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Nisson PL, Francis JJ, Michel M, Goel K, Patil CG. Extreme-aged patients (≥ 85 years) experience similar outcomes as younger geriatric patients following chronic subdural hematoma evacuation: a matched cohort study. GeroScience 2024; 46:3543-3553. [PMID: 38286851 PMCID: PMC11226415 DOI: 10.1007/s11357-024-01081-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/12/2024] [Indexed: 01/31/2024] Open
Abstract
Subdural hematoma (SDH) evacuation represents one of the most frequently performed neurosurgical procedures. Several reports cite a rise in both the age and number of patient's requiring treatment, due in part to an aging population and expanded anticoagulation use. However, limited data and conflicting conclusions exist on extreme-aged geriatric patients (≥ 85 years of age) after undergoing surgery. Patients undergoing SDH evacuation at a tertiary academic medical center between November 2013-December 2021 were retrospectively identified. The study group consisted of patients ≥ 85 years (Group 1) diagnosed with a chronic SDH surgically evacuated. A control group was created matching patients by 70-84 years of age, gender, and anticoagulation use (Group 2). Multiple metrics were evaluated between the two including length-of hospital-stay, tracheostomy/PEG placement, reoperation rate, complications, discharge location, neurological outcome at the time of discharge, and survival. A total of 130 patients were included; 65 in Group 1 and 65 in Group 2. Patient demographics, medical comorbidities, SDH characteristics, international normalized ratio, partial thromboplastin time, and use of blood thinning agents were similar between the two groups. Kaplan Meier survival analysis at one-year was 80% for Group 1 and 76% for Group 2. No significant difference was identified using the log-rank test for equality of survivor functions (p = 0.26). All measured outcomes including GCS at time of discharge, length of stay, rate of reoperations, and neurological outcome were statistically similar between the two groups. Backwards stepwise conditional logistic regression revealed no significant association between poor outcomes at the time of discharge and age. Alternatively, anticoagulation use was found to be associated with poor outcomes (OR 3.55, 95% CI 1.08-11.60; p = 0.036). Several outcome metrics and statistical analyses were used to compare patients ≥ 85 years of age to younger geriatric patients (70-84 years) in a matched cohort study. Adjusting for age group, gender, and anticoagulation use, no significant difference was found between the two groups including neurological outcome at discharge, reoperation rate, and survival.
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Affiliation(s)
- Peyton L Nisson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - John J Francis
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Michelot Michel
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Chirag G Patil
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Trevisi G, Scerrati A, Rustemi O, Ricciardi L, Raneri F, Tomatis A, Piazza A, Auricchio AM, Stifano V, Dughiero M, DE Bonis P, Mangiola A, Sturiale CL. The role of the craniotomy size in the surgical evacuation of acute subdural hematomas in elderly patients: a retrospective multicentric study. J Neurosurg Sci 2024; 68:403-411. [PMID: 35380204 DOI: 10.23736/s0390-5616.22.05648-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Elderly patients operated for an acute subdural hematoma (ASDH) frequently have a poor outcome, with a high frequency of death, vegetative status, or severe disability (Glasgow Outcome Score [GOS] 1-3). Minicraniotomy has been proposed as a minimally invasive surgical treatment to reduce the impact of surgery in the elderly population. The present study aimed to compare the influence of the size of the craniotomy on the functional outcome in patients undergoing surgical treatment for ASDH. METHODS We selected patients ≥70 years old admitted to 5 Italian tertiary referral neurosurgical for the treatment of a post-traumatic ASDH between January 1, 2016, and December 31, 2019. We collected demographic data, clinical data (GCS, GOS, Charlson Comorbidity Index [CCI], antiplatelet/anticoagulant therapy, neurological deficits, seizure, pupillary size, length of stay), surgical data (craniotomy size, dividing the patients into 3 groups based on the corresponding tertile, and surgery duration), radiological data (ASDH side and thickness, midline shift, other post-traumatic lesions, extent of ASDH evacuation) and we assessed the functional outcome at hospital discharge and 6-month follow-up considering GOS=1-3 as a poor outcome. ANOVA and χ2 Tests and logistic regression models were used to assess differences in and associations between clinical-radiological characteristics and functional outcomes. RESULTS We included 136 patients (76 males) with a mean age of 78±6 years. Forty-five patients underwent a small craniotomy, 47 a medium size, and 44 a large craniotomy. Among the different craniotomy size groups, there were no differences in gender, anticoagulant/antithrombotic therapy, CCI, side of ASDH, ASDH thickness, preoperative GCS, focal deficits, seizures, and presence of other post-traumatic lesions. Patients undergoing small craniotomies were older than patients undergoing medium-large craniotomies; ASDH treated with medium size craniotomy were thinner than the others; patients undergoing large craniotomies showed greater midline shift and a higher rate of anisocoria. The three groups did not differ for functional outcome and postoperative midline shift, but the length of surgery and the rate of >50% of ASDH evacuation were lower in the small craniotomy group. CONCLUSIONS A small craniotomy was not inferior to larger craniotomies in determining functional outcomes in the treatment of ASDH in the elderly.
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Affiliation(s)
| | - Alba Scerrati
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Oriela Rustemi
- Unit of Neurosurgery1, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Luca Ricciardi
- Unit of Neurosurgery, NESMOS Department, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Fabio Raneri
- Unit of Neurosurgery1, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Alberto Tomatis
- Unit of Neurosurgery, Santo Spirito Hospital, Pescara, Italy
| | - Amedeo Piazza
- Unit of Neurosurgery, NESMOS Department, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Anna M Auricchio
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vito Stifano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michele Dughiero
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Pasquale DE Bonis
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Annunziato Mangiola
- Unit of Neurosurgery, Santo Spirito Hospital, Pescara, Italy
- Department of Neurosciences, Imaging and Clinical Sciences, G. D'Annunzio University, Chieti, Italy
| | - Carmelo L Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy -
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3
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Nisson PL, Francis J, Michel M, Maeda T, Patil C. A proposed stratification system to address the heterogeneity of Subdural Hematoma Outcome reporting in the literature. Neurosurg Rev 2024; 47:207. [PMID: 38713250 PMCID: PMC11076356 DOI: 10.1007/s10143-024-02444-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/15/2024] [Accepted: 04/28/2024] [Indexed: 05/08/2024]
Abstract
A major challenge within the academic literature on SDHs has been inconsistent outcomes reported across studies. Historically, patients have been categorized by the blood-product age identified on imaging (i.e., acute, subacute, or chronic). However, this schematic has likely played a central role in producing the heterogeneity encountered in the literature. In this investigation, a total of 494 patients that underwent SDH evacuation at a tertiary medical center between November 2013-December 2021 were retrospectively identified. Mechanism of injury was reviewed by the authors and categorized as either positive or negative for a high-velocity impact (HVI) injury. Any head strike injury leading to the formation of a SDH while traveling at a velocity beyond that of normal locomotion or daily activities was categorized as an HVI. Patients were subsequently stratified by those with an acute SDHs after a high-velocity impact (aSDHHVI), those with an acute SDH without a high-velocity impact injury (aSDHWO), and those with any combination of subacute or chronic blood products (mixed-SDH [mSDH]). Nine percent (n = 44) of patients experienced an aSDHHVI, 23% (n = 113) aSDHWO, and 68% (n = 337) mSDH. Between these groups, highly distinct patient populations were identified using several metrics for comparison. Most notably, aSDHHVI had a significantly worse neurological status at discharge (50% vs. 23% aSDHWO vs. 8% mSDH; p < 0.001) and mortality (25% vs. 8% aSDHWO vs. 4% mSDH; p < 0.001). Controlling for gender, midline shift (mm), and anticoagulation use in the acute SDH population, multivariable logistic regression revealed a 6.85x odds ratio (p < 0.001) for poor outcomes in those with a positive history for a high-velocity impact injury. As such, the distribution of patients that suffer an HVI related acute SDH versus those that do not can significantly affect the outcomes reported. Adoption of this stratification system will help address the heterogeneity of SDH reporting in the literature while still closely aligning with conventional reporting.
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Affiliation(s)
- Peyton L Nisson
- Department of Neurosurgery, Cedars-Sinai, 127 S. San Vicente Blvd., Ste. A6213, Los Angeles, CA, USA.
| | - John Francis
- Department of Neurosurgery, Cedars-Sinai, 127 S. San Vicente Blvd., Ste. A6213, Los Angeles, CA, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Michelot Michel
- Department of Neurosurgery, Cedars-Sinai, 127 S. San Vicente Blvd., Ste. A6213, Los Angeles, CA, USA
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Takuma Maeda
- Department of Translational Neuroscience, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Chirag Patil
- Department of Neurosurgery, Cedars-Sinai, 127 S. San Vicente Blvd., Ste. A6213, Los Angeles, CA, USA
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Lee CH, Kim YH, Oh BK, Lee CH, Kim CH, Sung SK, Lee SW, Song GS. Does the COVID-19 Screening Test Affect the Postoperative Prognosis of Patients Who Undergo Emergency Surgery for Cerebral Hemorrhage? Korean J Neurotrauma 2022; 18:198-207. [PMID: 36381433 PMCID: PMC9634325 DOI: 10.13004/kjnt.2022.18.e48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/26/2022] [Accepted: 08/04/2022] [Indexed: 11/18/2022] Open
Abstract
Objective The coronavirus disease 2019 (COVID-19) pandemic has affected all medical fields, including neurosurgery. Particularly, performing preoperative screening tests has become mandatory, potentially extending the time from admission to the emergency room and operating room, thus possibly affecting patients' prognosis. This study aimed to determine the influence of COVID-19 screening time on patients' postoperative prognosis. Methods From September 10, 2020, to May 31, 2021, we retrospectively evaluated 54 patients with cerebral hemorrhage who underwent emergency surgery in the emergency room after the screening test. The control group included 89 patients with cerebral hemorrhage who underwent emergency surgery between January 2019 and March 2020, i.e., the period before the COVID-19 pandemic. Prognosis was measured using the Glasgow Coma Scale scores, which were obtained preoperatively, postoperatively, and at discharge, and the modified Rankin Scale (mRS). Additionally, unfavorable outcomes (mRS score 3-6) and in-hospital mortality rates were investigated for postoperative prognostic assessments. Results No remarkable differences were observed in the time to surgical intervention and prognostic evaluation scores between patients with cerebral hemorrhage who underwent COVID-19 screening tests and subjects in the control group. Conclusion This study confirmed that patient treatment and prognosis were not significantly affected by additional preoperative screening testing times during the pandemic. We believe that our results are informative for the evaluation and performance of emergency neurosurgery during the pandemic.
