Age and Salvageability: Analysis of Outcome of Patients Older than 65 Years Undergoing Craniotomy for Acute Traumatic Subdural Hematoma

Mortality and discharge disposition among older adults with moderate to severe traumatic brain injury

PURPOSE

This study examined the research on older adults with a moderate to severe traumatic brain injury (TBI), with a focus on mortality and discharge disposition.

METHOD

Systematic searches were conducted in MEDLINE, CINAHL, EMBASE and PsycINFO for studies up to April 2022 in accordance with PRISMA guidelines.

RESULTS

64 studies, published from 1992 to 2022, met the inclusion criteria. Mortality was higher for older adults ≥60 years old than for their younger counterparts; with a dramatic increase for those ≥80 yr, with rates as high as 93 %. Similar findings were reported regarding mortality in intensive care, surgical mortality, and mortality post-hospital discharge; with an 80 % rate at 1-year post-discharge. Up to 68.4 % of older adults were discharged home; when compared to younger adults, those ≥65 years were less likely to be discharged home (50-51 %), compared to those <64 years (77 %). Older adults were also more likely to be discharged to long-term care (up to 31.6 %), skilled nursing facilities (up to 46.1 %), inpatient rehabilitation (up to 26.9 %), and palliative or hospice care (up to 58 %).

CONCLUSION

Given their vulnerability, optimizing outcomes for older adults with moderate-severe TBI across the healthcare continuum is critical.

A proposed stratification system to address the heterogeneity of Subdural Hematoma Outcome reporting in the literature

A major challenge within the academic literature on SDHs has been inconsistent outcomes reported across studies. Historically, patients have been categorized by the blood-product age identified on imaging (i.e., acute, subacute, or chronic). However, this schematic has likely played a central role in producing the heterogeneity encountered in the literature. In this investigation, a total of 494 patients that underwent SDH evacuation at a tertiary medical center between November 2013-December 2021 were retrospectively identified. Mechanism of injury was reviewed by the authors and categorized as either positive or negative for a high-velocity impact (HVI) injury. Any head strike injury leading to the formation of a SDH while traveling at a velocity beyond that of normal locomotion or daily activities was categorized as an HVI. Patients were subsequently stratified by those with an acute SDHs after a high-velocity impact (aSDHHVI), those with an acute SDH without a high-velocity impact injury (aSDHWO), and those with any combination of subacute or chronic blood products (mixed-SDH [mSDH]). Nine percent (n = 44) of patients experienced an aSDHHVI, 23% (n = 113) aSDHWO, and 68% (n = 337) mSDH. Between these groups, highly distinct patient populations were identified using several metrics for comparison. Most notably, aSDHHVI had a significantly worse neurological status at discharge (50% vs. 23% aSDHWO vs. 8% mSDH; p < 0.001) and mortality (25% vs. 8% aSDHWO vs. 4% mSDH; p < 0.001). Controlling for gender, midline shift (mm), and anticoagulation use in the acute SDH population, multivariable logistic regression revealed a 6.85x odds ratio (p < 0.001) for poor outcomes in those with a positive history for a high-velocity impact injury. As such, the distribution of patients that suffer an HVI related acute SDH versus those that do not can significantly affect the outcomes reported. Adoption of this stratification system will help address the heterogeneity of SDH reporting in the literature while still closely aligning with conventional reporting.

Clinical characteristics and functional outcome of surgically treated adult head trauma patients with acute subdural hematoma: Ethiopian tertiary hospitals experience

Background

Acute subdural hematoma (ASDH) is one of the most common and devastating lesions in traumatic brain injury with a mortality rate upto 60 % especially in low-income countries. The present study aimed to determine the clinical characteristics and functional outcomes and the associated factors of surgically treated head trauma patients with ASDH.

Methods

Between January 2018 and January 2021 we identified 140 head trauma patients with ASDH who underwent surgical evacuation in three tertiary hospitals. Epidemiological data were collected; the six-month functional outcome was studied using an extended Glasgow outcome score (EGOS) and associated factors were also studied. Univariate analysis was performed at first, and variables with a P-value of <0.05 were entered into the multivariable logistic regression model.

Results

Male predominance was seen accounting for 87 % and assault was the most common mechanism of injury (35.7 %). Sixty-five (56.5 %) of patients achieved favorable functional recovery (EGOS of 5-8) and 50 (43.5 %) of patients had unfavorable recovery (EGOS of 1-4) after 6 months of follow-up. In multivariate logistic regression models, GCS <5, Pupillary abnormality, hypotension, oxygen saturation <90 at presentation, and hospital-acquired pneumonia were the independent factors associated with unfavorable functional outcomes.

Conclusion

In our setup, most of the patients are male from assault injuries. There is still a high rate of unfavorable outcomes in patients with acute subdural hematoma. GCS <5, pupillary abnormality, hypotension and desaturation at presentation, and postoperative hospital-acquired infection are predictors for unfavorable functional outcomes.

Craniotomy versus craniectomy for traumatic acute subdural hematoma-coarsened exact matched analysis of outcomes

BACKGROUND AND OBJECTIVES

Acute subdural hematoma (aSDH) after traumatic brain injury frequently requires emergent craniotomy (CO) or decompressive craniectomy (DC). We sought to determine the variables associated with either surgical approach and to compare outcomes between matched patients.

METHODS

A multi-center retrospective review was used to identify traumatic aSDH patients who underwent CO or DC. Patient variables independently associated with surgical approach were used for coarsened exact matching.Multivariate logistic regression and multivariate Cox proportional-hazards regression wereconducted on matched patients to determine independent predictors of mortality.

RESULTS

Seventy-six patients underwent CO and sixty-two underwent DC for aSDH evacuation. DC patients were21.4 years younger (P < 0.001), more likely to be male (80.6 % vs 60.5 %,P = 0.011), and present with GCS ≤ 8 (64.5 % vs 36.8 %,P = 0.001). Age (P < 0.001), epidural hematoma (P = 0.01), skull fracture (P = 0.001), and cisternal effacement (P = 0.02) were independently associated with surgical approach. After coarsened exact matching, DC (P = 0.008), older age (P = 0.007), male sex (P = 0.04), and intraventricular hemorrhage (P = 0.02), were independently associated with inpatient mortality. Multivariate Cox proportional-hazards regression demonstrated that DC was independently associated with mortality at 90-days (P = 0.001) and 1-year post-operation (P = 0.003).

CONCLUSION

aSDH patients who receive surgical evacuation via DC as opposed to CO are younger, more likely to be male, and have worse clinical exam. After controlling for patient differences via coarsened exact matching, DC is independently associated with mortality.

The Utility of the 5 Factor Modified Frailty Index in Outcome Prediction for Patients with Chronic Subdural Hematoma Treated with Surgical Drainage

OBJECTIVE

Increasing frailty is a significant determinant of perioperative morbidity and mortality within neurosurgical literature. This study investigates the predictive value of the modified frailty index 5 (mFI-5) for postoperative morbidity and mortality following surgical drainage of chronic subdural hematoma (cSDH).

METHODS

A retrospective cohort study was performed on patients who underwent surgical evacuation of a cSDH. The mFI-5 score was calculated for each patient and used to stratify patients: prefrail (mFI-5<2), frail (mFI-5 = 2), and severely frail (mFI-5>2). Multivariate Cox proportional hazards (CPH) regression analysis were used to identify factors associated with our primary outcomes: overall survival and 30-day readmission. Secondary outcomes included nonhome discharge, length of stay, hematoma accumulation, development of new postoperative neurologic deficits, resolution of preoperative neurologic deficits, and a modified Rankin score >2 at discharge.

