National trend in prevalence, cost, and discharge disposition after subdural hematoma from 1998–2007*

Extreme-aged patients (≥ 85 years) experience similar outcomes as younger geriatric patients following chronic subdural hematoma evacuation: a matched cohort study

Subdural hematoma (SDH) evacuation represents one of the most frequently performed neurosurgical procedures. Several reports cite a rise in both the age and number of patient's requiring treatment, due in part to an aging population and expanded anticoagulation use. However, limited data and conflicting conclusions exist on extreme-aged geriatric patients (≥ 85 years of age) after undergoing surgery. Patients undergoing SDH evacuation at a tertiary academic medical center between November 2013-December 2021 were retrospectively identified. The study group consisted of patients ≥ 85 years (Group 1) diagnosed with a chronic SDH surgically evacuated. A control group was created matching patients by 70-84 years of age, gender, and anticoagulation use (Group 2). Multiple metrics were evaluated between the two including length-of hospital-stay, tracheostomy/PEG placement, reoperation rate, complications, discharge location, neurological outcome at the time of discharge, and survival. A total of 130 patients were included; 65 in Group 1 and 65 in Group 2. Patient demographics, medical comorbidities, SDH characteristics, international normalized ratio, partial thromboplastin time, and use of blood thinning agents were similar between the two groups. Kaplan Meier survival analysis at one-year was 80% for Group 1 and 76% for Group 2. No significant difference was identified using the log-rank test for equality of survivor functions (p = 0.26). All measured outcomes including GCS at time of discharge, length of stay, rate of reoperations, and neurological outcome were statistically similar between the two groups. Backwards stepwise conditional logistic regression revealed no significant association between poor outcomes at the time of discharge and age. Alternatively, anticoagulation use was found to be associated with poor outcomes (OR 3.55, 95% CI 1.08-11.60; p = 0.036). Several outcome metrics and statistical analyses were used to compare patients ≥ 85 years of age to younger geriatric patients (70-84 years) in a matched cohort study. Adjusting for age group, gender, and anticoagulation use, no significant difference was found between the two groups including neurological outcome at discharge, reoperation rate, and survival.

ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma

ARISE (Aneurysm/AVM/cSDH Roundtable Discussion With Industry and Stroke Experts) organized a one-and-a-half day meeting and workshop and brought together representatives from academia, industry, and government to discuss the most promising approaches to improve outcomes for patients with chronic subdural hematoma (cSDH). The emerging role of middle meningeal artery embolization in clinical practice and the design of current and potential future trials were the primary focuses of discussion. Existing evidence for imaging, indications, agents, and techniques was reviewed, and areas of priority for study and key questions surrounding the development of new and existing treatments for cSDH were identified. Multiple randomized, controlled trials have met their primary efficacy end points, providing high-level evidence that middle meningeal artery embolization is a potent adjunctive therapy to the standard (surgical and nonsurgical) management of neurologically stable cSDH patients in terms of reducing rates of disease recurrence. Pooled data analyses following the formal conclusion and publication of these trials will form a robust foundation upon which guidelines can be strengthened for cSDH treatment modalities and optimal patient selection, as well as delineate future lines of investigation.

Cerebral Amyloid Angiopathy and Risk of Isolated Nontraumatic Subdural Hemorrhage

Importance

Cerebral amyloid angiopathy (CAA) is a common cause of spontaneous intracerebral hemorrhage in older patients. Although other types of intracranial hemorrhage can occur in conjunction with CAA-related intracerebral hemorrhage, the association between CAA and other subtypes of intracranial hemorrhage, particularly in the absence of intracerebral hemorrhage, remains poorly understood.

Objective

To determine whether CAA is an independent risk factor for isolated nontraumatic subdural hemorrhage (SDH).

Design, Setting, and Participants

A population-based cohort study was performed using a 2-stage analysis of prospectively collected data in the UK Biobank cohort (discovery phase, 2006-2022) and the All of Us Research Program cohort (replication phase, 2018-2022). Participants included those who contributed at least 1 year of data while they were older than 50 years, in accordance with the diagnostic criteria for CAA. Participants with prevalent intracranial hemorrhage were excluded. Data were analyzed from October 2022 to October 2023.

Exposure

A diagnosis of CAA, identified using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code.

Main Outcomes and Measures

The outcome was an isolated nontraumatic SDH, identified using ICD-10-CM codes. Two identical analyses were performed separately in the 2 cohorts. First, the risk of SDH in patients with and without CAA was assessed using Cox proportional hazards models, adjusting for demographic characteristics, cardiovascular comorbidities, and antithrombotic medication use. Second, multivariable logistic regression was used to study the association between CAA and SDH.

Results

The final analytical sample comprised 487 223 of the total 502 480 individuals in the UK Biobank cohort and 158 008 of the total 372 082 individuals in the All of Us cohort. Among the 487 223 participants in the discovery phase of the UK Biobank, the mean (SD) age was 56.5 (8.1) years, and 264 195 (54.2%) were female. There were 649 cases of incident SDH. Of the 126 participants diagnosed with CAA, 3 (2.4%) developed SDH. In adjusted Cox regression analyses, participants with CAA had an increased risk of having an SDH compared with those without CAA (hazard ratio [HR], 8.0; 95% CI, 2.6-24.8). Multivariable logistic regression analysis yielded higher odds of SDH among participants with CAA (odds ratio [OR], 7.6; 95% CI, 1.8-20.4). Among the 158 008 participants in the All of Us cohort, the mean (SD) age was 63.0 (9.5) years, and 89 639 (56.7%) were female. The findings were replicated in All of Us, in which 52 participants had CAA and 320 had an SDH. All of Us participants with CAA had an increased risk of having an SDH compared with those without CAA (HR, 4.9; 95% CI, 1.2-19.8). In adjusted multivariable logistic regression analysis, CAA was associated with higher odds of SDH (OR, 5.2; 95% CI, 0.8-17.6).

Conclusions and Relevance

In 2 large, heterogeneous cohorts, CAA was associated with increased risk of SDH. These findings suggest that CAA may be a novel risk factor for isolated nontraumatic SDH.

Deadliness of Traumatic Subdural Hematomas in the First Quarter of the Year: A Measurement by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP)

Background Traumatic acute subdural hematoma (ASDH) is a surgical emergency and has been associated with high morbidity and mortality. However, it is not known whether mortality from ASDH occurs more frequently in a particular season. Methodology We queried the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) from 2016 to 2019. They were identified in the NSQIP using the International Classification of Diseases (ICD-10) code S06.5 to capture all admissions with a primary diagnosis of traumatic subdural hematoma. Mortality rates were reviewed per season, defined as three consecutive months in the year. Demographics such as age, race, ethnicity, height, and weight were reviewed. Comorbidities such as diabetes, risk factors, including smoking history, and hospitalization characteristics, such as admission year, operation year, and inpatient/outpatient treatment type, were also reviewed. Results A total of 1,656 patients were included in this study. The mean age of all participants was 70.6 years, with 37% (604/1,656) being female. The mortality rate was highest in January, February, and March at 24.5% (104/425, P = 0.045) of admitted patients compared to mortality rates of 18.8% (70/373) in April to June, 18.4% (81/441) in July to September, and 17.5% (73/417) in October to December. Conclusions Mortality is significantly greater during the winter months of January, February, and March among patients with ASDH. Despite better survival rates of ASDH over the past two decades, postoperative mortality rates still remain high.

Acute Traumatic Subdural Hematoma in the Elderly and Associated Factors that May Influence Chronicity

Traumatic acute subdural hematomas (TASDH) is by far the most common traumatic brain injury in adult patients with blunt trauma, who presented to the Emergency Department (ED). One of the serious sequale of TASDH is the development of Chronic Subdural Hematomas (CSD) with associated deterioration in mental status and convulsion.1,2 Studies to identify the risk factors that favors development of chronicity of TASDH are few and inconclusive. As seen in our prior initial study, there were few factors which were common in those who developed chronicity of their TASDH, and we elected to expand our pool of patients to include those admitted between the years of 2015 and 2021 with ATSDH and identify the common factors associated with development of CSD.