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Affiliation(s)
- Chang Ho Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Young Ha Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Bu Kwang Oh
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Chi Hyung Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Chang Hyeun Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Soon Ki Sung
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Sang Weon Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Geun Sung Song
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
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Kaewborisutsakul A, Tunthanathip T. Development and internal validation of a nomogram for predicting outcomes in children with traumatic subdural hematoma. Acute Crit Care 2022; 37:429-437. [PMID: 35791657 PMCID: PMC9475159 DOI: 10.4266/acc.2021.01795] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/07/2022] [Indexed: 12/23/2022] Open
Abstract
Background A subdural hematoma (SDH) following a traumatic brain injury (TBI) in children can lead to unexpected death or disability. The nomogram is a clinical prediction tool used by physicians to provide prognosis advice to parents for making decisions regarding treatment. In the present study, a nomogram for predicting outcomes was developed and validated. In addition, the predictors associated with outcomes in children with traumatic SDH were determined. Methods In this retrospective study, 103 children with SDH after TBI were evaluated. According to the King’s Outcome Scale for Childhood Head Injury classification, the functional outcomes were assessed at hospital discharge and categorized into favorable and unfavorable. The predictors associated with the unfavorable outcomes were analyzed using binary logistic regression. Subsequently, a two-dimensional nomogram was developed for presentation of the predictive model. Results The predictive model with the lowest level of Akaike information criterion consisted of hypotension (odds ratio [OR], 9.4; 95% confidence interval [CI], 2.0–42.9), Glasgow coma scale scores of 3–8 (OR, 8.2; 95% CI, 1.7–38.9), fixed pupil in one eye (OR, 4.8; 95% CI, 2.6–8.8), and fixed pupils in both eyes (OR, 3.5; 95% CI, 1.6–7.1). A midline shift ≥5 mm (OR, 1.1; 95% CI, 0.62–10.73) and co-existing intraventricular hemorrhage (OR, 6.5; 95% CI, 0.003–26.1) were also included. Conclusions SDH in pediatric TBI can lead to mortality and disability. The predictability level of the nomogram in the present study was excellent, and external validation should be conducted to confirm the performance of the clinical prediction tool.
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Affiliation(s)
- Anukoon Kaewborisutsakul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Thara Tunthanathip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Manivannan S, Spencer R, Marei O, Mayo I, Elalfy O, Martin J, Zaben M. Acute subdural haematoma in the elderly: to operate or not to operate? A systematic review and meta-analysis of outcomes following surgery. BMJ Open 2021; 11:e050786. [PMID: 34862284 PMCID: PMC8647543 DOI: 10.1136/bmjopen-2021-050786] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Acute subdural haematoma (ASDH) is a devastating pathology commonly found on CT brain scans of patients with traumatic brain injury. The role of surgical intervention in the elderly has been increasingly questioned due to its associated morbidity and mortality. Therefore, a systematic review and meta-analysis of the literature to quantify the mortality and functional outcomes associated with surgical management of ASDH in the elderly was performed. DESIGN/SETTING A multidatabase literature search between January 1990 and May 2020, and meta-analysis of proportions was performed to quantify mortality and unfavourable outcome (Glasgow Outcome scale 1-3; death/ severe disability) rates. PARTICIPANTS Studies reporting patients aged 60 years or older. INTERVENTIONS Craniotomy, decompressive craniectomy, conservative management. OUTCOME MEASURES Mortality and functional outcomes (discharge, long-term follow-up (LTFU)). RESULTS 2572 articles were screened, yielding 21 studies for final inclusion and 15 for meta-analysis. Pooled estimates of mortality were 39.83% (95% CI 32.73% to 47.14%; 10 studies, 308/739 patients, I2=73%) at discharge and 49.30% (95% CI 42.01% to 56.61%; 10 studies, 277/555 patients, I2=63%) at LTFU. Mean duration of follow-up was 7.1 months (range 2-12 months). Pooled estimate of percentage of poor outcomes was 81.18% (95% CI 75.61% to 86.21%; 6 studies, 363/451 patients, I2=45%) at discharge, and 79.25% (95% CI 72.42% to 85.37%; 8 studies, 402/511 patients, I2=66%) at LTFU. Mean duration of follow-up was 6.4 months (range 2-12 months). Potential risk factors for poor outcome included age, baseline functional status, preoperative neurological status and imaging parameters. CONCLUSIONS Outcomes following surgical evacuation of ASDH in patients aged 60 years and above are poor. This constitutes the best level of evidence in the current literature that surgical intervention for ASDH in the elderly carries significant risks, which must be weighed against benefits. PROSPERO REGISTRATION NUMBER CRD42020189508.
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Affiliation(s)
- Susruta Manivannan
- Department of Neurosurgery, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Robert Spencer
- Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Omar Marei
- School of Medicine, Cardiff University, Cardiff, UK
| | - Isaac Mayo
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Omar Elalfy
- School of Medicine, Cardiff University, Cardiff, UK
| | - John Martin
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Malik Zaben
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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Haddad AF, DiGiorgio AM, Lee YM, Lee AT, Burke JF, Huang MC, Dhall SS, Manley GT, Tarapore PE. The Morbidity and Mortality of Surgery for Traumatic Brain Injury in Geriatric Patients: A Study of Over 100 000 Patient Cases. Neurosurgery 2021; 89:1062-1070. [PMID: 34624082 DOI: 10.1093/neuros/nyab359] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Geriatric patients have the highest rates of Traumatic Brain Injury (TBI)-related hospitalization and death. This contributes to an assumption of futility in aggressive management in this population. OBJECTIVE To evaluate the effect of surgical intervention on the morbidity and mortality of geriatric patients with TBI. METHODS A retrospective analysis of patients ≥80 yr old with TBI from 2003 to 2016 was performed using the National Trauma Data Bank. Univariate and multivariate analyses were performed to compare outcomes between surgery and nonsurgery groups. RESULTS A total of 127 129 patient incidents were included: 121 185 (95.3%) without surgery and 5944 (4.7%) with surgery. The surgical group was slightly younger (84.0 vs 84.3, P < .001) and predominantly male (60.2% vs 44.4%, P < .001). Mean emergency department (ED) Glasgow Coma Scale (GCS) was lower in surgical patients (12.4 vs 13.7, P < .001). Complications (OR = 1.91, CI:1.80-2.02, P < .001) and hospital length of stay (LOS, ß = 5.25, CI:5.08-5.42, P < .001) were independently associated with surgery. Intensive care unit (ICU) LOS (ß = 3.19, CI:3.05-3.34, P < .001), ventilator days (ß = 1.57, CI:1.22-1.92, P < .001), and reduced discharge home (OR = 0.434, CI:0.400-0.470, P < .001) were also independently associated with surgery. However, surgery was not independently associated with mortality on multivariate analysis (OR = 1.03, CI:0.955-1.12, P = .423). Recursive partitioning analysis identified ED GCS and injury severity score (ISS) as prognosticators of mortality following surgical intervention. CONCLUSION Surgical treatment of geriatric patients with TBI is associated with increased complications, hospital LOS, ICU LOS, and ventilator days as well as reduced discharge to home. However, surgery is not associated with increased mortality. ISS and ED GCS are prognosticators of mortality following surgical intervention.
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Affiliation(s)
- Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California, USA
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California, USA
| | - Young M Lee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California, USA
| | - Anthony T Lee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California, USA
| | - John F Burke
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California, USA
| | - Michael C Huang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California, USA
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California, USA
| | - Phiroz E Tarapore
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.,Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California, USA
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Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit. World Neurosurg 2021; 158:e441-e450. [PMID: 34767994 DOI: 10.1016/j.wneu.2021.11.004] [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: 09/02/2021] [Revised: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207). METHODS Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge. RESULTS Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes. CONCLUSIONS Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.
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Farraj Y, Buxboim A, Cohen JE, Kan-Tor Y, Glasner Hagege S, Weiss D, Goldman V, Beatus T. Measuring pupil size and light response through closed eyelids. BIOMEDICAL OPTICS EXPRESS 2021; 12:6485-6495. [PMID: 34745751 PMCID: PMC8548001 DOI: 10.1364/boe.435508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/18/2021] [Accepted: 09/01/2021] [Indexed: 06/13/2023]
Abstract
Monitoring pupillary size and light-reactivity is a key component of the neurologic assessment in comatose patients after stroke or brain trauma. Currently, pupillary evaluation is performed manually at a frequency often too low to ensure timely alert for irreversible brain damage. We present a novel method for monitoring pupillary size and reactivity through closed eyelids. Our method is based on side illuminating in near-IR through the temple and imaging through the closed eyelid. Successfully tested in a clinical trial, this technology can be implemented as an automated device for continuous pupillary monitoring, which may save staff resources and provide earlier alert to potential brain damage in comatose patients.
