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Gavrila Laic RA, Sloten JVANDER, Depreitere B. Neurosurgical treatment in elderly patients with Traumatic brain injury: A 20-year follow-up study. BRAIN & SPINE 2023; 3:101723. [PMID: 37383432 PMCID: PMC10293208 DOI: 10.1016/j.bas.2023.101723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 06/30/2023]
Abstract
Introduction Traumatic brain injury in the elderly population can have a substantial impact on patients' quality of life. In this regard, successful treatment strategies are hard to define to date. Research question In order to facilitate further insight, this study assessed outcomes following acute subdural hematoma evacuation in patients aged ≥65 years in a large patient series. Material and methods A manual screening of the clinical records of 2999 TBI patients aged ≥65 years, admitted to the University Hospital Leuven (Belgium) between 1999 and 2019, was performed. Results A total of 149 patients were identified with aSDH, of whom 32 underwent early surgery, 33 underwent delayed surgery and 84 were treated conservatively. Patients who underwent early surgery had the lowest median GCS, poorest Marshall CT scores, longest hospital and ICU stay, and highest intensive care unit admission and redo surgery rates. 30-d mortality was 21.9% in patients undergoing early surgery, 3.0% in patients undergoing late surgery and 16.7% in patients who were treated conservatively. Discussion and conclusion In conclusion, patients in whom surgery could not be delayed had the worst presentation and poorest outcomes as opposed in patients in whom delay was possible. Surprisingly, patients treated conservatively had worse outcomes than those treated with delayed surgery. These results might indicate that if the GCS at admission is still adequate, an initial strategy of waiting and seeing might be associated with better outcomes. Future prospective studies with sufficient sample size are warranted to draw more definitive conclusions on the value of early vs. late surgery in elderly patients with aSDH.
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Manivannan S, Spencer R, Marei O, Mayo I, Elalfy O, Martin J, Zaben M. Acute subdural haematoma in the elderly: to operate or not to operate? A systematic review and meta-analysis of outcomes following surgery. BMJ Open 2021; 11:e050786. [PMID: 34862284 PMCID: PMC8647543 DOI: 10.1136/bmjopen-2021-050786] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Susruta Manivannan
- Department of Neurosurgery, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Robert Spencer
- Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Omar Marei
- School of Medicine, Cardiff University, Cardiff, UK
| | - Isaac Mayo
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Omar Elalfy
- School of Medicine, Cardiff University, Cardiff, UK
| | - John Martin
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Malik Zaben
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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Moshref R, Alsinani TA, Al-Sinani A. Case Report: Surgical Management in Acute Subdural Hematoma Induced by Chronic Myelogenous Leukemia. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932787. [PMID: 34426567 PMCID: PMC8404166 DOI: 10.12659/ajcr.932787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 45-year-old
Final Diagnosis: Chronic myelogenous leukemia
Symptoms: Loss of consciousness
Medication:—
Clinical Procedure: Crainotomy
Specialty: Neurosurgery
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Affiliation(s)
- Rana Moshref
- Department of Neurosurgery, King Fahad General Hospital, Jeddah, Saudi Arabia
| | - Taghreed A Alsinani
- Department of Neurosurgery, King Fahad General Hospital, Jeddah, Saudi Arabia
| | - Asrar Al-Sinani
- Department Internal Medicine, Jeddah Eye Hospital, Jeddah, Saudi Arabia
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Posti JP, Luoto TM, Rautava P, Kytö V. Mortality After Trauma Craniotomy Is Decreasing in Older Adults-A Nationwide Population-Based Study. World Neurosurg 2021; 152:e313-e320. [PMID: 34082165 DOI: 10.1016/j.wneu.2021.05.090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE No evidence-based guidelines are available for operative neurosurgical treatment of older patients with traumatic brain injuries (TBIs), and no population-based results of current practice have been reported. The objective of the present study was to investigate the rates of trauma craniotomy operations and later mortality in older adults with TBI in Finland. METHODS Nationwide databases were searched for all admissions with a TBI diagnosis and after trauma craniotomy, and later deaths for persons aged ≥60 years from 2004 to 2018. RESULTS The study period included 2166 patients (64% men; mean age, 70.3 years) who had undergone TBI-related craniotomy. The incidence rate of operations decreased with a concomitant decrease in adjusted mortality (30-day mortality, P < 0.001; 1-year mortality, P < 0.001) and increase in mean patient age (R2 = 0.005; P < 0.001) during the study period. The cumulative mortality was 25% at 30 days and 38% at 1 year. The comorbidities increasing the hazard for 30-day mortality were diabetes, a history of malignancy, peripheral vascular disease, and a history of myocardial infarction. For 1-year mortality, the comorbidities were heart failure and a history of myocardial infarction. Evacuation of an epidural hematoma decreased the hazard for mortality. In contrast, evacuation of an intracerebral hematoma and decompressive craniectomy increased the risk at both 30 days and 1 year. CONCLUSIONS Among older adults in Finland, the rate of trauma craniotomy and later mortality has been decreasing although the mean age of operated patients has been increasing. This can be expected to be related to an improved understanding of geriatric TBIs and, consequently, improved selection of patients for targeted therapy.
