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Trevisi G, Scerrati A, Rustemi O, Ricciardi L, Raneri F, Tomatis A, Piazza A, Auricchio AM, Stifano V, Dughiero M, DE Bonis P, Mangiola A, Sturiale CL. The role of the craniotomy size in the surgical evacuation of acute subdural hematomas in elderly patients: a retrospective multicentric study. J Neurosurg Sci 2024; 68:403-411. [PMID: 35380204 DOI: 10.23736/s0390-5616.22.05648-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Elderly patients operated for an acute subdural hematoma (ASDH) frequently have a poor outcome, with a high frequency of death, vegetative status, or severe disability (Glasgow Outcome Score [GOS] 1-3). Minicraniotomy has been proposed as a minimally invasive surgical treatment to reduce the impact of surgery in the elderly population. The present study aimed to compare the influence of the size of the craniotomy on the functional outcome in patients undergoing surgical treatment for ASDH. METHODS We selected patients ≥70 years old admitted to 5 Italian tertiary referral neurosurgical for the treatment of a post-traumatic ASDH between January 1, 2016, and December 31, 2019. We collected demographic data, clinical data (GCS, GOS, Charlson Comorbidity Index [CCI], antiplatelet/anticoagulant therapy, neurological deficits, seizure, pupillary size, length of stay), surgical data (craniotomy size, dividing the patients into 3 groups based on the corresponding tertile, and surgery duration), radiological data (ASDH side and thickness, midline shift, other post-traumatic lesions, extent of ASDH evacuation) and we assessed the functional outcome at hospital discharge and 6-month follow-up considering GOS=1-3 as a poor outcome. ANOVA and χ2 Tests and logistic regression models were used to assess differences in and associations between clinical-radiological characteristics and functional outcomes. RESULTS We included 136 patients (76 males) with a mean age of 78±6 years. Forty-five patients underwent a small craniotomy, 47 a medium size, and 44 a large craniotomy. Among the different craniotomy size groups, there were no differences in gender, anticoagulant/antithrombotic therapy, CCI, side of ASDH, ASDH thickness, preoperative GCS, focal deficits, seizures, and presence of other post-traumatic lesions. Patients undergoing small craniotomies were older than patients undergoing medium-large craniotomies; ASDH treated with medium size craniotomy were thinner than the others; patients undergoing large craniotomies showed greater midline shift and a higher rate of anisocoria. The three groups did not differ for functional outcome and postoperative midline shift, but the length of surgery and the rate of >50% of ASDH evacuation were lower in the small craniotomy group. CONCLUSIONS A small craniotomy was not inferior to larger craniotomies in determining functional outcomes in the treatment of ASDH in the elderly.
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Affiliation(s)
| | - Alba Scerrati
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Oriela Rustemi
- Unit of Neurosurgery1, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Luca Ricciardi
- Unit of Neurosurgery, NESMOS Department, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Fabio Raneri
- Unit of Neurosurgery1, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Alberto Tomatis
- Unit of Neurosurgery, Santo Spirito Hospital, Pescara, Italy
| | - Amedeo Piazza
- Unit of Neurosurgery, NESMOS Department, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Anna M Auricchio
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vito Stifano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michele Dughiero
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Pasquale DE Bonis
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Annunziato Mangiola
- Unit of Neurosurgery, Santo Spirito Hospital, Pescara, Italy
- Department of Neurosciences, Imaging and Clinical Sciences, G. D'Annunzio University, Chieti, Italy
| | - Carmelo L Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy -
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Courville EN, Owodunni OP, Courville JT, Kazim SF, Kassicieh AJ, Hynes AM, Schmidt MH, Bowers CA. Frailty Is Associated With Decreased Survival in Adult Patients With Nonoperative and Operative Traumatic Subdural Hemorrhage: A Retrospective Cohort Study of 381,754 Patients. ANNALS OF SURGERY OPEN 2023; 4:e348. [PMID: 38144491 PMCID: PMC10735122 DOI: 10.1097/as9.0000000000000348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/06/2023] [Indexed: 12/26/2023] Open
Abstract