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Affiliation(s)
- Yousef Farraj
- Casali Center for Applied Chemistry, Institute of Chemistry, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Equally contributed
| | - Amnon Buxboim
- The Benin School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Department of Developmental and Cell Biology, The Silberman Institute of Life Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- The Alexander Grass Bioengineering Center, Faculty of Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Equally contributed
| | - Jose E. Cohen
- Department of Neurosurgery, Hadassah Hebrew University Medical Center, Jerusalem 9112001, Israel
| | - Yoav Kan-Tor
- The Benin School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Department of Developmental and Cell Biology, The Silberman Institute of Life Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- The Alexander Grass Bioengineering Center, Faculty of Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
| | - Shira Glasner Hagege
- School of Business Administration, The Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Dor Weiss
- School of Business Administration, The Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Vladimir Goldman
- Department of Orthopedic Surgery, Hadassah Hebrew University Medical Center, Jerusalem 9112001, Israel
| | - Tsevi Beatus
- The Benin School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- The Alexander Grass Bioengineering Center, Faculty of Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Department of Neurobiology, The Silberman Institute of Life Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
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Diamond-Shaped Mini-Craniotomy: A New Concept in Neurosurgery. J Neurol Surg A Cent Eur Neurosurg 2021; 83:236-241. [PMID: 34344051 DOI: 10.1055/s-0041-1730942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND We describe, step by step, a modified, less invasive, diamond-shaped mini-craniotomy that optimizes dural opening and can be performed in elderly patients affected by acute subdural or intracerebral hematomas, in therapy with antiplatelets or anticoagulants. METHODS We retrospectively analyzed the clinical records of 67 patients (mean age of 78.5 years) treated in our institution, during a period of 10 years, with this novel diamond-shaped craniotomy. Seventeen patients were treated for intracerebral hemorrhage and 50 patients for acute subdural hematomas. All the patients were in therapy with antiplatelets or anticoagulants. RESULTS Approach-related complications were not detected. Ten of 67 patients (14.9%) presented temporal muscle atrophy; there was no scar deformity, paresthesia, hyperalgesia, or ramus frontalis palsy around the scalp incision. Thirty-day mortality was 22%. The mean follow-up was 1.3 years. One-month postoperative brain computed tomography scans showed a satisfactory hematoma evacuation in 57 of 67 patients (85%). CONCLUSIONS The diamond-shaped mini-craniotomy for acute subdural and intracerebral hematomas is safe and effective, and it should be considered as an alternative to traditional approaches, particularly in elderly patients.
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Posti JP, Luoto TM, Rautava P, Kytö V. Mortality After Trauma Craniotomy Is Decreasing in Older Adults-A Nationwide Population-Based Study. World Neurosurg 2021; 152:e313-e320. [PMID: 34082165 DOI: 10.1016/j.wneu.2021.05.090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE No evidence-based guidelines are available for operative neurosurgical treatment of older patients with traumatic brain injuries (TBIs), and no population-based results of current practice have been reported. The objective of the present study was to investigate the rates of trauma craniotomy operations and later mortality in older adults with TBI in Finland. METHODS Nationwide databases were searched for all admissions with a TBI diagnosis and after trauma craniotomy, and later deaths for persons aged ≥60 years from 2004 to 2018. RESULTS The study period included 2166 patients (64% men; mean age, 70.3 years) who had undergone TBI-related craniotomy. The incidence rate of operations decreased with a concomitant decrease in adjusted mortality (30-day mortality, P < 0.001; 1-year mortality, P < 0.001) and increase in mean patient age (R2 = 0.005; P < 0.001) during the study period. The cumulative mortality was 25% at 30 days and 38% at 1 year. The comorbidities increasing the hazard for 30-day mortality were diabetes, a history of malignancy, peripheral vascular disease, and a history of myocardial infarction. For 1-year mortality, the comorbidities were heart failure and a history of myocardial infarction. Evacuation of an epidural hematoma decreased the hazard for mortality. In contrast, evacuation of an intracerebral hematoma and decompressive craniectomy increased the risk at both 30 days and 1 year. CONCLUSIONS Among older adults in Finland, the rate of trauma craniotomy and later mortality has been decreasing although the mean age of operated patients has been increasing. This can be expected to be related to an improved understanding of geriatric TBIs and, consequently, improved selection of patients for targeted therapy.
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Affiliation(s)
- Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Centre, Turku University Hospital and University of Turku, Turku, Finland.
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland; Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland; Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland; Administative Center, Hospital District of Southwest Finland, Turku, Finland
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García-Pérez D, Panero-Pérez I, Eiriz Fernández C, Moreno-Gomez LM, Esteban-Sinovas O, Navarro-Main B, Gómez López PA, Castaño-León AM, Lagares A. Densitometric analysis of brain computed tomography as a new prognostic factor in patients with acute subdural hematoma. J Neurosurg 2021; 134:1940-1950. [PMID: 32736362 DOI: 10.3171/2020.4.jns193445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/22/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Acute subdural hematoma (ASDH) is a major cause of mortality and morbidity after traumatic brain injury (TBI). Surgical evacuation is the mainstay of treatment in patients with altered neurological status or significant mass effect. Nevertheless, concerns regarding surgical indication still persist. Given that clinicians often make therapeutic decisions on the basis of their prognosis assessment, to accurately evaluate the prognosis is of great significance. Unfortunately, there is a lack of specific and reliable prognostic models. In addition, the interdependence of certain well-known predictive variables usually employed to guide surgical decision-making in ASDH has been proven. Because gray matter and white matter are highly susceptible to secondary insults during the early phase after TBI, the authors aimed to assess the extent of these secondary insults with a brain parenchyma densitometric quantitative CT analysis and to evaluate its prognostic capacity. METHODS The authors performed a retrospective analysis among their prospectively collected cohort of patients with moderate to severe TBI. Patients with surgically evacuated, isolated, unilateral ASDH admitted between 2010 and 2017 were selected. Thirty-nine patients were included. For each patient, brain parenchyma density in Hounsfield units (HUs) was measured in 10 selected slices from the supratentorial region. In each slice, different regions of interest (ROIs), including and excluding the cortical parenchyma, were defined. The injured hemisphere, the contralateral hemisphere, and the absolute differences between them were analyzed. The outcome was evaluated using the Glasgow Outcome Scale-Extended at 1 year after TBI. RESULTS Fifteen patients (38.5%) had a favorable outcome. Collected demographic, clinical, and radiographic data did not show significant differences between favorable and unfavorable outcomes. In contrast, the densitometric analysis demonstrated that greater absolute differences between both hemispheres were associated with poor outcome. These differences were detected along the supratentorial region, but were greater at the high convexity level. Moreover, these HU differences were far more marked at the cortical parenchyma. It was also detected that these differences were more prone to ischemic and/or edematous insults than to hyperemic changes. Age was significantly correlated with the side-to-side HU differences in patients with unfavorable outcome. CONCLUSIONS The densitometric analysis is a promising prognostic tool in patients diagnosed with ASDH. The supplementary prognostic information provided by the densitometric analysis should be evaluated in future studies.
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Spencer RJ, Manivannan S, Zaben M. Endoscope-assisted techniques for evacuation of acute subdural haematoma in the elderly: The lesser of two evils? A scoping review of the literature. Clin Neurol Neurosurg 2021; 207:106712. [PMID: 34091423 DOI: 10.1016/j.clineuro.2021.106712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/10/2021] [Accepted: 05/23/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Surgical evacuation of acute subdural haematoma (ASDH) in the elderly remains a point of contention due to the significant associated mortality. Therefore, there is a dire need for alternative treatment options. Endoscope-assisted techniques (EAT) have been increasingly reported over the last decade with variable outcomes. In this scoping review, we identify studies reporting the use of EAT for ASDH evacuation in elderly patients. Outcomes and patient selection criteria are discussed to identify patients that may benefit from EAT. METHODS A multi-database literature search was performed between January 1990 and January 2021. Studies including patients aged 60 years or above who underwent EAT for ASDH evacuation with reported outcomes were included. RESULTS A total of 13 studies and 122 patients were eligible for inclusion. Patient age ranged from 65 to 101 years, and average age from 78.6 to 87.4 years. High comorbidity burden, advanced age, absence of adverse imaging features, and pre-operative neurological status were the most common eligibility criteria for EAT. 52% of all procedures were performed under local anaesthetic (LA). Mortality rates ranged between 0% and 40%, whilst favourable outcomes ranged between 26.7% and 96.4%. Re-bleed was the most commonly reported complication, ranging between 0% and 13%. CONCLUSIONS EAT pose a viable compromise for elderly patients with ASDH that may be unfit for GA. Heterogeneity of patient selection criteria prevents meaningful comparison between EAT and other approaches, and there is a clear impact of patient selection on outcome among studies reporting EAT. Further studies are required to identify the patient cohort that may benefit from this approach.
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Affiliation(s)
- R J Spencer
- Department of Neurosurgery, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - S Manivannan
- Department of Neurosurgery, Southampton General Hospital, Southampton, UK
| | - M Zaben
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK.
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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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Pastor IS, Dumbravă LP, Siserman C, Stan H, Para I, Florian IȘ. Predictive factors of 30-day mortality in patients with traumatic subdural hematoma. Exp Ther Med 2021; 22:757. [PMID: 34035854 DOI: 10.3892/etm.2021.10189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/19/2021] [Indexed: 11/05/2022] Open
Abstract
In the present study, we aimed to assess and analyze the predictive factors of 30-day mortality in patients with acute subdural hematoma (ASDH) who underwent surgical intervention after traumatic brain injury (TBI). We conducted a retrospective study, which included a cohort of 135 consecutive patients diagnosed with ASDH who required surgical evacuation. We assessed the demographic and clinical data, the imaging data of the hematoma described by preoperative computed tomography (CT) and the type of neurosurgical intervention for hematoma evacuation via either craniectomy or craniotomy. The patients were followed up for 30 days after head trauma and the occurrence of death was noted. Death was recorded in 63 (46.6%) patients at 30 days after TBI. There was a significant number of deceased patients who underwent craniectomy (71.4%). The Glasgow Coma Scale (GCS) was statistically significantly lower in patients who died (P<0.001), with a cut-off value of ≤12, under which the probability of death increased [AUC 0.830 (95% CI, 0.756-0.889); Se 90.48% (95% CI, 80.4-96.4); Sp 66.7% (95% CI, 54.6-77.3); P<0.001]. The midline shift was statistically significantly higher in deceased patients (P=0.005), with a cut-off value of >7 mm, over which the probability of death increased [AUC 0.637 (95% CI, 0.550-0.718); Se 38.1% (95% CI, 26.1-51.2); Sp 86.1% (95% CI, 75.9-93.1); P=0.003]. There were significantly more deceased patients with intracranial hypertension, brain herniation, brain swelling, intraparenchymal hematoma and cranial fracture. In multivariate analysis only a Glasgow score ≤12 and a midline shift >7 mm were independently linked to mortality. Brain herniation and intraparenchymal hematoma were associated with a higher probability of dying, but the statistical threshold was slightly exceeded. The type of neurosurgery performed for patients with ASDH was not an independent predictive factor for 30-day mortality. However, craniectomy was associated with a higher mortality in patients with ASDH.
