Neurosurgery in the elderly: brain tumors and subdural hematomas

Subdural evacuating port system with subdural thrombolysis for the treatment of chronic subdural hematoma in patients older than 80 years

Objective

The subdural evacuating port system (SEPS) is a minimally invasive approach that can be performed under local anesthesia for the treatment of chronic subdural hematoma (CSDH). Subdural thrombolysis has been described as an exhaustive drainage strategy and found to be safe and effective for improving drainage. We aim to analyze the effectiveness of SEPS with subdural thrombolysis in patients older than 80 years.

Method

Consecutive patients aged ≥80 years old who presented with symptomatic CSDH and underwent SEPS followed by subdural thrombolysis between January 2014 and February 2021 were retrospectively studied. Outcome measures included complications, mortality, recurrence, and modified Rankin Scale (mRS) scores at discharge and 3 months.

Results

In total, 52 patients with CSDH in 57 hemispheres were operated on, with a mean age of 83.9 ± 3.3 years, and 40 (76.9%) patients were men. The preexisting medical comorbidities were observed in 39 patients (75.0%). Postoperative complications occurred in nine patients (17.3%), with two having significant complications (3.8%). The complications observed included pneumonia (11.5%), acute epidural hematoma (3.8%), and ischemic stroke (3.8%). One patient experienced contralateral malignant middle cerebral artery infarction and died of subsequent severe herniation, contributing to a perioperative mortality rate of 1.9%. Discharge and 3 months of favorable outcomes (mRS score 0-3) were achieved in 86.5% and 92.3% of patients, respectively. CSDH recurrence was observed in five patients (9.6%), and repeat SEPS was performed.

Conclusion

As an exhaustive drainage strategy, SEPS followed by thrombolysis is safe and effective with excellent outcomes among elderly patients. It is a technically easy and less invasive procedure with similar complications, mortality, and recurrence rates compared with burr-hole drainage in the literature.

Application of YL-1 Needle in Chronic Subdural Hematoma Treatment for Super-Aged Patients

Objective:

The proportion of the super-aged population (at the age of 80 or above) in patients with chronic subdural hematoma (CSDH) and the incidence of CSDH of the population have been increasing. Since it is widely accepted that YL-1 needle is effective in CSDH treatment, this paper aimed to probe into the efficacy of YL-1 needle in minimally invasive surgery for super-aged (at the age of 80–90) CSDH patients.

Methods:

A retrospective analysis on the clinical information of 17 super-aged CSDH patients having received the YL-1 needle puncture treatment provided by the hospital from May 2012 to December 2016 was performed. At the same time, another 19 CSDH patients (ages 60–79) who were hospitalized during the same period were randomly selected to form a control group. The same surgical treatment was provided for both groups to observe and compare the treatment efficacy.

Results:

The patients of both groups were cured and discharged. Among the super-aged patients, there was 1 patient with postoperative hematoma recurrence, 1 patient with pneumocephalus, and 1 patient with wound infection; among the aged patients, 1 reported postoperative recurrence and 2 had pneumocephalus; The average length of stay of the super-aged group was 9.235 ± 2.948 days while that of the aged group was 7.316 ± 3.660 days, which showed no statistical difference.

Conclusion:

The YL-1 needle puncture treatment is safe and efficacious for both the super-aged and the aged CSDH patients.

Outcomes of chronic subdural hematoma drainage in nonagenarians and centenarians: a multicenter study

OBJECTIVE

Chronic subdural hemorrhage (SDH) or hematoma is a condition that affects elderly individuals. With advances in medical care, the number of nonagenarians and centenarians will increase. However, surgical treatments in this age group are associated with high rates of morbidity and mortality. Because no data are available on the rates of survival among elderly patients with chronic SDHs who undergo surgical drainage or receive only conservative care, the goal of this study was to determine survival rates in patients 90 years of age or older with symptomatic chronic SDHs.

METHODS

The authors conducted a retrospective analysis of patient data that were collected at 3 hospitals over a 13-year period (from January 2001 to June 2013). The data from patients 90 years or older with symptomatic chronic SDHs and who were offered surgical treatment were included in the analysis. Patients who underwent surgical treatment were included in the surgical group and patients who declined an operation were included in the conservative care group. The patients' Charlson Comorbidity Index score, Karnofsky Performance Scale score, dates of death, presenting symptoms, Glasgow Coma Scale score, length of stay in the hospital, discharge location, side of the SDH, and neurological improvements at 30-day and 6-month follow-ups were recorded. Data were statistically analyzed with Fisher exact test, Kaplan-Meier curves, and logistic regression.

