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Rivier CA, Kamel H, Sheth KN, Iadecola C, Gupta A, de Leon MJ, Ross E, Falcone GJ, Murthy SB. Cerebral Amyloid Angiopathy and Risk of Isolated Nontraumatic Subdural Hemorrhage. JAMA Neurol 2024; 81:163-169. [PMID: 38147345 PMCID: PMC10751656 DOI: 10.1001/jamaneurol.2023.4918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/29/2023] [Indexed: 12/27/2023]
Abstract
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.
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Affiliation(s)
- Cyprien A. Rivier
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
- Yale Center for Brain and Mind Health, Yale School of Medicine, New Haven, Connecticut
| | - Hooman Kamel
- Deputy Editor, JAMA Neurology
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
- Yale Center for Brain and Mind Health, Yale School of Medicine, New Haven, Connecticut
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Ajay Gupta
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Mony J. de Leon
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Elizabeth Ross
- Center for Neurogenetics, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Guido J. Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
- Yale Center for Brain and Mind Health, Yale School of Medicine, New Haven, Connecticut
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
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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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Msheik A, Fares Y, Mohanna M, Aoude A, Shkeir M, Chehade F, Kanj A, Mohanna A. Middle meningeal artery embolisation: The review of a new treatment for chronic subdural hematomas. Surg Neurol Int 2023; 14:66. [PMID: 36895214 PMCID: PMC9990792 DOI: 10.25259/sni_1096_2022] [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: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/26/2023] Open
Abstract
Background This is a literature review aiming to provide an update about the recent findings related to the efficacy of middle meningeal artery embolization (MMAE) in the treatment of chronic subdural hematomas (cSDHs), comparison with conventional therapy and deduction of the current recommendations and indications. Methods The literature is reviewed using a search through the PubMed index using keywords. Studies are then screened, skimmed, and thoroughly read. 32 studies fulfilled the inclusion criteria and are included in the study. Results Five indications for the application of MMA embolization (MMAE) are deducted from the literature. The usage as a preventive measure after surgical treatment of symptomatic cSDHs in patients with a high risk of recurrence and the usage as a standalone procedure has been the most common reasons for indication of this procedure. Rates of failures for the aforementioned indications have been 6.8% and 3.8%, respectively. Conclusion The safety of MMAE as a procedure is regarded as a general theme in the literature and can be considered for future applications. Usage of this procedure in clinical trials with more patient segregation and timeframe assessment relative to surgical intervention are recommendations of this literature review.
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Affiliation(s)
- Ali Msheik
- Department of Neurological Surgery, Lebanese University, Faculty of Medical Sciences
| | - Youssef Fares
- Department of Neurological Surgery, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Lebanon
| | - Mohammad Mohanna
- Department of Oncology, Cleveland Clinic, Weston, Florida, United States
| | - Ahmad Aoude
- Department of Neurological Surgery, Al Rassoul Al-Azam Hospital
| | - Mohamad Shkeir
- Head of Radiology Department, Zahraa Hospital University Medical Center
| | - Feras Chehade
- Department of Nuclear Medicine Radiobiology Radiopathology, Faculty of Medical Sciences, Lebanese University
| | - Ali Kanj
- Radiology Department, Bahman Hospital, Faculty of Medicine, Lebanese University
| | - Assaad Mohanna
- Head of Department of Radiology, Faculty of Medicine, Lebanese University, Bahman Hospital, Centre Hospitalier Vallee de la Maurienne-France, Beirut, Lebanon
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Singh RD, van Dijck JTJM, van Essen TA, Lingsma HF, Polinder SS, Kompanje EJO, van Zwet EW, Steyerberg EW, de Ruiter GCW, Depreitere B, Peul WC. Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design. Trials 2022; 23:242. [PMID: 35351178 PMCID: PMC8962939 DOI: 10.1186/s13063-022-06184-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024. DISCUSSION The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered. TRIAL REGISTRATION Nederlands Trial Register (NTR), Trial NL9012 . CLINICALTRIALS gov, Trial NCT04648436 .
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Affiliation(s)
- Ranjit D Singh
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Thomas A van Essen
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Hester F Lingsma
- Centre for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Suzanne S Polinder
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Erik W van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Godard C W de Ruiter
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | | | - Wilco C Peul
- University Neurosurgical Center Holland, LUMC, HMC and Haga Teaching Hospital, Leiden and The Hague, J11 Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Singh R, Prasad RS, Singh K, Sahu A, Pandey N. Clinical, Surgical and Outcome Predictive Factor Analysis of Operated Acute Subdural Hematoma Cases: A Retrospective Study of 114 Operated Cases at Tertiary Centre. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0040-1719201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Objective To analyze clinical, surgical and outcome predictive factors of operated acute subdural hematoma (SDH) cases for prognostication and surgical outcome prediction.
Material and Methods This retrospective study includes 114 patients operated for acute SDH in the Department of Neurosurgery of IMS BHU, Varanasi, India, a tertiary care center, between 1 August 2018 and 1 November 2019. Each patient was evaluated for age, sex, mode of injury, localization of hematoma, clinical presentation, comorbidity, severity of injury, best motor response, CT findings, and Glasgow outcome scale (GOS) at discharge. The outcome was also evaluated by further making a dichotomized group using GOS in death/dependent (1–3) versus independent (4–5). Statistical tests were done using the GraphPad Prism version 8.3.0.
Results The most common age group operated upon in this study was the 40 to 60 years age group (n = 45, 39.48%). Males were 78% with male to female ratio of 3.56:1. The most common clinical presentation was altered sensorium (98.25%). The most common comorbidity was hypertension (n = 32, 28.07%). GCS at admission, severity of injury, pupillary changes, and best motor response (p < 0.0001) were significantly associated with surgical outcome.