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Affiliation(s)
- Iulia-Sevastiana Pastor
- Department of Neurosurgery, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Lăcrimioara Perju Dumbravă
- First Department of Neurology, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Costel Siserman
- Department of Legal Medicine, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Horațiu Stan
- Department of Neurosurgery, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Ioana Para
- Department of Internal Medicine, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Ioan Ștefan Florian
- Department of Neurosurgery, Faculty of Medicine, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Aromatario M, Torsello A, D’Errico S, Bertozzi G, Sessa F, Cipolloni L, Baldari B. Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57020125. [PMID: 33535407 PMCID: PMC7912597 DOI: 10.3390/medicina57020125] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 04/09/2023]
Abstract
Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.
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Affiliation(s)
| | - Alessandra Torsello
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Stefano D’Errico
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Giuseppe Bertozzi
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
- Correspondence:
| | - Francesco Sessa
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Luigi Cipolloni
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Benedetta Baldari
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00186 Rome, Italy;
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Lee H, Tan C, Tran V, Mathew J, Fitzgerald M, Leong R, Kambourakis T, Gantner D, Udy A, Hunn M, Rosenfeld JV, Tee J. The Utility of the Modified Frailty Index in Outcome Prediction for Elderly Patients with Acute Traumatic Subdural Hematoma. J Neurotrauma 2020; 37:2499-2506. [DOI: 10.1089/neu.2019.6943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Hui Lee
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
| | - Caleb Tan
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
| | - Vanessa Tran
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
| | - Joseph Mathew
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Trauma Services, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Trauma Services, Alfred Health, Melbourne, Victoria, Australia
| | - Ronald Leong
- Aged Care Services, Alfred Health, Melbourne, Victoria, Australia
| | | | - Dashiell Gantner
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Martin Hunn
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey V. Rosenfeld
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jin Tee
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Akbik OS, Starling R, Green R, Zhu Y, Lewis J. Delayed Surgical Intervention in Acute Subdural Hematoma. Cureus 2020; 12:e11592. [PMID: 33364114 PMCID: PMC7752740 DOI: 10.7759/cureus.11592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Current guidelines recommend an acute subdural hematoma (ASDH) with a thickness greater than or equal to 10 mm or a midline shift greater than or equal to 5 mm be evacuated regardless of Glasgow Coma Scale (GCS). A large craniotomy versus craniectomy is the preferred surgical treatment for ASDH. A subset of patients who are typically older if not elderly meet the above criteria but have a monitorable neurologic exam. These patients can be followed and taken in a delayed manner allowing the ASDH to become chronic. The delay in treatment allows for a smaller surgery in regards to size of incision, size of craniotomy, and duration of anesthesia. Methods Between February 2013 and July 2019, we retrospectively identified 19 patients who underwent delayed evacuation of an ASDH, with the primary outcome being Glasgow Outcome Score (GOS) at discharge and three-month follow-up. Results Eight patients (42%) were female and 11 patients (58%) were male. The median age was 77 years, with a range from 49 to 93 years. Sixteen patients (84%) were 60 years of age or older. Mechanism of injury was a fall for 10 patients (53%). Median number of days from initial evaluation and surgical evacuation was 11 days with a range from 6 to 31 days. Thirteen patients (68%) had a GOS of 4-5 at three-month follow-up. Six patients (32%) had a GOS 1-3 at three-month follow-up. Two mortalities (11%) recorded in the postoperative period. Conclusion Surgically evacuated ASDH in the elderly population is known to carry a significant mortality and morbidity. With close neuromonitoring, delayed intervention in older patients with an ASDH, initially meeting surgical criteria with a good neurologic exam, is a safe practice. Delayed treatment allows for smaller surgery, decreased operative time, and decreased surgical risk which affects older patients even more than younger patients.
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Affiliation(s)
- Omar S Akbik
- Neurosurgery, University of New Mexico, Albuquerque, USA
| | | | - Ross Green
- Neurosurgery, University of New Mexico, Albuquerque, USA
| | - Yiliang Zhu
- Statistics, University of New Mexico School of Medicine, Albuquerque, USA
| | - Jeremy Lewis
- Neurosurgery, University of New Mexico, Albuquerque, USA
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Trevisi G, Sturiale CL, Scerrati A, Rustemi O, Ricciardi L, Raneri F, Tomatis A, Piazza A, Auricchio AM, Stifano V, Romano C, De Bonis P, Mangiola A. Acute subdural hematoma in the elderly: outcome analysis in a retrospective multicentric series of 213 patients. Neurosurg Focus 2020; 49:E21. [DOI: 10.3171/2020.7.focus20437] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe objective of this study was to analyze the risk factors associated with the outcome of acute subdural hematoma (ASDH) in elderly patients treated either surgically or nonsurgically.METHODSThe authors performed a retrospective multicentric analysis of clinical and radiological data on patients aged ≥ 70 years who had been consecutively admitted to the neurosurgical department of 5 Italian hospitals for the management of posttraumatic ASDH in a 3-year period. Outcome was measured according to the Glasgow Outcome Scale (GOS) at discharge and at 6 months’ follow-up. A GOS score of 1–3 was defined as a poor outcome and a GOS score of 4–5 as a good outcome. Univariate and multivariate statistics were used to determine outcome predictors in the entire study population and in the surgical group.RESULTSOverall, 213 patients were admitted during the 3-year study period. Outcome was poor in 135 (63%) patients, as 65 (31%) died during their admission, 33 (15%) were in a vegetative state, and 37 (17%) had severe disability at discharge. Surgical patients had worse clinical and radiological findings on arrival or during their admission than the patients undergoing conservative treatment. Surgery was performed in 147 (69%) patients, and 114 (78%) of them had a poor outcome. In stratifying patients by their Glasgow Coma Scale (GCS) score, the authors found that surgery reduced mortality but not the frequency of a poor outcome in the patients with a moderate to severe GCS score. The GCS score and midline shift were the most significant predictors of outcome. Antiplatelet drugs were associated with better outcomes; however, patients taking such medications had a better GCS score and better radiological findings, which could have influenced the former finding. Patients with fixed pupils never had a good outcome. Age and Charlson Comorbidity Index were not associated with outcome.CONCLUSIONSTraumatic ASDH in the elderly is a severe condition, with the GCS score and midline shift the stronger outcome predictors, while age per se and comorbidities were not associated with outcome. Antithrombotic drugs do not seem to negatively influence pretreatment status or posttreatment outcome. Surgery was performed in patients with a worse clinical and radiological status, reducing the rate of death but not the frequency of a poor outcome.
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Affiliation(s)
| | - Carmelo Lucio Sturiale
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Alba Scerrati
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
- 4Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Oriela Rustemi
- 5UOC Neurochirurgia 1, Azienda ULSS 8 Berica Ospedale San Bortolo, Vicenza
| | - Luca Ricciardi
- 6UOC di Neurochirurgia, Azienda Ospedaliera Sant’Andrea, Dipartimento NESMOS, Sapienza-Roma; and
| | - Fabio Raneri
- 5UOC Neurochirurgia 1, Azienda ULSS 8 Berica Ospedale San Bortolo, Vicenza
| | | | - Amedeo Piazza
- 6UOC di Neurochirurgia, Azienda Ospedaliera Sant’Andrea, Dipartimento NESMOS, Sapienza-Roma; and
| | - Anna Maria Auricchio
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Vito Stifano
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Carmine Romano
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
| | - Pasquale De Bonis
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
- 4Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Annunziato Mangiola
- 1Neurosurgical Unit, Ospedale Santo Spirito, Pescara
- 7Department of Neurosciences, Imaging and Clinical Sciences, “G. D’Annunzio” University, Chieti, Italy
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Kerezoudis P, Goyal A, Puffer RC, Parney IF, Meyer FB, Bydon M. Morbidity and mortality in elderly patients undergoing evacuation of acute traumatic subdural hematoma. Neurosurg Focus 2020; 49:E22. [DOI: 10.3171/2020.7.focus20439] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAcute traumatic subdural hematoma (atSDH) can be a life-threatening neurosurgical emergency that necessitates immediate evacuation. The elderly population can be particularly vulnerable to tearing bridging veins. The aim of this study was to evaluate inpatient morbidity and mortality, as well as predictors of inpatient mortality, in a national trauma database.METHODSThe authors queried the 2016–2017 National Trauma Data Bank registry for patients aged 65 years and older who had undergone evacuation of atSDH. Patients were categorized into three age groups: 65–74, 75–84, and 85+ years. A multivariable logistic regression model was fitted for inpatient mortality adjusting for age group, sex, race, presenting Glasgow Coma Scale (GCS) category (3–8, 9–12, and 13–15), Injury Severity Score, presence of coagulopathy, presence of additional hemorrhages (epidural hematoma [EDH], intraparenchymal hematoma [IPH], and subarachnoid hemorrhage [SAH]), presence of midline shift > 5 mm, and pupillary reactivity (both, one, or none).RESULTSA total of 2508 patients (35% females) were analyzed. Age distribution was as follows: 990 patients at 65–74 years, 1096 at 75–84, and 422 at 85+. Midline shift > 5 mm was present in 72% of cases. With regard to additional hemorrhages, SAH was present in 21%, IPH in 10%, and EDH in 2%. Bilaterally reactive pupils were noted in 90% of patients. A major complication was observed in 14.4% of patients, and the overall mortality rate was 18.3%. In the multivariable analysis, the presenting GCS category was found to be the strongest predictor of postoperative inpatient mortality (3–8 vs 13–15: OR 3.63, 95% CI 2.68–4.92, p < 0.001; 9–12 vs 13–15: OR 2.64, 95% CI 1.79–3.90, p < 0.001; 30% of overall variation), followed by the presence of SAH (OR 2.86, 95% CI 2.21–3.70, p < 0.001; 25% of overall variation) and the presence of midline shift > 5 mm (OR 2.40, 95% CI 1.74–3.32, p < 0.001; 11% of overall variation). Model discrimination was excellent (c-index 0.81). Broken down by age decile group, mortality increased from 8.0% to 15.4% for GCS 13–15 to around 36% for GCS 9–12 to almost as high as 60% for GCS 3–8, particularly in those aged 85 years and older.CONCLUSIONSThe present results from a national trauma database will, the authors hope, assist surgeons in preoperative discussions with patients and their families with regard to expected postoperative outcomes following surgical evacuation of an atSDH.