Objective We investigated frailty's impact on traumatic subdural hematoma (tSDH), examining its relationship with major complications, length of hospital stay (LOS), mortality, high level of care discharges, and survival probabilities following nonoperative and operative management. Background Despite its frequency as a neurosurgical emergency, frailty's impact on tSDH remains underexplored. Frailty characterized by multisystem impairments significantly predicts poor outcomes, necessitating further investigation. Methods A retrospective study examining tSDH patients ≥18 years and assigned an abbreviated injury scale score ≥3, and entered into ACS-TQIP between 2007 and 2020. We employed multivariable analyses for risk-adjusted associations of frailty and our outcomes, and Kaplan-Meier plots for survival probability. Results Overall, 381,754 tSDH patients were identified by mFI-5 as robust-39.8%, normal-32.5%, frail-20.5%, and very frail-7.2%. There were 340,096 nonoperative and 41,658 operative patients. The median age was 70.0 (54.0-81.0) nonoperative, and 71.0 (57.0-80.0) operative cohorts. Cohorts were predominately male and White. Multivariable analyses showed a stepwise relationship with all outcomes P < 0.001; 7.1% nonoperative and 14.9% operative patients had an 20% to 46% increased risk of mortality, that is, nonoperative: very frail (HR: 1.20 [95% CI: 1.13-1.26]), and operative: very frail (HR: 1.46 [95% CI: 1.38-1.55]). There were precipitous reductions in survival probability across mFI-5 strata. Conclusion Frailty was associated with major complications, LOS, mortality, and high level care discharges in a nationwide population of 381,754 patients. While timely surgery may be required for patients with tSDH, rapid deployment of point-of-care risk assessment for frailty creates an opportunity to equip physicians in allocating resources more precisely, possibly leading to better outcomes.
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Affiliation(s)
- Evan N. Courville
- From the Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM
| | - Oluwafemi P. Owodunni
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM
| | - Jordyn T. Courville
- Louisiana State University Health and Sciences Center School of Medicine, Shreveport, Louisiana, US; University of New Mexico School of Medicine, Albuquerque, NM
| | - Syed F. Kazim
- From the Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM
| | - Alexander J. Kassicieh
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM
- Louisiana State University Health and Sciences Center School of Medicine, Shreveport, Louisiana, US; University of New Mexico School of Medicine, Albuquerque, NM
| | - Allyson M. Hynes
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM
- Division of Critical Care, Department of Surgery, University of New Mexico Hospital, Albuquerque, NM
| | - Meic H. Schmidt
- From the Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM
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Aziz N, O'Halloran PJ, McKenna GS. Subdural haematoma in the elderly: management and outcomes of a UK Major Trauma Centre. Br J Neurosurg 2023; 37:1604-1612. [PMID: 36218868 DOI: 10.1080/02688697.2022.2122402] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/04/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND An estimated 40% of all traumatic brain injury (TBI) occurs in ≥70-year-olds with a high prevalence of traumatic subdural haematoma (tSDH). It is anticipated that an expanding elderly population will lead to a proportional increase in the incidence of patients with tSDH presenting to UK trauma centres, but the long-term clinical outcomes and factors influencing functional outcomes in this patient group remain poorly understood. AIM To examine the management and clinical outcomes for elderly (≥70 years) patients diagnosed with tSDH. METHODS Patient data for this single-centre, retrospective cohort study were analysed from a Major Trauma Centre (MTC) electronic patient records between January 2013 and December 2019. RESULTS Two hundred and eighty patients were included, 43% aged 70-79, 42% aged 80-89 and 15% >90. In total, 37% underwent a surgical intervention. The 6-month survival in the severe, moderate, and mild TBI groups was 14%, 43%, and 67%, respectively. The 6-month survival in the surgical group was 58%, vs. 60% in the conservatively managed group. Surgical intervention did not significantly impact Extended Glasgow Coma Score (GOS-E) at 6 months, regardless of injury severity. Advanced age (p = 0.04), mixed intracranial injuries (p < 0.0001), craniotomies (p = 0.03), and poor premorbid performance status (p = 0.02) were associated with worse survival and functional outcomes. CONCLUSIONS Our study demonstrated that increasing age, increasing severity of TBI and poorer premorbid performance status were associated with significantly poorer 6-month survival and functional outcomes in elderly patients with tSDH. Burr hole evacuation was associated with better functional outcomes compared to craniotomy, but overall, there was no significant difference in the outcomes of the surgical and non-surgical groups. We identified strong risk factors for death and poor functional outcomes at 6-months which are important to consider when counselling patients and families about the long-term prognosis of elderly patients with tSDH and can help guide clinical decision-making.
