Acute subdural hematoma in the elderly: outcome analysis in a retrospective multicentric series of 213 patients

Correlating Age and Hematoma Volume with Extent of Midline Shift in Acute Subdural Hematoma Patients: Validation of an Artificial Intelligence Tool for Volumetric Analysis

OBJECTIVE

Decision for intervention in acute subdural hematoma patients is based on a combination of clinical and radiographic factors. Age has been suggested as a factor to be strongly considered when interpreting midline shift (MLS) and hematoma volume data for assessing critical clinical severity during operative intervention decisions for acute subdural hematoma patients. The objective of this study was to demonstrate the use of an automated volumetric analysis tool to measure hematoma volume and MLS and quantify their relationship with age.

METHODS

A total of 1789 acute subdural hematoma patients were analyzed using qER-Quant software (Qure.ai, Mumbai, India) for MLS and hematoma volume measurements. Univariable and multivariable regressions analyzed association between MLS, hematoma volume, age, and MLS:hematoma volume ratio.

RESULTS

In comparison to young patients (≤ 70 years), old patients (>70 years) had significantly higher average hematoma volume (old: 62.2 mL vs. young 46.8 mL, P < 0.0001), lower average MLS (old: 6.6 mm vs. young: 7.4 mm, P = 0.025), and lower average MLS:hematoma volume ratio (old: 0.11 mm/mL vs. young 0.15 mm/mL, P < 0.0001). Young patients had an average of 1.5 mm greater MLS for a given hematoma volume in comparison to old patients. With increasing age, the ratio between MLS and hematoma volume significantly decreases (P = 0.0002).

CONCLUSIONS

Commercially available, automated, artificial intelligence (AI)-based tools may be used for obtaining quantitative radiographic measurement data in patients with acute subdural hematoma. Our quantitative results are consistent with the qualitative relationship previously established between age, hematoma volume, and MLS, which supports the validity of using AI-based tools for acute subdural hematoma volume estimation.

Clinical characteristics and functional outcome of surgically treated adult head trauma patients with acute subdural hematoma: Ethiopian tertiary hospitals experience

Background

Acute subdural hematoma (ASDH) is one of the most common and devastating lesions in traumatic brain injury with a mortality rate upto 60 % especially in low-income countries. The present study aimed to determine the clinical characteristics and functional outcomes and the associated factors of surgically treated head trauma patients with ASDH.

Methods

Between January 2018 and January 2021 we identified 140 head trauma patients with ASDH who underwent surgical evacuation in three tertiary hospitals. Epidemiological data were collected; the six-month functional outcome was studied using an extended Glasgow outcome score (EGOS) and associated factors were also studied. Univariate analysis was performed at first, and variables with a P-value of <0.05 were entered into the multivariable logistic regression model.

Results

Male predominance was seen accounting for 87 % and assault was the most common mechanism of injury (35.7 %). Sixty-five (56.5 %) of patients achieved favorable functional recovery (EGOS of 5-8) and 50 (43.5 %) of patients had unfavorable recovery (EGOS of 1-4) after 6 months of follow-up. In multivariate logistic regression models, GCS <5, Pupillary abnormality, hypotension, oxygen saturation <90 at presentation, and hospital-acquired pneumonia were the independent factors associated with unfavorable functional outcomes.

Conclusion

In our setup, most of the patients are male from assault injuries. There is still a high rate of unfavorable outcomes in patients with acute subdural hematoma. GCS <5, pupillary abnormality, hypotension and desaturation at presentation, and postoperative hospital-acquired infection are predictors for unfavorable functional outcomes.

Frailty Is Associated With Decreased Survival in Adult Patients With Nonoperative and Operative Traumatic Subdural Hemorrhage: A Retrospective Cohort Study of 381,754 Patients

Objective

We investigated frailty's impact on traumatic subdural hematoma (tSDH), examining its relationship with major complications, length of hospital stay (LOS), mortality, high level of care discharges, and survival probabilities following nonoperative and operative management.

Background

Despite its frequency as a neurosurgical emergency, frailty's impact on tSDH remains underexplored. Frailty characterized by multisystem impairments significantly predicts poor outcomes, necessitating further investigation.

Methods

A retrospective study examining tSDH patients ≥18 years and assigned an abbreviated injury scale score ≥3, and entered into ACS-TQIP between 2007 and 2020. We employed multivariable analyses for risk-adjusted associations of frailty and our outcomes, and Kaplan-Meier plots for survival probability.

Results

Overall, 381,754 tSDH patients were identified by mFI-5 as robust-39.8%, normal-32.5%, frail-20.5%, and very frail-7.2%. There were 340,096 nonoperative and 41,658 operative patients. The median age was 70.0 (54.0-81.0) nonoperative, and 71.0 (57.0-80.0) operative cohorts. Cohorts were predominately male and White. Multivariable analyses showed a stepwise relationship with all outcomes P < 0.001; 7.1% nonoperative and 14.9% operative patients had an 20% to 46% increased risk of mortality, that is, nonoperative: very frail (HR: 1.20 [95% CI: 1.13-1.26]), and operative: very frail (HR: 1.46 [95% CI: 1.38-1.55]). There were precipitous reductions in survival probability across mFI-5 strata.

Conclusion

Frailty was associated with major complications, LOS, mortality, and high level care discharges in a nationwide population of 381,754 patients. While timely surgery may be required for patients with tSDH, rapid deployment of point-of-care risk assessment for frailty creates an opportunity to equip physicians in allocating resources more precisely, possibly leading to better outcomes.