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Affiliation(s)
- Panagiotis Kerezoudis
- 1Department of Neurologic Surgery, Mayo Clinic; and
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Anshit Goyal
- 1Department of Neurologic Surgery, Mayo Clinic; and
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Mohamad Bydon
- 1Department of Neurologic Surgery, Mayo Clinic; and
- 2Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
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Posti JP, Sipilä JOT, Luoto TM, Rautava P, Kytö V. A decade of geriatric traumatic brain injuries in Finland: population-based trends. Age Ageing 2020; 49:779-785. [PMID: 32134443 DOI: 10.1093/ageing/afaa037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND we investigated trends of traumatic brain injury (TBI)-related hospitalisations, deaths, acute neurosurgical operations (ANO), and lengths of hospital stay (LOS) in patients aged ≥70 years in Finland using a population-based cohort. METHODS nationwide databases were searched for all admissions with a TBI diagnosis as well as later deaths for persons ≥70 years of age during 2004-2014. RESULTS the study period included 20,259 TBI-related hospitalisations (mean age = 80.7 years, men = 48.9%). The incidence of TBI-related hospitalisations was 283/100,000 person-years with an estimated overall annual increase of 2.9% (95% CI: 0.4-5.9%). There was an annual decrease of 2.2% in in-hospital mortality (IHM) in men (95% CI: 0.1-4.3%), with no change in women or overall. There was an annual decrease of 1.1% in odds for ANOs among hospitalised overall (95% CI: 0.1-2.1%) and of 1.4% in men (95% CI: 0.0-2.7%), while no change was observed in women. LOS decreased annually by 2.5% (95% CI: 2.1-2.9%). The incidence of TBI-related deaths was 70/100,000 person-years with an estimated annual increase of 1.6% in women (95% CI: 0.2-2.9%), but no change in men or overall. Mean ages of TBI-related admissions and deaths increased (P < 0.001). INTERPRETATION the incidence rate of geriatric TBI-related hospitalisations increased, especially in women, but LOS and the rate of ANOs among hospitalised decreased. The overall TBI-related mortality remained stable, and IHM decreased in men, while in women, the overall mortality increased and IHM remained stable. However, the overall incidence rates of TBI-related hospitalisations and deaths and the number of cases of IHM were still higher in men.
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Affiliation(s)
- Jussi P Posti
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Turku Brain Injury Centre, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, University of Turku, Finland
| | - Jussi O T Sipilä
- Department of Clinical Neurosciences, University of Turku, Finland
- Division of Clinical Neurosciences, Department of Neurology, Turku University Hospital, Turku, Finland
- Department of Neurology, Siun sote, North Karelia Central Hospital, Joensuu, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital, Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital, Turku, Finland
- Department of Public Health, University of Turku, Turku, Finland
| | - Ville Kytö
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
- Heart Centre, Turku University Hospital, University of Turku, Turku, Finland
- Center for Population Health Research, Turku University Hospital, University of Turku, Turku, Finland
- Administative Center, Hospital District of Southwest Finland, Turku, Finland
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Hiraizumi S, Shiomi N, Echigo T, Oka H, Hino A, Baba M, Hitosugi M. Factors Associated with Poor Outcomes in Patients with Mild or Moderate Acute Subdural Hematomas. Neurol Med Chir (Tokyo) 2020; 60:402-410. [PMID: 32565532 PMCID: PMC7431873 DOI: 10.2176/nmc.oa.2020-0030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The factors influencing the outcomes of mild/moderate acute subdural hematoma (ASDH) are still unclear. Retrospective analyses were performed to identify such factors. The medical records of all patients who were admitted to Saiseikai Shiga Hospital with mild (Glasgow Coma Scale [GCS] score of 14–15) or moderate (GCS score of 9–13) ASDH between April 2008 and March 2017 were reviewed. Comparisons between the patients who exhibited favorable and poor outcomes were performed. Then, independent factors that contributed to poor outcomes were identified via logistic regression analyses. A total of 266 patients with a mean age of 70.2 were included in this study. The most common concomitant injuries were subarachnoid hemorrhages (SAHs; 56.8%). The patients’ Injury Severity Scores (ISS) ranged from 16 to 75 (median: 21). The 66 moderate ASDH patients exhibited significantly higher frequencies of surgery and mortality (24.2% and 13.6%, respectively) than the 200 mild ASDH patients (8.0% and 4.5%, respectively). The factors associated with poor outcomes were age (odds ratio [OR]: 1.06) and the ISS (OR: 1.24) in the mild ASDH patients, and older age (OR: 1.09) and the higher ISS (OR: 1.15) in the moderate group, too.
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Affiliation(s)
- Shiho Hiraizumi
- Emergency and Critical Care Medicine, Saiseikai Shiga Hospital.,Department of Legal Medicine, Shiga University of Medical Science
| | - Naoto Shiomi
- Emergency and Critical Care Medicine, Saiseikai Shiga Hospital
| | - Tadashi Echigo
- Emergency and Critical Care Medicine, Saiseikai Shiga Hospital
| | - Hideki Oka
- Department of Neurosurgery, Saiseikai Shiga Hospital
| | - Akihiko Hino
- Department of Neurosurgery, Saiseikai Shiga Hospital
| | - Mineko Baba
- Center for Integrated Medical Research, Keio University School of Medicine
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Robinson D, Khoury JC, Kleindorfer D. Regional Variation in the Management of Nontraumatic Subdural Hematomas Across the United States. World Neurosurg 2019; 135:e418-e423. [PMID: 31862343 DOI: 10.1016/j.wneu.2019.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 11/26/2022]
Abstract
BACKGOUND Nontraumatic subdural hematomas are a common indication for inpatient hospitalization in the United States, yet there is little high-quality evidence regarding which patients should receive surgical or medical treatment. We sought to assess variation in surgical management and medical treatment with steroids for nontraumatic subdural hematomas across the United States. METHODS Using the Premier database, we analyzed patients with a primary discharge diagnosis of nontraumatic subdural hematoma in 2014. International Classification of Diseases, Ninth Revision, procedure codes were used to identify patients who underwent surgical management, and pharmacy data were used to identify patients treated with dexamethasone. Univariable and multivariable analyses were used to examine the association of age, race, sex, academic versus nonacademic center, and regions of the United States with conservative or surgical management. RESULTS There were 3915 inpatient hospitalizations for nontraumatic subdural hematomas in 2014 in the Premier database, of whom 1860 (47.5%) underwent surgery, and 360 (9.2%) underwent treatment with dexamethasone, either as a primary treatment or as an adjuvant to surgery. Older age, female sex, and being managed outside of the Western U.S. region were associated with a lower likelihood of undergoing surgical management on multivariable analysis; only younger age was associated with a greater likelihood of being treated with dexamethasone. CONCLUSIONS There is considerable variability in surgical management of nontraumatic subdural hematomas across the United States based on age, sex, and region. Future studies should explore the reasons for the variability and attempt to better clarify indications for surgical management of subdural hematomas.
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Affiliation(s)
- David Robinson
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA.
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Sufaro Y, Avraham E, Alguyn F, Azriel A, Melamed I. Unfavorable functional outcome is expected for elderly patients suffering from acute subdural hematoma even when presenting with preserved level of consciousness. J Clin Neurosci 2019; 67:167-171. [PMID: 31262452 DOI: 10.1016/j.jocn.2019.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 03/22/2019] [Accepted: 05/11/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Yuval Sufaro
- Department of Neurosurgery, Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Elad Avraham
- Department of Neurosurgery, Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Farouq Alguyn
- Department of Neurosurgery, Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Amit Azriel
- Department of Neurosurgery, Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Israel Melamed
- Department of Neurosurgery, Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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Benko MJ, Abdulla SG, Cuoco JA, Dhiman N, Klein BJ, Guilliams EL, Marvin EA, Howes GA, Collier BR, Hamill ME. Short- and Long-Term Geriatric Mortality After Acute Traumatic Subdural Hemorrhage. World Neurosurg 2019; 130:e350-e355. [PMID: 31229743 DOI: 10.1016/j.wneu.2019.06.086] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/11/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Michael J Benko
- Division of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA.
