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Axial computed tomography (CT) of the head showing an acute subdural hematoma on the right side with brain shift
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Due to the aging population, neurosurgeons are confronted with an increasing number of very old patients suffering from traumatic brain injury. Many of these patients present with an acute subdural hematoma. There is a lack of data on neurosurgical decision-making in elderly people. We investigated the importance of imaging criteria, patients’ wish...
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Background: Acute subdural hematoma is one of the frequent complications of severe head trauma, it is a neurosurgical emergency. The aim of this study is to determine and evaluate the outcome of patients operated by craniotomy versus decompressive craniectomy. Methods: This is a retrospective and analytical study over two years from Results: 73 pat...
Citations
... However, in some cases, palliative care would be in the best interest of the patient [44], and our study shows that treatment-limiting decisions are common for elderly patients with severe TBI in our region, consistent with another Norwegian study [45]. Interestingly, a German and Austrian study found that even if neurosurgeons were willing to perform an emergency operation on an elderly patient with a life-threatening TBI [46], the elderly patients themselves might not wish for a life-prolonging intervention if it would involve severe disability [47]. ...
Background:
Patients with moderate and severe traumatic brain injury (TBI) are admitted to general hospitals (GHs) without neurosurgical services, but few studies have addressed the management of these patients. This study aimed to describe these patients, the rate of and reasons for managing patients entirely at the GH, and differences between patients managed entirely at the GH (GH group) and patients transferred to the regional trauma centre (RTC group). We specifically examined the characteristics of elderly patients.
Methods:
Patients with moderate (Glasgow Coma Scale score 9-13) and severe (score ≤ 8) TBIs who were admitted to one of the seven GHs without neurosurgical services in central Norway between 01.10.2004 and 01.10.2014 were retrospectively identified. Demographic, injury-related and outcome data were collected from medical records. Head CT scans were reviewed.
Results:
Among 274 patients admitted to GHs, 137 (50%) were in the GH group. The transferral rate was 58% for severe TBI and 40% for moderate TBI. Compared to the RTC group, patients in the GH group were older (median age: 78 years vs. 54 years, p < 0.001), more often had a preinjury disability (50% vs. 39%, p = 0.037), and more often had moderate TBI (52% vs. 35%, p = 0.005). The six-month case fatality rate was low (8%) in the GH group when transferral was considered unnecessary due to a low risk of further deterioration and high (90%, median age: 87 years) when neurosurgical intervention was considered nonbeneficial. Only 16% of patients ≥ 80 years old were transferred to the RTC. For this age group, the in-hospital case fatality rate was 67% in the GH group and 36% in the RTC group and 84% and 73%, respectively, at 6 months.
Conclusions:
Half of the patients were managed entirely at a GH, and these were mainly patients considered to have a low risk of further deterioration, patients with moderate TBI, and elderly patients. Less than two of ten patients ≥ 80 years old were transferred, and survival was poor regardless of the transferral status.
... In addition, the mean presenting GCS in these delayed surgery patients was rather low (12.4 ± 3.5) compared to what was expected in ASDH cases undergoing surgery. This is probably due to the awareness of the intrinsic high risk of this surgery in elderly patients [8,17,[29][30][31], thus reflecting the current uncertainty of the best initial treatment in these patients [7]. Furthermore, this reflects the tendency of most neurosurgeons to choose to delay a possible craniotomy in elderly patients who do not show an initial serious clinical condition in the hope of a secondary chronicization of the hematoma, opening the possibility of its evacuation with a minimally invasive technique [32,33]. ...
Background:
The incidence of traumatic acute subdural hematomas (ASDH) in the elderly is increasing. Despite surgical evacuation, these patients have poor survival and low rate of functional outcome, and surgical timing plays no clear role as a predictor. We investigated whether the timing of surgery had a major role in influencing the outcome in these patients.
Methods:
We retrospectively retrieved clinical and radiological data of all patients ≥70 years operated on for post-traumatic ASDH in a 3 year period in five Italian hospitals. Patients were divided into three surgical timing groups from hospital arrival: ultra-early (within 6 h); early (6-24 h); and delayed (after 24 h). Outcome was measured at discharge using two endpoints: survival (alive/dead) and functional outcome at the Glasgow Outcome Scale (GOS). Univariate and multivariate predictor models were constructed.
Results:
We included 136 patients. About 33% died as a result of the consequences of ASDH and among the survivors, only 24% were in good functional outcome at discharge. Surgical timing groups appeared different according to presenting the Glasgow Outcome Scale (GCS), which was on average lower in the ultra-early surgery group, and radiological findings, which appeared worse in the same group. Delayed surgery was more frequent in patients with subacute clinical deterioration. Surgical timing appeared to be neither associated with survival nor with functional outcome, also after stratification for preoperative GCS. Preoperative midline shift was the strongest outcome predictor.