RESULTS

118 patients with a mean age of 74.4 ± 11.9 years were analyzed. All baseline demographics were similar across the 3 groups. On multivariate analysis, severely frail patients (N = 24, 20.3%) had increased rates of 30-day readmission (hazard ratio [HR] 4.3, CPH regression P value<0.001) and postoperative mortality (HR 3.1, CPH regression P value<0.01) compared to the prefrail cohort. Severely frail patients had increased rates of nonhome disposition (HR 9.6, CPH regression P value< 0.001), development of new postoperative neurologic deficits (HR 2.75, CPH regression P value = 0.03), and hematoma reaccumulation (HR 4.07, CPH regression P value = 0.004). A novel scoring system accounting for patient age and frailty was predictive of 90-day mortality (area under the curve 0.77).

CONCLUSIONS

Frailty, measured by the mFI-5, and our novel scoring system hold a predictive value regarding outcomes for patients undergoing surgical drainage of a cSDH.

Rehabilitation of Older Asian Traumatic Brain Injury Inpatients: A Retrospective Study Comparing Functional Independence between Age Groups

Across traumatic brain injury (TBI) severities, a geriatric TBI tsunami has emerged. Mixed outcomes are reported for elderly TBI with positive functional improvements with acute inpatient rehabilitation. We studied the effect of age at TBI on discharge functional outcomes, levels of independence and length of stay. A retrospective analysis of Asian TBI patients during inpatient rehabilitation over a 4-year period was conducted. Independent variables included admission GCS, post-traumatic amnesia (PTA) duration and injury subtypes. Primary outcomes were discharge Functional Independence Measure (Td-FIM) and FIM gain. In total, 203 datasets were analysed; 60.1% (122) were aged ≥65 years (older), while 39.9% (81) were <65 years (younger). At discharge, older TBI had a significantly lower Td-FIM by 15 points compared to younger (older 90/126 vs. younger 105/126, p < 0.001). Median FIM gains (younger 27 vs. older 23, p = 0.83) and rehabilitation LOS (older 29.5 days vs. younger 27.5 days, p = 0.79) were similar for both age groups. Older TBIs had significantly lower independence (Td-FIM category ≥ 91) levels (49.4% older vs. 63.9% younger, p = 0.04), higher institutionalisation rates (23.5% older vs. 10.7% younger, p = 0.014) and need for carers (81.5% older vs. 66.4% younger, p = 0.019) on discharge. Although 77% of older TBI patients returned home, a significantly higher proportion needed care. This study supports the functional benefits of TBI rehabilitation in increasing independence regardless of age without incurring longer inpatient rehabilitation days.

Mortality of Surgically Treated Neurotrauma in Elderly Patients and the Development of a Prediction Score: Geriatric Neurotrauma Mortality Score

BACKGROUND

As the population worldwide is aging, the need for surgery in elderly patients with neurotrauma is increasing. The aim of this study was to compare the outcome of elderly patients undergoing surgery for neurotrauma with younger patients and to identify the risk factors for mortality.

METHODS

We retrospectively analyzed consecutive patients undergoing craniotomy or craniectomy for neurotrauma at our institution from 2012 to 2019. Patients were divided into two groups (≥70 years or <70 years) and compared. The primary outcome was the 30-day mortality rate. Potential risk factors for 30-day mortality were assessed in a uni- and multivariate regression model for both age groups, forming the basis of a 30-day mortality prediction score.

RESULTS

We included 163 consecutive patients (average age 57.98 ± 19.87 years); 54 patients were ≥70 years. Patients ≥70 years showed a significantly better median preoperative Glasgow Coma Scale (GCS) score compared with young patients (P < 0.001), and fewer pupil asymmetry (P = 0.001), despite having a higher Marshall score (P = 0.07) at admission. Multivariate regression analysis identified low pre- and postoperative GCS scores and the lack of prompt postoperative prophylactic low-molecular-weight heparin treatment as risk factors for 30-day mortality. Our score showed moderate accuracy in predicting 30-day mortality with an area under the curve of 0.76.

CONCLUSIONS

Elderly patients after neurotrauma present with a better GCS at admission despite having more severe radiographic injuries. Mortality and favorable outcome rates are comparable between the age groups.

Aging-Associated Thyroid Dysfunction Contributes to Oxidative Stress and Worsened Functional Outcomes Following Traumatic Brain Injury

The incidence of traumatic brain injury (TBI) increases dramatically with advanced age and accumulating evidence indicates that age is one of the important predictors of an unfavorable prognosis after brain trauma. Unfortunately, thus far, evidence-based effective therapeutics for geriatric TBI is limited. By using middle-aged animals, we first confirm that there is an age-related change in TBI susceptibility manifested by increased inflammatory events, neuronal death and impaired functional outcomes in motor and cognitive behaviors. Since thyroid hormones function as endogenous regulators of oxidative stress, we postulate that age-related thyroid dysfunction could be a crucial pathology in the increased TBI severity. By surgically removing the thyroid glands, which recapitulates the age-related increase in TBI-susceptible phenotypes, we provide direct evidence showing that endogenous thyroid hormone-dependent compensatory regulation of antioxidant events modulates individual TBI susceptibility, which is abolished in aged or thyroidectomized individuals. The antioxidant capacity of melatonin is well-known, and we found acute melatonin treatment but not liothyronine (T3) supplementation improved the TBI-susceptible phenotypes of oxidative stress, excitotoxic neuronal loss and promotes functional recovery in the aged individuals with thyroid dysfunction. Our study suggests that monitoring thyroid function and acute administration of melatonin could be feasible therapeutics in the management of geriatric-TBI in clinic.

Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute?

The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.

Moderate and severe traumatic brain injury in general hospitals: a ten-year population-based retrospective cohort study in central Norway

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.

Does the Timing of the Surgery Have a Major Role in Influencing the Outcome in Elders with Acute Subdural Hematomas?

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.

Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design

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 < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024.

DISCUSSION

The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered.

TRIAL REGISTRATION

Nederlands Trial Register (NTR), Trial NL9012 .

CLINICALTRIALS

gov, Trial NCT04648436 .

Craniotomies following acute traumatic brain injury in Finland-a national study between 1997 and 2018

Background

A number of patients who sustain a traumatic brain injury (TBI) require surgical intervention due to acute intracranial bleeding. The aim of this retrospective study was to assess the national trends of acute craniotomies following TBI in the Finnish adult population.

Methods

The data were collected retrospectively from the Finnish Care Register for Health Care (1997–2018). The study cohort covered all first-time registered craniotomies following TBI in patients aged 18 years or older. A total of 7627 patients (median age = 59 years, men = 72%) were identified.

Results

The total annual incidence of acute trauma craniotomies decreased by 33%, from 8.6/100,000 in 1997 to 5.7/100,000 in 2018. The decrease was seen in both genders and all age groups, as well as all operation subgroups (subdural hematoma, SDH; epidural hematoma, EDH; intracerebral hematoma, ICH). The greatest incidence rate of 15.4/100,000 was found in patients 70 years or older requiring an acute trauma craniotomy. The majority of surgeries were due to an acute SDH and the patients were more often men. The difference between genders decreased with age (18–39 years = 84% men, 40–69 = 78% men, 70 + years = 55% men). The median age of the patients increased from 58 to 65 years during the 22-year study period.