| | - Sarah G Abdulla
- Department of Surgery, Harbor - University of California at Los Angeles, Torrance, California, USA
| | - Joshua A Cuoco
- Division of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
| | - Nitasha Dhiman
- Department of Radiology, Columbia University, New York, New York, USA
| | - Brendan J Klein
- Division of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
| | - Evin L Guilliams
- Division of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
| | - Eric A Marvin
- Division of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
| | - Gregory A Howes
- Division of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech School of Neuroscience, Blacksburg, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA
| | - Bryan R Collier
- Division of Trauma Surgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Mark E Hamill
- Division of Trauma Surgery, Carilion Clinic, Roanoke, Virginia, USA
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Akbik OS, Starling RV, Gahramanov S, Zhu Y, Lewis J. Mortality and Functional Outcome in Surgically Evacuated Acute Subdural Hematoma in Elderly Patients. World Neurosurg 2019; 126:e1235-e1241. [DOI: 10.1016/j.wneu.2019.02.234] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 11/15/2022]
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Papangelou A, Zink EK, Chang WTW, Frattalone A, Gergen D, Gottschalk A, Geocadin RG. Automated Pupillometry and Detection of Clinical Transtentorial Brain Herniation: A Case Series. Mil Med 2019; 183:e113-e121. [PMID: 29315412 DOI: 10.1093/milmed/usx018] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/24/2017] [Indexed: 11/14/2022] Open
Abstract
Introduction Transtentorial herniation (TTH) is a life-threatening neurologic condition that typically results from expansion of supratentorial mass lesions. A change in bedside pupillary examination is central to the clinical diagnosis of TTH. Materials and. Methods To quantify the changes in the pupillary examination that precede and accompany TTH and its treatment, we evaluated 12 episodes of herniation in three patients with supratentorial mass lesions using automated pupillometry (NeurOptics, Inc., Irvine, CA). Herniation was defined clinically by the onset of fixed and dilated pupils in association with decreased levels of consciousness. Automated pupillometry was measured simultaneously with the bedside clinical examination, but the clinical team was blinded to these results and could not act on the data. Data from the pupillometer were downloaded 1-2 times per week onto a secured laptop, and data processing was facilitated by the use of Mathematica 8.0. Results Neurologic Pupil Index measurements, values generated by the pupillometer based on an algorithm that incorporates pupillary size and reactivity in a normal population, were found to be abnormal before 73% of TTHs. This abnormality occurred at a median of 7.4 h before TTH. All episodes of TTH were reversed after clinical intervention at a median of 43 min after the event. The value did not fall to 0 in 42% of clinical herniations, but it did decrease to very abnormal values of 0.5-0.8. Conclusions The potential of automated pupillometry to guide the management of severely injured neurologic patients is intriguing and warrants further study in the critical care unit and beyond. The utility of a portable device in the combat setting may allow for triage of patients with severe neurologic injury.
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Affiliation(s)
- Alexander Papangelou
- Department of Anesthesiology, Emory University Hospital, 1364 Clifton Road NE, Atlanta GA 30322
| | - Elizabeth K Zink
- The Johns Hopkins Hospital Department of Neuroscience Nursing, 600N Wolfe Street, Baltimore MD 21287
| | - Wan-Tsu W Chang
- Department of Neurology, University of Maryland Medical Systems, 22S Greene Street, G7K55, Baltimore MD 21201.,Department of Emergency Medicine, University of Maryland Medical Systems, 22S Greene Street, G7K55, Baltimore MD 21201
| | - Anthony Frattalone
- Department of Neurology, San Antonio Military Medical, Center, 3551 Roger Brooke Drive, San Antonio TX 78219.,Department of Trauma Critical Care, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio TX 78219
| | - Daniel Gergen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287
| | - Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287.,Department of Neurosurgery, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287
| | - Romergryko G Geocadin
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287.,Department of Neurosurgery, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287.,Department of Neurology, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287
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Baucher G, Troude L, Pauly V, Bernard F, Zieleskiewicz L, Roche PH. Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series. World Neurosurg 2019; 126:e944-e952. [PMID: 30876998 DOI: 10.1016/j.wneu.2019.02.194] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on. METHODS This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed. RESULTS At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5. CONCLUSIONS The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH.
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Affiliation(s)
- Guillaume Baucher
- Department of Neurosurgery, North University Hospital, APHM, Aix Marseille University, Marseille, France.
| | - Lucas Troude
- Department of Neurosurgery, North University Hospital, APHM, Aix Marseille University, Marseille, France
| | - Vanessa Pauly
- CEReSS, Health Service Research and Quality of life Center, La Timone Medical Campus, Aix Marseille University, Marseille, France; Department of Public Health, La Conception Hospital, APHM, Aix Marseille University, Marseille, France
| | - Florian Bernard
- Department of Neurosurgery, CHU Angers, University of Angers, Angers, France
| | - Laurent Zieleskiewicz
- Department of Anesthesiology and Critical Care, North University Hospital, APHM, Aix Marseille University, Marseille, France
| | - Pierre-Hugues Roche
- Department of Neurosurgery, North University Hospital, APHM, Aix Marseille University, Marseille, France
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Bartek J, Laugesen C, Mirza S, Forsse A, Petersen MA, Corell A, Dyhrfort PW, Redebrandt HN, Reen L, Zolfaghari S, Tobieson L, Carlsvärd B, Bergholt B, Bashir A, Soerensen P, Bilgin A, Johansson C, Lindvall P, Förander P, Bellander BM, Springborg JB, Jakola AS. Scandinavian Multicenter Acute Subdural Hematoma (SMASH) Study: Study Protocol for a Multinational Population-Based Consecutive Cohort. Neurosurgery 2019; 84:799-803. [PMID: 29762769 DOI: 10.1093/neuros/nyy173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 04/04/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Traumatic acute subdural hematomas (ASDHs) are associated with high rate of morbidity and mortality, especially in elderly individuals. However, recent reports indicate that the morbidity and mortality rates might have improved. OBJECTIVE To evaluate postoperative (30-d) mortality in younger vs elderly (≥70 yr) patients with ASDH. Comparing younger and elderly patients, the secondary objectives are morbidity patterns of care and 6 mo outcome according to Glasgow outcome scale (GOS). Finally, in patients with traumatic ASDH, we aim to provide prognostic variables. METHODS This is a large-scale population-based Scandinavian study including all neurosurgical departments in Denmark and Sweden. All adult (≥18 yr) patients surgically treated between 2010 and 2014 for a traumatic ASDH in Denmark and Sweden will be included. Identification at clinicaltrials.gov is NCT03284190. EXPECTED OUTCOMES We expect to provide data on potential differences between younger vs elderly patients in terms of mortality and morbidity. We hypothesize that elderly patients selected for surgery have a similar pattern of care as compared with younger patients. We will provide functional outcome in terms of GOS at 6 mo in younger vs elderly patients undergoing ASDH evacuation. Finally, clinical useful prognostic factors for favorable (GOS 4-5) vs unfavorable (GOS 1-3) will be identified. DISCUSSION An improved understanding of the clinical outcome, treatment and resource allocation, clinical course, and the prognostic factors of traumatic ASDH will allow neurosurgeons to make better treatment decisions.
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Affiliation(s)
- Jiri Bartek
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Denmark.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Laugesen
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Sadia Mirza
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Axel Forsse
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | | | - Alba Corell
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Linus Reen
- Department of Neurosurgery, Lund University Hospital, Lund, Sweden
| | | | - Lovisa Tobieson
- Department of Neurosurgery, Linköping University Hospital, Linköping, Sweden
| | - Björn Carlsvärd
- Department of Neurosurgery, Linköping University Hospital, Linköping, Sweden
| | - Bo Bergholt
- Department of Neurosurgery, Århus University Hospital, Århus, Denmark
| | - Asma Bashir
- Department of Neurosurgery, Århus University Hospital, Århus, Denmark
| | - Preben Soerensen
- Department of Neurosurgery, Ålborg University Hospital, Ålborg, Denmark
| | - Arzu Bilgin
- Department of Neurosurgery, Ålborg University Hospital, Ålborg, Denmark
| | - Conny Johansson
- Department of Neurosurgery, Umeå University Hospital, Umeå, Sweden
| | - Peter Lindvall
- Department of Neurosurgery, Umeå University Hospital, Umeå, Sweden
| | - Petter Förander
- Department of Neurosurgery, Uppsala University Hospital, Uppsala Sweden
| | | | - Jacob B Springborg
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Asgeir S Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
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Bus S, Verbaan D, Kerklaan BJ, Sprengers MES, Vandertop WP, Stam J, Bouma GJ, van den Munckhof P. Do older patients with acute or subacute subdural hematoma benefit from surgery? Br J Neurosurg 2018; 33:51-57. [PMID: 30317874 DOI: 10.1080/02688697.2018.1522418] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE According to the international guidelines, acute subdural hematomas (aSDH) with a thickness of >10 mm, or causing a midline shift of >5 mm, should be surgically evacuated. However, high mortality rates in older patients resulted in ongoing controversy whether elderly patients benefit from surgery. We identified predictors of outcome in a single-centre cohort of elderly patients undergoing surgical evacuation of aSDH or subacute subdural hematoma (saSDH). MATERIALS AND METHODS This retrospective study included all patients aged ≥65 years undergoing surgical evacuation of aSDH/saSDH from 2000 to 2015. One-year outcome was dichotomized into favourable (Glasgow Outcome Scale (GOS) 4-5) and unfavourable (GOS 1-3). Predictors of outcome were identified by analysing patient characteristics. RESULTS Eighty-four patients aged ≥65 years underwent craniotomy for aSDH/saSDH during the 16 year time period. Twenty-five percent regained functional independence, 11% survived severely disabled, and 64% died. Most patients died of respiratory failure following withdrawal of artificial respiration or following restriction of treatment. Age of the SDH or Glasgow Coma Scores ≤8/intubation did not predict unfavourable outcome. All patients with bilaterally absent pupillary light reflexes died, also those who still exhibited one normal-sized pupil. CONCLUSION The low number of operated patients per year probably suggests that this cohort represents a selection of patients who were judged to have good chances of favouring from surgery. Functional independence at one-year follow-up was reached in 25% of patients, 64% died. Patients with bilaterally absent pupillary light reflexes did not benefit from surgery. The tendency to restrict treatment because of presumed poor prognosis may have acted as a self-fulfilling prophecy.