Pilot Biomarker Analysis and Decision Tree Algorithm Modeling of Patients with Chronic Subdural Hematomas

The elderly population are at high risk for developing chronic subdural hematoma (cSDH). Surgical evacuation of cSDH is one of the most common procedures performed in neurosurgery. The present study aims to identify potential inflammatory biomarkers associated with its development and recurrence. Patients (>65 years of age) who presented with symptomatic cSDH (≥1 cm thickness or ≥5 mm midline shift [MLS]), requiring surgical intervention, were prospectively enrolled. The collected cSDH fluid was analyzed for inflammatory markers. Computed tomography (CT) scan data included pre-operative cSDH thickness and MLS. Outcome data included Glasgow Outcome Scale-Extended (GOS-E) score at 3, 6, and 12 months post-surgery, as well as cSDH recurrence. A decision tree model was used to determine the predictive power of extracted analytes for MLS, cSDH thickness, and recurrence. This pilot study includes 20 enrolled patients (mean age 77.9 ± 7.4 years and 85% falls). Rate of cSDH recurrence was 42%, with 21% requiring reoperation. Chemokine (C-X-C motif) ligand 9 (CXCL9) concentrations correlated with cSDH thickness (r = 0.975, p = 0.040). Interleukin (IL)-6 and vascular endothelial growth factor (VEGF)-A concentrations correlated with MLS (r = 0.974, p = 0.005; r = 0.472, p = 0.036, respectively). IL-5 concentrations correlated with more favorable GOS-E scores at 3, 6, and 12 months (r = 0.639, p = 0.006; r = 0.727, p = 0.003; r = 0.693, p = 0.026, respectively). Regulated on activation, normal T-cell expressed and secreted (RANTES) concentrations correlated with complete cSDH resolution (r = 0.514, p = 0.021). The decision tree model identified that higher concentrations of CXCL9 were predictive of MLS (risk ratio [RR] = 12.0), higher concentrations of IL-5 were predictive of cSDH thickness (RR = 4.5), and lower concentrations of RANTES were predictive of cSDH recurrence (RR = 2.2). CXCL9, IL-6, VEGF, IL-5, and RANTES are associated with recurrence after surgery and may be potential biomarkers for predicting cSDH recurrence and neurological outcomes.

Length of Stay, Cost, and Outcomes related to Traumatic Subdural Hematoma in inpatient setting in the United States

OBJECTIVE

In the US, the prevalence of traumatic subdural hematoma (TSDH) continues to increase. Using a nationally representative sample of discharge records of patients with TSDH, the study objectives were to estimate trend in number of TSDH cases, surgical management, inpatient cost, length of stay (LOS), mortality rate, and complication rate; and to identify the association of sociodemographic, clinical and hospital characteristics with complications and mortality.

METHOD

We identified patients with a primary diagnosis of TSDH from the National Inpatient Sample (NIS) database from 2010 to 2017. Quarterly and monthly trends were estimated using interrupted time series design. Multivariate logistic regressions measured association between various factors and inpatient death and complications.

RESULTS

Number of cases, mean LOS, rate of complication increased. Proportion of patients undergoing surgery, mean inpatient cost, inpatient mortality decreased. Mean inpatient cost was $23,182.40 and LOS was 6.41 days. Odds of inpatient death and complications increased with injury severity score and comorbid conditions requiring use of anticoagulants. Odds of inpatient death were highest among those ≥85 years old and in south and northeast region.

CONCLUSION

Given the increase in prevalence of TSDH in USA, additional resources should be allocated toward improving patient outcomes and lowering healthcare costs.

Challenges Encountered in Surgical Traumatic Brain Injury Research: A Need for Methodological Improvement of Future Studies

BACKGROUND

Investigating neurosurgical interventions for traumatic brain injury (TBI) involves complex methodological and practical challenges. In the present report, we have provided an overview of the current state of neurosurgical TBI research and discussed the key challenges and possible solutions.

METHODS

The content of our report was based on an extensive literature review and personal knowledge and expert opinions of senior neurosurgeon researchers and epidemiologists.

RESULTS

Current best practice research strategies include randomized controlled trials (RCTs) and comparative effectiveness research. The performance of RCTs has been complicated by the heterogeneity of TBI patient populations with the associated sample size requirements, the traditional eminence-based neurosurgical culture, inadequate research budgets, and the often acutely life-threatening setting of severe TBI. Statistical corrections can mitigate the effects of heterogeneity, and increasing awareness of clinical equipoise and informed consent alternatives can improve trial efficiency. The substantial confounding by indication, which limits the interpretability of observational research, can be circumvented by using an instrumental variable analysis. Traditional TBI outcome measures remain relevant but do not adequately capture the subtleties of well-being, suggesting a need for multidimensional approaches to outcome assessments.

CONCLUSIONS

In settings in which traditional RCTs are difficult to conduct and substantial confounding by indication can be present, observational studies using an instrumental variable analysis and "pragmatic" RCTs are promising alternatives. Embedding TBI research into standard clinical practice should be more frequently considered but will require fundamental modifications to the current health care system. Finally, multimodality outcome assessment will be key to improving future surgical and nonsurgical TBI research.

Impact of Frailty on Morbidity and Mortality in Adult Patients Undergoing Surgical Evacuation of Acute Traumatic Subdural Hematoma

OBJECTIVE

The aim of this study was to determine if baseline frailty was an independent predictor of extended hospital length of stay (LOS), nonroutine discharge, and in-hospital mortality after evacuation of an acute traumatic subdural hematomas (SDH).

METHODS

A retrospective cohort study was performed. All adult patients who underwent surgery for an acute traumatic SDH were identified using the National Trauma Database (NTDB) from the year 2017. Patients were categorized into three cohorts based on the criteria of the 5-item modified frailty index (mFI-5): mFI=0, mFI=1, or mFI=2+. A multivariate logistic regression analysis was used to identify independent predictors of extended LOS, nonroutine discharge, and in-hospital mortality.

RESULTS

Of the 2,620 patients identified, 41.7% were classified as mFI=0, 32.7% as mFI=1, and 25.6% as mFI=2+. Rates of extended LOS and in-hospital mortality did differ significantly between the cohorts, with the mFI=0 cohort most often experiencing a prolonged LOS (mFI=0: 29.41% vs. mFI=1: 19.45% vs. mFI=2+: 19.73%, p<0.001) and in-hospital mortality (mFI=0: 24.66% vs. mFI=1: 18.11% vs. mFI=2+: 21.58%, p=0.002). On multivariate regression analysis, when compared to mFI=0, mFI=2+ [OR: 1.4, p=0.03] predicted extended LOS and non-routine discharge [OR: 1.61, p=0.001].

CONCLUSION

Our study demonstrates that baseline frailty may be an independent predictor of extended LOS and nonroutine discharge, but not in-hospital mortality, in patients undergoing evacuation for an acute traumatic SDH. Further investigations are warranted as they may guide treatment plans and reduce healthcare expenditures for frail patients with SDH.

Heavily T2-Weighted Magnetic Resonance Myelography as a Safe Cerebrospinal Fluid Leakage Detection Modality for Nontraumatic Subdural Hematoma

OBJECTIVE

Nontraumatic subdural hematoma (SDH) is a common disease, and spinal cerebrospinal fluid (CSF) leakage is a possible etiology of unknown significance, which is commonly investigated by several invasive studies. This study demonstrates that heavily T2-weighted magnetic resonance myelography (HT2W-MRM) is a safe and clinically effective imaging modality for detecting CSF leakage in patients with nontraumatic SDH.

METHODS

All patients who underwent HT2W-MRM for nontraumatic SDH workup at our institution were searched and enrolled in this study. Several parameters were measured and analyzed, including patient demographic data, initial modified Rankin Scale (mRS) score upon presentation, SDH bilaterality, hematoma thickness upon presentation, CSF leakage sites, treatment modalities, follow-up hematoma thickness, and follow-up mRS score.