Conclusions

The number of trauma craniotomies is gradually decreasing; nonetheless, the incidence of TBI-related craniotomies remains high among geriatric patients. Further studies are needed to determine the indications and derive evidence-based guidelines for the neurosurgical care of older adults with TBIs to meet the challenges of the growing elderly population.

Incidence of emergency neurosurgical TBI procedures: a population-based study

BACKGROUND

The rates of emergency neurosurgery in traumatic brain injury (TBI) patients vary between populations and trauma centers. In planning acute TBI treatment, knowledge about rates and incidence of emergency neurosurgery at the population level is of importance for organization and planning of specialized health care services. This study aimed to present incidence rates and patient characteristics for the most common TBI-related emergency neurosurgical procedures.

METHODS

Oslo University Hospital is the only trauma center with neurosurgical services in Southeast Norway, which has a population of 3 million. We extracted prospectively collected registry data from the Oslo TBI Registry - Neurosurgery over a five-year period (2015-2019). Incidence was calculated in person-pears (crude) and age-adjusted for standard population. We conducted multivariate multivariable logistic regression models to assess variables associated with emergency neurosurgical procedures.

RESULTS

A total of 2151 patients with pathological head CT scans were included. One or more emergency neurosurgical procedure was performed in 27% of patients. The crude incidence was 3.9/100,000 person-years. The age-adjusted incidences in the standard population for Europe and the world were 4.0/100,000 and 3.3/100,000, respectively. The most frequent emergency neurosurgical procedure was the insertion of an intracranial pressure monitor, followed by evacuation of the mass lesion. Male sex, road traffic accidents, severe injury (low Glasgow coma score) and CT characteristics such as midline shift and compressed/absent basal cisterns were significantly associated with an increased probability of emergency neurosurgery, while older age was associated with a decreased probability.

CONCLUSIONS

The incidence of emergency neurosurgery in the general population is low and reflects neurosurgery procedures performed in patients with severe injuries. Hence, emergency neurosurgery for TBIs should be centralized to major trauma centers.

Neurointensive care of traumatic brain injury in the elderly-age-specific secondary insult levels and optimal physiological levels to target need to be defined

BACKGROUND

Elderly patients with traumatic brain injury increase. Current targets and secondary insult definitions during neurointensive care (NIC) are mostly based on younger patients. The aim was therefore to study the occurrence of predefined secondary insults and the impact on outcome in different ages with particular focus on elderly.

METHODS

Patients admitted to Uppsala 2008-2014 were included. Patient characteristics, NIC management, monitoring data, and outcome were analyzed. The percentage of monitoring time for ICP, CPP, MAP, and SBP above-/below-predefined thresholds was calculated.

RESULTS

Five hundred seventy patients were included, 151 elderly ≥ 65 years and 419 younger 16-64 years. Age ≥ 65 had significantly higher percentage of CPP > 100, MAP > 120, and SBP > 180 and age 16-64 had higher percentage of ICP ≥ 20, CPP ≤ 60, and MAP ≤ 80. Age ≥ 65 contributed independently to the different secondary insult patterens. When patients in all ages were analyzed, low percentage of CPP > 100 and SBP > 180, respectively, was significant predictors of favorable outcome and high percentage of ICP ≥ 20, CPP > 100, SBP ≤ 100, and SBP > 180, respectively, was predictors of death. Analysis of age interaction showed that patients ≥ 65 differed and had a higher odds for favorable outcome with large proportion of good monitoring time with SBP > 180.

CONCLUSIONS

Elderly ≥ 65 have different patterns of secondary insults/physiological variables, which is independently associated to age. The finding that SBP > 180 increased the odds of favorable outcome in the elderly but decreased the odds in younger patients may indicate that blood pressure should be treated differently depending on age.

Acute subdural haematoma in the elderly: to operate or not to operate? A systematic review and meta-analysis of outcomes following surgery

OBJECTIVES

Acute subdural haematoma (ASDH) is a devastating pathology commonly found on CT brain scans of patients with traumatic brain injury. The role of surgical intervention in the elderly has been increasingly questioned due to its associated morbidity and mortality. Therefore, a systematic review and meta-analysis of the literature to quantify the mortality and functional outcomes associated with surgical management of ASDH in the elderly was performed.

DESIGN/SETTING

A multidatabase literature search between January 1990 and May 2020, and meta-analysis of proportions was performed to quantify mortality and unfavourable outcome (Glasgow Outcome scale 1-3; death/ severe disability) rates.

PARTICIPANTS

Studies reporting patients aged 60 years or older.

INTERVENTIONS

Craniotomy, decompressive craniectomy, conservative management.

OUTCOME MEASURES

Mortality and functional outcomes (discharge, long-term follow-up (LTFU)).

RESULTS

2572 articles were screened, yielding 21 studies for final inclusion and 15 for meta-analysis. Pooled estimates of mortality were 39.83% (95% CI 32.73% to 47.14%; 10 studies, 308/739 patients, I²=73%) at discharge and 49.30% (95% CI 42.01% to 56.61%; 10 studies, 277/555 patients, I²=63%) at LTFU. Mean duration of follow-up was 7.1 months (range 2-12 months). Pooled estimate of percentage of poor outcomes was 81.18% (95% CI 75.61% to 86.21%; 6 studies, 363/451 patients, I²=45%) at discharge, and 79.25% (95% CI 72.42% to 85.37%; 8 studies, 402/511 patients, I²=66%) at LTFU. Mean duration of follow-up was 6.4 months (range 2-12 months). Potential risk factors for poor outcome included age, baseline functional status, preoperative neurological status and imaging parameters.

CONCLUSIONS

Outcomes following surgical evacuation of ASDH in patients aged 60 years and above are poor. This constitutes the best level of evidence in the current literature that surgical intervention for ASDH in the elderly carries significant risks, which must be weighed against benefits.

PROSPERO REGISTRATION NUMBER

CRD42020189508.

Superiority of craniotomy over supportive care for octogenarians and nonagenarians in operable acute traumatic subdural hematoma

OBJECTIVE

Neurosurgical evacuation in elderly trauma patients is controversial. We analyzed impact of craniotomy for acute subdural hematoma on survival in octogenarians and nonagenarians. Methods The study population included all patients aged ≥ 80 years who presented with acute traumatic SDHs 09/01/15 - 01/01/20, with radiography indicating operative eligibility (i.e. MLS >5 mm and/or overall thickness >10 mm). Of 1054 TBIs aged ≥ 80 years, 104 (9.87%) were surgically indicated. Of these, 35 received craniotomy and 69 received supportive measures due to family/patient wishes or surgeon's professional decision. We analyzed these data using a Poisson regression adjusted for influence of covariates.