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Affiliation(s)
- Sander Bus
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
| | - Dagmar Verbaan
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
| | - Bertjan J Kerklaan
- b Department of Neurology , Onze Lieve Vrouwe Gasthuis, Amsterdam, and Zaans Medical Centre , Zaandam , The Netherlands
| | | | - William P Vandertop
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
| | - Jan Stam
- d Department of Neurology , Academic Medical Centre , Amsterdam , The Netherlands
| | - Gerrit J Bouma
- a Neurosurgical Centre Amsterdam , Academic Medical Centre , Amsterdam , The Netherlands
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Evans LR, Jones J, Lee HQ, Gantner D, Jaison A, Matthew J, Fitzgerald MC, Rosenfeld JV, Hunn MK, Tee JW. Prognosis of Acute Subdural Hematoma in the Elderly: A Systematic Review. J Neurotrauma 2018; 36:517-522. [PMID: 29943683 DOI: 10.1089/neu.2018.5829] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Acute subdural hematoma (aSDH) is among the most common injury types encountered by neurosurgeons, and carries a poor prognosis, particularly in the elderly. As the incidence of aSDH in the elderly population rises, identifying those patients who may benefit from operative intervention is crucial. This systematic review aimed to identify data on prognostic factors or indices, such as the modified frailty index, that may help predict outcome, and hence guide management. A comprehensive search of online databases was conducted by two independent authors, and data on prognostic factors and outcomes were extracted. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Of 769 studies identified in the initial search, 7 satisfied inclusion and exclusion criteria. Mortality and morbidity varied considerably among studies. Initial Glasgow Coma Scale (GCS) of 3-8 was the most consistently reported negative prognostic feature. Several studies evaluated the impact of medical comorbidities and premorbid frailty, but were limited by small sample size. A previous history of pneumonia was shown to increase the risk of Glasgow Outcome Score (GOS) 1-3 (odds ratio [OR] 6.4 [95% CI 1.6-25.2], p = 0.04) in a single study, which also reported a greater increase in GOS at 3 months in those with fewer than five comorbidities (56% vs. 19%, p < 0.01). There are limited data describing prognostic factors or the use of frailty indices within the specific group of elderly patients with aSDH. Prospective research is needed to evaluate the utility of accurate and validated assessments of frailty to enhance the neurosurgeon's ability to appropriately manage this complex and expanding patient group.
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Affiliation(s)
- Lachlan R Evans
- 1 National Trauma Research Institute , Melbourne, Australia .,2 Department of Neurosurgery, The Alfred Hospital , Melbourne, Australia
| | - Jordan Jones
- 1 National Trauma Research Institute , Melbourne, Australia
| | - Hui Q Lee
- 1 National Trauma Research Institute , Melbourne, Australia
| | - Dashiell Gantner
- 3 Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital , Melbourne, Australia .,4 Australian and New Zealand Intensive Care Research Centre , Monash University, Melbourne, Australia
| | - Ashish Jaison
- 5 Department of Emergency and Trauma Centre, The Alfred Hospital , Melbourne, Australia
| | - Joseph Matthew
- 1 National Trauma Research Institute , Melbourne, Australia .,6 Department of Trauma Service, The Alfred Hospital , Melbourne, Australia
| | - Mark C Fitzgerald
- 1 National Trauma Research Institute , Melbourne, Australia .,6 Department of Trauma Service, The Alfred Hospital , Melbourne, Australia
| | | | - Martin K Hunn
- 1 National Trauma Research Institute , Melbourne, Australia
| | - Jin W Tee
- 1 National Trauma Research Institute , Melbourne, Australia .,2 Department of Neurosurgery, The Alfred Hospital , Melbourne, Australia
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Lavrador JP, Teixeira JC, Oliveira E, Simão D, Santos MM, Simas N. Acute Subdural Hematoma Evacuation: Predictive Factors of Outcome. Asian J Neurosurg 2018; 13:565-571. [PMID: 30283506 PMCID: PMC6159091 DOI: 10.4103/ajns.ajns_51_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Acute subdural hematoma (aSDH) is a major cause of admission at Neurosurgical Emergency Department. Nevertheless, concerns regarding surgical indication in patients with multiple comorbidities, poor neurological status, antithrombotic therapy, and older age still persist. Therefore, a correct recognition of predictive outcome factors at hospital discharge is crucial to an appropriate neurosurgical treatment. METHODS Eighty-nine medical records of consecutive patients with age ≥18 years old who were submitted to aSDH evacuation between January 2008 and May 2012 were reviewed. Demographic characteristics, neurological status on admission, anticoagulant or antiplatelet therapy, and outcome on discharge were collected. Patients with insufficient data concerning these variables were excluded from the study. RESULTS Sixty-nine patients were included; 52% were male; 74% were older than 65 years; 41% were under oral antithrombotic therapy (OAT); at admission, 54% presented with Glasgow coma scale (GCS) ≤8; 23% were submitted to a craniectomy instead of a craniotomy; 26% of the patients died, 32% were dependent, and 42% were independent on discharge. Crude analysis revealed craniectomy, A/A pupils, GCS ≤8 at admission statistically significant related with the worst outcome (P < 0.05). In the adjusted evaluation only A/A pupils (P = 0.04) was associated to poor outcome (spontaneous etiology P = 0.052). Considering daily living independency at hospital discharge, either male gender (P = 0.044) and A/A pupils (P = 0.030) were related to the worst outcome. No effect of age in outcome was observed. CONCLUSIONS Male gender and A/A pupils are associated with lower probability of achieving independency living at hospital discharge. A/A pupils, low GCS at admission, spontaneous etiology, and craniectomy were associated with the worst outcome. Age and OAT were not predictive factors in this series. Caution should be taken when considering these factors in the surgical decision.
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Affiliation(s)
| | | | - Edson Oliveira
- Department of Neurosurgery, Hospital Santa Maria, Lisbon, Portugal
| | - Diogo Simão
- Department of Neurosurgery, Hospital Santa Maria, Lisbon, Portugal
| | | | - Nuno Simas
- Department of Neurosurgery, Hospital Santa Maria, Lisbon, Portugal
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Gardner RC, Dams-O'Connor K, Morrissey MR, Manley GT. Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions. J Neurotrauma 2018; 35:889-906. [PMID: 29212411 PMCID: PMC5865621 DOI: 10.1089/neu.2017.5371] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.
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Affiliation(s)
- Raquel C. Gardner
- Department of Neurology, University of California San Francisco, and San Francisco VA Medical Center, San Francisco, California
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Molly Rose Morrissey
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Geoffrey T. Manley
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
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McGinity MJ, Michalek JE, Rodriguez JS, Floyd JR. Surgical evacuation of acute subdural hematoma in octogenarians: a ten-year experience from a single trauma center. Br J Neurosurg 2017; 31:714-717. [DOI: 10.1080/02688697.2017.1341041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Michael J. McGinity
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Joel E. Michalek
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Jesse S. Rodriguez
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - John R. Floyd
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Li LF, Lui WM, Wong HHT, Yuen WK, Leung GKK. Outcome after operative intervention for traumatic brain injuries in the elderly. Asian J Neurosurg 2017; 12:37-43. [PMID: 28413530 PMCID: PMC5379801 DOI: 10.4103/1793-5482.148787] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The management of traumatic brain injuries in the elderly (age ≥ 65 years) is a constant dilemma. The aim of this study is to investigate for factors that may predict outcome of operative treatment in this group of patients. MATERIALS AND METHODS A retrospective analysis was conducted on 68 elderly patients who had been operated in a designated center from 2006 to 2010. Patients' age, Glasgow Coma score (GCS), pupillary responses, imaging findings, medical conditions, and the use of anticoagulant/antiplatelet agents on patient outcomes were studied. RESULTS The overall mortality rate was 55.9%. Older age, abnormal pupillary response, low GCS, the presence of midline shift and cistern obliteration on computerized tomography were associated with poor survival. Patient aged 75-84 with normal bilateral pupillary response still had an overall survival rate of 52.6% and good outcomes (Glasgow outcome score: 4 or 5) in 36.8% of patients. Abnormal pupillary response in at least one eye and preoperative GCS ≤ 12 were associated with very poor prognosis. CONCLUSIONS More advanced age was found to be associated with progressively worse outcome. A subgroup patients aged below 85 would survive and could achieve good clinical outcome. The prognosis of those aged over 85 with moderate or severe head injuries was extremely poor.
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Affiliation(s)
- Lai-Fung Li
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wai-Man Lui
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Heidi Hay-Tai Wong
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wai-Kei Yuen
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Gilberto Ka-Kit Leung
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Chesnut R, Videtta W, Vespa P, Le Roux P. Intracranial pressure monitoring: fundamental considerations and rationale for monitoring. Neurocrit Care 2015; 21 Suppl 2:S64-84. [PMID: 25208680 DOI: 10.1007/s12028-014-0048-y] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability worldwide. In large part critical care for TBI is focused on the identification and management of secondary brain injury. This requires effective neuromonitoring that traditionally has centered on intracranial pressure (ICP). The purpose of this paper is to review the fundamental literature relative to the clinical application of ICP monitoring in TBI critical care and to provide recommendations on how the technique maybe applied to help patient management and enhance outcome. A PubMed search between 1980 and September 2013 identified 2,253 articles; 244 of which were reviewed in detail to prepare this report and the evidentiary tables. Several important concepts emerge from this review. ICP monitoring is safe and is best performed using a parenchymal monitor or ventricular catheter. While the indications for ICP monitoring are well established, there remains great variability in its use. Increased ICP, particularly the pattern of the increase and ICP refractory to treatment is associated with increased mortality. Class I evidence is lacking on how monitoring and management of ICP influences outcome. However, a large body of observational data suggests that ICP management has the potential to influence outcome, particularly when care is targeted and individualized and supplemented with data from other monitors including the clinical examination and imaging.