RESULTS

Forty patients were identified, of which 22 (55.0%) had CSF leakage at various spinal locations. Five patients (12.5%) showed no change in mRS score, whereas the remaining (87.5%) showed decreases in follow-up mRS scores. In terms of the overall hematoma thickness, four patients (10.0%) showed increased thickness, two (5.0%) showed no change, 32 (80.0%) showed decreased thickness, and two (5.0%) did not undergo follow-up imaging for hematoma thickness measurement.

CONCLUSION

HT2W-MRM is not only safe but also clinically effective as a primary diagnostic imaging modality to investigate CSF leakage in patients with nontraumatic SDH. Moreover, this study suggests that CSF leakage is a common etiology for nontraumatic SDH, which warrants changes in the diagnosis and treatment strategies.

Role of Brain Natriuretic Peptide in the Prediction of Early Postoperative Seizures Following Surgery for Traumatic Acute Subdural Hematoma: A Prospective Study

INTRODUCTION

Brain natriuretic peptide (BNP) is a reliable biomarker in the acute phase of traumatic brain injury. However, the relationship between BNP and traumatic acute subdural hematoma (aSDH) has not yet been addressed. This study aimed to analyze BNP levels on admission in surgically treated patients and assess their relationship with early postoperative seizures (EPS) and functional outcomes.

METHODS

Patients with unilateral traumatic aSDH who were surgically treated in our department between July 2017 and May 2020 were included in the study. BNP was preoperatively measured. Patients' neurologic condition, radiographic variables on initial cranial computed tomography, sodium serum levels on admission, and occurrence of EPS were prospectively assessed. Functional outcome was assessed using the modified Rankin Scale (mRS) at discharge and follow-up (at 2-3 months). A poor outcome was defined by a mRS score > 3.

RESULTS

EPS occurred in 20 (19.6%) of 102 surgically treated patients in the final cohort on the median day 3. A significant association between EPS and a poor Glasgow Coma Scale score at the 7th postoperative day was found, which in turn independently predicted a poor functional outcome at discharge and follow-up. Nonetheless, EPS were not associated with poor functional outcomes. The multivariate analysis revealed BNP > 95.4 pg/ml (aOR = 5.7, p = 0.003), sodium < 137.5 mmol/l (aOR = 4.6, p = 0.009), and left-sided aSDH (aOR = 4.4, p = 0.020) as independent predictors of EPS.

CONCLUSION

In the early postoperative phase of traumatic aSDH, EPS were associated with worse neurologic conditions, which in turn independently predicted poor outcomes at discharge and follow-up. Although several EPS risk factors have already been elucidated, this study presents BNP as a novel reliable predictor of EPS. Further larger studies are needed to determine whether a more precise estimate of EPS risk using BNP levels can be reached.

Factors Favoring the Development of Chronic Subdural Hematoma After Traumatic Acute Subdural Hematoma in the Elderly

INTRODUCTION

Traumatic acute subdural hematoma (TASDH) is by far the most common traumatic brain injury in elderly patients presented to the emergency department, and a number of those treated conservatively will develop chronic subdural hematoma (CSDH). The factors contributing to chronicity were not well studied in the elderly; therefore, we retrospectively analyzed our elderly patients with acute subdural hematomas to identify the risk factors which might contribute to the development of subsequent CSDH.

METHODS

A retrospective analysis of 254 patients with TASDH admitted between 2012 and 2016 to our level 2 trauma department in a community hospital was collected. Data include age, sex, comorbid conditions, CT findings, anticoagulant therapy, surgical interventions, disposition after discharge, and mortality. Data on those readmitted within the first 2 months with the diagnosis of CSDH were also studied (group A), and compared to those not readmitted (group B). Multiple logistic regression was used to determine the risk factors associated with readmission at P ≤ .05. Institutional review board approval was obtained for this study.

RESULTS

There were 254 patients who were admitted with TASDH, 144 male (56.7%) and 110 female (43.3%), with the mean age of 71.4 (SD ± 19.38) years. Only 37 patients (14.6%) went for surgery in their initial admission. A total of 14 patients (5.6%) were readmitted subsequently with the diagnosis of CSDH within two months of initial discharge (group A). Only four patients (28.5%) were on anticoagulant therapy and these patients went for emergency craniotomy for evacuation of hematoma. All 14 patients had a history of coronary artery disease and hypertension and only 5 (35.7%) were diabetic. Review of head CT on initial admission of those patients revealed 4 patients (28.5%) had multiple lesions and 4 (28.5%) had tentorial/falax bleeding and 4 (28.5%) had a shift. The initial size and thickness of the bleeding was 1.4-5 mm. The adjusted model identified diabetes, race, and initial disposition as significant risk factors (P < .05).

CONCLUSION

Risk associated with the transformation of TASDH to CSDH is difficult to assess in those group of elderly patients because of the small number; however, diabetes, race, and initial disposition to home pointed toward a risk for future development of CSDH and those patients should be followed clinically and radiographically over the next few months after discharge, particularly those on anticoagulant therapy.

Surgical Management of Chronic Subdural Hematoma in Older Adults: A Systematic Review

BACKGROUND

Chronic subdural hematoma (cSDH) is a form of intracranial hemorrhage common in older adults. Optimal treatment remains controversial. We conducted a systematic review to identify surgical thresholds, characterize outcomes, and delineate critical considerations in the surgical management of older adults in order to summarize the evidence supporting the best contemporary management of cSDH.

METHODS

A systematic review exploring surgical management of cSDH among individuals aged 65 years and older was conducting by searching the PubMed, Embase, and Scopus databases for articles in English. Abstracts from articles were read and selected for full-text review according to a priori criteria. Relevant full-text articles were analyzed for bibliographic data, aim, study design, population, interventions, and outcomes.

RESULTS

Of 1473 resultant articles, 21 were included. Surgery rationale was case-by-case for symptomatic patients with cSDH. Surgery was superior to conservative management and promoted equivalent neurologic outcomes and rates of complications. Recurrence and reoperation rates in older adults were similar to younger individuals. Some studies reported higher mortality rates for older adults, while others reported no difference. Anticoagulation or antiplatelet agent use did not seem to be associated with poorer outcomes in older adults.

CONCLUSIONS

Surgery for cSDH in older adults leads to favorable neurologic outcomes without increased risk of overall complications, recurrence, or reoperation compared to younger patients. However, older adults may be at increased risk for mortality after surgery. It is important to determine use of anticoagulant or antiplatelet agents in older adults to optimally manage patients with cSDH.

Influence of Insurance Status on Subdural Hematoma Management- An NTDB Analysis

BACKGROUND

Traumatic brain injury is a major public health concern with a rising incidence in the United States. Prior studies have looked at associations between insurance status and traumatic brain injury, but none have focused specifically on traumatic subdural hematomas (SDH). It is important to evaluate whether insurance and/or other social determinants of health play a role in treatment and outcomes of traumatic SDH.

METHODS

A retrospective analysis of the National Trauma Data Bank was conducted from 2012 to 2016 to look at associations between insurance status and management of SDH with surgery versus intracranial pressure (ICP)/EVD monitoring. Secondary outcomes of interest were emergency department (ED) length of stay (LOS), hospital LOS, ICU admission, ICU LOS, and mortality.

RESULTS

We identified 68,687 adult patients with a single diagnosis of subdural hematoma. Overall, self-pay patients with SDH were younger, predominately male, and more likely to be non-white compared to patients with public or private health insurance.  More specifically, Black/African American SDH patients made up a large percentage of the self-pay category (15.5%; P < 0.001) compared to publicly and privately insured (7.5% and 8.0%, respectively). After adjusting for age, sex, injury severity score (ISS), Glasgow Coma Scale, alcohol intoxication, and trauma center level, publicly insured patients were 1.86 (95% CI 1.36-2.55, P < 0.001) times more likely to undergo a craniotomy or craniectomy compared to self-pay patients. However, insurance status did not appear to impact whether a patient received ICP/EVD monitoring (OR 0.52; 95% CI 0.24-1.18, P = 0.118). There was no statistically significant difference in ED LOS, Hospital LOS, and ICU LOS between insurance categories.

CONCLUSIONS

Publicly insured patients have higher odds of undergoing surgical management for traumatic SDH compared to self-pay patients. Further studies evaluating this association are warranted.