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Affiliation(s)
- Natasha Aziz
- School of Medicine, Queen Mary University of London, London, UK
| | - Philip J O'Halloran
- Department of Neurosurgery, Royal London Hospital, London, UK
- Department of Physiology & Medical Physics, Royal College of Surgeons in Ireland, London, UK
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Beucler N, Bonnet J, Dagain A. How I do it: simplified craniotomy for acute subdural hematoma in the elderly. Acta Neurochir (Wien) 2023; 165:3181-3185. [PMID: 37707593 DOI: 10.1007/s00701-023-05800-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/03/2023] [Indexed: 09/15/2023]
Abstract
CONTEXT Acute subdural hematoma (ASH) is responsible for significant morbidity and mortality in the elderly. As military neurosurgeons, we perform a simplified technique using a linear skin incision and a small craniotomy bone flap in order to ease perioperative tolerance. METHODS The patient lies supine, a pad under the shoulder ipsilateral to the ASH, the head completely rotated on the other side and placed on a circular pad, without head clamp. The linear frontotemporal skin incision should be twice the size of the bone flap's diameter, allowing to access the whole subdural space. Care is taken to obtain complete decompression of the temporal fossa in order to alleviate uncal herniation. A subdural drain can be placed, and the subdural space is filled with warm saline solution in order to create a closed drainage system. CONCLUSION The patient is allowed to sit at postoperative day 1 and to walk at postoperative day 2. Simplified craniotomy for ASH allows to reduce operative time and provides faster functional recovery.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery department, Sainte-Anne Military Teaching Hospital, 2 boulevard Sainte-Anne, 83800, Toulon Cedex 9, France.
- Ecole du Val-de-Grâce, French Military health Service Academy, 1 place Alphonse Laveran, 75230, Paris Cedex 5, France.
| | - Jeanne Bonnet
- Operating theatre (OR nurse), Sainte-Anne Military Teaching Hospital, 2 boulevard Sainte-Anne, 83800, Toulon Cedex 9, France
| | - Arnaud Dagain
- Neurosurgery department, Sainte-Anne Military Teaching Hospital, 2 boulevard Sainte-Anne, 83800, Toulon Cedex 9, France
- Val-de-Grâce Military Academy, 1 place Alphonse Laveran, 75230, Paris Cedex 5, France
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Beucler N. Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article. Asian J Neurosurg 2023; 18:454-467. [PMID: 38152528 PMCID: PMC10749853 DOI: 10.1055/s-0043-1772763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
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Does the Timing of the Surgery Have a Major Role in Influencing the Outcome in Elders with Acute Subdural Hematomas? J Pers Med 2022; 12:jpm12101612. [PMID: 36294751 PMCID: PMC9604688 DOI: 10.3390/jpm12101612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Beucler N, Cungi PJ, Baucher G, Coze S, Dagain A, Roche PH. The Kernohan-Woltman Notch Phenomenon : A Systematic Review of Clinical and Radiologic Presentation, Surgical Management, and Functional Prognosis. J Korean Neurosurg Soc 2022; 65:652-664. [PMID: 35574584 PMCID: PMC9452377 DOI: 10.3340/jkns.2022.0002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/26/2022] [Indexed: 11/27/2022] Open
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Kerezoudis P, Puffer RC, Parney IF. Letter: The Morbidity and Mortality of Surgery for Traumatic Brain Injury in Geriatric Patients: A Study of Over 100 000 Patient Cases. Neurosurgery 2022; 91:e20-e21. [PMID: 35482321 DOI: 10.1227/neu.0000000000002008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/10/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Ross C Puffer
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Ian F Parney
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