Conclusions:
An earlier surgery was offered to patients with worse clinical-radiological findings. Additionally, after stratification for GCS, it was not associated with better outcome. Among the radiological markers, preoperative midline shift was the strongest outcome predictor.
... 3.5) compared to what expected in ASDH cases undergoing surgery. This is probably due to the awareness of the intrinsic high risk of this surgery in elderly patients [8,16,[21][22][23], thus reflecting the current uncertainty of the best initial treatment in these patients7. Furthermore, this reflects the tendency of most neurosurgeons to choose to delay a possible craniotomy in elderly patients who do not show an initial serious clinical condition in the hope of a secondary chronicization of the hematoma, opening the possibility of its evacuation with a minimally invasive technique [24,25]. ...
Background: The incidence of traumatic acute subdural hematomas (ASDH) in elderly is increasing. Despite surgical evacuation, these patients have poor survival and low rate of functional outcome, and surgical timing plays a no clear role as predictor. We investigated if the timing of surgery has a major role in influencing outcome in these patients.Methods: We retrospectively retrieved clinical and radiological data of all patients ≥70 years operated on for post-traumatic ASDH in a 3 years period in 5 Italian Hospitals. Patients were divided in 3 surgical timing groups from hospital arrival: ultra-early (within 6h); early (6-24h); delayed (after 24h). Outcome was measured at discharge using two endpoints: survival (alive/dead) and functional outcome at Glasgow Outcome Scale (GOS). Univariate and multivariate predictor models were constructed.Results: We included 136 patients. About 33% died for consequences of ASDH and among the survivors only 24% were in good functional outcome at discharge. Surgical timing groups appeared different according to presenting GCS, which was on average lower in ultra-early surgery group, and radiological findings, which appeared worse in the same group. Delayed surgery was more frequent in patients with subacute clinical deterioration. Surgical timing appeared associated neither with survival nor with functional outcome also after stratification for preoperative GCS. Preoperative midline shift was the strongest outcome predictor. Conclusions: An earlier surgery was offered to patients with worse clinical-radiological findings. Also after stratification for GCS it was not associated with better outcome. Among the radiological markers, preoperative midline shift was the strongest outcome predictor.
... Therefore, age cannot be used as a general criteria to exclude patients from treatment (21). However, the appropriate treatment of elderly patients with a post-traumatic ASDH associated with altered consciousness remains an ethical dilemma due to the expected poor prognosis, the concomitant family expectations, and the possible legal implications especially in some environments (22). Careful and detailed communication with family members and the acquisition of any previously expressed wills from the patients are strongly advised. ...
Background:
Elderly patients operated for an acute subdural hematoma (ASDH) frequently have a poor outcome, with a high frequency of death, vegetative status, or severe disability (Glasgow Outcome Score, GOS, 1-3). Minicraniotomy has been proposed as a minimally invasive surgical treatment to reduce the impact of surgery in the elderly population. The present study aimed to compare the influence of the size of the craniotomy on the functional outcome in patients undergoing surgical treatment for ASDH.
Methods:
We selected patients ≥70 years old admitted to 5 Italian tertiary referral neurosurgical for the treatment of a post-traumatic ASDH between January 1st 2016 and December 31st 2019. We collected demographic data, clinical data (GCS, GOS, Charlson Comorbidity Index-CCI, antiplatelet/anticoagulant therapy, neurological deficits, seizure, pupillary size, length of stay), surgical data (craniotomy size, dividing the patients into 3 groups based on the corresponding tertile, and surgery duration), radiological data (ASDH side and thickness, midline shift, other post-traumatic lesions, extent of ASDH evacuation) and we assessed the functional outcome at hospital discharge and 6-month follow-up considering GOS=1-3 as a poor outcome. ANOVA and Chi-squared tests and logistic regression models were used to assess differences in and associations between clinicalradiological characteristics and functional outcomes.
Results:
We included 136 patients (76 males) with a mean age of 78±6 years. Forty-five patients underwent a small craniotomy, 47 a medium size, and 44 a large craniotomy. Among the different craniotomy size groups, there were no differences in gender, anticoagulant/antithrombotic therapy, CCI, side of ASDH, ASDH thickness, preoperative GCS, focal deficits, seizures, and presence of other posttraumatic lesions. Patients undergoing small craniotomies were older than patients undergoing medium-large craniotomies; ASDH treated with medium size craniotomy were thinner than the others; patients undergoing large craniotomies showed greater midline shift and a higher rate of anisocoria. The three groups did not differ for functional outcome and postoperative midline shift, but the length of surgery and the rate of >50% of ASDH evacuation were lower in the small craniotomy group.
Conclusions:
A small craniotomy was not inferior to larger craniotomies in determining functional outcomes in the treatment of ASDH in the elderly.