RESULTS

In total, 101 patients met the inclusion criteria of this study; 70 of these patients underwent surgical drainage, and 31 received conservative care. Patients in the surgical group had statistically significantly (p < 0.001) higher survival at both the 30-day and 6-month follow-ups, with 92.9% and 81.4% of the patients in this group surviving for at least 30 days and 6 months, respectively, versus 58.1% and 41.9%, respectively, in the conservative care group. Moreover, the mean overall length of survival of 34.4 ± 28.7 months was longer in the surgical group than it was in the conservative care group (11.3 ± 16.6 months). Overall, 95.7% of patients in the surgical group exhibited an improvement in neurological status after the SDH drainage, whereas none of the patients in the conservative care group showed any neurological improvement during their hospital stay. The surgical complication rate was 11.4%, and the overall rate of chronic SDH recurrence after surgery was 12.9%.

CONCLUSIONS

Surgical drainage of chronic SDHs in nonagenarians and centenarians is associated with lower incidence of inpatient death and higher 30-day and 6-month survival rates.

Postoperative hemorrhage in an elderly patient with a glioblastoma multiform and a calcified chronic subdural hematoma

Background

Cases with brain tumor and subdural hematoma are rare; surgical management of the elderly patients with a glioblastoma multiform (GBM) and a chronic subdural hematoma (CSDH) can be intractable.

Case description

We report a 77-year-old patient, who had a left front lobe GBM and a giant, calcified, left frontoparietaloccipitotemporal CSDH. The patient recovered well from anesthesia after removal of the GBM and CSDH. However, the patient developed severe hemiplegia and aphasia because of the in-situ hemorrhage 1 day later. Laboratory tests indicated disseminated intravascular coagulation (DIC) leading to the postoperative hemorrhage. The patient was left with hemiparesis and alalia after the in-situ hematoma evacuation.

Conclusions

We presume elderly patients have a higher incidence of postoperative hemorrhage in residual intracranial cavity owing to higher possibility to get DIC. A less aggressive surgical management could be a more appropriate choice.

Incidental findings on cranial imaging in nonagenarians

Object

The aim of this article was to report on the nature and prevalence of incidental imaging findings in a consecutive series of patients older than 90 years of age who underwent intracranial imaging for any reason.

Methods

The authors retrospectively reviewed the electronic medical and imaging records of consecutive patients who underwent brain MR imaging at a single institution over a 153-month interval and were at least 90 but less than 100 years of age at the time of the imaging study. The prevalence of lesions by type in this consecutive series of MR imaging evaluations was calculated for all patients. The authors reviewed the medical record to evaluate whether a change in management was recommended based on MR imaging findings. They evaluated patient age at the time of death and the time interval between MR imaging and death.

Results

The authors identified 177 patients who met the study criteria. The group included 119 women (67%) and 58 (33%) men. Their mean age was 92.3 ± 1.8 years. Evidence of acute ischemic changes or cerebrovascular accident (CVA) was found in 36 patients (20%). Fifteen patients (8%) had an intracranial tumor. Intracranial aneurysms were incidentally identified in 6 patients (3%). Chronic subdural hematomas were found in 3 patients (2%). Overall, 25 patients (14%) had some change in medical management as a result of the MR imaging findings. The most common MR imaging finding that resulted in a change in medical management was an acute CVA (p < 0.0001). The mean time to death from date of MR imaging was 2.5 ± 2.3 years.

Conclusions

Intracranial imaging is rarely performed in patients older than 90 years. In cases of suspected stroke, MR imaging findings may influence treatment decisions. Brain MR imaging studies ordered for other indications in this age group rarely influence treatment decisions. Incidentally discovered lesions in this age group are generally not treated.

Geriatric surgery is about disease, not age

Maintaining life span and quality of life remains a valid aim of surgery in elderly people. Surgery can be an effective way of restoring both length and quality of life to older people. Minimally invasive techniques and surgery under local anaesthesia make fewer demands on geriatric physiology; given that co-morbidity is a stronger predictor of outcome from surgery than age, this is a significant consideration.