PURPOSE OF REVIEW To highlight recent findings on the evaluation and impact of frailty in the management of patients with traumatic brain injury (TBI). RECENT FINDINGS Frailty is not a direct natural consequence of aging. Rather, it commonly results from the intersection of age-related decline with chronic diseases and conditions. It is associated with adverse outcomes such as institutionalization, falls, and worsening health status. Growing evidence suggests that frailty should be a key consideration both in care planning and in adverse outcome prevention. The prevalence of elderly patients with TBI is increasing, and low-energy trauma (i.e., ground or low-level falls, which are typical in frail patients) is the major cause. Establishing the real incidence of frailty in TBI requires further studies. Failure to detect frailty potentially exposes patients to interventions that may not benefit them, and may even harm them. Moreover, considering patients as 'nonfrail' purely on the basis of their age is unacceptable. The future challenge is to shift to a new clinical paradigm characterized by more appropriate, goal-directed care of frail patients. SUMMARY The current review highlights the crucial importance of frailty evaluation in TBI, also given the changing epidemiology of this condition. To ensure adequate assessment, prevention and management, both in and outside hospital, there is an urgent need for a valid screening tool and a specific frailty-based and comorbidity-based clinical approach.
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Nevalainen N, Luoto TM, Iverson GL, Mattila VM, Huttunen TT. Craniotomies following acute traumatic brain injury in Finland-a national study between 1997 and 2018. Acta Neurochir (Wien) 2022; 164:625-633. [PMID: 35119493 PMCID: PMC8913452 DOI: 10.1007/s00701-022-05140-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/24/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Nea Nevalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Teemu M. Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Grant L. Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, USA
- Spaulding Rehabilitation Hospital and Spaulding Research Institute, Boston, USA
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA USA
| | - Ville M. Mattila
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Division of Orthopaedics and Traumatology, Department of Trauma, Musculoskeletal Surgery and Rehabilitation, Tampere University Hospital, Tampere, Finland
- Coxa Joint Replacement Hospital, Tampere, Finland
| | - Tuomas T. Huttunen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Cardio-Thoracic Surgery, Tampere Heart Hospital, Tampere University Hospital, Tampere, Finland
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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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McCook O, Scheuerle A, Denoix N, Kapapa T, Radermacher P, Merz T. Localization of the hydrogen sulfide and oxytocin systems at the depth of the sulci in a porcine model of acute subdural hematoma. Neural Regen Res 2021; 16:2376-2382. [PMID: 33907009 PMCID: PMC8374554 DOI: 10.4103/1673-5374.313018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/17/2020] [Accepted: 12/10/2020] [Indexed: 11/24/2022] Open
Abstract
In the porcine model discussed in this review, the acute subdural hematoma was induced by subdural injection of autologous blood over the left parietal cortex, which led to a transient elevation of the intracerebral pressure, measured by bilateral neuromonitoring. The hematoma-induced brain injury was associated with albumin extravasation, oxidative stress, reactive astrogliosis and microglial activation in the ipsilateral hemisphere. Further proteins and injury markers were validated to be used for immunohistochemistry of porcine brain tissue. The cerebral expression patterns of oxytocin, oxytocin receptor, cystathionine-γ-lyase and cystathionine-β-synthase were particularly interesting: these four proteins all co-localized at the base of the sulci, where pressure-induced brain injury elicits maximum stress. In this context, the pig is a very relevant translational model in contrast to the rodent brain. The structure of the porcine brain is very similar to the human: the presence of gyri and sulci (gyrencephalic brain), white matter to grey matter proportion and tentorium cerebelli. Thus, pressure-induced injury in the porcine brain, unlike in the rodent brain, is reflective of the human pathophysiology.
