Mortality in Elderly Patients Operated for an Acute Subdural Hematoma: A Surgical Case Series

doi:10.1016/j.wneu.2015.10.095

World Neurosurgery

Volume 88, April 2016, Pages 592-597

https://doi.org/10.1016/j.wneu.2015.10.095 Get rights and content

Background

Surgery for elderly patients with acute subdural hematomas (ASDH) is controversial, because postoperative mortality rates are reported to be high and long-term outcomes unknown. Thus, we aimed to describe midterm and long-term mortality rates of elderly patients operated for an ASDH.

Methods

We reviewed all consecutive ≥75-year-old patients operated on for an ASDH between 2009 and 2012. We recorded data on preadmission functional status (independent or dependent) and use of antithrombotic medication. Patients were followed up a median of 4.2 years (range, 2.5–6.4 years).

Results

Forty-four patients were included. The majority of the patients (70%) were independent and taking antithrombotic medication (77%). Independent patients had a 1-year mortality of 42%, compared to 69% for dependent patients; 56% of patients taking antithrombotics and 30% of those without antithrombotics died within the first postoperative year. All patients with an admission Glasgow coma scale score of 3–8 died within the first postoperative year, if they used antithrombotics or were dependent before the injury. Of all 1-year survivors, 77% were alive at the end of follow-up.

Conclusion

In this first surgical case series of 75-year-old or older patients with ASDH, the overall mortality rate appears to be relatively low, especially for preoperatively conscious and independent patients without antithrombotic medication. Patients alive at 1-year after surgery had a life expectancy comparable to their age-matched peers. The prognosis seems to be detrimental for preoperatively unconscious patients who were functionally dependent or used antithrombotic medication before the injury.

Introduction

The mean age of patients with traumatic brain injury (TBI) is rapidly increasing, especially in the Western world.1, 2 During the last decades, the median age of patients with TBI has increased from 25 to 55 years, and it presumably continues to increase in the future.3, 4, 5, 6, 7, 8 Current treatment guidelines are based on studies performed on much younger study populations than commonly seen in daily practice.⁹ In elderly patients with TBI, particularly, the use of antithrombotic medication together with comorbidities poses treatment challenges.

Early studies from the era preceding computed tomography have shown poor outcome for patients with acute subdural hematomas (ASDHs),¹⁰ and even poorer outcome in the elderly.¹¹ Nowadays, craniotomy and hematoma evacuation is standard care for patients with expansive ASDHs.⁹ For younger patients (<65 years old), large observational cohorts have reported mortality rates of 35%–55%, despite the surgical evacuation of hematoma. For patients older than 65 years, studies from the 1980s and 1990s have reported much higher postoperative mortality rates, ranging from 74% to 88%.12, 13, 14, 15, 16, 17, 18 Since the turn of the millennium, only a few studies have reported outcomes of elderly patients with surgically treated ASDHs, and reported mortality rates have varied between 35% and 50%.19, 20, 21 However, no studies focusing on patients of 75 years of age and older have been published.

In the current study, we analyzed medium-term and long-term (1- and 3-year) mortality rates of elderly patients (≥75 years old) operated on for ASDHs in our institution between 2009 and 2012. We specifically aimed to determine the role of pretrauma functional status and usage of antithrombotic medications on mortality rates, and estimate excess mortality rates for elderly ASDH survivors.

Section snippets

Study Population and Data Collection

We conducted a retrospective case series study including all elderly patients (defined as age ≥ 75 years) operated consecutively for ASDHs in our level 1 trauma center (Helsinki University Hospital) between January 1, 2009, and December 31, 2012. Our trauma center is a public, nonprofit hospital with a catchment area of nearly 2 million people, being the largest trauma center in Finland.