Conclusion GCS at admission, severity of injury, pupillary changes, and best motor response were significantly (p < 0.05) associated with surgical outcome. Age and gender of patients were not found to be significantly associated.
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Affiliation(s)
- Rahul Singh
- Department of Neurosurgery, Institute of Medical Sciences–Banaras Hindu University (IMS–BHU), Varanasi, India
| | - Ravi Shankar Prasad
- Department of Neurosurgery, Institute of Medical Sciences–Banaras Hindu University (IMS–BHU), Varanasi, India
| | - Kulwant Singh
- Department of Neurosurgery, Institute of Medical Sciences–Banaras Hindu University (IMS–BHU), Varanasi, India
| | - Anurag Sahu
- Department of Neurosurgery, Institute of Medical Sciences–Banaras Hindu University (IMS–BHU), Varanasi, India
| | - Nityanand Pandey
- Department of Neurosurgery, Institute of Medical Sciences–Banaras Hindu University (IMS–BHU), Varanasi, India
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Scullen T, Mathkour M, Nerva JD, Dumont AS. Commentary: Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations. Neurosurgery 2021; 88:E130-E132. [PMID: 33045740 DOI: 10.1093/neuros/nyaa432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - John D Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
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Preventive role of tranexamic acid in post-operative recurrence of chronic subdural haemorrhage: Do we have sufficient evidence? J Clin Neurosci 2021; 89:455-456. [PMID: 33431243 DOI: 10.1016/j.jocn.2020.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022]
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Sastry RA, Pertsch N, Tang O, Shao B, Toms SA, Weil RJ. Frailty and Outcomes after Craniotomy or Craniectomy for Atraumatic Chronic Subdural Hematoma. World Neurosurg 2020; 145:e242-e251. [PMID: 33065346 DOI: 10.1016/j.wneu.2020.10.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Frailty is a measure of decreased physiologic reserve and has been associated with increased morbidity and mortality in a variety of surgical disciplines. No data exist regarding the relationship of frailty with adverse outcomes in craniotomy for chronic subdural evacuation. We assessed the relationship between frailty and the incidence of major postoperative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after craniotomy for atraumatic subdural evacuation. METHODS A retrospective cohort study was conducted on a population of 1647 adult patients undergoing craniotomy for evacuation of atraumatic subdural hematoma in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index (mFI-5). Multivariable logistic regression was performed using all covariates deemed eligible through clinical relevance and statistical significance. RESULTS The overall rates of major complication (25.4%), discharge to destination other than home (49.8%), 30-day readmission (11.7%), and 30-day mortality (12.8%) in this analysis were high and rose with increasing frailty. In multivariable regression analyses, medium frailty (mFI-5 = 2) was associated with increased odds of major complication (adjusted odds ratio [aOR] 1.64, 95% confidence interval [CI] 1.03-2.63), discharge to destination other than home (aOR 2.04, 95% CI 1.38-3.02), and 30-day mortality (aOR 2.27, 95% CI 1.08-4.78). High frailty (mFI-5 >2) was associated with increased odds of 30-day mortality (aOR 2.85, 95% CI 1.13-7.14). CONCLUSIONS Preoperative frailty, as determined by mFI-5, is associated with increased odds of major postoperative complication, discharge to destination other than home, and 30-day mortality after craniotomy for chronic subdural hematoma.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
| | - Nathan Pertsch
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Oliver Tang
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Belinda Shao
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
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Role of prophylactic antiepileptic drugs in chronic subdural hematoma-a systematic review and meta-analysis. Neurosurg Rev 2020; 44:2069-2077. [PMID: 32910368 DOI: 10.1007/s10143-020-01388-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/30/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
Chronic subdural hematoma is a common neurosurgical pathology, which is more commonly seen in the elderly age group. Few patients with chronic subdural hematoma (cSDH) can have seizures-either before or after surgical intervention. Reported incidence of seizures varies from 0.7-18.5% in patients with cSDH. Many factors which have been proposed to increase the risk of seizures in these patients include the presence of encapsulated membranes, occult cortical injury, mass effect, or an acute hemorrhage. The role of prophylactic antiepileptic drugs is not very clear in cSDH. We reviewed the currently available evidence for the use of prophylactic antiepileptic drugs (AEDs) in patients with cSDH. We included 13 studies in the systematic review and 6 studies compared the incidence of seizures in patients who received antiepileptic drugs with those who did not. Our review did not find any significant reduction in the incidence of seizures in patients with cSDH following administration of antiepileptic drugs.
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Neifert SN, Chaman EK, Hardigan T, Ladner TR, Feng R, Caridi JM, Kellner CP, Oermann EK. Increases in Subdural Hematoma with an Aging Population-the Future of American Cerebrovascular Disease. World Neurosurg 2020; 141:e166-e174. [PMID: 32416236 DOI: 10.1016/j.wneu.2020.05.060] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Emily K Chaman
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Travis R Ladner
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Rui Feng
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - John M Caridi
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | | | - Eric Karl Oermann
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA.