RESULTS

Of 35 craniotomies, 21 (60.00%) were deceased at 2 years of follow-up, compared to 48 (69.57%) deceased of 69 non-surgical patients. No significant demographic differences existed between these groups, other than age (craniotomy patients were younger; median age 84 vs 86; p < 0.001). In outcomes, the craniotomy cohort survived longer and in higher proportions (p = 0.028; Gehan-Breslow-Wilcoxon). When adjusting for covariates, this effect became more pronounced: craniotomy patients died at 41.1% the rate of non-surgical ones. Of all the covariates, only initial GCS significantly impacted the protective effect of craniotomy. In a logarithmic relationship, each point on initial GCS was associated with less benefit from surgery. We also found that patients with GCS< 3 were overall less likely to benefit from surgery. Our conclusions are limited by the impact of patient/surgeon choice on whether or not to operate. It is possible healthier subjects elected for craniotomies. We have attempted to correct for this by including comorbidities as covariates in our regression analyses.

CONCLUSIONS

Our results indicate a surgical benefit for this elderly cohort, consistent with prior findings of benefit in the setting of severe traumatic aSDH. Patients with worse neurologic impairment, i.e. low GCS, had the greatest survival benefit from surgical intervention.

The Morbidity and Mortality of Surgery for Traumatic Brain Injury in Geriatric Patients: A Study of Over 100 000 Patient Cases

BACKGROUND

Geriatric patients have the highest rates of Traumatic Brain Injury (TBI)-related hospitalization and death. This contributes to an assumption of futility in aggressive management in this population.

OBJECTIVE

To evaluate the effect of surgical intervention on the morbidity and mortality of geriatric patients with TBI.

METHODS

A retrospective analysis of patients ≥80 yr old with TBI from 2003 to 2016 was performed using the National Trauma Data Bank. Univariate and multivariate analyses were performed to compare outcomes between surgery and nonsurgery groups.

RESULTS

A total of 127 129 patient incidents were included: 121 185 (95.3%) without surgery and 5944 (4.7%) with surgery. The surgical group was slightly younger (84.0 vs 84.3, P < .001) and predominantly male (60.2% vs 44.4%, P < .001). Mean emergency department (ED) Glasgow Coma Scale (GCS) was lower in surgical patients (12.4 vs 13.7, P < .001). Complications (OR = 1.91, CI:1.80-2.02, P < .001) and hospital length of stay (LOS, ß = 5.25, CI:5.08-5.42, P < .001) were independently associated with surgery. Intensive care unit (ICU) LOS (ß = 3.19, CI:3.05-3.34, P < .001), ventilator days (ß = 1.57, CI:1.22-1.92, P < .001), and reduced discharge home (OR = 0.434, CI:0.400-0.470, P < .001) were also independently associated with surgery. However, surgery was not independently associated with mortality on multivariate analysis (OR = 1.03, CI:0.955-1.12, P = .423). Recursive partitioning analysis identified ED GCS and injury severity score (ISS) as prognosticators of mortality following surgical intervention.

CONCLUSION

Surgical treatment of geriatric patients with TBI is associated with increased complications, hospital LOS, ICU LOS, and ventilator days as well as reduced discharge to home. However, surgery is not associated with increased mortality. ISS and ED GCS are prognosticators of mortality following surgical intervention.

Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit

BACKGROUND AND OBJECTIVE

Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207).

METHODS

Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge.

RESULTS

Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes.

CONCLUSIONS

Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.

A systematic review of the qualitative literature on older individuals' experiences of care and well-being during physical rehabilitation for acquired brain injury

Aims

To acquire an in‐depth understanding of how older individuals diagnosed with acquired brain injury (ABI) experience their well‐being and care when undergoing physical rehabilitation.

Design

Systematic literature review.

Data sources

The electronic databases of PubMed, CINAHL, APA PsycInfo, ASSIA and SCOPUS were searched from 2005 to 2020. Extensive reference checking was also conducted.

Review methods

A systematic review was conducted following PRISMA guidelines, including predominantly qualitative studies. Studies’ quality was appraised using the critical apraisal skills programme (CASP) tool.

Results

Seventeen studies met the inclusion criteria. Following methods of thematic synthesis, four overarching interpretive themes were identified: (a) Rehabilitation processes and their impact on older individuals’ well‐being; (b) Identity and embodiment concerns of older individuals during rehabilitation; (c) Institutional factors affecting older individuals’ care and well‐being experiences; and (d) Older individuals’ participation in creative activities as part of rehabilitation.

Conclusion

Organizational and structural care deficiencies as well as health disparities can adversely impact older individuals’ autonomous decision‐making and goal‐setting potentials. The discrepancy between older individuals’ expectations and the reality of returning home along with the illusionary wish to return to a perceived normality, can further negatively affect older individuals’ sense of well‐being. Constructive communication, emotional support, family involvement in rehabilitation and creating a stimulating, enriching social environment can humanize and facilitate older individuals’ adjustment to their new reality following ABI.

Impact

There is a lack of qualitative research on older individuals’ ABI rehabilitation experiences, especially traumatic brain injury incidents. Further study should consider patients’ concerns over their involvement in decision‐making and goal setting about their care. Overall, this review reveals the need to examine further the significance of humanizing care and the factors that affect older individuals’ sense of well‐being.

A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score

The Subdural Hematoma in the Elderly (SHE) score was developed as a model to predict 30-day mortality from acute, chronic, and mixed subdural hematoma in the elderly population after minor or no trauma. Emerging evidence suggests frailty to be predictive of mortality and morbidity in the elderly. In this study, we aim to externally validate the SHE for chronic subdural hematoma (CSDH) alone, and we hypothesize that the incorporation of frailty into the SHE may increase its predictive power. A retrospective cohort of elderly patients with CSDH after minor or no trauma being treated at our institution was evaluated with the SHE. Thirty-day mortality and outcome were documented. Patients were assessed with the Clinical Frailty Scale (CFS), which was incorporated into a modified SHE (mSHE). Both the SHE and the mSHE were then assessed in their predictive powers through receiver operating characteristic statistics. We included 168 patients. Most (n = 124, 74%) had a favorable outcome at 30 days. Mortality was low at n = 7, 4%. The SHE failed to predict mortality (AUC = .564, p = .565). Contrarily, the mSHE performed well in both mortality (AUC = .749, p = .026) and outcome (AUC = .862, p < .001). A threshold of mSHE = 3 is predictive of mortality with a sensitivity of 50% and a specificity of 75% and of poor outcome with a sensitivity of 88% and a specificity of 64%. Frailty should be routinely evaluated in elderly individuals, as it can predict outcome and mortality, providing the possibility for medical, surgical, nutritional, cognitive, and physical exercise interventions.

Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma

Background

Acute subdural hematoma (ASDH) is a traumatic lesion commonly found secondary to traumatic brain injury. Radiological findings on CT, such as hematoma thickness (HT) and structures midline shift (MLS), have an important prognostic role in this disease. The relationship between HT and MLS has been rarely studied in the literature. Thus, this study aimed to assess the prognostic accuracy of the difference between MLS and HT for acute outcomes in patients with ASDH in a low-income to middle-income country.

Methods

This was a post-hoc analysis of a prospective cohort study conducted in a university-associated tertiary-level hospital in Brazil. The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis) statement guidelines were followed. The difference values between MLS and HT (Zumkeller index, ZI) were divided into three categories (<0.00, 0.01–3, and >3). Logistic regression analyses were performed to reveal the OR of categorized ZI in predicting primary outcome measures. A Cox regression was also performed and the results were presented through HR. The discriminative ability of three multivariate models including clinical and radiological variables (ZI, Rotterdam score, and Helsinki score) was demonstrated.