We included only TBI patients whose main finding was an ASDH, and who were operated on an emergency basis

Baseline Characteristics

During the study period between 2009 and 2012, 1000 patients with TBIs were treated in our neurosurgical intensive care unit. Of these, 124 patients were 75 years of age or older. Of the 124 patients, 76 patients had an operable ASDH without any other major intracranial injuries. Of these, 44 patients were operated on and included in the present study. Of the included 44 patients, 70% (n = 31/44) were independent and 30% (n = 13/44) were dependent before injury. Only 4 patients (9%) lived in a

Discussion

In this first study of medium-term and long-term mortality rates after emergency surgery for ASDHs in 75-year-old and older patients, 22 of 44 operated elderly patients were alive at 1 year. Only 5 of 22 one-year survivors died during the following 2 years. Of the 17 three-year survivors, no one died during the follow-up. Thus, 1-year survivors seem to have a mortality rate comparable to their peers. As for younger patients with TBI, the level of consciousness on admission, measured using the

Conclusion

In this first surgical case series of 75-year-old or older patients with ASDH, the overall mortality rate appears to be relatively low, especially for preoperatively conscious and independent patients without antithrombotic medication. The prognosis seems to be detrimental for preoperatively unconscious patients being dependent or taking antithrombotic medication. Patients who were alive 1 year after surgery had a life expectancy comparable to their age-matched peers.

References (27)

E. Herou et al.
Acute traumatic brain injury: mortality in the elderly
World Neurosurg
(2015)
P. Taussky et al.
Age and salvageability: analysis of outcome of patients older than 65 years undergoing craniotomy for acute traumatic subdural hematoma
World Neurosurg
(2012)
G. Teasdale et al.
Assessment of coma and impaired consciousness. A practical scale
Lancet
(1974)
B. Roozenbeek et al.
Changing patterns in the epidemiology of traumatic brain injury
Nat Rev Neurol
(2013)
F. Tagliaferri et al.
A systematic review of brain injury epidemiology in Europe
Acta Neurochir (Wien)
(2006)
T.M. Andriessen et al.
Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study
J Neurotrauma
(2011)
M.A. Foulkes et al.
The Traumatic Coma Data Bank: design, methods, and baseline characteristics
J Neurosurg
(1991)
G.D. Murray et al.
The European Brain Injury Consortium survey of head injuries
Acta Neurochir (Wien)
(1999)
L.S. Murray et al.
Head injuries in four British neurosurgical centres
Br J Neurosurg
(1999)
R. Raj et al.
Predicting six-month mortality of patients with traumatic brain injury: usefulness of common intensive care severity scores
Crit Care
(2014)

N. Stocchetti et al.

Traumatic brain injury in an aging population

J Neurotrauma

(2012)

Brain Trauma Foundation

American Association of Neurological Surgeons, Congress of Neurological Surgeons: Guidelines for the management of severe traumatic brain injury

J Neurotrauma

(2007)

J. Hernesniemi

Outcome following acute subdural haematoma

Acta Neurochir (Wien)

(1979)

Cited by (41)