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Affiliation(s)
- Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Angelika Scheuerle
- Department of Neuropathology, Ulm University Medical Center, Günzburg, Germany
| | - Nicole Denoix
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
- Clinic for Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, Ulm, Germany
| | - Thomas Kapapa
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
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Superiority of craniotomy over supportive care for octogenarians and nonagenarians in operable acute traumatic subdural hematoma. Clin Neurol Neurosurg 2021; 212:107069. [PMID: 34844161 DOI: 10.1016/j.clineuro.2021.107069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 12/30/2022]
Abstract
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.
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A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score. Neurosurg Rev 2021; 45:701-708. [PMID: 34231088 PMCID: PMC8827338 DOI: 10.1007/s10143-021-01586-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/05/2021] [Accepted: 06/14/2021] [Indexed: 10/27/2022]
Abstract
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.
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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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de Souza MR, Fagundes CF, Solla DJF, da Silva GCL, Barreto RB, Teixeira MJ, Oliveira de Amorim RL, Kolias AG, Godoy D, Paiva WS. Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma. Trauma Surg Acute Care Open 2021; 6:e000707. [PMID: 34104799 PMCID: PMC8144027 DOI: 10.1136/tsaco-2021-000707] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/05/2021] [Accepted: 04/11/2021] [Indexed: 11/08/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Davi Jorge Fontoura Solla
- Department of Neurology, University of São Paulo, São Paulo, Brazil.,Department of Neurology, University of Cambridge, Cambridge, UK
| | | | | | | | | | - Angelos G Kolias
- Department of Clinical Neuroscience - Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Daniel Godoy
- Intensive Care Unit, San Juan Bautista Hospital, San Fernando del Valle de Catamarca, Argentina
| | - Wellingson Silva Paiva
- Department of Neurology, University of São Paulo, São Paulo, Brazil.,Department of Neurology, University of Cambridge, Cambridge, UK
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Pastor IS, Dumbravă LP, Siserman C, Stan H, Para I, Florian IȘ. Predictive factors of 30-day mortality in patients with traumatic subdural hematoma. Exp Ther Med 2021; 22:757. [PMID: 34035854 DOI: 10.3892/etm.2021.10189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/19/2021] [Indexed: 11/05/2022] Open
Abstract
In the present study, we aimed to assess and analyze the predictive factors of 30-day mortality in patients with acute subdural hematoma (ASDH) who underwent surgical intervention after traumatic brain injury (TBI). We conducted a retrospective study, which included a cohort of 135 consecutive patients diagnosed with ASDH who required surgical evacuation. We assessed the demographic and clinical data, the imaging data of the hematoma described by preoperative computed tomography (CT) and the type of neurosurgical intervention for hematoma evacuation via either craniectomy or craniotomy. The patients were followed up for 30 days after head trauma and the occurrence of death was noted. Death was recorded in 63 (46.6%) patients at 30 days after TBI. There was a significant number of deceased patients who underwent craniectomy (71.4%). The Glasgow Coma Scale (GCS) was statistically significantly lower in patients who died (P<0.001), with a cut-off value of ≤12, under which the probability of death increased [AUC 0.830 (95% CI, 0.756-0.889); Se 90.48% (95% CI, 80.4-96.4); Sp 66.7% (95% CI, 54.6-77.3); P<0.001]. The midline shift was statistically significantly higher in deceased patients (P=0.005), with a cut-off value of >7 mm, over which the probability of death increased [AUC 0.637 (95% CI, 0.550-0.718); Se 38.1% (95% CI, 26.1-51.2); Sp 86.1% (95% CI, 75.9-93.1); P=0.003]. There were significantly more deceased patients with intracranial hypertension, brain herniation, brain swelling, intraparenchymal hematoma and cranial fracture. In multivariate analysis only a Glasgow score ≤12 and a midline shift >7 mm were independently linked to mortality. Brain herniation and intraparenchymal hematoma were associated with a higher probability of dying, but the statistical threshold was slightly exceeded. The type of neurosurgery performed for patients with ASDH was not an independent predictive factor for 30-day mortality. However, craniectomy was associated with a higher mortality in patients with ASDH.