Diffusion-Weighted Imaging Reveals Distinct Patterns of Cytotoxic Edema in Patients with Subdural Hematomas

Subdural hematomas (SDHs) are increasingly common and can cause ischemic brain injury. Previous work has suggested that this is driven largely by vascular compression from herniation, although this work was done before the era of magnetic resonance imaging (MRI). We thus sought to study SDH-related ischemic brain injury by looking at patterns of cytotoxic edema on diffusion-weighted MRI. To do so, we identified all SDH patients at a single institution from 2015 to 2019 who received an MRI within 2 weeks of presentation. We reviewed all MRIs for evidence of restricted diffusion consistent with cytotoxic edema. Cases were excluded if the restricted diffusion could have occurred as a result of alternative etiologies (e.g., cardioembolic stroke or diffuse axonal injury). We identified 450 SDH patients who received an MRI within 2 weeks of presentation. Twenty-nine patients (∼6.5% of all MRIs) had SDH-related cytotoxic edema, which occurred in two distinct patterns. In one pattern (N = 9), patients presented as comatose with severe midline shift and were found to have cytotoxic edema in the vascular territories of the anterior and posterior cerebral artery, consistent with herniation-related vascular compression. In the other pattern (N = 19), patients often presented as awake with less midline shift and developed cytotoxic edema in the cortex adjacent to the SDH outside of typical vascular territories (peri-SDH cytotoxic edema). Both patterns occurred in 1 patient. The peri-SDH cytotoxic edema pattern is a newly described type of secondary injury and may involve direct toxic effects of the SDH, spreading depolarizations, or other mechanisms.

Delayed Treatment of Acute Subdural Hematomas: Retrospective Outcome Analysis of 215 Patients

BACKGROUND: The preferred treatment method for acute subdural hematoma (aSDH) is surgical intervention. AIM: We aimed to show that, regardless of the good results of surgical treatment, conventional delayed treatment might be very useful in some situations and might lead to chronicity of hematoma as well as reduction of surgical intervention scope and reduce risk of anesthesia. It might also give rise to spontaneous resorption of hematoma. METHODS: In the period March 1, 2013–March 1, 2020, we retrospectively examined 215 aSDH patients. The basic result of the outcome analysis was evaluated on the basis of the Glasgow Outcome Scale (GOS) at discharge after 3-month and 6-month follow-up. RESULTS: A total of 215 patients with aSDH and minor or moderate brain injury were examined, while applying conventional delayed treatment, the following results were obtained: large craniotomy was carried out in 123 patients (57.2%) on the 2nd–3rd day of observation, small craniotomy with drainage was applied in 29 patients (13.5%) and spontaneous resorption of subdural hematoma occurred in 63 patients (29.3%). The median score as per the Glasgow Coma Scale at admission to the hospital was 11.4. CONCLUSION: This study showed that conventional delayed treatment applied in patients with aSDH and minor or moderate craniocerebral injury might lead to chronicity and resorption of aSDH. The outcomes as per the GOS scale also showed good data three and 6 months after hospitalization.

Minimally Invasive Endoscopy for Acute Subdural Hematomas: A Report of 3 Cases

BACKGROUND

Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time.

OBJECTIVE

To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study.

METHODS

We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018.

RESULTS

The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3).

CONCLUSION

Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.

Densitometric analysis of brain computed tomography as a new prognostic factor in patients with acute subdural hematoma

OBJECTIVE

Acute subdural hematoma (ASDH) is a major cause of mortality and morbidity after traumatic brain injury (TBI). Surgical evacuation is the mainstay of treatment in patients with altered neurological status or significant mass effect. Nevertheless, concerns regarding surgical indication still persist. Given that clinicians often make therapeutic decisions on the basis of their prognosis assessment, to accurately evaluate the prognosis is of great significance. Unfortunately, there is a lack of specific and reliable prognostic models. In addition, the interdependence of certain well-known predictive variables usually employed to guide surgical decision-making in ASDH has been proven. Because gray matter and white matter are highly susceptible to secondary insults during the early phase after TBI, the authors aimed to assess the extent of these secondary insults with a brain parenchyma densitometric quantitative CT analysis and to evaluate its prognostic capacity.

METHODS

The authors performed a retrospective analysis among their prospectively collected cohort of patients with moderate to severe TBI. Patients with surgically evacuated, isolated, unilateral ASDH admitted between 2010 and 2017 were selected. Thirty-nine patients were included. For each patient, brain parenchyma density in Hounsfield units (HUs) was measured in 10 selected slices from the supratentorial region. In each slice, different regions of interest (ROIs), including and excluding the cortical parenchyma, were defined. The injured hemisphere, the contralateral hemisphere, and the absolute differences between them were analyzed. The outcome was evaluated using the Glasgow Outcome Scale-Extended at 1 year after TBI.

RESULTS

Fifteen patients (38.5%) had a favorable outcome. Collected demographic, clinical, and radiographic data did not show significant differences between favorable and unfavorable outcomes. In contrast, the densitometric analysis demonstrated that greater absolute differences between both hemispheres were associated with poor outcome. These differences were detected along the supratentorial region, but were greater at the high convexity level. Moreover, these HU differences were far more marked at the cortical parenchyma. It was also detected that these differences were more prone to ischemic and/or edematous insults than to hyperemic changes. Age was significantly correlated with the side-to-side HU differences in patients with unfavorable outcome.

CONCLUSIONS

The densitometric analysis is a promising prognostic tool in patients diagnosed with ASDH. The supplementary prognostic information provided by the densitometric analysis should be evaluated in future studies.

Antithrombotic regimens and need for critical care interventions among patients with subdural hematomas

BACKGROUND

Antithrombotic-associated subdural hematomas (SDHs) are increasingly common, and the possibility of clinical deterioration in otherwise stable antithrombotic-associated SDH patients may prompt unnecessary admissions to intensive care units. It is unknown whether all antithrombotic regimens are equally associated with the need for critical care interventions. We sought to compare the frequency of critical care interventions and poor functional outcomes among three cohorts of noncomatose SDH patients: patients on no antithrombotics, patients on anticoagulants, and patients on antiplatelets alone.

METHODS

We performed a retrospective cohort study on all noncomatose SDH patients (Glasgow Coma Scale > 12) presenting to an academic health system in 2018. The three groups of patients were compared in terms of clinical course and functional outcome. Multivariable logistic regression was used to determine predictors of need for critical care interventions and poor functional outcome at hospital discharge.

RESULTS

There were 281 eligible patients presenting with SDHs in 2018, with 126 (45%) patients on no antithrombotics, 106 (38%) patients on antiplatelet medications alone, and 49 (17%) patients on anticoagulants. Significant predictors of critical care interventions were coagulopathy (OR 5.1, P < 0.001), presence of contusions (OR 3, P = 0.007), midline shift (OR 3.4, P = 0.002), and maximum SDH thickness (OR 2.4, P = 0.002). Significant predictors of poor functional outcome were age (OR 1.8, P < 0.001), admission Glasgow Coma Scale score (OR 0.3, P < 0.001), dementia history (OR 4.2, P = 0.001), and coagulopathy (OR 3.5, P = 0.02). Isolated antiplatelet use was not associated with either critical care interventions or functional outcome.

CONCLUSION

Isolated antiplatelet use is not a significant predictor of need for critical care interventions or poor functional outcome among SDH patients and should not be used as a criterion for triage to the intensive care unit.

Spreading depolarization may represent a novel mechanism for delayed fluctuating neurological deficit after chronic subdural hematoma evacuation

OBJECTIVE

Most patients with chronic subdural hematoma (cSDH) recover after surgical evacuation with a straightforward course. There is a subset of patients who develop transient and fluctuating deficits not explained by seizures, stroke, or mass effect after evacuation. The objective of this study was to investigate whether these postoperative neurological deficits may be related to temporary brain dysfunction caused by cortical spreading depolarizations (SDs).