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Maslink C, Cheng K, Smith TR, Das S. Advanced Age Is Not a Universal Predictor of Poorer Outcome in Patients Undergoing Neurosurgery. World Neurosurg 2019; 130:e375-e382. [PMID: 31229751 DOI: 10.1016/j.wneu.2019.06.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Advances in medical care and technology have dramatically improved outcomes in patients undergoing neurosurgical intervention; however, certain patient subgroups (e.g., older adults) may encounter greater rates of morbidity and mortality in the perioperative period. The objective of this study was to determine the effects of patient and hospital characteristics, including age, on in-hospital mortality, and complication rates of 3 routine neurosurgical operations: subdural hematoma evacuation, brain tumor resection, and degenerative spine procedures. METHODS A retrospective multivariable analysis of the 2014 National Inpatient Sample was performed. The setting was a national sample of hospitalized inpatient stays occurring in 2014 in the United States. Patients (N = 48,963) included those undergoing subdural hematoma evacuation, brain tumor resection, or degenerative spine procedures, stratified according to age group (<65, 65-74, 75-84, 85+ years). Mortality and complication rate were measured. RESULTS Age ≥85 years was found to increase the odds of mortality (odds ratio 11.32) and complications (odds ratio 2.64) in patients undergoing degenerative spine procedures, whereas age had no significant effect on mortality and complication rate in subdural hematoma evacuation and brain tumor resection. Multiple comorbidities and nonelective status were predictors of increased mortality and complication rate in all procedure groups. CONCLUSIONS Overall, our data would suggest that increased age does not universally predict worse outcome and that, for many procedures, surgical decision-making in older patients should instead consider other pertinent factors, such as comorbidities and elective status.
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Affiliation(s)
- Colin Maslink
- Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Kathleen Cheng
- Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Timothy R Smith
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sunit Das
- Division of Neurosurgery, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.
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Bah AB, Souaré IS, Diawara S, Boubane D, Saran KO. [Surgical treatment of chronic subdural hematoma in Guinea: Analysis of 22 cases at the Kipe hospital of Conakry]. Neurochirurgie 2019; 65:83-88. [PMID: 30953620 DOI: 10.1016/j.neuchi.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 03/06/2019] [Accepted: 03/20/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We report the results of surgical treatment of chronic subdural hematoma in the Kipe Hospital in Conakry, Guinea, for the period July 2012 to November 2015. MATERIAL AND METHOD Clinical, radiological and therapeutic data from 22 cases were collected retrospectively and analyzed, with a mean follow-up of 61.6 days. Univariate analysis screened for factors for neurological outcome on the Markwalder Grading Scale (MGS; 0=normal to 4=coma). RESULTS Male-female sex ratio was 2.6:1. Mean age at diagnosis was 71.09±8 years, with peak incidence of CSDH in the 60-79 age group. Traumatic brain injury was identified as causal in 40.9% of cases. Burrhole trepanation was used in 86.36% of cases, under local anesthesia in 76%, and with postoperative drainage in all cases. No recurrences were recorded. At follow-up, mean postoperative MGS was 0.59 (up from 3.08 preoperatively); 54.54% of patients had normal neurological examination (grade 0). Age 60-79 years, time to diagnosis>12 weeks and preoperative MGS≥3 had significant negative impact on outcome (respective P-values: 0.03, 0.001, 0.001). CONCLUSION Our data were similar to those of the literature, but with longer time to diagnosis and poorer initial clinical status, with negative impact on clinical progression.
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Affiliation(s)
- A B Bah
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée; Service de chirurgie générale, CHU Ignace Deen, Kaloum, Conakry, Guinée.
| | - I S Souaré
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée
| | - S Diawara
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée; Service de neurochirurgie, CHU Donka, Donka, Conakry, Guinée
| | - D Boubane
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée
| | - K O Saran
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée
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Lee KB, Yoon SC, Kim JS, Hong BY, Park JG, Sung WJ, Park HJ, Lim SH. Delayed Extensive White Matter Injury Caused by a Subdural Hemorrhage and Role of Corticospinal Tract Integrity. BRAIN & NEUROREHABILITATION 2019. [DOI: 10.12786/bn.2019.12.e15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Kyoung Bo Lee
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Cheol Yoon
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Sung Kim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bo Young Hong
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Geun Park
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Jin Sung
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hye Jung Park
- Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea
| | - Seong Hoon Lim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Kuhn EN, Erwood MS, Oster RA, Davis MC, Zeiger HE, Pittman BC, Fisher WS. Outcomes of Subdural Hematoma in the Elderly with a History of Minor or No Previous Trauma. World Neurosurg 2018; 119:e374-e382. [DOI: 10.1016/j.wneu.2018.07.168] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