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Affiliation(s)
- Iulia-Sevastiana Pastor
- Department of Neurosurgery, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Lăcrimioara Perju Dumbravă
- First Department of Neurology, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Costel Siserman
- Department of Legal Medicine, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Horațiu Stan
- Department of Neurosurgery, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Ioana Para
- Department of Internal Medicine, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Ioan Ștefan Florian
- Department of Neurosurgery, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Aromatario M, Torsello A, D’Errico S, Bertozzi G, Sessa F, Cipolloni L, Baldari B. Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57020125. [PMID: 33535407 PMCID: PMC7912597 DOI: 10.3390/medicina57020125] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 04/09/2023]
Abstract
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.
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Affiliation(s)
| | - Alessandra Torsello
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Stefano D’Errico
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Giuseppe Bertozzi
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
- Correspondence:
| | - Francesco Sessa
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Luigi Cipolloni
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Benedetta Baldari
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00186 Rome, Italy;
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19
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Lee H, Tan C, Tran V, Mathew J, Fitzgerald M, Leong R, Kambourakis T, Gantner D, Udy A, Hunn M, Rosenfeld JV, Tee J. The Utility of the Modified Frailty Index in Outcome Prediction for Elderly Patients with Acute Traumatic Subdural Hematoma. J Neurotrauma 2020; 37:2499-2506. [DOI: 10.1089/neu.2019.6943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Hui Lee
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
| | - Caleb Tan
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
| | - Vanessa Tran
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
| | - Joseph Mathew
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Trauma Services, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Trauma Services, Alfred Health, Melbourne, Victoria, Australia
| | - Ronald Leong
- Aged Care Services, Alfred Health, Melbourne, Victoria, Australia
| | | | - Dashiell Gantner
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Martin Hunn
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey V. Rosenfeld
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jin Tee
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
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20
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Trevisi G, Sturiale CL, Scerrati A, Rustemi O, Ricciardi L, Raneri F, Tomatis A, Piazza A, Auricchio AM, Stifano V, Romano C, De Bonis P, Mangiola A. Acute subdural hematoma in the elderly: outcome analysis in a retrospective multicentric series of 213 patients. Neurosurg Focus 2020; 49:E21. [DOI: 10.3171/2020.7.focus20437] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe 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.METHODSThe 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.RESULTSOverall, 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.CONCLUSIONSTraumatic 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.
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Affiliation(s)
| | - Carmelo Lucio Sturiale
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Alba Scerrati
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
- 4Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Oriela Rustemi
- 5UOC Neurochirurgia 1, Azienda ULSS 8 Berica Ospedale San Bortolo, Vicenza
| | - Luca Ricciardi
- 6UOC di Neurochirurgia, Azienda Ospedaliera Sant’Andrea, Dipartimento NESMOS, Sapienza-Roma; and
| | - Fabio Raneri
- 5UOC Neurochirurgia 1, Azienda ULSS 8 Berica Ospedale San Bortolo, Vicenza
| | | | - Amedeo Piazza
- 6UOC di Neurochirurgia, Azienda Ospedaliera Sant’Andrea, Dipartimento NESMOS, Sapienza-Roma; and
| | - Anna Maria Auricchio
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Vito Stifano
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Carmine Romano
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
| | - Pasquale De Bonis
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
- 4Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Annunziato Mangiola
- 1Neurosurgical Unit, Ospedale Santo Spirito, Pescara
- 7Department of Neurosciences, Imaging and Clinical Sciences, “G. D’Annunzio” University, Chieti, Italy
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21
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Kerezoudis P, Goyal A, Puffer RC, Parney IF, Meyer FB, Bydon M. Morbidity and mortality in elderly patients undergoing evacuation of acute traumatic subdural hematoma. Neurosurg Focus 2020; 49:E22. [DOI: 10.3171/2020.7.focus20439] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAcute 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.METHODSThe 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).RESULTSA 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.CONCLUSIONSThe 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.
