure went well, she was discharged home the next day, and hopefully our efforts helped her live a longer, more functional life. We will never know for sure if what we did was the right decision. But given the limited information available to us at the time, I would like to think this was the best decision.