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Won SY, Dubinski D, Bruder M, Cattani A, Seifert V, Konczalla J. Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome. Neurosurg Focus 2018; 43:E12. [PMID: 29088960 DOI: 10.3171/2017.8.focus17421] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Isolated acute subdural hematoma (aSDH) is increasing in older populations and so is the use of oral anticoagulant therapy (OAT). The dramatic increase of OAT-with direct oral anticoagulants (DOACs) as well as with conventional anticoagulants-is leading to changes in the care of patients who present with aSDH while receiving OAT. The purpose of this study was to determine the management and outcome of patients being treated with OAT at the time of aSDH presentation. METHODS In this single-center, retrospective study, the authors analyzed 116 consecutive cases involving patients with aSDH treated from January 2007 to June 2016. The following parameters were assessed: patient characteristics, admission status, anticoagulation status, perioperative management, comorbidities, clinical course, and outcome as determined at discharge and through 6 months of follow-up. Oral anticoagulants were classified as thrombocyte inhibitors, vitamin K antagonists, and DOACs. Patients were stratified based on which type of medication they were taking, and subgroup analyses were performed. Predictors of unfavorable outcome at discharge and follow-up were identified. RESULTS Of 116 patients, 74 (64%) had been following an OAT regimen at presentation with aSDH. The patients who were taking oral anticoagulants (OAT group) were significantly older (OR 12.5), more often comatose 24 hours postoperatively (OR 2.4), and more often had ≥ 4 comorbidities (OR 3.2) than patients who were not taking oral anticoagulants (no-OAT group). Accordingly, the rate of unfavorable outcome was significantly higher in patients in the OAT group, both at discharge (OR 2.3) and at follow-up (OR 2.2). Of the patients in the OAT group, 37.8% were taking a thrombocyte inhibitor, 54.1% a vitamin K antagonist, and 8.1% DOACs. In all cases, OAT was stopped on discovery of aSDH. For reversal of anticoagulation, patients who were taking a thrombocyte inhibitor received desmopressin 0.4 μg/kg, 1-2 g tranexamic acid, and preoperative transfusion with 2 units of platelets. Patients following other oral anticoagulant regimens received 50 IU/kg of prothrombin complex concentrates and 10 mg of vitamin K. There was no significant difference in the rebleeding rate between the OAT and no-OAT groups. The in-hospital mortality rate was significantly higher for patients who were taking a thrombocyte inhibitor (OR 3.3), whereas patients who were taking a vitamin K antagonist had a significantly higher 6-month mortality rate (OR 2.7). Patients taking DOACs showed a tendency toward unfavorable outcome, with higher mortality rates than patients on conventional OAT or patients in the vitamin K antagonist subgroup. Independent predictors for unfavorable outcome at discharge were comatose status 24 hours after surgery (OR 93.2), rebleeding (OR 9.8), respiratory disease (OR 4.1), and infection (OR 11.1) (Nagelkerke R2 = 0.684). Independent predictors for unfavorable outcome at follow-up were comatose status 24 hours after surgery (OR 12.7), rebleeding (OR 3.1), age ≥ 70 years (OR 3.1), and 6 or more comorbidities (OR 3.1, Nagelkerke R2 = 0.466). OAT itself was not an independent predictor for worse outcome. CONCLUSIONS An OAT regimen at the time of presentation with aSDH is associated with increased mortality rates and unfavorable outcome at discharge and follow-up. Thrombocyte inhibitor treatment was associated with increased short-term mortality, whereas vitamin K antagonist treatment was associated with increased long-term mortality. In particular, patients on DOACs were seriously affected, showing more unfavorable outcomes at discharge as well as at follow-up. The suggested medical treatment for aSDH in both OAT and no-OAT patients seems to be effective and reasonable, with comparable rebleeding and favorable outcome rates in the 2 groups. In addition, prior OAT is not a predictor for aSDH outcome.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Markus Bruder
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Adriano Cattani
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
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Won SY, Zagorcic A, Dubinski D, Quick-Weller J, Herrmann E, Seifert V, Konczalla J. Excellent accuracy of ABC/2 volume formula compared to computer-assisted volumetric analysis of subdural hematomas. PLoS One 2018; 13:e0199809. [PMID: 29944717 PMCID: PMC6019668 DOI: 10.1371/journal.pone.0199809] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/10/2018] [Indexed: 11/19/2022] Open
Abstract
Background Subdural hematoma (SDH) is a common disease associated with high morbidity, which is becoming more prominent due to the increasing incidence. Decision for a surgical evacuation is made depending on the clinical appearance and the volume of SDH, wherefore it is important to have a simple ‘bedside’ method to measure and compare the volume of SDH. Objective The aim of the study was to verify the accuracy of the simplified ABC/2 volumetric formula to determine a valuable tool for the clinical practice. Methods Preoperative CT-scans of 83 patients with SDHs were used for the computer-assisted volumetric measurement via BrainLab® as well as the ABC/2 volumetric measurement. A = largest length (anterior to posterior) of the SDH; B = maximum width (lateral to midline) 90° to A; C = maximum height (coronal plane or multiplication of slices) of the hematoma. These measurements were performed by two independent clinicians in a blinded fashion. Both volumes were compared by linear regression analysis of Pearson and Bland-Altman regression analysis. Results Among 100 SDHs, 53% were under an 47% were over 100cm3 showing a well distribution of the hematoma sizes. There was an excellent correlation between computer-assisted volumetric measurement and ABC/2 (R2 = 0.947, p<0.0001) and no undesirable deviation and trend were detected (p = 0.101; p = 0.777). A 95% tolerance region of the ratios of both methods was [0.805–1.201]. Conclusion The ABC/2 method is a simple and fast bedside formula for the measurement of SDH volume in a timely manner without limited access through simple adaption, which may replace the computer-assisted volumetric measurement in the clinical and research area. Reason for the good accuracy seems to be the spherical form of SDH, which has a similarity to a half ellipsoid.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
- * E-mail:
| | - Andrea Zagorcic
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
- Deparment of Neuroradiology, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Johanna Quick-Weller
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Department of Medicine, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
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Won SY, Dubinski D, Brawanski N, Strzelczyk A, Seifert V, Freiman TM, Konczalla J. Significant increase in acute subdural hematoma in octo- and nonagenarians: surgical treatment, functional outcome, and predictors in this patient cohort. Neurosurg Focus 2017; 43:E10. [DOI: 10.3171/2017.7.focus17417] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAcute 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.METHODSThe 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).RESULTSIn 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).CONCLUSIONSThe 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.