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Affiliation(s)
- Panagiotis Kerezoudis
- 1Department of Neurologic Surgery, Mayo Clinic; and
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Anshit Goyal
- 1Department of Neurologic Surgery, Mayo Clinic; and
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Mohamad Bydon
- 1Department of Neurologic Surgery, Mayo Clinic; and
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
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Katsuki M, Kakizawa Y, Nishikawa A, Kunitoki K, Yamamoto Y, Wada N, Uchiyama T. Fifteen Cases of Endoscopic Treatment of Acute Subdural Hematoma with Small Craniotomy under Local Anesthesia: Endoscopic Hematoma Removal Reduces the Intraoperative Bleeding Amount and the Operative Time Compared with Craniotomy in Patients Aged 70 or Older. Neurol Med Chir (Tokyo) 2020; 60:439-449. [PMID: 32801274 PMCID: PMC7490600 DOI: 10.2176/nmc.oa.2020-0071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We report cases of acute subdural hematoma (ASDH) treated by endoscopic hematoma removal with a small craniotomy under local anesthesia. From 2015 to 2019, we retrospectively analyzed 15 ASDH patients who were 70 years or older and met our criteria for endoscopic treatment: (1) comorbidities indicated risks associated with a large craniotomy under general anesthesia; (2) decompressive craniectomy was unlikely; and (3) an enlarging hematoma was absent. We also performed a case–control study using the inverse probability weighting method to compare the 15 patients to 20 ASDH patients who were 70 years or older, met criteria (2) and (3), and were treated by craniotomy between 2012 and 2019. Among the 15 ASDH patients, the median age was 86 (range, 70–101) years, and fall was the common cause. The median Glasgow Coma Scale score on admission, operative time, stay time in the operation room, and bleeding amount were 8 (6–15), 91 (48–156) min, 120 (80–205) min, and 20 (5–400) mL, respectively. The extraction rates of all the hematomas exceeded 90%. No patients required conversion to craniotomy under general anesthesia. Three patients had favorable outcomes, and five died. The comparison with craniotomy revealed that the endoscopic procedure reduced the intraoperative bleeding amount, operative time, and stay time in the operation room (p <0.001, p = 0.02, and p <0.001, respectively). In summary, endoscopic hematoma removal for selected ASDH patients aged 70 years or older did not improve functional outcomes but reduced the bleeding amount and the operative time compared with craniotomy.
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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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Younsi A, Fischer J, Habel C, Riemann L, Scherer M, Unterberg A, Zweckberger K. Mortality and functional outcome after surgical evacuation of traumatic acute subdural hematomas in octa- and nonagenarians. Eur J Trauma Emerg Surg 2020; 47:1499-1510. [PMID: 32594213 PMCID: PMC8476355 DOI: 10.1007/s00068-020-01419-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/15/2020] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Alexander Younsi
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, INF 400, 69120, Heidelberg, Germany.
| | - Jessica Fischer
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Cleo Habel
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Lennart Riemann
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Moritz Scherer
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, INF 400, 69120, Heidelberg, Germany
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25
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Hiraizumi S, Shiomi N, Echigo T, Oka H, Hino A, Baba M, Hitosugi M. Factors Associated with Poor Outcomes in Patients with Mild or Moderate Acute Subdural Hematomas. Neurol Med Chir (Tokyo) 2020; 60:402-410. [PMID: 32565532 PMCID: PMC7431873 DOI: 10.2176/nmc.oa.2020-0030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Shiho Hiraizumi
- Emergency and Critical Care Medicine, Saiseikai Shiga Hospital.,Department of Legal Medicine, Shiga University of Medical Science
| | - Naoto Shiomi
- Emergency and Critical Care Medicine, Saiseikai Shiga Hospital
| | - Tadashi Echigo
- Emergency and Critical Care Medicine, Saiseikai Shiga Hospital
| | - Hideki Oka
- Department of Neurosurgery, Saiseikai Shiga Hospital
| | - Akihiko Hino
- Department of Neurosurgery, Saiseikai Shiga Hospital
| | - Mineko Baba
- Center for Integrated Medical Research, Keio University School of Medicine
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26
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The changing face of neurosurgery for the older person. J Neurol 2020; 267:2469-2474. [PMID: 32335794 PMCID: PMC7223995 DOI: 10.1007/s00415-020-09854-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 11/30/2022]
Abstract
Increased life expectancy and illness prevention and treatment have led to a growing population of older patients. These changes in patient population are apparent in neurosurgery; however, relatively little is reported about specific outcomes and prognostication in this group. This review summarises the challenges and management changes occurring in the treatment of three common neurosurgical pathologies; aneurysmal subarachnoid haemorrhage, head injury, and haemorrhagic stroke. A move towards less invasive neurosurgical techniques has implications on the risk–benefit profile of interventions. This creates the opportunity to intervene in older patients with greater co-morbidity, as long as improved outcomes can be evidenced. A critical part of assessing appropriateness for surgical intervention in older patients may be to change from a mindset of age to one of frailty and growing interest in scales assessing this may aid treatment decisions in the future.