Results

A total of 114 patients were included. Logistic regression demonstrated an OR value equal to 8.12 for the ZI >3 category (OR 8.12, 95% CI 1.16 to 40.01; p=0.01), which proved to be an independent predictor of mortality in the adjusted model for surgical intervention, age, and Glasgow Coma Scale (GCS) score. Cox regression analysis demonstrated that this category was associated with 14-day survival (HR 2.92, 95% CI 1.38 to 6.16; p=0.005). A multivariate analysis performed for three models including age and GCS with categorized ZI or Helsinki or Rotterdam score demonstrated area under the receiver operating characteristic curve values of 0.745, 0.767, and 0.808, respectively.

Conclusions

The present study highlights the potential usefulness of the difference between MLS and HT as a prognostic variable in patients with ASDH.

Level of evidence

Level III, epidemiological study.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Traumatic brain injury-the effects of patient age on treatment intensity and mortality

Background

Ageing is associated with worse treatment outcome after traumatic brain injury (TBI). This association may lead to a self-fulfilling prophecy that affects treatment efficacy. The aim of the current study was to evaluate the role of treatment bias in patient outcomes by studying the intensity of diagnostic procedures, treatment, and overall 30-day mortality in different age groups of patients with TBI.

Methods

Included in this study was consecutively admitted patients with TBI, aged ≥ 15 years, with a cerebral CT showing intracranial signs of trauma, during the time-period between 2015–2018. Data were extracted from our prospective quality control registry for admitted TBI patients. As a measure of management intensity in different age groups, we made a composite score, where placement of intracranial pressure monitor, ventilator treatment, and evacuation of intracranial mass lesion each gave one point. Uni- and multivariate survival analyses were performed using logistic multinomial regression.

Results

A total of 1,571 patients with TBI fulfilled the inclusion criteria. The median age was 58 years (range 15–98), 70% were men, and 39% were ≥ 65 years. Head injury severity was mild in 706 patients (45%), moderate in 437 (28%), and severe in 428 (27%). Increasing age was associated with less management intensity, as measured using the composite score, irrespective of head injury severity. Multivariate analyses showed that the following parameters had a significant association with an increased risk of death within 30 days of trauma: increasing age, severe comorbidities, severe TBI, Rotterdam CT-score ≥ 3, and low management intensity.

Conclusion

The present study indicates that the management intensity of hospitalised patients with TBI decreased with advanced age and that low management intensity was associated with an increased risk of 30-day mortality. This suggests that the high mortality among elderly TBI patients may have an element of treatment bias and could in the future be limited with a more aggressive management regime.

Acute subdural hematoma in the elderly: outcome analysis in a retrospective multicentric series of 213 patients

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.

Morbidity and mortality in elderly patients undergoing evacuation of acute traumatic subdural hematoma

OBJECTIVE

Acute traumatic subdural hematoma (atSDH) can be a life-threatening neurosurgical emergency that necessitates immediate evacuation. The elderly population can be particularly vulnerable to tearing bridging veins. The aim of this study was to evaluate inpatient morbidity and mortality, as well as predictors of inpatient mortality, in a national trauma database.

METHODS

The authors queried the 2016–2017 National Trauma Data Bank registry for patients aged 65 years and older who had undergone evacuation of atSDH. Patients were categorized into three age groups: 65–74, 75–84, and 85+ years. A multivariable logistic regression model was fitted for inpatient mortality adjusting for age group, sex, race, presenting Glasgow Coma Scale (GCS) category (3–8, 9–12, and 13–15), Injury Severity Score, presence of coagulopathy, presence of additional hemorrhages (epidural hematoma [EDH], intraparenchymal hematoma [IPH], and subarachnoid hemorrhage [SAH]), presence of midline shift > 5 mm, and pupillary reactivity (both, one, or none).

RESULTS

A total of 2508 patients (35% females) were analyzed. Age distribution was as follows: 990 patients at 65–74 years, 1096 at 75–84, and 422 at 85+. Midline shift > 5 mm was present in 72% of cases. With regard to additional hemorrhages, SAH was present in 21%, IPH in 10%, and EDH in 2%. Bilaterally reactive pupils were noted in 90% of patients. A major complication was observed in 14.4% of patients, and the overall mortality rate was 18.3%. In the multivariable analysis, the presenting GCS category was found to be the strongest predictor of postoperative inpatient mortality (3–8 vs 13–15: OR 3.63, 95% CI 2.68–4.92, p < 0.001; 9–12 vs 13–15: OR 2.64, 95% CI 1.79–3.90, p < 0.001; 30% of overall variation), followed by the presence of SAH (OR 2.86, 95% CI 2.21–3.70, p < 0.001; 25% of overall variation) and the presence of midline shift > 5 mm (OR 2.40, 95% CI 1.74–3.32, p < 0.001; 11% of overall variation). Model discrimination was excellent (c-index 0.81). Broken down by age decile group, mortality increased from 8.0% to 15.4% for GCS 13–15 to around 36% for GCS 9–12 to almost as high as 60% for GCS 3–8, particularly in those aged 85 years and older.

CONCLUSIONS

The present results from a national trauma database will, the authors hope, assist surgeons in preoperative discussions with patients and their families with regard to expected postoperative outcomes following surgical evacuation of an atSDH.

Outcomes of Surgical Evacuation of Chronic Subdural Hematoma in the Aged: Institutional Experience and Systematic Review

BACKGROUND

Surgical intervention for chronic subdural hematoma (cSDH) in the elderly population remains a clinical challenge given that associated morbidity and outcomes do not always equate radiographic success with clinical success. Our objective was to compare outcome measures of 2 age groups of patients undergoing surgical intervention for cSDH evacuation and to perform a systematic review of the literature related to this topic.

METHODS

A retrospective analysis of adult patients undergoing surgical evacuation of cSDH at our institution was performed. Primary outcome measures of modified Rankin Scale (mRS) score at discharge and 3 months were assessed. In addition, a systematic search was performed to collect all relevant studies addressing outcomes after surgical intervention in aged patients with cSDH.

RESULTS

There were 72 patients in the younger cohort (<70 years) and 113 patients in the aged cohort (≥70 years). Multivariate analysis showed significant association between age and higher mRS score at discharge and 3 months follow-up. There were also significant differences in length of stay and disposition between the 2 groups. Twenty-one studies were reviewed, and 11 studies were included in a meta-analysis of recurrence rates between studied age groups.

CONCLUSIONS

The aged cohort had worse outcomes than the younger cohort as determined by mRS score at discharge and 3 months. A systematic review of outcomes is provided with limited meta-analysis because of the heterogenous nature of outcome reporting and the observational design of previous studies. Further studies with standardized reporting and long-term follow-up are warranted to further study outcomes in this increasing population.

Mortality and functional outcome after surgical evacuation of traumatic acute subdural hematomas in octa- and nonagenarians

Purpose

The incidence of acute subdural hematomas (aSDH) is rising. However, beneficial effects of surgery for the oldest aSDH patients remain unclear. We hence describe the postoperative outcome of octa- and nonagenarians with aSDH in comparison to a younger patient cohort.

Methods

Patients aged ≥ 80 years surgically treated for traumatic aSDH at a single institution between 2006 and 2016 were retrospectively reviewed. Clinical and imaging variables were assessed, and univariate analysis was performed to identify factors predicting outcome at discharge. Results were compared to a cohort of younger aSDH patients and statistical analysis was performed. Long-term outcome was prospectively evaluated with the GOSE and QOLIBRI.