... Over time, with faster transfers directly from accident to level I trauma hospitals, improved diagnostic tools and acute medical and intensive care, mortality rates in elderly patients with ASDH have declined from 90 to between 30 and 60% [15]. Along with this, neurologists', trauma-and neurosurgeons' traditional reserved attitude towards elderly patients has gradually shifted towards a more "aggressive" surgical approach [16,17]. Despite this trend towards a more intensive treatment approach in the elderly sustaining TBI, the question whether to surgically or conservatively manage elderly patients with an ASDH remains a matter of huge controversy [18]. ...
Abstract Background The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH Methods In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH 5 mm, or a GCS
... One year after decompressive craniectomy, 80% of elderly patients with severe TBI had poor outcome [24]. For all these reasons, clinical decision-making in old patients with aSDH is cumbersome with a heterogenous approach among neurosurgeons as described elsewhere [17,31,32]. Besides the decision if to perform surgery at all, the extent of the surgical approach is also a matter of debate, as DC is often associated with serious complications like extraaxial fluid collection, skin-flap-associated subcutaneous hematoma, or external brain herniation [10]. ...
... Therefore, the choice of the surgical procedure in elderly patients is still based on data generated in younger patients or on the surgeon's expertise. Important factors influencing indication for surgery in the elderly include age, midline shift, hematoma thickness, and presence of anticoagulation therapy [31]. Interestingly, in patients on oral anticoagulation medication and aged above 80 years, those radiological parameters do not seem to influence outcome and an oral anticoagulant therapy regimen is exceedingly common as seen in our data (84%) and the literature [37,38]. ...
... Minor traumatic events in elderly patients on anticoagulant therapy can easily cause aSDH, resulting in a delayed appearance of symptoms with initial unremarkable neurological status [2,14]. Given the results of an online questionary, almost half of neurosurgeons choose a large osteoplastic craniotomy when performing surgery, in contrast to 13% considering a small osteoplastic craniotomy or 28% performing a decompressive craniectomy [31]. The latter comes with drawbacks including subdural effusion, leakage of cerebrospinal fluid, or external herniation [9,10]. ...
Surgical treatment of acute subdural hematoma (aSDH) is still matter of debate, especially in the elderly. A retrospective study to compare two different surgical approaches, namely standard (SC, craniotomy size > 8 cm) and limited craniotomy (LC, craniotomy size < 8 cm), was conducted in elderly patients with traumatic aSDH to identify the role of craniotomy size in terms of clinical and radiological outcome. Sixty-four patients aged 75 or older with aSDH as sole lesion were retrospectively analyzed. Data were collected pre- and postoperatively including clinical and radiological criteria. The primary outcome parameter was 30-day mortality. Secondary outcome parameters were radiological. The mean age was 79.2 (± 3.1) years with no difference between groups and almost equal distribution of craniotomy size. Mortality rate was significantly higher in the SC group in comparison to the LC group (68.4% vs. 31.6%; p = 0.045). The preoperative HD (p = 0.08) and the MLS (p = 0.09) were significantly higher in the SC group, whereas postoperative radiological evaluation showed no significant difference in HD or MLS. A limited craniotomy is sufficient for adequate evacuation of an aSDH in the elderly achieving the same radiological and clinical outcome.
... 2,9,10 Even with an awareness of these adverse events, some factors such as family pressure, medico-legal aspects, and intradepartmental reputation could influence whether an aggressive surgical approach is followed despite the expectation of a poor outcome. 11 Among the outcome predictors, level of consciousness according to the Glasgow Coma Scale (GCS) score, ASDH thickness, and amount of midline shift have been recognized as the most important, 2,6,7,[12][13][14] while the role of antithrombotic therapy 15,16 and the presence of comorbidities 17,18 remain controversial. ...
Objective:
The objective of this study was to analyze the risk factors associated with the outcome of acute subdural hematoma (ASDH) in elderly patients treated either surgically or nonsurgically.
Methods:
The authors performed a retrospective multicentric analysis of clinical and radiological data on patients aged ≥ 70 years who had been consecutively admitted to the neurosurgical department of 5 Italian hospitals for the management of posttraumatic ASDH in a 3-year period. Outcome was measured according to the Glasgow Outcome Scale (GOS) at discharge and at 6 months' follow-up. A GOS score of 1-3 was defined as a poor outcome and a GOS score of 4-5 as a good outcome. Univariate and multivariate statistics were used to determine outcome predictors in the entire study population and in the surgical group.