METHODS

The authors conducted a prospective observational study of 40 patients who underwent cSDH evacuation. At the time of surgery, a 1 × 6 subdural electrode strip was placed on the cortex parallel to the subdural drain. Clinical outcomes were assessed utilizing the Markwalder Grading Scale, need for clinical EEG for new deficit, and presence of new deficits.

RESULTS

Definitive SD was detected in 6 (15%) of 40 patients. Baseline and cSDH characteristics did not differ between patients with and without SD. More patients experienced postoperative neurological deterioration if they had SD (50%) compared to those without SD (8.8%; p = 0.03). Only 2 patients in the entire cohort demonstrated early neurological deterioration, both of whom had SD. One of these cases demonstrated a time-locked new focal neurological deficit (aphasia) at the start of a series of multiple clusters of SD.

CONCLUSIONS

This is the first observation of SD occurring after cSDH evacuation. SD occurred at a rate of 15% and was associated with neurological deterioration. This may represent a novel mechanism for otherwise unexplained fluctuating neurological deficit after cSDH evacuation. This could provide a new therapeutic target, and SD-targeted therapies should be evaluated in prospective clinical trials.

Management of chronic subdural hematoma with the subdural evacuating port system: Systematic review and meta-analysis

The subdural evacuating port system (SEPS) is a minimally invasive option for treating chronic subdural hematoma (cSDH). Individual case series have shown it to be safe and effective, but outcomes have not been systematically reviewed. We sought to review the literature in order to determine the safety and efficacy of SEPS as a first line treatment for cSDH. A comprehensive literature search for outcomes following SEPS placement as a primary treatment for cSDH was performed. The primary outcome was treatment success, which was defined as a composite of improvement in presenting symptoms and no need for further treatment in the operating room. Additional outcomes included discharge disposition, length of stay (LOS), hematoma recurrence, and complications. A total of 12 studies comprising 953 patients who underwent SEPS placement met the inclusion criteria. The pooled rate of a successful outcome was 0.79 (95% CI 0.75-0.83). Frequency of delayed hematoma recurrence was 0.15 (95% CI 0.10-0.21). The pooled inpatient mortality rate was 0.02 (95% CI 0.01-0.03). Complications rates included 0.02 (95% CI 0.00-0.03) for any acute hemorrhage, 0.01 (95% CI 0.00-0.01) for acute hemorrhage requiring surgery, and 0.02 (95% CI 0.01-0.03) for seizure. SEPS placement is associated with a success rate of 79% and very low rates of acute hemorrhage and seizure. This data supports its use as a first-line management strategy, although prospective randomized studies are needed.

Factors Associated with Early versus Delayed Expansion of Acute Subdural Hematomas Initially Managed Conservatively

Acute subdural hematomas (ASDHs) are highly morbid and increasingly common. Hematoma expansion is a potentially fatal complication, and few studies have examined whether factors associated with hematoma expansion vary over time. To answer this, we performed a case-control study in a cohort of initially conservatively managed patients with ASDH. Two time periods were considered, early (<72 h from injury) and delayed (>72 h from injury). Cases were defined as patients who developed ASDH expansion in the appropriate period; controls were patients who had stable imaging. Associated factors were determined with logistic regression. We identified 68 cases and 237 controls in the early follow-up cohort. Early ASDH expansion was associated with coagulopathy (adjusted odds ratio [aOR] 2.3, 95 % CI: 1.2-4.5; p = 0.02), thicker ASDHs (aOR 1.1, 95% CI: 1.03-1.2; p = 0.006), additional intracranial lesions (aOR 3, 95% CI: 1.6-6.2; p = 0.002), no/minimal trauma history (aOR 0.4, 95% CI: 0.2-0.9; p = 0.03), and duration between injury and initial scan (aOR 0.9, 95% CI: 0.8-0.97; p = 0.04). In the delayed follow-up cohort, there were 41 cases and 126 controls. Delayed ASDH expansion was associated with older age (aOR 1.3 per 10 years, 95% CI: 1.1-1.6; p = 0.01), systolic blood pressure (SBP) >160 on hospital presentation (aOR 4.5, 95% CI: 1.8-11.3; p = 0.001), midline shift (aOR 1.5 per 1 mm, 95% CI: 1.3-1.9; p < 0.001), and convexity location (aOR 14.1, 95% CI: 2.6-265; p = 0.013). We conclude that early and delayed ASDH expansion are different processes with different associated factors, and that elevated SBP may be a modifiable risk factor of delayed expansion.

Hemorrhagic presentations of COVID-19: Risk factors for mortality

OBJECTIVE

We aim to characterize the incidence, risk for mortality, and identify risk factors for mortality in patients presenting with hemorrhage and COVID-19.

METHODS

This retrospective cohort study included a cohort of patients admitted to one of three major hospitals of our healthcare network including, an academic medical center and comprehensive stroke center, which accepts transfers for complex cases from eight community hospitals, during March 1 to May 1, 2020. All patients that received imaging of the neuroaxis and had positive PCR testing for COVID-19 were identified and reviewed by an attending neuroradiologist. Demographics and comorbidities were recorded. Biomarkers were recorded from the day of the hemorrhagic event. Vital signs from the day of the hemorrhagic event mechanical ventilation orders at admission were recorded. Imaging findings were divided into 5 subtypes; acute subdural hematoma (SDH), subarachnoid hemorrhage (SAH), multi-compartmental hemorrhage (MCH), multi-focal intracerebral hemorrhage (MFH), and focal intracerebral hemorrhage (fICH). Outcomes were recorded as non-routine discharge and mortality.

RESULTS

We found a total of 35 out of 5227 patients with COVID-19 that had hemorrhage of some kind. Mortality for the entire cohort was 45.7 % (n = 16). SDH patients had a mortality rate of 35.3 % (n = 6), SAH had a mortality of 50 % (n = 1), MCH patients had a mortality of 71.4 % (n = 5), MFH patients had a mortality of 50 % (n = 2), fICH patients had a mortality of 40 % (n = 2). Patients with severe pulmonary COVID requiring mechanical ventilation (OR 10.24 [.43-243.12] p = 0.015), with INR > 1.2 on the day of the hemorrhagic event (OR 14.36 [1.69-122.14] p = 0.015], and patients presenting with spontaneous vs. traumatic hemorrhage (OR 6.11 [.31-118.89] p = 0.023) had significantly higher risk for mortality.

CONCLUSIONS

Hemorrhagic presentations with COVID-19 are a rare but serious way in which the illness can manifest. It is important for neurosurgeons to realize that patients can present with these findings without primary pulmonary symptoms, and that severe pulmonary symptoms, elevated INR, and spontaneous hemorrhagic presentations is associated with increased risk for mortality.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Chronic subdural hematoma-incidence, complications, and financial impact

OBJECTIVE

To examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT).

METHODS

A retrospective cohort (1990-2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical follow-up visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland).

RESULTS

The incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4-6 weeks' postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia.

CONCLUSIONS

Based on our population-based study, the number of CSDH patients has increased markedly during the study period (1990-2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.

Traumatic Brain Injury in the Elderly: Can We Reduce Readmissions? : A Community Hospital Experience

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of mortality and long-term morbidity in trauma patients, with a growing incidence among the elderly. Injury-related disability has many costs, and rehospitalization is a significant part of that. The current study was carried out in an elderly population with TBI to identify risk factors and measures associated with rehospitalization.

METHODS

We performed a retrospective analysis of 299 patients with a primary diagnosis of TBI admitted between 2016 and 2018. Variables selected for analysis encompassed the following: patient age, sex, comorbidities, diagnosis, length of stay, use of anticoagulants, 6-month readmission rate, and diagnosis for readmission. Chi-square analysis was used to identify potential risk factors, and multiple regression analysis was conducted to model the relationship.

RESULTS

209 patients met inclusion criteria, with a mean age of 69 years (SD ± 18.6 years), with (51.5%) males and (48.5%) females. 188 (62.9%) patients were on anticoagulant therapy. 120 patients were discharged to home (40.1%). 79 patients (26.4%) were readmitted within 6 months of discharge, the majority of whom (48 patients, 60.8%) presented with a subdural hematoma (SDH). 38 readmitted patients (49%) came from home, and 57 patients (80%) were on anticoagulant therapy.