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Affiliation(s)
- Randall Chesnut
- Brain and Spine Center, Suite 370, Medical Science Building, Lankenau Medical Center, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA
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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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Kim BJ, Park KJ, Park DH, Lim DJ, Kwon TH, Chung YG, Kang SH. Risk factors of delayed surgical evacuation for initially nonoperative acute subdural hematomas following mild head injury. Acta Neurochir (Wien) 2014; 156:1605-13. [PMID: 24943910 DOI: 10.1007/s00701-014-2151-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although the majority of patients with minimal acute subdural hematomas (aSDHs) can be managed conservatively, some require delayed aSDH evacuation due to hematoma enlargement. This study was designed to determine the risk factors associated with delayed hematoma enlargement leading to surgery in patients with aSDHs who did not initially require surgical intervention. METHODS From 2002 to 2012, 98 patients were treated for nonoperative aSDHs following mild head injury (Glasgow Coma Scale scores of 13-15). The outcome variables were radiographic evidence of SDH enlargement on serially obtained computed tomography (CT) images and later surgical evacuation. Univariate and multivariate analyses were applied to both the demographic and initial radiographic features to identify risk factors for SDH progression and surgery. RESULTS Overall, 64 patients (65 %) revealed minimal SDH or spontaneous hematoma resolution (conservative group) with conservative management at their last follow-up CT scan. The remaining 34 patients (35 %) received delayed hematoma evacuation (delayed surgery group) a median of 17 days after the head trauma. There were no significant differences between the two groups for baseline characteristics, including age, injury type, degree of brain atrophy, prior history of antithrombotic drugs, and coagulopathy. The presence of cerebral contusions and subarachnoid hemorrhages was more common in the conservative group (p = 0.003 and p = 0.003, respectively). On multivariate analysis, hematoma volume (p = 0.01, odds ratio [OR] = 1.094, 95 % confidence interval [CI] = 1.021-1.173) and degree of midline shift (p = 0.01, OR = 1.433, 95 % CI = 1.088-1.888) on the initial CT scan were independently associated with delayed hematoma evacuation. CONCLUSIONS A critical proportion of patients with minimal aSDHs occurring after mild head injury can progress over several weeks and require hematoma evacuation. Especially patients with a large initial SDH volume and accompanying midline shift require careful monitoring of hematoma progression.
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Affiliation(s)
- Bum-Joon Kim
- Department of Neurosurgery, Korea University College of Medicine, #126, 5-ga, Anam-Dong, Seongbuk-Gu, Seoul, 136-705, Korea
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Zisakis AK, Varsos V, Exadaktylos A. What is New and Innovative in Emergency Neurosurgery? Emerging Diagnostic Technologies Provide Better Care and Influence Outcome: A Specialist Review. Emerg Med Int 2013; 2013:568960. [PMID: 24349786 PMCID: PMC3847970 DOI: 10.1155/2013/568960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 10/08/2013] [Indexed: 12/02/2022] Open
Abstract
The development of emergency medical services and especially neurosurgical emergencies during recent decades has necessitated the development of novel tools. Although the gadgets that the neurosurgeon uses today in emergencies give him important help in diagnosis and treatment, we still need new technology, which has rapidly developed. This review presents the latest diagnostic tools, which offer precious help in everyday emergency neurosurgery practice. New ultrasound devices make the diagnosis of haematomas easier. In stroke, the introduction of noninvasive new gadgets aims to provide better treatment to the patient. Finally, the entire development of computed tomography and progress in radiology have resulted in innovative CT scans and angiographic devices that advance the diagnosis, treatment, and outcome of the patent. The pressure on physicians to be quick and effective and to avoid any misjudgement of the patient has been transferred to the technology, with the emphasis on developing new systems that will provide our patients with a better outcome and quality of life.
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Affiliation(s)
- Athanasios K. Zisakis
- Department of Neurosurgery, Red Cross Hospital, 1st Erythrou Staurou and Athanasaki Street, 11526 Ampelokipoi, Athens, Greece
| | - Vassilios Varsos
- Department of Neurosurgery, Red Cross Hospital, 1st Erythrou Staurou and Athanasaki Street, 11526 Ampelokipoi, Athens, Greece
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Abstract
OBJECT Subdural hematoma (SDH) is a common diagnosis in neurosurgical and neurocritical practice. Comprehensive outcome data are lacking for nontraumatic SDH. The authors determined which factors are associated with in-hospital mortality in a large sample of patients with nontraumatic SDH. METHODS Using the Nationwide Inpatient Sample, the authors selected adults who had been hospitalized in the US between 2007 and 2009 and in whom a primary diagnosis of nontraumatic SDH (ICD-9-CM code 432.1) had been made. Demographics, comorbidities, surgical treatment, and discharge outcomes were identified. Univariate and multivariate analyses were performed to identify predictors of in-hospital mortality. RESULTS Among 14,093 patients with acute nontraumatic SDH, the mean age was 71.4 ± 14.8 (mean ± standard deviation). In addition, 22.2% of the patients were admitted during the weekend. Surgical evacuation was performed in 51.4% of the patients, and 11.8% of all patients died during hospitalization. In multivariate analyses, patient age (adjusted OR 1.02, 95% CI 1.012-1.022), congestive heart failure (adjusted OR 1.42, 95% CI 1.19-1.71), warfarin use (adjusted OR 1.41, 95% CI 1.17-1.70), coagulopathy (adjusted OR 2.14, 95% CI 1.75-2.61), mechanical ventilation (adjusted OR 16.85, 95% CI 14.29-19.86), and weekend admission (adjusted OR 1.19, 95% CI 1.02-1.38) were independent predictors of in-hospital mortality. Race (Hispanic: adjusted OR 0.65, 95% CI 0.51-0.83; black: adjusted OR 0.78, 95% CI 0.63-0.96), urban hospital location (adjusted OR 0.69, 95% CI 0.54-0.89), and surgical SDH evacuation (adjusted OR 0.52, 95% CI 0.45-0.60) were strong independent predictors for decreased mortality. CONCLUSIONS One in 9 patients with nontraumatic SDH dies during hospitalization. Among the several predictors of in-hospital mortality, the weekend effect and treatment with surgical evacuation are potentially modifiable factors. Further investigation may lead to improvements in management and outcomes.
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Affiliation(s)
- Katharina M Busl
- Department of Neurological Sciences, Section of Neurocritical Care, Rush University Medical Center; and
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Schulz C, Mauer UM. [Postoperative course after acute traumatic subdural hematoma in the elderly. Does the extent of craniotomy influence outcome?]. Z Gerontol Geriatr 2012; 44:177-80. [PMID: 21505941 DOI: 10.1007/s00391-011-0168-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM The goal of the study was to analyze the short-term outcome after surgical treatment of acute subdural hematomas in two treatment groups in a patient population >65 years. Whether there are disadvantages from invasive treatment or whether advantages can be achieved with the less invasive treatment has not been previously examined in a prospective study. METHODS A prospective, nonrandomized study of 50 patients >65 years with acute traumatic subdural hematoma was performed, comparing the short-term outcome after two different primary surgical procedures: limited craniotomy (group A, n=25) and large decompressive craniectomy (group B, n=25). RESULTS There were no differences of hematoma volume, degree of midline structure shift, and time from trauma to operation between the two groups. Initial Glasgow coma scale and short-term outcome after 4 weeks measured by the Glasgow outcome score in both groups showed no significant differences. CONCLUSION No significant differences between short-term outcome after limited craniotomy versus large decompressive craniectomy were found for patients >65 years, and the results indicate that decompressive craniectomy can be accepted as a surgical treatment option for acute traumatic subdural hematoma even in elderly patients.
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Affiliation(s)
- C Schulz
- Neurochirurgische Klinik, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, Ulm, Germany.
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Acute traumatic subdural hematoma outcome in patients older than 65 years. World Neurosurg 2012; 78:228-30. [PMID: 22366744 DOI: 10.1016/j.wneu.2012.02.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 02/15/2012] [Indexed: 11/23/2022]
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Valadka AB, Sprunt JM. Craniotomy for acute subdural hematoma in the elderly: not as bad as you thought. World Neurosurg 2011; 78:231-2. [PMID: 22381290 DOI: 10.1016/j.wneu.2011.12.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 12/09/2011] [Indexed: 10/14/2022]
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Lau D, El-Sayed AM, Ziewacz JE, Jayachandran P, Huq FS, Zamora-Berridi GJ, Davis MC, Sullivan SE. Postoperative outcomes following closed head injury and craniotomy for evacuation of hematoma in patients older than 80 years. J Neurosurg 2011; 116:234-45. [PMID: 21888477 DOI: 10.3171/2011.7.jns11396] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Advances in the management of trauma-induced intracranial hematomas and hemorrhage (epidural, subdural, and intraparenchymal hemorrhage) have improved survival in these conditions over the last several decades. However, there is a paucity of research investigating the relation between patient age and outcomes of surgical treatment for these conditions. In this study, the authors examined the relation between patient age over 80 years and postoperative outcomes following closed head injury and craniotomy for intracranial hemorrhage. METHODS A consecutive population of patients undergoing emergent craniotomy for evacuation of intracranial hematoma following closed head trauma between 2006 and 2009 was identified. Using multivariable logistic regression models, the authors assessed the relation between age (> 80 vs ≤ 80 years) and postoperative complications, intensive care unit stay, hospital stay, morbidity, and mortality. RESULTS Of 103 patients, 27 were older than 80 years and 76 patients were 80 years of age or younger. Older age was associated with longer length of hospital stay (p = 0.014), a higher rate of complications (OR 5.74, 95% CI 1.29-25.34), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI 1.13-9.74). However, there were no statistically significant differences between the age groups in 30-day mortality or ability to recover to functional baseline status. CONCLUSIONS The findings suggest that in comparison with younger patients, patients over 80 years of age may be similarly able to return to preinjury functional baselines but may require increased postoperative medical attention in the forms of rehabilitation and longer hospital stays. Prospective studies concerned with the relation between older age, perioperative parameters, and postoperative outcomes following craniotomy for intracranial hemorrhage are needed. Nonetheless, the findings of this study may allow for more informed decisions with respect to the care of elderly patients with intracranial hemorrhage.
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Affiliation(s)
- Darryl Lau
- University of Michigan Medical School, Ann Arbor, Michigan, USA
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