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Affiliation(s)
| | | | | | - Adam Strzelczyk
- 2Neurology, and
- 3Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University, Frankfurt am Main, Germany
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Weimer JM, Gordon E, Frontera JA. Predictors of Functional Outcome After Subdural Hematoma: A Prospective Study. Neurocrit Care 2017; 26:70-79. [PMID: 27230968 DOI: 10.1007/s12028-016-0279-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although the incidence of subdural hematoma (SDH) has increased in the US in the last decade, limited prospective data exist examining risk factors for poor outcome. METHODS A prospective, observational study of consecutive SDH patients was conducted from 7/2008 to 11/2011. Baseline clinical data, hospital and surgical course, complications, and imaging data were compared between those with good versus poor 3-month outcomes (modified Rankin Scores [mRS] 0-3 vs. 4-6). A multivariable logistic regression model was constructed to identify independent predictors of poor outcome. RESULTS 116 SDH patients (18 acute, 56 mixed acute/subacute/chronic, 42 subacute/chronic) were included. At 3 months, 61 (53 %) patients had good outcomes (mRS 0-3) while 55 (47 %) were severely disabled or dead (mRS 4-6). Of those who underwent surgical evacuation, 54/94 (57 %) had good outcomes compared to 7/22 (32 %) who did not (p = 0.030). Patients with mixed acuity or subacute/chronic SDH had significantly better 3-month mRS with surgery (median mRS 1 versus 5 without surgery, p = 0.002) compared to those with only acute SDH (p = 0.494). In multivariable analysis, premorbid mRS, age, admission Glasgow Coma Score, history of smoking, and fever were independent predictors of poor 3-month outcome (all p < 0.05; area under the curve 0.90), while SDH evacuation tended to improve outcomes (adjusted OR 3.90, 95 % CI 0.96-18.9, p = 0.057). CONCLUSIONS Nearly 50 % of SDH patients were dead or moderate-severely disabled at 3 months. Older age, poor baseline, poor admission neurological status, history of smoking, and fever during hospitalization predicted poor outcomes, while surgical evacuation was associated with improved outcomes among those with mixed acuity or chronic/subacute SDH.
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Affiliation(s)
- Jonathan M Weimer
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, 9500 Euclid Ave. S80, Cleveland, OH, 44195, USA
| | - Errol Gordon
- Neuroscience Intensive Care Unit, Department of Critical Care, Mount Sinai School of Medicine, New York, NY, USA
| | - Jennifer A Frontera
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, 9500 Euclid Ave. S80, Cleveland, OH, 44195, USA.
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Unterhofer C, Ho WM, Wittlinger K, Thomé C, Ortler M. "I am not afraid of death"-a survey on preferences concerning neurosurgical interventions among patients over 75 years. Acta Neurochir (Wien) 2017. [PMID: 28623411 DOI: 10.1007/s00701-017-3240-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Treatment decisions in elderly patients with traumatic brain injury (TBI) are mainly determined by trauma severity and patient age. The aim of this study was to explore personal preferences of potential patients regarding life-prolonging neurosurgical interventions by interviewing ambulatory, autonomous elderly people. METHODS One hundred consecutive patients older than 75 years frequenting the outpatient clinic of the Department of Neurosurgery were interviewed about their attitudes regarding the hypothetical case of an 81-year-old patient with TBI and a space-occupying acute subdural hematoma (aSDH) using a 21-point questionnaire. RESULTS Fifty-one percent of the consulted persons declined life-prolonging surgical measures. If surgery was associated with physical disability, 68% of the people wished no surgery. In case of cognitive impairment after surgery, 91% were against any surgical intervention. The majority feared being a burden to relatives (76%) and becoming unable to master an independent life (75%). Four-fifths of the interviewed patients (82%) were not afraid of death. CONCLUSIONS The majority of elderly patients only consent to surgical measures if no relevant disabilities are involved and if they can return to their previous life. These findings need consideration in case of life-threatening neurosurgical emergencies as well as in the surgical treatment of elderly patients in general.
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Affiliation(s)
- Claudia Unterhofer
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Wing Mann Ho
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Katrin Wittlinger
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Martin Ortler
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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Nathan S, Goodarzi Z, Jette N, Gallagher C, Holroyd-Leduc J. Anticoagulant and antiplatelet use in seniors with chronic subdural hematoma. Neurology 2017; 88:1889-1893. [DOI: 10.1212/wnl.0000000000003918] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/26/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:To address whether to restart older patients on anticoagulants or antiplatelet agents in the setting of a chronic subdural hematoma (cSDH).Methods:This is an update of a previous review (searched until July 2012). Medline, EMBASE, ISI Web of Knowledge, Google Scholar, PLOS, and the Cochrane Register for Systematic Reviews databases were searched from January 2012 to December 2016. Studies included older adults (those over 65 years) experiencing traumatic subdural hematoma or cSDH who were on anticoagulation or antiplatelet agents.Results:Seven studies were included (mean age 72 years). Four out of 7 studies provided combined data on anticoagulants or antiplatelet use. Only one study found anticoagulant or antiplatelet agent use to be a significant factor for cSDH rebleeding. Two studies considered anticoagulant use only and both reported similar increased odds of rebleeding (odds ratio [OR] 1.75, 95% confidence interval [CI] 0.18–16.86; OR 2.7 95% CI 1.42–6.96). Antiplatelets were not found to be associated with rebleeding. Ideal timing to resume anticoagulants or antiplatelets was unclear.Conclusions:Anticoagulant medication was associated with increased rebleeding risk in older adults with cSDH. However, antiplatelet medication was not associated with increased risk of rebleeding.