Results

27 aSDH patients aged ≥ 80 years were identified. On admission, 41% were in a comatose state and in-hospital mortality was 33%. At discharge, 22% had a favorable outcome (GOS 4 + 5). In univariate statistical analysis, better neurological status (GCS > 8), ≤ 1 comorbidity and smaller aSDH volumes were significant predictors for a favorable outcome. Comparison to 27 younger aSDH patients revealed significant differences in the prevalence of comorbidities and antithrombotics. At long-term follow-up, quality of life of aSDH patients was reduced (median QOLIBRI 54%).

Conclusion

Outcome after surgical treatment of aSDH in octa- and nonagenarians is not detrimental per se. Predictors for a favorable outcome are a non-comatose state on admission (GCS > 8), ≤ 1 preexisting comorbidity and a lower aSDH volume in patients aged ≥ 80 years. In individual patients, surgical evacuation of aSDH might remain a treatment option even in high ages.

Factors Associated with Poor Outcomes in Patients with Mild or Moderate Acute Subdural Hematomas

The factors influencing the outcomes of mild/moderate acute subdural hematoma (ASDH) are still unclear. Retrospective analyses were performed to identify such factors. The medical records of all patients who were admitted to Saiseikai Shiga Hospital with mild (Glasgow Coma Scale [GCS] score of 14–15) or moderate (GCS score of 9–13) ASDH between April 2008 and March 2017 were reviewed. Comparisons between the patients who exhibited favorable and poor outcomes were performed. Then, independent factors that contributed to poor outcomes were identified via logistic regression analyses. A total of 266 patients with a mean age of 70.2 were included in this study. The most common concomitant injuries were subarachnoid hemorrhages (SAHs; 56.8%). The patients’ Injury Severity Scores (ISS) ranged from 16 to 75 (median: 21). The 66 moderate ASDH patients exhibited significantly higher frequencies of surgery and mortality (24.2% and 13.6%, respectively) than the 200 mild ASDH patients (8.0% and 4.5%, respectively). The factors associated with poor outcomes were age (odds ratio [OR]: 1.06) and the ISS (OR: 1.24) in the mild ASDH patients, and older age (OR: 1.09) and the higher ISS (OR: 1.15) in the moderate group, too.

Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network?

Objectives: Within the pan London Major Trauma System many patients with minor or non-life threatening traumatic brain injury (TBI) remain at their local hospital and are not transferred to a major trauma centre (MTC). Our aim was to identify factors that influence the decision to transfer patients with TBI to a neurosurgical centre.Methods: This is a single centre prospective cohort study of all patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4-month period (Sept 2016-Jan 2017). Our primary outcome was transferred to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, antithrombotic therapy and severity of TBI based on initial Glasgow Coma Scale (GCS) and Marshall CT score. A multivariable logistic regression analysis was performed.Results: A total of 339 patients were referred from regional hospitals with TBI and of these, 53 (15.6%) were transferred to our hospital. The mean age of patients referred was 70.6 years, 62.5% were men and 43% on antithrombotic drugs. Eighty-six percent of patients had mild TBI (GCS 13-15) on initial assessment and 79% had a Marshall CT score of 2. The adjusted analysis revealed only higher age, higher Marshall Score, the presence of chronic subdural haematoma (CSDH), the presence of contusion(s) and fracture(s) predicted transfer (p<.05). Subgroup analysis consistently showed a higher Marshall score predicted transfer (p<.05).Conclusions: In our cohort higher Marshall score consistently predicted transfer to our neurosurgical centre. Presenting GCS, transfer distance and antithrombotic therapy did not influence decision to transfer.

Identification of clinical characteristics and factors predicting favorable treatment outcomes in elderly patients with traumatic brain injury

Age is an important prognostic factor for patients with traumatic brain injury (TBI), and worse treatment outcomes have been reported in elderly patients. Therefore, proper treatment is needed for the increasing number of elderly patients with TBI. We aimed to analyze predictive factors of favorable treatment outcomes (FTO) in elderly patients. Clinical and radiological data from 493 patients with TBI who visited a single institute were retrospectively collected from January 2014 to December 2015. We compared the characteristics of the elderly group (individuals above 65 years) and younger group (16-65 years). We analyzed the characteristics and outcomes in both groups and the factors related to the Glasgow outcome scale-extended score at 6 months after injury in 170 elderly patients. The treatment outcomes were dichotomized into favorable and unfavorable groups. In the elderly group, the proportion of female patients and the incidence of subdural hemorrhage (SDH) were higher than in the younger group. Among the 170 elderly patients, 62 had pure SDH, and 21 of the 62 with pure SDH had undergone surgical treatment. Compared with other types of intracranial hemorrhage, FTO was as high as 85.5%, and mortality was as low as 11.3% in patients with pure SDH. High initial Glasgow coma scale score, low injury severity score, and normal pupillary reflex were significantly related to FTO in multivariate analysis. Therefore, active therapeutic strategies, including surgery should be considered for elderly patients with pure SDH without intra-parenchymal injury.

Advanced Age Is Not a Universal Predictor of Poorer Outcome in Patients Undergoing Neurosurgery

BACKGROUND

Advances in medical care and technology have dramatically improved outcomes in patients undergoing neurosurgical intervention; however, certain patient subgroups (e.g., older adults) may encounter greater rates of morbidity and mortality in the perioperative period. The objective of this study was to determine the effects of patient and hospital characteristics, including age, on in-hospital mortality, and complication rates of 3 routine neurosurgical operations: subdural hematoma evacuation, brain tumor resection, and degenerative spine procedures.

METHODS

A retrospective multivariable analysis of the 2014 National Inpatient Sample was performed. The setting was a national sample of hospitalized inpatient stays occurring in 2014 in the United States. Patients (N = 48,963) included those undergoing subdural hematoma evacuation, brain tumor resection, or degenerative spine procedures, stratified according to age group (<65, 65-74, 75-84, 85+ years). Mortality and complication rate were measured.

RESULTS

Age ≥85 years was found to increase the odds of mortality (odds ratio 11.32) and complications (odds ratio 2.64) in patients undergoing degenerative spine procedures, whereas age had no significant effect on mortality and complication rate in subdural hematoma evacuation and brain tumor resection. Multiple comorbidities and nonelective status were predictors of increased mortality and complication rate in all procedure groups.

CONCLUSIONS

Overall, our data would suggest that increased age does not universally predict worse outcome and that, for many procedures, surgical decision-making in older patients should instead consider other pertinent factors, such as comorbidities and elective status.

Short- and Long-Term Geriatric Mortality After Acute Traumatic Subdural Hemorrhage

BACKGROUND

Acute subdural hemorrhage often occurs in those ≥65 years of age after trauma and tends to yield poor clinical outcomes. Previous studies have demonstrated a propensity toward high in-hospital mortality rates in this population; however, postdischarge mortality data are limited. The objective of the present study was to analyze short- and long-term mortality data after acute traumatic subdural hemorrhage in the geriatric population as well as review the impact of associated clinical variables including mechanism of injury, pre-morbid antithrombotic use, and need for surgical decompression on mortality rates.