CONCLUSION

In elderly patients with TBI, discharge to a home setting correlates with a higher risk of readmission within 6 months, a majority with a diagnosis of recurrent SDH. Anticoagulant therapy and frequent past readmissions also correlated with a higher risk of subsequent readmission.

Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study

BACKGROUND

The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI.

METHODS

We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation.

RESULTS

A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%).

CONCLUSION

In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.

Thirty- and 90-Day Readmissions After Treatment of Traumatic Subdural Hematoma: National Trend Analysis

OBJECTIVE

Subdural hematoma (SDH), a form of traumatic brain injury, is a common disease that requires extensive patient management and resource utilization; however, there remains a paucity of national studies examining the likelihood of readmission in this patient population. The aim of this study is to investigate differences in 30- and 90-day readmissions for treatment of traumatic SDH using a nationwide readmission database.

METHODS

The Nationwide Readmission Database years 2013-2015 were queried. Patients with a diagnosis of traumatic SDH and a primary procedure code for incision of cerebral meninges for drainage were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R).

RESULTS

We identified a total of 14,355 patients, with 3106 (21.6%) patients encountering a readmission (30-R: n = 2193 [15.3%]; 90-R: n = 913 [6.3%]; Non-R: n = 11,249). The most prevalent 30- and 90-day diagnoses seen among the readmitted cohorts were postoperative infection (30-R: 10.5%, 90-R: 13.0%) and epilepsy (30-R: 3.7%, 90-R: 1.1%). On multivariate logistic regression analysis, Medicare, Medicaid, hypertension, diabetes, renal failure, congestive heart failure, and coagulopathy were independently associated with 30-day readmission; Medicare and rheumatoid arthritis/collagen vascular disease were independently associated with 90-day readmission.

CONCLUSIONS

In this study, we determine the relationship between readmission rates and complications associated with surgical intervention for traumatic subdural hematoma.

Increases in Subdural Hematoma with an Aging Population-the Future of American Cerebrovascular Disease

BACKGROUND

Subdural hematomas (SDHs) are a common and dangerous condition, with potential for a rapid rise in incidence given the aging U.S. population, but the magnitude of this increase is unknown. Our objective was to characterize the number of SDHs and practicing neurosurgeons from 2003-2016 and project these numbers to 2040.

METHODS

Using the National Inpatient Sample years 2003-2016 (nearly 500 million hospitalizations), all hospitalizations with a diagnosis of SDH were identified and grouped by age. Numerical estimates of SDHs were projected to 2040 in 10-year increments for each age group using Poisson modeling with population estimates from the U.S. Census Bureau. The number of neurosurgeons who billed the Centers for Medicare and Medicaid Services from 2012 to 2017 was noted and linearly projected to 2040.

RESULTS

From 2020-2040, SDH volume is expected to increase by 78.3%, from 135,859 to 208,212. Most of this increase will be seen in the elderly, as patients 75-84 years old will experience an increase from 37,941 to 69,914 and patients older than 85 years old will experience an increase from 31,200 to 67,181. The number of neurosurgeons is projected to increase from 4675 in 2020 to 6252 in 2040.

CONCLUSIONS

SDH is expected to increase significantly from 2020-2040, with the majority of this increase being concentrated in elderly patients. While the number of neurosurgeons will also increase, the ability of current neurosurgical resources to properly handle this expected increase in SDH will need to be addressed on a national scale.

Exploring discharge destination following severe stroke

Background:

Patients with severe stroke frequently present with substantial impairments but are often not prioritised for post-discharge rehabilitation. There is a need to determine where these patients are discharged to in order to facilitate appropriate allocation of post-discharge pathway resources.

Aim:

The present study aimed to describe the discharge pathways of patients with severe stroke and to identify predictors of discharge destination for these patients.

Method:

A descriptive, retrospective design was utilised to determine the discharge destination for 770 patients with severe stroke in Queensland, Australia. Binomial logistic regression was used to determine the variables that predicted discharge destination.

Results:

The results indicated that 58.44% of patients were discharged home (n = 450). Age, length of stay, discharge ward and geographical region emerged as significant predictors of discharge destination. The full model containing all predictors was statistically significant and, as a whole, explained 36.50% of the variance in discharge destination.

Conclusion:

These results highlight the importance of these variables in influencing the outcomes of patients with severe stroke, which may assist post-hospital discharge services in allocating resources for patients with severe stroke.

Non-Traumatic Subdural Hemorrhage and Risk of Arterial Ischemic Events

Background and Purpose- The risk of arterial ischemic events after subdural hemorrhage (SDH) is poorly understood. This study aimed to evaluate the risk of acute ischemic stroke and myocardial infarction among patients with and without nontraumatic SDH. Methods- We performed a retrospective cohort study using claims data from 2008 through 2014 from a nationally representative sample of Medicare beneficiaries. The exposure was nontraumatic SDH. Our primary outcome was an arterial ischemic event, a composite of acute ischemic stroke and acute myocardial infarction. Secondary outcomes were ischemic stroke alone and myocardial infarction alone. We used validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes to identify our predictor and outcomes. Using Cox regression and corresponding survival probabilities, adjusted for demographics and vascular comorbidities, we computed the hazard ratio in 4-week intervals after SDH discharge. We performed secondary analyses stratified by strong indications for antithrombotic therapy (composite of atrial fibrillation, peripheral vascular disease, valvular heart disease, and venous thromboembolism). Results- Among 1.7 million Medicare beneficiaries, 2939 were diagnosed with SDH. In the 4 weeks after SDH, patients' risk of an arterial ischemic event was substantially increased (hazard ratio, 3.6 [95% CI, 1.9-5.5]). There was no association between SDH diagnosis and arterial ischemic events beyond 4 weeks. In secondary analysis, during the 4 weeks after SDH, patients' risk of ischemic stroke was increased (hazard ratio, 4.2 [95% CI, 2.1-7.3]) but their risk of myocardial infarction was not (hazard ratio, 0.8 [95% CI, 0.2-1.7]). Patients with strong indications for antithrombotic therapy had increased risks for arterial ischemic events similar to patients in the primary analysis, but those without such indications did not demonstrate an increased risk for arterial ischemic events. Conclusions- Among Medicare beneficiaries, we found a heightened risk of arterial ischemic events driven by an increased risk of ischemic stroke, in the 4 weeks after nontraumatic SDH. This increased risk may be due to interruption of antithrombotic therapy after SDH diagnosis.

Regional Variation in the Management of Nontraumatic Subdural Hematomas Across the United States

BACKGOUND

Nontraumatic subdural hematomas are a common indication for inpatient hospitalization in the United States, yet there is little high-quality evidence regarding which patients should receive surgical or medical treatment. We sought to assess variation in surgical management and medical treatment with steroids for nontraumatic subdural hematomas across the United States.

METHODS

Using the Premier database, we analyzed patients with a primary discharge diagnosis of nontraumatic subdural hematoma in 2014. International Classification of Diseases, Ninth Revision, procedure codes were used to identify patients who underwent surgical management, and pharmacy data were used to identify patients treated with dexamethasone. Univariable and multivariable analyses were used to examine the association of age, race, sex, academic versus nonacademic center, and regions of the United States with conservative or surgical management.

RESULTS

There were 3915 inpatient hospitalizations for nontraumatic subdural hematomas in 2014 in the Premier database, of whom 1860 (47.5%) underwent surgery, and 360 (9.2%) underwent treatment with dexamethasone, either as a primary treatment or as an adjuvant to surgery. Older age, female sex, and being managed outside of the Western U.S. region were associated with a lower likelihood of undergoing surgical management on multivariable analysis; only younger age was associated with a greater likelihood of being treated with dexamethasone.

CONCLUSIONS

There is considerable variability in surgical management of nontraumatic subdural hematomas across the United States based on age, sex, and region. Future studies should explore the reasons for the variability and attempt to better clarify indications for surgical management of subdural hematomas.