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Unterhofer C, Hartmann S, Freyschlag CF, Thomé C, Ortler M. Severe head injury in very old patients: to treat or not to treat? Results of an online questionnaire for neurosurgeons. Neurosurg Rev 2017; 41:183-187. [PMID: 28220369 DOI: 10.1007/s10143-017-0833-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 11/29/2022]
Abstract
Due to the aging population, neurosurgeons are confronted with an increasing number of very old patients suffering from traumatic brain injury. Many of these patients present with an acute subdural hematoma. There is a lack of data on neurosurgical decision-making in elderly people. We investigated the importance of imaging criteria, patients' wishes, their surrogates' wishes, and patient demographics on treatment decisions chosen by neurosurgeons. An online questionnaire was sent to all German neurosurgical units via the German Society of Neurosurgery (DGNC). The survey was based on the reported case of an unconscious 81-year-old patient with an acute subdural hematoma and consisted of 13 questions. Of these questions, nine addressed indication and treatment plan and four evaluated the neurosurgeon's interest in gathering additional information on the patient's social environment and supposed patient's wishes or advance directive. Eighty-five percent of the interviewed neurosurgeons would perform an emergency operation in the presented case. Midline shift (84%), hematoma thickness (81%), and time between traumatic injury and treatment (81%) were considered to be the most important factors for surgical treatment. Gathering information on the social environment of the patient (66%) and discussion with family members (57%) were felt to be either unimportant. Neurosurgeons in Central Europe tend to treat acute subdural hematoma in very old patients based on imaging findings and according to mechanistic views. Social circumstances and patient wishes are considered to be less important. Education of the medical profession and the general public should aim to bring these factors into focus in the decision-making process.
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Affiliation(s)
- Claudia Unterhofer
- Department of Neurosurgery, Medical University of Innsbruck, 6020, Innsbruck, Austria.
| | - Sebastian Hartmann
- Department of Neurosurgery, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | | | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Martin Ortler
- Department of Neurosurgery, Medical University of Innsbruck, 6020, Innsbruck, Austria
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Schoedel P, Bruendl E, Hochreiter A, Scheitzach J, Bele S, Brawanski A, Schebesch KM. Restoration of Functional Integrity After Evacuation of Chronic Subdural Hematoma—An Age-Adjusted Analysis of 697 Patients. World Neurosurg 2016; 94:465-470. [DOI: 10.1016/j.wneu.2016.07.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/06/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
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Munteanu V, Luca-Husti I, Coman TC, Ciurea AV. Differential diagnostic problems in elderly chronic subdural hematoma patients. ROMANIAN NEUROSURGERY 2016. [DOI: 10.1515/romneu-2016-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Chronic subdural hematomas (CSDH) are recognized as common in older people (over 70 years). They are produced in minor injuries (falls on the same level). These CSDH have minor symptoms (headache, memory disorders, balance disorders, cognitive disorders, etc. and are classified as signs for the onset of dementia, circulatory failure - basilar vertebra, Alzheimer, etc. A simple brain CT scan can highlight these hematomas and a neurosurgical intervention will achieve extremely favorable prognosis. There are many pitfalls in the differential diagnosis of CSH especially with strokes being so common at this age.
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Szczygielski J, Gund SM, Schwerdtfeger K, Steudel WI, Oertel J. Factors Affecting Outcome in Treatment of Chronic Subdural Hematoma in ICU Patients: Impact of Anticoagulation. World Neurosurg 2016; 92:426-433. [PMID: 27241090 DOI: 10.1016/j.wneu.2016.05.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 05/14/2016] [Accepted: 05/18/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND The use of anticoagulants and older age are the main risk factors for chronic subdural hematoma (CSDH). Because the age of the population and use of anticoagulants are increasing, a growing number of CSDH cases is expected. To address this issue, we analyzed the impact of anticoagulants on postsurgical outcome in patients in the intensive care unit (ICU). METHODS Demographic data, coagulation parameters, surgical details, radiologic appearance of hematoma, Glasgow Coma Scale (GCS) score on admission, and Glasgow Outcome Scale (GOS) score on discharge were retrieved and retrospectively analyzed in 98 patients with CSDH treated in the neurosurgical ICU using correlation coefficient tests and multivariate analysis test. RESULTS Overall outcome was good (GOS score 4 and 5) in 55.1% of patients. Overall mortality was 9.1%. There was a correlation between GCS score on admission and GOS score. There was no correlation between hematoma thickness/radiologic appearance and impaired coagulation. Disturbance in thrombocyte function (usually resulting from aspirin intake) correlated with improved outcome, whereas warfarin-related coagulopathy correlated with poor recovery. Nevertheless, patients with thrombocytopathy presented with better initial GCS scores. Neither hematoma size nor recurrence rate affected the outcome. CONCLUSIONS The size of CSDH was not associated with poor outcome and is not necessarily determined by the use of anticoagulants. Coagulopathy does not rule out a good outcome, but the impact of anticoagulation on treatment results in CSDH varies between the main groups of drugs (warfarin vs. antiplatelet drugs). Patients in good neurologic condition on ICU admission have better chances of recovery.
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Affiliation(s)
- Jacek Szczygielski
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany.
| | - Sina-Maria Gund
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Karsten Schwerdtfeger
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Wolf-Ingo Steudel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
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Carr SB, Bolles GE. Complete resolution of acute subdural hematoma in an elderly patient with the subdural evacuating port system. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408615592428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 79-year-old patient on an antiplatelet medication presented to the emergency department following a fall at home. She was found to have an enlarging mixed density acute subdural hematoma with significant mass effect and impaired neurologic status and was successfully treated with a subdural evacuating port system drain placement. The patient had rapid and complete radiographic resolution of the hematoma and return to her premorbid neurologic status. A craniotomy, and the associated risks, was avoided. Elderly patients are at particular risk for developing subdural hematomas given the high rates of receiving antiplatelet and anticoagulation therapies, risk for falls, and difficulties with safe ambulation and independent living. Twist drill craniostomy drainage through catheter or subdural evacuating port system placement has been used effectively in the treatment of liquefied older chronic or subacute subdural hematomas. However, acute subdural hematomas, when large or symptomatic enough to require evacuation have historically been treated by craniotomy. Craniotomy in elderly patients with a subdural hematoma has significant risks and typically requires several days of hospitalization and intensive care, which was avoided in this patient. Subdural evacuating port system drain placement can be an effective treatment option in some elderly patients with acute subdural hematomas, which have a significant hypodense component.
