Subdural haematoma in the elderly: management and outcomes of a UK Major Trauma Centre

Surgical versus conservative management for traumatic brain injury in elderly patients: A propensity-matched cohort study

OBJECTIVE

The management of traumatic brain injury in elderly patients remains a topic of conflicting evidence in the literature. While some studies suggest that surgical intervention is beneficial, others indicate increased mortality and morbidity. Therefore, we conducted this retrospective matched cohort study to further investigate the role of surgical and conservative management for traumatic brain injury in elderly individuals.

METHODS

The authors conducted a retrospective review comparing patients with traumatic brain injury who underwent nonoperative management (NOM) versus those who underwent operative management (OM). Case matching was employed to create an artificial control group matched for age, sex, noncontrast computed tomography (NCCT) findings, and symptoms at a 1:1 ratio of treatment to control. The inclusion criteria included patients aged 60 years and above who presented to the emergency medicine department with head injuries resulting from various causes, such as road traffic accidents, falls, or assault, whereas the exclusion criteria included polytrauma, severe hypovolemic shock, and referrals to other institutions. The outcomes of interest included all-cause mortality and Glasgow Outcome Scale (GOS) scores, with statistical significance set at P < 0.05.

RESULTS

Optimal case matching was achieved for 52 out of 96 patients who underwent surgical management. There was no statistically significant difference in all-cause mortality between patients who underwent surgical management (32.69%) and those who did not (28.82%). Similarly, there was no statistically significant difference in the GOS score at 1 month between the two groups. A subgroup analysis based on the severity of traumatic brain injury and radiological diagnosis of intracranial injury revealed no difference between the OM and NOM groups, except for patients who underwent midline shift surgery.

CONCLUSION

There was no difference in all-cause mortality among elderly patients with traumatic brain injury regardless of whether they received conservative or surgical management, except for patients who underwent midline shift surgery.

The impact of early surgery on mortality and functional recovery in older adults with traumatic intracranial lesions: a propensity score-based analysis

BACKGROUND

There is skepticism about the benefit of surgery in elderly patients affected by traumatic brain injury (TBI) due to the negative effect of age on the outcome and surgical complications. However, there are few studies that have investigated differences in patient's outcome between surgically and conservatively managed patients after adjusting for the imbalance in preinjury characteristics and clinical and radiological features. The primary aim of this study was to evaluate the effect of early surgery on mortality and functional recovery in a cohort of older adults with acute traumatic intracranial lesions after adjustment by Propensity Score (PS) matching.     MATERIALS AND METHODS: We conducted a retrospective cohort study on older adult patients (≥ 65 years) admitted for TBI between 2013 and 2023 to a single level 1 trauma center. Patients were categorized based on whether they underwent early surgery (< 48 h after TBI) for a space-occupying lesion evacuation. PS model was constructed based on age, frailty, comorbidities (Charlson comorbity index and American Society of Anaesthesiologists score), anticoagulants, hypoxia, shock, pupillary abnormalities and GCS motor response upon admission, midline shift, basal cistern effacement, volume of subdural and intracerebral hematomas, and limitation of life-sustaining treatment decisions.The effect of early surgery on 30-day mortality and unfavorable functional outcomes (GOSE 1-3) at 6 and 12 months were investigated after matching by paired test.

RESULTS

We identified and reviewed 301 patients who met all inclusion criteria and contained no exclusions. After matching, 62 patients (31 pairs of conservative and surgical patients) remained as the matched datasets. Our key finding was that older adult TBI patients who underwent early surgery had a statistically significant reduction in the risk of 30-day mortality (OR 0.313, 95% CI 0.114-0.853, p = 0.023) and unfaourable outcome at 12 months after TBI (OR 0.286, 95% CI 0.094-0.868, p = 0.027).

CONCLUSIONS

Early surgery was associated with decreased 30-day mortality and better functional outcome at 12 months after TBI in older adults with few comorbidities and good functionality when clinically affected by acute traumatic intracranial lesions with mass effect.

Recovering from physical trauma in late life, a struggle to recapture autonomy: A grounded theory study

AIM

The study aimed to explore the experiences of care and recovery among older patients treated for physical trauma.

DESIGN

A qualitative study with a constructivist grounded theory design.

METHODS

Fifteen in-depth interviews with older adults recovering from physical trauma were conducted and analysed between 2019 and 2023, in accordance with grounded theory methodology.

RESULTS

The findings show that for older patients who suffered physical trauma, the core category was the strive to recapture autonomy. This was achieved by means of Adaptation, Reflection and Interactions, which constitute the three main categories. Recovery involves facing and navigating various new life challenges, such as increased dependency on others, managing difficult symptoms and adapting in various ways to everyday life. The recovery process was influenced by fear, hope and the attitude towards new challenges.

CONCLUSION

Older adults being cared for after a traumatic event have a difficult path to recovery ahead of them. Dealing with increased unwanted dependency on others was a main concern for the participants. Undertreated symptoms can lead to undesired isolation, delayed recovery and further increase unwanted dependency. On the other hand, hope, which was defined as having a positive approach to life and longing for the future, was a strong accelerating factor in the recovery process.

IMPACT

As a result of this study, we have established that older patients experience the initial period after trauma as difficult and that support in the initial phase can be helpful when returning home. As healthcare services are under increasing pressure because of an ageing population, this study contributes by addressing an understudied population and clarifying their concerns.

REPORTING METHOD

Reporting adheres to the COREQ (COnsolidated criteria for REporting Qualitative research) Checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.