Feasibility and Safety of Endoscopic Procedure in Burr-Hole Surgery for Chronic Subdural Hematoma in Patients of Very Advanced Age

OBJECTIVE

The usefulness of endoscopic procedures for chronic subdural hematoma (CSDH) has been described, but the indications in patients of very advanced age have not been analyzed. The aim of this study was to evaluate the feasibility, safety, and usefulness of introduction of an endoscopic procedure for such patients.

METHODS

We retrospectively analyzed the data of 540 CSDHs treated by burr-hole surgery with endoscopic examination. The safety of the endoscopic procedure was assessed according to postoperative complications, morbidity, and mortality. The outcome was evaluated by statistical comparison among 4 different age-groups, and the recurrence rate and risk factors for recurrence was investigated in patients of very advanced age.

RESULTS

Postoperative complications occurred in 7 cases (1.5%). The 6-month morbidity and mortality were 13.5% and 4.5%. No complications, morbidity, or mortality associated with the additional endoscopic procedure occurred even in patients of very advanced age. The endoscopic features of trabecular structures and residual septa separating the cavity were also risk factors for recurrence in patients of very advanced age. Releasing of the septa showed the possibility of decreasing the risk of recurrence to 6.6% in patients aged ≥85 years as well as in younger patients. There were some inevitable problems such as prolongation of the surgical time and inadequate endoscopic surgical skill.

CONCLUSIONS

An endoscopic procedure for CSDH can be safely indicated and useful even in patients aged ≥85 years. However, clinicians should carefully select the patients based on clinical information associated with risk factors for recurrence.

Predictors of Thirty-day Mortality and Length of Stay in Operative Subdural Hematomas

The rate of postoperative morbidity and mortality after subdural hematoma (SDH) evacuation is high. The aim of this study was to compare mortality statistics from a high-volume database to historical figures and determine the most significant preoperative predictors of mortality and length of stay (LOS). The National Surgical Quality Improvement Program registry was searched (2005-2016) for patients with operatively treated SDHs, of which 2709 were identified for univariate analysis. After exclusion for missing data, 2010 individuals were analyzed with multivariable logistic regression. Primary outcome was 30-day mortality. The average patient age was 68.8 ± 14.9 years, and 64.1% were males. Upon multivariate analysis, nine variables were found to be associated with increased mortality: platelet count < 135,000 (OR 2.04, 95% CI 1.39-2.99), INR >1.2 (OR 1.87, 95% CI 1.34-2.6), bleeding disorder (OR 1.80, 95% CI 1.32-2.46), need for dialysis within two weeks preoperatively (OR 5.69, 95% CI 3.15-10.27), ventilator dependence in the 48 hours preceding surgery (OR 3.99, 95% CI 2.82-5.63), disseminated cancer (OR 2.95, 95% CI 1.34-6.47), WBC count >10,000 (OR 1.55, 95% CI 1.15-2.08), totally dependent functional status (OR 1.84, 95% CI 1.2-2.8), and each increasing year of age (OR 1.04, 95% CI 1.031-1.05). It is not surprising that chronic conditions and functional status were associated with increased mortality. However, specific laboratory abnormalities were also associated with increased mortality at levels generally considered within normal limits. More studies are needed to determine if correcting lab abnormalities preoperatively can improve outcomes in patients with intrinsic coagulopathy.

Seizure and status epilepticus in chronic subdural hematoma

BACKGROUND

Acute symptomatic seizure (ASz) and status epilepticus (SE) are serious conditions associated with poor quality of life, with unfavorable psychosocial and functional outcome. Chronic subdural hematoma (cSDH) is a common neurosurgical disease related to those complications; therefore, we aimed to evaluate incidence, predictors of ASz/SE, and outcome in this cohort.

METHODS

We retrospectively analyzed patient diagnosed cSDH between 2010 and 2017. Beside their incidence of ASz/SE, patient characteristics, symptoms at admission, comorbidities, and all previously published relevant parameters were assessed. Recurrence rate and functional outcome were analyzed at hospital discharge and 90-day follow-up.

RESULTS

A total of 375 patients were included; incidence of ASz was 15.2% and of SE, 1.9%. In the univariate analysis, drainage insertion (P =  0.004; OR = 0.3) was a significant negative predictor for ASz/SE and multivariate analysis, including all significant parameters, designated GCS ≤13 at admission (P = 0.09; OR = 1.9), remote stroke (P = 0.009; OR = 2.9), and recurrence rate within 14 days (P = 0.001; OR = 3.3; with an incidence of 13%) as independent predictors for ASz/SE. Overall, patients with ASz/SE had significantly unfavorable outcome at discharge (54.7%; P < 0.001) and follow-up (39.5%; P < 0.001) with only slight improvement. Late seizures occurred in 3.8% within follow-up period. Any patient with SE had an unfavorable outcome at discharge without any improvement at follow-up having a mortality rate of 14.2%.

CONCLUSION

Independent predictors for ASz/SE are GCS ≤13 at admission, remote stroke, and recurrent hematoma in patients with cSDH, which is associated with worse functional outcome, particularly those with SE. Due to the higher rate of seizures than recurrence rate, a routine pre- and postoperative EEG besides CT is recommended.

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

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

Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox?

BACKGROUND

The decision whether to operate or not in patients with a traumatic acute subdural hematoma (t-ASDH) can, in many cases, be a neurosurgical dilemma. There is a general conception that operating on severe cases leads to the survival of severely disabled patients and is associated with relatively high medical costs. There is however little information on the quality of life of patients after operation for t-ASDH, let alone on the cost-effectiveness.

METHODS

This study retrospectively investigated patient outcome and in-hospital costs for 108 consecutive patients with a t-ASDH. Patient outcome was assessed using the Glasgow Outcome Score (GOS) and the Traumatic Brain Injury (TBI)-specific QOLIBRI questionnaire. The in-hospital costs were calculated using the Dutch guidelines for costs calculation.

RESULTS

Out of 108 patients, 40 were classified as having sustained a mild (Glasgow Coma Scale (GCS) 13-15), 19 a moderate (GCS 9-12), and 49 a severe (GCS 3-8) TBI. As expected, mortality rates increased with higher TBI severity (23%, 47%, and 61% respectively), whereas the chance for favorable outcome (GOS 4-5) decreased (72%, 47%, and 29%). Interestingly, the mean QOLIBRI scores for survivors were quite similar between the TBI severity groups (61, 61, and 64). Healthcare consumption and in-hospital costs increased with TBI severity. In-hospital costs were relatively high (€24,980), especially after emergency surgery (€28,670) and when additional ICP monitoring was used (€36,580).

CONCLUSIONS

Although this study confirms that outcome is often "unfavorable" after t-ASDH, it also shows that "favorable" outcome can be achieved, even in the most severely injured patients. In-hospital treatment costs were substantial and mainly related to TBI severity, with admission and surgery as main cost drivers. These results serve as a basis for necessary future research focusing on the value-based cost-effectiveness of surgical treatment of patients with a t-ASDH.

Non-electrographic Seizures Due to Subdural Hematoma: A Case Series and Review of the Literature

Seizures due to subdural hematoma (SDH) are a common finding, typically diagnosed using electroencephalography (EEG). At times, aggressive management of seizures is necessary to improve neurologic recovery and outcomes. Here, we present three patients who had undergone emergent SDH evacuation and showed postoperative focal deficits without accompanying electrographic epileptiform activity. After infarction and recurrent hemorrhage were ruled out, seizures were suspected despite a negative EEG. Patients were treated aggressively with AEDs and eventually showed clinical improvement. Long-term monitoring with EEG revealed electrographic seizures in a delayed fashion. EEG recordings are an important tool for seizure detection, but should be used as an adjunct to, rather than a replacement for, the clinical examination in the acute setting. At times, aggressive treatment of suspected postoperative seizures is warranted despite lack of corresponding electrographic activity and can improve clinical outcomes.

Rates of Repeated Operation for Isolated Subdural Hematoma Among Older Adults

IMPORTANCE

Elderly patients who undergo surgery for an isolated nontraumatic subdural hematoma (SDH) are at major risk for SDH reaccumulation, which can cause further injury and disability. Few population-based studies have examined how often nontraumatic SDH reaccumulates and necessitates repeated operation.