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Affiliation(s)
- Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Centre, Turku University Hospital and University of Turku, Turku, Finland.
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland; Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland; Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland; Administative Center, Hospital District of Southwest Finland, Turku, Finland
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5
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Spencer RJ, Manivannan S, Zaben M. Endoscope-assisted techniques for evacuation of acute subdural haematoma in the elderly: The lesser of two evils? A scoping review of the literature. Clin Neurol Neurosurg 2021; 207:106712. [PMID: 34091423 DOI: 10.1016/j.clineuro.2021.106712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/10/2021] [Accepted: 05/23/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Surgical evacuation of acute subdural haematoma (ASDH) in the elderly remains a point of contention due to the significant associated mortality. Therefore, there is a dire need for alternative treatment options. Endoscope-assisted techniques (EAT) have been increasingly reported over the last decade with variable outcomes. In this scoping review, we identify studies reporting the use of EAT for ASDH evacuation in elderly patients. Outcomes and patient selection criteria are discussed to identify patients that may benefit from EAT. METHODS A multi-database literature search was performed between January 1990 and January 2021. Studies including patients aged 60 years or above who underwent EAT for ASDH evacuation with reported outcomes were included. RESULTS A total of 13 studies and 122 patients were eligible for inclusion. Patient age ranged from 65 to 101 years, and average age from 78.6 to 87.4 years. High comorbidity burden, advanced age, absence of adverse imaging features, and pre-operative neurological status were the most common eligibility criteria for EAT. 52% of all procedures were performed under local anaesthetic (LA). Mortality rates ranged between 0% and 40%, whilst favourable outcomes ranged between 26.7% and 96.4%. Re-bleed was the most commonly reported complication, ranging between 0% and 13%. CONCLUSIONS EAT pose a viable compromise for elderly patients with ASDH that may be unfit for GA. Heterogeneity of patient selection criteria prevents meaningful comparison between EAT and other approaches, and there is a clear impact of patient selection on outcome among studies reporting EAT. Further studies are required to identify the patient cohort that may benefit from this approach.
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Affiliation(s)
- R J Spencer
- Department of Neurosurgery, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - S Manivannan
- Department of Neurosurgery, Southampton General Hospital, Southampton, UK
| | - M Zaben
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK.
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Craniotomy size for traumatic acute subdural hematomas in elderly patients-same procedure for every age? Neurosurg Rev 2021; 45:459-465. [PMID: 33900496 PMCID: PMC8827226 DOI: 10.1007/s10143-021-01548-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/25/2021] [Accepted: 04/12/2021] [Indexed: 12/03/2022]
Abstract
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.
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Skaansar O, Tverdal C, Rønning PA, Skogen K, Brommeland T, Røise O, Aarhus M, Andelic N, Helseth E. Traumatic brain injury-the effects of patient age on treatment intensity and mortality. BMC Neurol 2020; 20:376. [PMID: 33069218 PMCID: PMC7568018 DOI: 10.1186/s12883-020-01943-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/29/2020] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Ola Skaansar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Cathrine Tverdal
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | - Karoline Skogen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Tor Brommeland
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Olav Røise
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Eirik Helseth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
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8
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Tverdal C, Aarhus M, Andelic N, Skaansar O, Skogen K, Helseth E. Characteristics of traumatic brain injury patients with abnormal neuroimaging in Southeast Norway. Inj Epidemiol 2020; 7:45. [PMID: 32867838 PMCID: PMC7461333 DOI: 10.1186/s40621-020-00269-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022] Open
Abstract
Background The vast majority of hospital admitted patients with traumatic brain injury (TBI) will have intracranial injury identified by neuroimaging, requiring qualified staff and hospital beds. Moreover, increased pressure in health care services is expected because of an aging population. Thus, a regular evaluation of characteristics of hospital admitted patients with TBI is needed. Oslo TBI Registry – Neurosurgery prospectively register all patients with TBI identified by neuroimaging admitted to a trauma center for southeast part of Norway. The purpose of this study is to describe this patient population with respect to case load, time of admission, age, comorbidity, injury mechanism, injury characteristics, length of stay, and 30-days survival. Methods Data for 5 years was extracted from Oslo TBI Registry – Neurosurgery. Case load, time of admission, age, sex, comorbidity, injury mechanism, injury characteristics, length of stay, and 30-days survival was compiled and compared. Results From January 1st, 2015 to December 31st, 2019, 2153 consecutive patients with TBI identified by neuroimaging were registered. The admission rate of TBI of all severities has been stable year-round since 2015. Mean age was 52 years (standard deviation 25, range 0–99), and 68% were males. Comorbidities were common; 28% with pre-injury ASA score of ≥3 and 25% used antithrombotic medication. The dominating cause of injury in all ages was falls (55%) but increased with age. Upon admission, the head injury was classified as mild TBI in 46%, moderate in 28%, and severe (Glasgow coma score ≤ 8) in 26%. Case load was stable without seasonal variation. Majority of patients (68%) were admitted during evening, night or weekend. 68% was admitted to intensive care unit. Length of hospital stay was 4 days (median, interquartile range 3–9). 30-day survival for mild, moderate and severe TBI was 98, 94 and 69%, respectively. Conclusions The typical TBI patients admitted to hospital with abnormal neuroimaging were aged 50–79 years, often with significant comorbidity, and admitted outside ordinary working hours. This suggests the necessity for all-hour presence of competent health care professionals.