Endoscope-assisted techniques for evacuation of acute subdural haematoma in the elderly: The lesser of two evils? A scoping review of the literature
2021, Clinical Neurology and Neurosurgery
Surgical evacuation of acute subdural haematoma (ASDH) in the elderly remains a point of contention due to the significant associated mortality. Therefore, there is a dire need for alternative treatment options. Endoscope-assisted techniques (EAT) have been increasingly reported over the last decade with variable outcomes. In this scoping review, we identify studies reporting the use of EAT for ASDH evacuation in elderly patients. Outcomes and patient selection criteria are discussed to identify patients that may benefit from EAT.
A multi-database literature search was performed between January 1990 and January 2021. Studies including patients aged 60 years or above who underwent EAT for ASDH evacuation with reported outcomes were included.
A total of 13 studies and 122 patients were eligible for inclusion. Patient age ranged from 65 to 101 years, and average age from 78.6 to 87.4 years. High comorbidity burden, advanced age, absence of adverse imaging features, and pre-operative neurological status were the most common eligibility criteria for EAT. 52% of all procedures were performed under local anaesthetic (LA). Mortality rates ranged between 0% and 40%, whilst favourable outcomes ranged between 26.7% and 96.4%. Re-bleed was the most commonly reported complication, ranging between 0% and 13%.
EAT pose a viable compromise for elderly patients with ASDH that may be unfit for GA. Heterogeneity of patient selection criteria prevents meaningful comparison between EAT and other approaches, and there is a clear impact of patient selection on outcome among studies reporting EAT. Further studies are required to identify the patient cohort that may benefit from this approach.
Embolization of the Middle meningeal artery in chronic subdural hematoma — A systematic review
2019, Clinical Neurology and Neurosurgery
Citation Excerpt :
Moreover, the complication rate related directly to the MMAE was of 3.6%. Given that the one-year mortality rate of cSDH reported in other studies is up to 69% in dependent patients [46] and that diagnostic angiography procedures have a well-documented complication rate of 0–2.6%, the accuracy of the safety assessment performed in the reviewed studies is doubtful [47,48]. The low rates of morbidity/mortality could be due to the short length of available follow-up, which totaled a median of 6 months, poor documentation of complications in the charts or due to selection bias.
Chronic subdural hematomas (cSDH) are one of the most frequent reasons for consultation in neurosurgery. Multiple authors have proposed middle meningeal artery embolization (MMAE) as an option in cSDH patients to manage recurrence or avoid surgery altogether. Although many articles have been published on the matter, the current body of evidence still has to be evaluated before MMAE is integrated into clinical practice.
The goal of this study was to review the evidence on MMAE in cSDH to assess its safety, feasibility, indications and efficacy.
We performed a systematic review of the literature according to PRISMA guidelines using multiple electronic databases.
Our search yielded a total of 18 original articles from which data were extracted. A total of 190 patients underwent MMAE from which 81.3% were symptomatic cSDH. Over half (52.3%) of the described population were undergoing antithrombotic therapy. Most (83%) procedures used polyvinyl alcohol (PVA) particles and no complications were reported regarding the embolization procedures. Although the definition of resolution varied among authors, cSDH resolution was reported in 96.8% of cases.
MMAE is a feasible technique for cSDH, but the current body of evidence does not yet support its use as a standard treatment. Further studies with a higher level of evidence are necessary before MMAE can be formally recommended.
Advanced Age Is Not a Universal Predictor of Poorer Outcome in Patients Undergoing Neurosurgery
2019, World Neurosurgery
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.
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.
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.
Overall, our data would suggest that increased age does not universally predict worse outcome and that, for many procedures, surgical decision-making in older patients should instead consider other pertinent factors, such as comorbidities and elective status.
Short- and Long-Term Geriatric Mortality After Acute Traumatic Subdural Hemorrhage
2019, World Neurosurgery
Citation Excerpt :
Considering this, the use of antithrombotic medications in this age group has been steadily increasing despite the inherent risk of hemorrhagic complications and high fall risks.15 Premorbid antithrombotic use has been described as both an important15,22,36 and unimportant3,12,17,23,24,44 contributor to mortality after acute SDH in the geriatric population; however, our results clearly indicate a significant decrease in late survival for these patients. How much these observations can be attributed to the poor level of health intrinsic to those patients on these medications before presentation is still a matter of debate, but it follows that they are likely more debilitated at baseline with less reserve and a greater propensity for larger acute SDH volumes.
Acute subdural hemorrhage often occurs in those ≥65 years of age after trauma and tends to yield poor clinical outcomes. Previous studies have demonstrated a propensity toward high in-hospital mortality rates in this population; however, postdischarge mortality data are limited. The objective of the present study was to analyze short- and long-term mortality data after acute traumatic subdural hemorrhage in the geriatric population as well as review the impact of associated clinical variables including mechanism of injury, pre-morbid antithrombotic use, and need for surgical decompression on mortality rates.
We retrospectively reviewed 455 patients who presented with an isolated traumatic acute subdural hemorrhage to our level-1 trauma center over a 5 year period using our data registry. Patients were then cross-referenced in the National Social Security Death Index for postdischarge mortality rates. United States life tables were used for peer-controlled actuarial comparisons.
Acute traumatic subdural hemorrhage is often a fatal injury in the geriatric population, especially if taking antithrombotics or requiring surgical decompression. Specifically, they have greater in-hospital mortality rates than adults with similar injuries and have significantly lower survival rates for several years following discharge compared with their peer-matched controls.
Here, we found that age is a significant predictor of both short- and long-term survival after acute traumatic subdural hemorrhage. Moreover, the present study corroborates that the need for surgical decompression or the use of pre-morbid antithrombotic medications is associated with increased overall mortality.
Unfavorable functional outcome is expected for elderly patients suffering from acute subdural hematoma even when presenting with preserved level of consciousness
2019, Journal of Clinical Neuroscience
Alongside an increase in life expectancy, median age of patients presenting with traumatic acute subdural hematomas (ASDH) has increased as well. Treatment guidelines are based on studies performed on relatively young patients. The optimal management of elderly (>70 years old) patients with ASDH, specifically those with relatively preserved level of consciousness, was not thoroughly investigated so far. We retrospectively examined elderly patients presented to our medical center between the years 2006–2016 with traumatic convexity ASDH and GCS of 13–15. 773 patients were included in the initial cohort and 54 patients were included in the final analysis. The mean age at presentation was 81.5 years and the means of hematoma thickness and midline shift were 15.5 mm and 6.6 mm, respectively. Patients in our cohort had an overall unfavorable outcome (mRS 5–6) of 28% and 56% at discharge and at 1 year following injury, respectively. The results were not significantly different for the subgroups of patients older than 80 years and patients with high ASA-PS. Surgical evacuation of the ASDH was undertaken in 28 patients with focal neurologic deficit and/or worsening on subsequent brain scans. At 1 year, 64% (18 patients) in the surgery group had unfavorable outcome compared to 48% (12 patients) in the conservative group. We believe that these numbers should be taken under consideration when assessing elderly patients with convexity ASDH and relatively preserved level of consciousness.
Mortality and Functional Outcome in Surgically Evacuated Acute Subdural Hematoma in Elderly Patients
2019, World Neurosurgery
Significant morbidity and mortality is associated with surgical evacuation of acute subdural hematomas (ASDHs) in the elderly population. The literature remains mixed on risk factors associated with poor outcomes, specifically preoperative antithrombotic usage and postoperative seizures.
Between January 1, 2013, and December 31, 2017, we retrospectively identified 62 patients ≥65 years of age who underwent a craniotomy for evacuation of an ASDH, with the primary outcome being Glasgow Outcome Scale (GOS) score at discharge and 3- and 6-month follow-up.
Of the patients, 52% were women, with a median age of 78 years (range, 65–93 years). The mechanism of injury was because of a fall in 40 patients. Twenty-eight patients (44%) had a poor outcome (GOS score 1–2) at discharge, increasing to 31 patients (50%) at 3-month follow-up. Eight patients (13%) had a good outcome (GOS score 4–5) at discharge, increasing to 17 patients (27%) at 3-month follow-up. Perioperative mortality rate was 39%, increasing to 44% at 3-month follow-up. The strongest associations with mortality in descending order were 24-hour postoperative Glasgow Come Scale (GCS) score, midline shift, preoperative GCS score, and pupillary abnormalities. Although age was not a statistically significant factor for mortality, patients with a favorable outcome (GOS score 4–5) had a median age of 71 years versus 78 years for GOS score 1–3. Preoperative antithrombotic usage and postoperative seizures were not significant predictors of outcome or mortality.
A high percentage of morbidity and mortality remains in the management of ASDHs in the elderly population; however, a significant percentage (27%) can still go on to have a favorable outcome.