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Affiliation(s)
- Steven B Carr
- Department of Neurosurgery, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Department of Neurosurgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Gene E Bolles
- Department of Neurosurgery, Denver Health Medical Center, Denver, Colorado, USA
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Leroy HA, Aboukaïs R, Reyns N, Bourgeois P, Labreuche J, Duhamel A, Lejeune JP. Predictors of functional outcomes and recurrence of chronic subdural hematomas. J Clin Neurosci 2015; 22:1895-900. [PMID: 26260114 DOI: 10.1016/j.jocn.2015.03.064] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/14/2015] [Accepted: 03/18/2015] [Indexed: 11/16/2022]
Abstract
We aimed to evaluate the functional outcome and risk factors of recurrence in patients operated on for a chronic subdural hematoma (CSH), and discuss systematic early postoperative CT scans. CSH is a very common disease in neurosurgical practice, especially in elderly patients who are treated with anticoagulation. The challenge is to rapidly restore the independence of these patients. We retrospectively analyzed data from 164 consecutive surgical procedures performed on 140 CSH patients, including recurrent surgery, at our institution from June 2011 to June 2012. Pre- and postoperative CT scans, and medical records, were systematically reviewed using the institutional computing database. A poor functional outcome was defined by a modified Rankin scale (mRS) score>2 at 3 months. Among the 140 patients (mean age 76 years; 64% men), a single burr hole craniostomy was performed in 122 patients, and a craniotomy in 18. A poor functional outcome was recorded in 39 patients (28%; 95% confidence interval [CI] 20-35%). In multivariate analyses, an increased risk of poor functional outcome was associated with age >75 years (odds ratio [OR] 5.88; 95% CI 1.96-17.63), residual hematoma thickness >14 mm (OR 3.79; 95% CI 1.47-9.77), and GCS<15 (OR, 2.96; 95% CI, 1.18-7.40). Recurrences occurred in 24 patients (17%; 95% CI 11-23%), with a median delay to reintervention of 13 days. The independent predictors of CSH recurrence were preoperative anticoagulant therapy (OR 3.68; 95% CI 1.13-12.00), and persistence of mass effect on the postoperative CT scan (OR 5.61; 95% CI 1.52-20.66). Three months after surgical treatment, more than one quarter of the CSH patients had a mRS⩾3. The loss of independence was associated with older age, initial GCS<15, and residual hematoma thickness postoperatively. Anticoagulant therapy and persistence of postoperative mass effect heightened the risk of recurrence.
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Affiliation(s)
- Henri-Arthur Leroy
- Department of Neurosurgery, Lille University Hospital, Rue Emile Laine, 59037 Lille Cedex, France.
| | - Rabih Aboukaïs
- Department of Neurosurgery, Lille University Hospital, Rue Emile Laine, 59037 Lille Cedex, France
| | - Nicolas Reyns
- Department of Neurosurgery, Lille University Hospital, Rue Emile Laine, 59037 Lille Cedex, France
| | - Philippe Bourgeois
- Department of Neurosurgery, Lille University Hospital, Rue Emile Laine, 59037 Lille Cedex, France
| | - Julien Labreuche
- Department of Biostatistics, University of Lille Nord de France, Lille University Hospital, France
| | - Alain Duhamel
- Department of Biostatistics, University of Lille Nord de France, Lille University Hospital, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Lille University Hospital, Rue Emile Laine, 59037 Lille Cedex, France
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Alcalá-Cerra G, Young AM, Moscote-Salazar LR, Paternina-Caicedo Á. Efficacy and Safety of Subdural Drains After Burr-Hole Evacuation of Chronic Subdural Hematomas: Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2014; 82:1148-57. [DOI: 10.1016/j.wneu.2014.08.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
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Shimoda K, Maeda T, Tado M, Yoshino A, Katayama Y, Bullock MR. Outcome and Surgical Management for Geriatric Traumatic Brain Injury: Analysis of 888 Cases Registered in the Japan Neurotrauma Data Bank. World Neurosurg 2014; 82:1300-6. [DOI: 10.1016/j.wneu.2014.08.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 05/13/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
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Tabuchi S, Kadowaki M. Chronic subdural hematoma in patients over 90 years old in a super-aged society. J Clin Med Res 2014; 6:379-83. [PMID: 25110543 PMCID: PMC4125334 DOI: 10.14740/jocmr1907w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2014] [Indexed: 11/29/2022] Open
Abstract
Background Chronic subdural hematoma (CSDH) is one of the most common diseases in neurosurgical practice, particularly among aged patients. With the continuing increase in the aged population, further increases in incidence are expected. However, few studies have focused on CSDH in super-aged patients over 90 years old. Methods We retrospectively reviewed medical records for 20 consecutive patients over 90 years old with CSDH treated in our department between 2007 and 2013. The diagnosis of CSDH was confirmed by computed tomography (CT). Patients were divided into a surgery group and a conservative group. Surgical procedures included burr-hole surgery followed by insertion of a subdural drain under local anesthesia. Clinical data were compared and analyzed. Neurological status was evaluated according to the modified Rankin Scale at three time points: before suffering from CSDH; at the time of referral or admission to our department; and at discharge or 1 month after the first referral. Statistical tests were used to analyze data and values of P < 0.05 were considered significant. Results Mean age for the 20 cases was 92.6 years (range, 90 - 96 years). The leading symptoms in this population were hemiparesis and gait disturbance, followed by disturbance of consciousness and speech disturbance. Twelve patients underwent burr-hole surgery. Mean maximum thickness of subdural hematoma as measured on CT was significantly higher in the surgery group (28.2 ± 5.4 mm) than in the conservative group (17.0 ± 3.8 mm; P < 0.01). Postoperatively, mean neurological status was significantly improved in the surgery group (P < 0.01). After surgery, 66.7% of patients could return home directly from hospital. No significant perioperative complications directly related to surgery were encountered in the surgery group, except for transient postoperative restlessness and bruising of extremities due to falls. Conclusions Surgery for CSDH is safe and positively recommended even in super-aged patients over 90 years old if the patient’s physical status is fair. Pre-illness status is the most important factor for considering operative indications and represents a limiting factor for postoperative outcomes in this age population.