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27
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Choi MS, Jeong D, You N, Roh TH, Kim SH. Identification of clinical characteristics and factors predicting favorable treatment outcomes in elderly patients with traumatic brain injury. J Clin Neurosci 2019; 69:61-66. [PMID: 31451377 DOI: 10.1016/j.jocn.2019.08.035] [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: 05/30/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Mi Sun Choi
- Department of Neurosurgery, Inje University Seoul Paik Hospital, 9 Mareunnae-ro, Jung-gu, Seoul 04551, Republic of Korea
| | - Donghwan Jeong
- Department of Neurosurgery, Hallym University Medical Center, 7 Keunjaebong-gil, Hwaseong-si, Gyeonggi-do 18450, Republic of Korea
| | - Namkyu You
- Department of Neurosurgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon 16499, Republic of Korea
| | - Tae Hoon Roh
- Department of Neurosurgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon 16499, Republic of Korea
| | - Se-Hyuk Kim
- Department of Neurosurgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon 16499, Republic of Korea.
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28
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Bobeff EJ, Fortuniak J, Bryszewski B, Wiśniewski K, Bryl M, Kwiecień K, Stawiski K, Jaskólski DJ. Mortality After Traumatic Brain Injury in Elderly Patients: A New Scoring System. World Neurosurg 2019; 128:e129-e147. [PMID: 30981800 DOI: 10.1016/j.wneu.2019.04.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/05/2019] [Accepted: 04/06/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) remains a life-threatening condition characterized by growing incidence worldwide, particularly in the aging population, in which the primary goal of treatment appears to be avoidance of chronic institutionalization. METHODS To identify independent predictors of 30-day mortality or vegetative state in a geriatric population and calculate an intuitive scoring system, we screened 480 patients after TBI treated at a single department of neurosurgery over a 2-year period. We analyzed data of 214 consecutive patients aged ≥65 years, including demographics, medical history, cause and time of injury, neurologic state, radiologic reports, and laboratory results. A predictive model was developed using logistic regression modeling with a backward stepwise feature selection. RESULTS The median Glasgow Coma Scale (GCS) score on admission was 14 (interquartile range, 12-15), whereas the 30-day mortality or vegetative state rate amounted to 23.4%. Starting with 20 predefined features, the final prediction model highlighted the importance of GCS motor score (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.09-0.32); presence of comorbid cardiac, pulmonary, or renal dysfunction or malignancy (OR, 2.86; 9 5% CI, 1.08-7.61); platelets ≤100 × 109 cells/L (OR, 13.60; 95% CI, 3.33-55.49); and red blood cell distribution width coefficient of variation ≥14.5% (OR, 2.91; 95% CI, 1.09-7.78). The discovered coefficients were used for nomogram development. It was further simplified to facilitate clinical use. The proposed scoring system, Elderly Traumatic Brain Injury Score (eTBI Score), yielded similar performance metrics. CONCLUSIONS The eTBI Score is the first scoring system designed specifically for older adults. It could constitute a framework for clinical decision-making and serve as an outcome predictor. Its capability to stratify risk provides reliable criteria for assessing efficacy of TBI management.
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Affiliation(s)
- Ernest J Bobeff
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Jan Fortuniak
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland.
| | - Bartosz Bryszewski
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Karol Wiśniewski
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Maciej Bryl
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Katarzyna Kwiecień
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
| | - Konrad Stawiski
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Dariusz J Jaskólski
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland
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