Results:
Overall, 213 patients were admitted during the 3-year study period. Outcome was poor in 135 (63%) patients, as 65 (31%) died during their admission, 33 (15%) were in a vegetative state, and 37 (17%) had severe disability at discharge. Surgical patients had worse clinical and radiological findings on arrival or during their admission than the patients undergoing conservative treatment. Surgery was performed in 147 (69%) patients, and 114 (78%) of them had a poor outcome. In stratifying patients by their Glasgow Coma Scale (GCS) score, the authors found that surgery reduced mortality but not the frequency of a poor outcome in the patients with a moderate to severe GCS score. The GCS score and midline shift were the most significant predictors of outcome. Antiplatelet drugs were associated with better outcomes; however, patients taking such medications had a better GCS score and better radiological findings, which could have influenced the former finding. Patients with fixed pupils never had a good outcome. Age and Charlson Comorbidity Index were not associated with outcome.
Conclusions:
Traumatic ASDH in the elderly is a severe condition, with the GCS score and midline shift the stronger outcome predictors, while age per se and comorbidities were not associated with outcome. Antithrombotic drugs do not seem to negatively influence pretreatment status or posttreatment outcome. Surgery was performed in patients with a worse clinical and radiological status, reducing the rate of death but not the frequency of a poor outcome.
... despite the best efforts of the surgical team, a proportion of patients undergoing emergent neurosurgical procedures will be transitioned to comfort care (CC) postoperatively. 11,21,26,31 The reasons for initiating CC after emergency intervention are diverse: poor postoperative neurological condition, better understanding of a patient's wishes after reflection, diminishing chances of a meaningful recovery, or increasing clarity in the understanding of the chances of clinical recovery. ...
OBJECTIVE
It is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery.
METHODS
This retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively.
RESULTS
Of the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70–79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00.
CONCLUSIONS
Initiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.
... Four-fifths (82%) of the patients interviewed were not afraid of death, with 91% responding that they would not want lifesaving surgery if they were to be cognitively impaired afterwards. Half of the patients (51%) would not want any kind of life prolonging surgery, irrelevant of the likelihood of complete recovery, and the The same research group also asked neurosurgeons across Germany what factors they took into account when considering how to treat the hypothetical case of an unconscious 81-year-old with an acute subdural haematoma [13]. The patient was presenting with a Glasgow Coma Score of 3 and a maximally dilated minimally reactive right pupil, some 40 min after injury. ...
... Despite the bleak prognosis of such a case, 85% of respondents reported that they would go ahead with a decompressive craniectomy, citing clinical features such as the depth of the haematoma and midline shift as most important in their decision making process. Although 87% of respondents considered the patient's will to have an important role in deciding whether to offer surgery, 66% thought that gathering information about the patient's living circumstances was unimportant, and 57% felt that discussion with family members was less important or unimportant [13]. ...
Purpose of review:
Traumatic brain injury (TBI) remains an unfortunately common disease with potentially devastating consequences for patients and their families. However, it is important to remember that it is a spectrum of disease and thus, a one 'treatment fits all' approach is not appropriate to achieve optimal outcomes. This review aims to inform readers about recent updates in prehospital and neurocritical care management of patients with TBI.
Recent findings:
Prehospital care teams which include a physician may reduce mortality. The commonly held value of SBP more than 90 in TBI is now being challenged. There is increasing evidence that patients do better if managed in specialized neurocritical care or trauma ICU. Repeating computed tomography brain 12 h after initial scan may be of benefit. Elderly patients with TBI appear not to want an operation if it might leave them cognitively impaired.
Summary:
Prehospital and neuro ICU management of TBI patients can significantly improve patient outcome. However, it is important to also consider whether these patients would actually want to be treated particularly in the elderly population.
... There is a lack of data to use for clinical decision-making in these patients. Neurosurgeons tend to indicate surgery, e.g., removal of an acute subdural hematoma and/or decompression craniotomy, on imaging findings, thus being no different than in the younger patients [3]. ...
Introduction:
Treatment decisions in elderly patients with traumatic brain injury (TBI) are mainly determined by trauma severity and patient age. The aim of this study was to explore personal preferences of potential patients regarding life-prolonging neurosurgical interventions by interviewing ambulatory, autonomous elderly people.
Methods:
One hundred consecutive patients older than 75 years frequenting the outpatient clinic of the Department of Neurosurgery were interviewed about their attitudes regarding the hypothetical case of an 81-year-old patient with TBI and a space-occupying acute subdural hematoma (aSDH) using a 21-point questionnaire.
Results:
Fifty-one percent of the consulted persons declined life-prolonging surgical measures. If surgery was associated with physical disability, 68% of the people wished no surgery. In case of cognitive impairment after surgery, 91% were against any surgical intervention. The majority feared being a burden to relatives (76%) and becoming unable to master an independent life (75%). Four-fifths of the interviewed patients (82%) were not afraid of death.
Conclusions:
The majority of elderly patients only consent to surgical measures if no relevant disabilities are involved and if they can return to their previous life. These findings need consideration in case of life-threatening neurosurgical emergencies as well as in the surgical treatment of elderly patients in general.