View all citing articles on Scopus

: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

: The study was funded by grants from Finska Läkaresällskapet, Medicinska Understödsföreningen Liv och Hälsa, and the Maud Kuistila Memorial foundation.

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Original ArticleMortality in Elderly Patients Operated for an Acute Subdural Hematoma: A Surgical Case Series

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study Population and Data Collection

Baseline Characteristics

Discussion

Conclusion

World Neurosurg

World Neurosurg

Lancet

Changing patterns in the epidemiology of traumatic brain injury

Nat Rev Neurol

A systematic review of brain injury epidemiology in Europe

Acta Neurochir (Wien)

Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study

J Neurotrauma

The Traumatic Coma Data Bank: design, methods, and baseline characteristics

J Neurosurg

The European Brain Injury Consortium survey of head injuries

Acta Neurochir (Wien)

Head injuries in four British neurosurgical centres

Br J Neurosurg

Predicting six-month mortality of patients with traumatic brain injury: usefulness of common intensive care severity scores

Crit Care

Traumatic brain injury in an aging population

J Neurotrauma

American Association of Neurological Surgeons, Congress of Neurological Surgeons: Guidelines for the management of severe traumatic brain injury

J Neurotrauma

Outcome following acute subdural haematoma

Acta Neurochir (Wien)

Original Article
Mortality in Elderly Patients Operated for an Acute Subdural Hematoma: A Surgical Case Series