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Affiliation(s)
- Cathrine Tverdal
- Department of Neurosurgery, Ullevål Hospital, Oslo University Hospital, P. O. Box 4956 Nydalen, N-0424, Oslo, Norway. .,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Mads Aarhus
- Department of Neurosurgery, Ullevål Hospital, Oslo University Hospital, P. O. Box 4956 Nydalen, N-0424, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ola Skaansar
- Department of Neurosurgery, Ullevål Hospital, Oslo University Hospital, P. O. Box 4956 Nydalen, N-0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Karoline Skogen
- Department of Neuroradiology, Oslo University Hospital, Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Ullevål Hospital, Oslo University Hospital, P. O. Box 4956 Nydalen, N-0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Rawanduzy C, McIntyre MK, Afridi A, Honig J, Halabi M, Hehir J, Schmidt M, Cole C, Miller I, Gandhi C, Al-Mufti F, Bowers C. The Effect of Frailty and Patient Comorbidities on Outcomes After Acute Subdural Hemorrhage: A Preliminary Analysis. World Neurosurg 2020; 143:e285-e293. [PMID: 32711137 DOI: 10.1016/j.wneu.2020.07.106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Frailty is associated with worse outcomes across a variety of neurosurgical diseases. However, its effect on acute subdural hemorrhage (aSDH) outcomes is unclear. The goal of this study is to compare 3 measures of frailty with the gold standard (i.e., initial Glasgow Coma Scale [iGCS] score) for predicting outcomes after aSDH. METHODS Patients who presented between January 2016 and June 2018 were retrospectively identified based on International Classification of Diseases codes for aSDH. Patients' modified Frailty Index (mFI), temporalis muscle thickness (TMT), and age-adjusted Charlson Comorbidity Index (CCI) were calculated. Primary end points were death and discharge home. RESULTS Of 167 patients included, the mean age was 63.4 ± 1.9 years, the average CCI was 3.4 ± 0.2, mFI was 1.4 ± 0.1, TMT was 7.1 ± 0.2 mm, and iGCS score was 11.9 ± 0.3. Sixty-nine patients (41.3%) were discharged home and 32 (19.2%) died during hospitalization. In multivariate analysis, decreasing iGCS score (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.74-0.96; P = 0.0112) and midline shift (OR, 1.27; 95% CI, 1.08-1.50; P = 0.0048), but not age or frailty, predicted mortality. In addition to iGCS score (OR, 1.26; 95% CI, 1.10-1.44; P = 0.0011), lower CCI (OR, 0.32; 95% CI, 0.14-0.74; P = 0.0071) and larger TMT (OR, 2.63; 95% CI, 1.16-5.99; P = 0.0210) independently predicted increased rates of discharge home. mFI was not independently associated with either primary end point in multivariate analysis. CONCLUSIONS iGCS score predicts both mortality and discharge location after aSDH better than do age or frailty. However, CCI and TMT, but not mFI, are useful prognostic indicators of discharge to home after aSDH. The iGCS score should continue to be the primary prediction tool for patients with aSDH; however, frailty may be useful for resource allocation, especially when nearing discharge.
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Affiliation(s)
- Cameron Rawanduzy
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | | | - Adil Afridi
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jesse Honig
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Mohamed Halabi
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jacob Hehir
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Meic Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Ivan Miller
- Department of Emergency Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA; Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA.