OBJECTIVE

To determine the rate of repeated operation after evacuation of nontraumatic SDH.

DESIGN, SETTING, AND PARTICIPANTS

In a cohort study, 2 parallel analyses were performed using data from the National Surgical Quality Improvement Project (NSQIP) from January 1, 2012, through December 31, 2015, and inpatient and outpatient claims data from a 5% nationally representative sample of Medicare beneficiaries from January 1, 2009, to September 30, 2015. In both samples, our cohort comprised patients 65 years or older who underwent surgical evacuation of nontraumatic SDH. Data were analyzed from March 28 to April 13, 2018.

MAIN OUTCOMES AND MEASURES

The outcome variable was repeated operation for SDH after the index operation. Survival analysis and Kaplan-Meier statistics were used to calculate cumulative rates.

RESULTS

Among 2 831 274 cases submitted to the NSQIP registry, 515 patients 65 years or older (mean [SD] age, 76.9 [7.4] years; 177 [34.4%] women; 367 [71.3%] white) who underwent craniotomy or craniectomy for nontraumatic SDH were identified. Within 30 days after the index surgery, 37 patients underwent a repeated operation for SDH. The cumulative 30-day mortality rate was 13.8% (95% CI, 11.0%-17.1%), and the repeated operation rate was 7.8% (95% CI, 5.7%-10.7%). Among a cohort of 1 952 305 Medicare beneficiaries, 1534 patients (mean [SD] age, 77.7 [7.0] years; 498 [32.5%] women; 1244 [81.1%] white) who underwent evacuation of nontraumatic SDH were identified. A total of 103 patients underwent a repeated operation within 90 days. The cumulative 30-day mortality rate was 11.6% (95% CI, 10.1%-13.3%), and the repeated operation rate was 4.9% (95% CI, 3.9%-6.2%); the cumulative 90-day mortality rate was 17.6% (95% CI, 15.7%-19.6%), and the repeated operation rate was 7.5% (95% CI, 6.2%-9.0%). The study found no evidence of a significant difference in cumulative repeated operation rates at 90 days between patients whose index surgery was a burr-hole procedure for chronic SDH (11.7%; 95% CI, 6.3%-21.3%) vs a craniotomy or craniectomy (7.2%; 95% CI, 6.0%-8.8%) (P = .14 by the log-rank test).

CONCLUSIONS AND RELEVANCE

In 2 large cohorts of US patients, approximately 5% to 10% of patients who underwent surgery for nontraumatic SDH were required to undergo repeated operation within 30 to 90 days. These results may inform the design of future prospective studies and trials and help practitioners calibrate their index of suspicion to ensure that patients are referred for timely surgical care.

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

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

Subdural Instillation of a Thrombolytic Agent for Treatment of Recurrent Subdural Hematoma

OBJECTIVE

This study aims to report the case of a patient with recurrent subdural hemorrhage (SDH) who was administered tissue plasminogen activator through a subdural drain to enhance drainage and prevent recurrence.

METHODS

An 85-year-old man was treated for subacute over chronic SDH that kept on reaccumulating despite serial twist drill drainage, burr hole drainage, and craniotomy. No coagulopathy was identified with adequate blood pressure control.

RESULTS

Treatment with tissue plasminogen activator resulted in successful drainage of the SDH, and the patient had no further recurrence at 9-month follow-up.

Proposal for the Rapid Reversal of Coagulopathy in Patients with Nonoperative Head Injuries on Anticoagulants and/or Antiplatelet Agents: A Case Study and Literature Review

BACKGROUND

Emergency room physicians, trauma teams, and neurosurgeons are seeing increasing numbers of head-injured patients on anticoagulants, many of whom are nonoperative. Head injury and anticoagulation can lead to devastating consequences. These patients need immediate evaluation and often reversal of anticoagulation in order to decrease their high rates of morbidity and mortality.

OBJECTIVE

To review data on the prevalence, risks, treatment, and complications of head-injured anticoagulated patients and provide a proposal for their anticoagulant management, and imaging requirements.

METHODS

A PubMed database search was performed for articles on the prevalence, risks, treatment, and complications of patients who have sustained a head injury while on anticoagulant or antiplatelet agents.

RESULTS

A total of 1877 articles were found, of which 64 were selected for use based on direct relevance, information quality, and contribution of the article to the current understanding of anticoagulated head injury patients.

CONCLUSION

There are very few guidelines for the management of nonoperative head-injured patients. Rapid reversal guided by international normalized ratio values, Platelet Function Assays, computed tomography imaging of the head, and physical exam is suggested. The proposal presented in this paper enables patient management to begin quickly in a systematic approach, with the goal of achieving a significant decrease in the morbidity and mortality for the anticoagulated head-injured patient. Rapid reversal can potentially decrease mortality by as much as 38%.

First-line management of chronic subdural hematoma with the subdural evacuating port system: Institutional experience and predictors of outcomes

Chronic subdural hematoma (cSDH) is a common condition that disproportionately affects older patients. Given the greater risks of general anesthesia in this population, interest has turned towards less invasive surgical approaches such as the subdural evacuating port system (SEPS; Medtronic, Inc., Minneapolis, MN). There is a relative dearth of information about the outcomes following this procedure. Here, we present our institution's experience with SEPS and analyze factors associated with the outcomes. Using a prospectively maintained institutional database, we retrospectively identified all patients who presented with cSDH and received first line therapy with SEPS. Pre- and post-operative clinical and radiographic data was obtained from the electronic health record. Outcomes included success or failure, Modified Rankin Scale (mRS) at discharge, length of stay (LOS), and discharge disposition. A total of 126 patients met the inclusion criteria (36 females and 90 males; mean age of 71.6 years). None of the pre-procedural clinical or radiographic variables were associated with the likelihood of a successful outcome. Increasing age was associated with non-routine hospital discharge (p = 0.003), and lower presenting GCS was associated with longer hospital stay (p = 0.005). Greater thickness of the cSDH was associated with a lower likelihood of having a favorable outcome (mRS ≥ 3; p = 0.003). SEPS is an effective first-line therapy for cSDH. Variables previously reported to limit the effectiveness of the technique (presence of septations, mixed density collections) were not associated with treatment failure.

A propensity score analysis of the impact of surgical intervention on unexpected 30-day readmission following admission for subdural hematoma

OBJECTIVE

Subdural hematoma (SDH) is a common disease that is increasingly being managed nonoperatively. The all-cause readmission rate for SDH has not previously been described. This study seeks to describe the incidence of unexpected 30-day readmission in a cohort of patients admitted to an academic neurosurgical center. Additionally, the relationship between operative management, clinical outcome, and unexpected readmission is explored.

METHODS

This is an observational study of 200 consecutive adult patients with SDH admitted to the neurosurgical ICU of an academic medical center. Demographic information, clinical characteristics, and treatment strategies were compared between readmitted and nonreadmitted patients. Multivariable logistic regression, weighted by the inverse probability of receiving surgery using propensity scores, was used to evaluate the association between operative management and unexpected readmission.

RESULTS

Of 200 total patients, 18 (9%) died during hospitalization and were not included in the analysis. Overall, 48 patients (26%) were unexpectedly readmitted within 30 days. Sixteen patients (33.3%) underwent SDH evacuation during their readmission. Factors significantly associated with unexpected readmission were nonoperative management (72.9% vs 54.5%, p = 0.03) and female sex (50.0% vs 32.1%, p = 0.03). In logistic regression analysis weighted by the inverse probability of treatment and including likely confounders, surgical management was not associated with likelihood of a good outcome at hospital discharge, but was associated with significantly reduced odds of unexpected readmission (OR 0.19, 95% CI 0.08-0.49).

CONCLUSIONS

Over 25% of SDH patients admitted to an academic neurosurgical ICU were unexpectedly readmitted within 30 days. Nonoperative management does not affect outcome at hospital discharge but is significantly associated with readmission, even when accounting for the probability of treatment by propensity score weighted logistic regression. Additional research is needed to validate these results and to further characterize the impact of nonoperative management on long-term costs and clinical outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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