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Affiliation(s)
- Sadaharu Tabuchi
- Department of Neurosurgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Mitsutoshi Kadowaki
- Department of Neurosurgery, Tottori Prefectural Central Hospital, Tottori, Japan
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Panciani PP, Roca E, Lodoli G, Fontanella MM. Sudden worsening after subdural haematoma surgery: will there be a corpus callosum injury? BMJ Case Rep 2014; 2014:bcr-2013-203278. [PMID: 24862419 DOI: 10.1136/bcr-2013-203278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of mild encephalopathy with a reversible splenial lesion (MERS) which occurred after chronic subdural haematoma (CSDH) surgery. The patient was admitted to our hospital for drowsiness and marked asthenia. The cerebral CT scan revealed a CSDH and surgery allowed to improve the symptoms, but after several days we observed a sudden worsening. The patient developed left-sided myoclonic seizures followed by left hemiplegia and worsening drowsiness. Electrolytes imbalance and inflammatory causes were excluded. The CT scan showed a right cerebral swelling and the subsequent MRI revealed a single lesion in the splenium of the corpus callosum, hyperintense on diffusion-weighted images. After osmotic therapy the patient improved and on day 10 of admission the MRI showed a complete resolution of the lesion. This is the first report that described an association between CSDH and MERS. Possible aetiopathogenetic mechanisms are discussed.
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Affiliation(s)
- Pier Paolo Panciani
- Department of Neuroscience, Division of Neurosurgery, University of Brescia, Brescia, Italy
| | - Elena Roca
- Department of Neuroscience, Division of Neurosurgery, University of Brescia, Brescia, Italy
| | - Giovanni Lodoli
- Department of Neuroscience, Division of Diagnostic Imaging, University of Brescia, Brescia, Italy
| | - Marco Maria Fontanella
- Department of Neuroscience, Division of Neurosurgery, University of Brescia, Brescia, Italy
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Van Der Veken J, Duerinck J, Buyl R, Van Rompaey K, Herregodts P, D’Haens J. Mini-craniotomy as the primary surgical intervention for the treatment of chronic subdural hematoma--a retrospective analysis. Acta Neurochir (Wien) 2014; 156:981-7. [PMID: 24615068 DOI: 10.1007/s00701-014-2042-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 02/16/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The incidence of chronic subdural hematoma (CSDH) is increasing, but optimal treatment remains controversial. Recent meta-analyses suggest burr hole (BH) drainage is the best treatment because it provides optimal balance between recurrence and morbidity. Mini-craniotomy may offer supplementary technical advantages while maintaining equal or better outcomes. This study investigates the outcome of mini-craniotomy as the sole treatment in patients with CSDH. METHOD We analyzed all patients operated on for CSDH with mini-craniotomy in our neurosurgical center between 2005-2010. Baseline patient characteristics (age, sex, comorbidities, imaging characteristics, known risk factors for development of CSDH and neurological examination at presentation) and outcomes (mortality, complications, recurrence and neurological examination at discharge) were recorded. RESULTS One hundred twenty-six adult patients were included, mean age was 73.9 (range 18 to 95) years old, and the sex ratio (M:F) was 2:1. Eighty-four percent of the patients showed clinical improvement at discharge, as shown by a decrease in the Markwalder score postoperatively (with 57 % Markwalder 0 and 23 % Markwalder 1). Recurrence rate was 8.7 %. Overall complication rate was 34.1 % (27.8 % medical complications and 6.3 % surgical complications). In-hospital mortality was 13.5 % (8.7 % due to pulmonary infections and 1.6 % to surgical complications). Preoperative Markwalder grade correlated significantly with complication rate, as did the presence of a neurodegenerative disease (p = 0.018). Factors significantly related to mortality in univariate analysis were arterial hypertension (p = 0.038), heart failure (p = 0.02), renal failure (p = 0.017), neurodegenerative disease (p = 0.001), cerebrovascular accident (p = 0.008) and coagulopathy (p = 0.019). Multivariate analysis was not able to confirm any significant relationship. CONCLUSION This is the first published series of CSDH in which all consecutive patients were operated on by mini-craniotomy. The invasiveness and complication rate of mini-craniotomy are equal to those of burr hole treatment, but visualization is superior, resulting in lower recurrences. A randomized controlled trial is indicated to identify the best surgical strategy for the treatment of CSDH.
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Matis GK, Chrysou OI, Birbilis TA. The "Young men may die, but old men must die" concept reappraised: The case of subdural hematomas. J Neurosci Rural Pract 2013; 4:245-6. [PMID: 24250151 PMCID: PMC3821404 DOI: 10.4103/0976-3147.118757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Georgios K Matis
- Department of Neurosurgery, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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