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Van Essen TA, Volovici V, Cnossen MC, Kolias A, Ceyisakar I, Nieboer D, Peppel LD, Heijenbrok-Kal M, Ribbers G, Menon D, Hutchinson P, Depreitere B, de Ruiter GCW, Lingsma HF, Steyerberg EW, Maas AI, Peul WC. Comparative effectiveness of surgery in traumatic acute subdural and intracerebral haematoma: study protocol for a prospective observational study within CENTER-TBI and Net-QuRe. BMJ Open 2019; 9:e033513. [PMID: 31619435 PMCID: PMC6797419 DOI: 10.1136/bmjopen-2019-033513] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Controversy exists about the optimal treatment for patients with a traumatic acute subdural haematoma (ASDH) and an intracerebral haematoma/contusion (t-ICH). Treatment varies largely between different regions. The effect of this practice variation on patient outcome is unknown. Here, we present the protocol for a prospective multicentre observational study aimed at comparing the effectiveness of different treatment strategies in patients with ASDH and/or t-ICH. Specifically, the aims are to compare (1) an acute surgical approach to an expectant approach and (2) craniotomy to decompressive craniectomy when evacuating the haematoma. METHODS AND ANALYSIS Patients presenting to the emergency room with an ASDH and/or an t-ICH are eligible for inclusion. Standardised prospective data on patient and injury characteristics, treatment and outcome will be collected on 1000 ASDH and 750 t-ICH patients in 60-70 centres within two multicentre prospective observational cohort studies: the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and Neurotraumatology Quality Registry (Net-QuRe). The interventions of interest are acute surgery, defined as surgery directly after the first CT at presentation versus late or no surgery and craniotomy versus decompressive craniectomy. The primary outcome measure is the Glasgow Outcome Score-Extended at 6 months. Secondary outcome measures include in-hospital mortality, quality of life and neuropsychological tests. In the primary analysis, the effect of treatment preference (eg, proportion of patients in which the intervention under study is preferred) per hospital will be analysed with random effects ordinal regression models, adjusted for casemix and stratified by study. Such a hospital-level approach reduces confounding by the indication. Sensitivity analyses will include propensity score matching, with treatment defined on patient level. This study is designed to determine the best acute management strategy for ASDH and t-ICH by exploiting the existing between-hospital variability in surgical management. ETHICS AND DISSEMINATION Ethics approval was obtained in all participating countries. Results of surgical management of ASDH and t-ICH/contusion will separately be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02210221 and NL 5761.
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Affiliation(s)
- Thomas A Van Essen
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Victor Volovici
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Neurosurgery, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Maryse C Cnossen
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Iris Ceyisakar
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Daan Nieboer
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Lianne D Peppel
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, ErasmusMC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Majanka Heijenbrok-Kal
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, ErasmusMC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gerard Ribbers
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, ErasmusMC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
| | - Godard C W de Ruiter
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Hester F Lingsma
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
- Centre for Medical Decision Sciences, Department of Public Health, ErasmusMC - University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Centre and Haaglanden Medical Centre, Leiden and The Hague, The Netherlands
| | - Andrew I Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco C Peul
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden and The Hague, The Netherlands
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Operative versus non-operative treatment of traumatic brain injuries in patients 80 years of age or older. Neurosurg Rev 2019; 43:1305-1314. [PMID: 31414197 DOI: 10.1007/s10143-019-01159-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/13/2019] [Accepted: 08/05/2019] [Indexed: 12/25/2022]
Abstract
Traumatic brain injury (TBI) in older adults is an increasing issue in modern medicine. Nevertheless, it remains unclear which patients presenting with TBI and 80 years of age or older benefit from an operative treatment. The aim of this study was to explore the effect of an operative treatment in isolated TBI patients ≥ 80 years of age. Data were derived from the TraumaRegister DGU® from 2002 to 2016. Inclusion criteria were ≥ 80 years of age, an Abbreviated Injury ScaleHead (AIS) ≥ 3, and an AISNon-Head ≤ 1. The cohort was split in operatively and non-operatively treated patients, and outcome was assessed at discharge using the Glasgow Outcome Scale (GOS). A favorable outcome was defined as a GOS of 4 or 5. A total of 1.693 patients (431 operatively and 1.262 non-operatively treated patients) were analyzed. Mortality rate was 54.4% (687 patients) in the non-operative group and 49.4% in the operative group. Simultaneously, there were more patients discharged with a GOS 2 (persistent vegetative state) in the operative group (7.9%, 34 patients) than in the non-operative group (1.0%, 13 patients). An analysis of the operatively treated patients showed an association between a higher mortality risk and brainstem hemorrhage (p = 0.04), fixed pupils (p = 0.001), initial intubation (p = 0.03), and an AISHead of 5/6 (p = 0.03). Patients 80 years of age or older seem to benefit from an operative treatment regarding mortality rate. However, there has been a higher rate of a poor neurological outcome particularly with regard to persistent vegetative state in the operative treatment group at discharge.
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