METHODS

We retrospectively reviewed 455 patients who presented with an isolated traumatic acute subdural hemorrhage to our level-1 trauma center over a 5 year period using our data registry. Patients were then cross-referenced in the National Social Security Death Index for postdischarge mortality rates. United States life tables were used for peer-controlled actuarial comparisons.

RESULTS

Acute traumatic subdural hemorrhage is often a fatal injury in the geriatric population, especially if taking antithrombotics or requiring surgical decompression. Specifically, they have greater in-hospital mortality rates than adults with similar injuries and have significantly lower survival rates for several years following discharge compared with their peer-matched controls.

CONCLUSIONS

Here, we found that age is a significant predictor of both short- and long-term survival after acute traumatic subdural hemorrhage. Moreover, the present study corroborates that the need for surgical decompression or the use of pre-morbid antithrombotic medications is associated with increased overall mortality.

[Surgical treatment of chronic subdural hematoma in Guinea: Analysis of 22 cases at the Kipe hospital of Conakry]

OBJECTIVE

We report the results of surgical treatment of chronic subdural hematoma in the Kipe Hospital in Conakry, Guinea, for the period July 2012 to November 2015.

MATERIAL AND METHOD

Clinical, radiological and therapeutic data from 22 cases were collected retrospectively and analyzed, with a mean follow-up of 61.6 days. Univariate analysis screened for factors for neurological outcome on the Markwalder Grading Scale (MGS; 0=normal to 4=coma).

RESULTS

Male-female sex ratio was 2.6:1. Mean age at diagnosis was 71.09±8 years, with peak incidence of CSDH in the 60-79 age group. Traumatic brain injury was identified as causal in 40.9% of cases. Burrhole trepanation was used in 86.36% of cases, under local anesthesia in 76%, and with postoperative drainage in all cases. No recurrences were recorded. At follow-up, mean postoperative MGS was 0.59 (up from 3.08 preoperatively); 54.54% of patients had normal neurological examination (grade 0). Age 60-79 years, time to diagnosis>12 weeks and preoperative MGS≥3 had significant negative impact on outcome (respective P-values: 0.03, 0.001, 0.001).

CONCLUSION

Our data were similar to those of the literature, but with longer time to diagnosis and poorer initial clinical status, with negative impact on clinical progression.

Scandinavian Multicenter Acute Subdural Hematoma (SMASH) Study: Study Protocol for a Multinational Population-Based Consecutive Cohort

BACKGROUND

Traumatic acute subdural hematomas (ASDHs) are associated with high rate of morbidity and mortality, especially in elderly individuals. However, recent reports indicate that the morbidity and mortality rates might have improved.

OBJECTIVE

To evaluate postoperative (30-d) mortality in younger vs elderly (≥70 yr) patients with ASDH. Comparing younger and elderly patients, the secondary objectives are morbidity patterns of care and 6 mo outcome according to Glasgow outcome scale (GOS). Finally, in patients with traumatic ASDH, we aim to provide prognostic variables.

METHODS

This is a large-scale population-based Scandinavian study including all neurosurgical departments in Denmark and Sweden. All adult (≥18 yr) patients surgically treated between 2010 and 2014 for a traumatic ASDH in Denmark and Sweden will be included. Identification at clinicaltrials.gov is NCT03284190.

EXPECTED OUTCOMES

We expect to provide data on potential differences between younger vs elderly patients in terms of mortality and morbidity. We hypothesize that elderly patients selected for surgery have a similar pattern of care as compared with younger patients. We will provide functional outcome in terms of GOS at 6 mo in younger vs elderly patients undergoing ASDH evacuation. Finally, clinical useful prognostic factors for favorable (GOS 4-5) vs unfavorable (GOS 1-3) will be identified.

DISCUSSION

An improved understanding of the clinical outcome, treatment and resource allocation, clinical course, and the prognostic factors of traumatic ASDH will allow neurosurgeons to make better treatment decisions.

Do older patients with acute or subacute subdural hematoma benefit from surgery?

PURPOSE

According to the international guidelines, acute subdural hematomas (aSDH) with a thickness of >10 mm, or causing a midline shift of >5 mm, should be surgically evacuated. However, high mortality rates in older patients resulted in ongoing controversy whether elderly patients benefit from surgery. We identified predictors of outcome in a single-centre cohort of elderly patients undergoing surgical evacuation of aSDH or subacute subdural hematoma (saSDH).

MATERIALS AND METHODS

This retrospective study included all patients aged ≥65 years undergoing surgical evacuation of aSDH/saSDH from 2000 to 2015. One-year outcome was dichotomized into favourable (Glasgow Outcome Scale (GOS) 4-5) and unfavourable (GOS 1-3). Predictors of outcome were identified by analysing patient characteristics.

RESULTS

Eighty-four patients aged ≥65 years underwent craniotomy for aSDH/saSDH during the 16 year time period. Twenty-five percent regained functional independence, 11% survived severely disabled, and 64% died. Most patients died of respiratory failure following withdrawal of artificial respiration or following restriction of treatment. Age of the SDH or Glasgow Coma Scores ≤8/intubation did not predict unfavourable outcome. All patients with bilaterally absent pupillary light reflexes died, also those who still exhibited one normal-sized pupil.

CONCLUSION

The low number of operated patients per year probably suggests that this cohort represents a selection of patients who were judged to have good chances of favouring from surgery. Functional independence at one-year follow-up was reached in 25% of patients, 64% died. Patients with bilaterally absent pupillary light reflexes did not benefit from surgery. The tendency to restrict treatment because of presumed poor prognosis may have acted as a self-fulfilling prophecy.

Prognosis of Acute Subdural Hematoma in the Elderly: A Systematic Review

Acute subdural hematoma (aSDH) is among the most common injury types encountered by neurosurgeons, and carries a poor prognosis, particularly in the elderly. As the incidence of aSDH in the elderly population rises, identifying those patients who may benefit from operative intervention is crucial. This systematic review aimed to identify data on prognostic factors or indices, such as the modified frailty index, that may help predict outcome, and hence guide management. A comprehensive search of online databases was conducted by two independent authors, and data on prognostic factors and outcomes were extracted. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Of 769 studies identified in the initial search, 7 satisfied inclusion and exclusion criteria. Mortality and morbidity varied considerably among studies. Initial Glasgow Coma Scale (GCS) of 3-8 was the most consistently reported negative prognostic feature. Several studies evaluated the impact of medical comorbidities and premorbid frailty, but were limited by small sample size. A previous history of pneumonia was shown to increase the risk of Glasgow Outcome Score (GOS) 1-3 (odds ratio [OR] 6.4 [95% CI 1.6-25.2], p = 0.04) in a single study, which also reported a greater increase in GOS at 3 months in those with fewer than five comorbidities (56% vs. 19%, p < 0.01). There are limited data describing prognostic factors or the use of frailty indices within the specific group of elderly patients with aSDH. Prospective research is needed to evaluate the utility of accurate and validated assessments of frailty to enhance the neurosurgeon's ability to appropriately manage this complex and expanding patient group.

Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome

OBJECTIVE Isolated acute subdural hematoma (aSDH) is increasing in older populations and so is the use of oral anticoagulant therapy (OAT). The dramatic increase of OAT-with direct oral anticoagulants (DOACs) as well as with conventional anticoagulants-is leading to changes in the care of patients who present with aSDH while receiving OAT. The purpose of this study was to determine the management and outcome of patients being treated with OAT at the time of aSDH presentation. METHODS In this single-center, retrospective study, the authors analyzed 116 consecutive cases involving patients with aSDH treated from January 2007 to June 2016. The following parameters were assessed: patient characteristics, admission status, anticoagulation status, perioperative management, comorbidities, clinical course, and outcome as determined at discharge and through 6 months of follow-up. Oral anticoagulants were classified as thrombocyte inhibitors, vitamin K antagonists, and DOACs. Patients were stratified based on which type of medication they were taking, and subgroup analyses were performed. Predictors of unfavorable outcome at discharge and follow-up were identified. RESULTS Of 116 patients, 74 (64%) had been following an OAT regimen at presentation with aSDH. The patients who were taking oral anticoagulants (OAT group) were significantly older (OR 12.5), more often comatose 24 hours postoperatively (OR 2.4), and more often had ≥ 4 comorbidities (OR 3.2) than patients who were not taking oral anticoagulants (no-OAT group). Accordingly, the rate of unfavorable outcome was significantly higher in patients in the OAT group, both at discharge (OR 2.3) and at follow-up (OR 2.2). Of the patients in the OAT group, 37.8% were taking a thrombocyte inhibitor, 54.1% a vitamin K antagonist, and 8.1% DOACs. In all cases, OAT was stopped on discovery of aSDH. For reversal of anticoagulation, patients who were taking a thrombocyte inhibitor received desmopressin 0.4 μg/kg, 1-2 g tranexamic acid, and preoperative transfusion with 2 units of platelets. Patients following other oral anticoagulant regimens received 50 IU/kg of prothrombin complex concentrates and 10 mg of vitamin K. There was no significant difference in the rebleeding rate between the OAT and no-OAT groups. The in-hospital mortality rate was significantly higher for patients who were taking a thrombocyte inhibitor (OR 3.3), whereas patients who were taking a vitamin K antagonist had a significantly higher 6-month mortality rate (OR 2.7). Patients taking DOACs showed a tendency toward unfavorable outcome, with higher mortality rates than patients on conventional OAT or patients in the vitamin K antagonist subgroup. Independent predictors for unfavorable outcome at discharge were comatose status 24 hours after surgery (OR 93.2), rebleeding (OR 9.8), respiratory disease (OR 4.1), and infection (OR 11.1) (Nagelkerke R² = 0.684). Independent predictors for unfavorable outcome at follow-up were comatose status 24 hours after surgery (OR 12.7), rebleeding (OR 3.1), age ≥ 70 years (OR 3.1), and 6 or more comorbidities (OR 3.1, Nagelkerke R² = 0.466). OAT itself was not an independent predictor for worse outcome. CONCLUSIONS An OAT regimen at the time of presentation with aSDH is associated with increased mortality rates and unfavorable outcome at discharge and follow-up. Thrombocyte inhibitor treatment was associated with increased short-term mortality, whereas vitamin K antagonist treatment was associated with increased long-term mortality. In particular, patients on DOACs were seriously affected, showing more unfavorable outcomes at discharge as well as at follow-up. The suggested medical treatment for aSDH in both OAT and no-OAT patients seems to be effective and reasonable, with comparable rebleeding and favorable outcome rates in the 2 groups. In addition, prior OAT is not a predictor for aSDH outcome.

Acute Subdural Hematoma Evacuation: Predictive Factors of Outcome

BACKGROUND

Acute subdural hematoma (aSDH) is a major cause of admission at Neurosurgical Emergency Department. Nevertheless, concerns regarding surgical indication in patients with multiple comorbidities, poor neurological status, antithrombotic therapy, and older age still persist. Therefore, a correct recognition of predictive outcome factors at hospital discharge is crucial to an appropriate neurosurgical treatment.

METHODS

Eighty-nine medical records of consecutive patients with age ≥18 years old who were submitted to aSDH evacuation between January 2008 and May 2012 were reviewed. Demographic characteristics, neurological status on admission, anticoagulant or antiplatelet therapy, and outcome on discharge were collected. Patients with insufficient data concerning these variables were excluded from the study.

RESULTS

Sixty-nine patients were included; 52% were male; 74% were older than 65 years; 41% were under oral antithrombotic therapy (OAT); at admission, 54% presented with Glasgow coma scale (GCS) ≤8; 23% were submitted to a craniectomy instead of a craniotomy; 26% of the patients died, 32% were dependent, and 42% were independent on discharge. Crude analysis revealed craniectomy, A/A pupils, GCS ≤8 at admission statistically significant related with the worst outcome (P < 0.05). In the adjusted evaluation only A/A pupils (P = 0.04) was associated to poor outcome (spontaneous etiology P = 0.052). Considering daily living independency at hospital discharge, either male gender (P = 0.044) and A/A pupils (P = 0.030) were related to the worst outcome. No effect of age in outcome was observed.

CONCLUSIONS

Male gender and A/A pupils are associated with lower probability of achieving independency living at hospital discharge. A/A pupils, low GCS at admission, spontaneous etiology, and craniectomy were associated with the worst outcome. Age and OAT were not predictive factors in this series. Caution should be taken when considering these factors in the surgical decision.

Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions

This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.

Significant increase in acute subdural hematoma in octo- and nonagenarians: surgical treatment, functional outcome, and predictors in this patient cohort

OBJECTIVE

Acute subdural hematoma (aSDH) is a common disease increasing in prevalence given the demographic growth of the aging population. Yet, the benefit of surgical treatment for aSDH and the subsequent functional outcome in elderly patients (age ≥ 80 years) remain unclear. Therefore, the aims of this study were to evaluate the incidence of aSDH in patients 80 years or older, determine overall functional outcome, identify predictors of an unfavorable or favorable outcome, and establish specific risk factors for seizures.

METHODS

The authors retrospectively analyzed patients 80 years and older who presented with isolated aSDH in the past 10 years at their institution. The following parameters were assessed: baseline characteristics, clinical status on admission and 24 hours after surgery, and clinical course. Functional outcome was assessed at discharge and the 3-month follow-up (FU).

RESULTS

In the period from January 2007 to December 2016, 165 patients with aSDH were admitted to the authors’ institution. Sixty-eight patients (41.2%) were 80 years old or older, and the mean age overall was 85 years (range 80–96 years). The incidence of aSDH in the elderly had significantly increased over past decade, with more than 50% of patients admitted to our institution for aSDH now being 80 years or older. The overall mortality rate was 28% at discharge and 48% at the FU. Independent predictors of an unfavorable outcome at discharge were a GCS score ≤ 8 at 24 hours after operation (p < 0.001) and pneumonia (p < 0.02). At the FU, a GCS score ≤ 8 at 24 hours after operation (p < 0.001) and cumulative comorbidities (≥ 5; p < 0.05) were significant independent predictors. All patients with more than 6 comorbidities had died by the FU. Surgical treatment in comatose compared to noncomatose patients had statistically significant, higher mortality rates at discharge and the FU. Still, 23% of the comatose patients and more than 50% of the noncomatose patients had a favorable outcome at the FU (p = 0.06).

CONCLUSIONS

The number of octo- and nonagenarians with aSDH significantly increased over the last decade. These patients can achieve a favorable outcome, especially those with a noncomatose status and fewer than 5 comorbidities. Surgical and nonsurgical treatment of octo- and nonagenarians during and after discharge should be optimized to increase clinical improvement.