New horizons in subdural haematoma

Subdural haematoma (SDH) is a common injury sustained by older people living with frailty and multimorbidity, and typically following falls from a standing height. Anticoagulant and antiplatelet use are commonly indicated in older people with SDH, but few data inform decision-making surrounding these agents in the context of intracranial bleeding. Opposing risks of rebleeding and thrombosis must therefore be weighed judiciously. Decision-making can be complex and requires detailed awareness of the epidemiology to ensure the safest course of action is selected for each patient. Outcomes of surgical decompression in acute SDH are very poor in older people. However, burr hole drainage can be safe and effective in older adults with symptomatic chronic SDH (cSDH). Such patients need careful assessment to ensure symptoms arise from cSDH and not from coexisting medical pathology. Furthermore, the emerging treatment of middle meningeal artery embolisation offers a well-tolerated, minimally invasive intervention which may reduce the risks of rebleeding in older adults. Nonetheless, UK SDH management is heterogenous, and no accepted UK or European guidelines exist at present. Further randomised trial evidence is required to move away from clinical practice based on historic observational data.

Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article

Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.

Poor nutritional status is associated with incomplete functional recovery in elderly patients with mild traumatic brain injury

Background

The geriatric nutritional risk index (GNRI) is a simple index for evaluating the nutrition status of elderly patients. Many investigations have demonstrated that this index is associated with the prognosis of several diseases. This study aims to identify the relationship between the GNRI and recovery in elderly mild traumatic brain injury (mTBI) patients.

Methods

A total of 228 mTBI patients older than 65 years were included in this study. mTBI was defined as an injury to the brain with a loss of consciousness of 30 min or less, a duration of posttraumatic amnesia of &lt;24 h, and an admission Glasgow Coma Scale (GCS) score of 13–15. The Glasgow Outcome Scale Extended (GOSE), an outcome scale assessing functional independence, work, social activities, and personal relationships, was applied to assess the recovery of the patients. The clinical outcome was divided into complete recovery (GOSE = 8) and incomplete recovery (GOSE ≤ 7) at 6 months after the injury. Multivariate logistic regression was applied to evaluate the association between the GNRI and recovery of elderly mTBI patients, with adjustment for age, sex, hypertension, diabetes, and other important factors.

Results

The receiver operating curve (ROC) analysis demonstrated that the cutoff value of GNRI was 97.85, and the area under the curve (AUC) was 0.860. Compared to the patients with a high GNRI, the patients with a low GNRI were older, had a higher prevalence of anemia, acute subdural hematoma, and subarachnoid hemorrhage, had a higher age-adjusted Charlson Comorbidity Index value, and had lower levels of albumin, lymphocytes, and hemoglobin. Multivariable analysis showed that high GNRI was associated with a lower risk of 6-month incomplete recovery (OR, 0.770, 95% CI: 0.709–0.837, p &lt; 0.001).

Conclusion

The GNRI has utility as part of the objective risk assessment of incomplete 6-month functional recovery in elderly patients with mTBI.

Neurosurgical treatment in elderly patients with Traumatic brain injury: A 20-year follow-up study

Introduction

Traumatic brain injury in the elderly population can have a substantial impact on patients' quality of life. In this regard, successful treatment strategies are hard to define to date.

Research question

In order to facilitate further insight, this study assessed outcomes following acute subdural hematoma evacuation in patients aged ≥65 years in a large patient series.

Material and methods

A manual screening of the clinical records of 2999 TBI patients aged ≥65 years, admitted to the University Hospital Leuven (Belgium) between 1999 and 2019, was performed.

Results

A total of 149 patients were identified with aSDH, of whom 32 underwent early surgery, 33 underwent delayed surgery and 84 were treated conservatively. Patients who underwent early surgery had the lowest median GCS, poorest Marshall CT scores, longest hospital and ICU stay, and highest intensive care unit admission and redo surgery rates. 30-d mortality was 21.9% in patients undergoing early surgery, 3.0% in patients undergoing late surgery and 16.7% in patients who were treated conservatively.

Discussion and conclusion

In conclusion, patients in whom surgery could not be delayed had the worst presentation and poorest outcomes as opposed in patients in whom delay was possible. Surprisingly, patients treated conservatively had worse outcomes than those treated with delayed surgery. These results might indicate that if the GCS at admission is still adequate, an initial strategy of waiting and seeing might be associated with better outcomes. Future prospective studies with sufficient sample size are warranted to draw more definitive conclusions on the value of early vs. late surgery in elderly patients with aSDH.

Novel CT-based parameters assessing relative cross-sectional area to guide surgical management and predict clinical outcomes in patients with acute subdural hematoma

INTRODUCTION

Acute subdural hematoma (aSDH) is one of the most devastating entities secondary to traumatic brain injury (TBI). Even though radiological computed tomography (CT) findings, such as hematoma thickness (HT), midline shift (MLS), and MLS/HT ratio, have an important prognostic role, they suffer from important drawbacks. We hypothesized that relative cross-sectional area (rCSA) of specific brain regions would provide valuable information about brain compression and swelling, thus being a key determining factor governing the clinical course.

METHODS

We performed an 8-year retrospective analysis of patients with moderate to severe TBI with surgically evacuated, isolated, unilateral aSDH. We investigated the influence of aSDH rCSA and ipsilateral hemisphere rCSA along the supratentorial region on the subsequent operative technique employed for aSDH evacuation and patient's clinical outcomes (early death and Glasgow Outcome Scale [GOS] at discharge and after 1-year follow-up). Different conventional radiological variables were also assessed.

RESULTS

The study included 39 patients. Lower HT, MLS, hematoma volume, and aSDH rCSA showed a significant association with decompressive craniectomy (DC) procedure. Conversely, higher ipsilateral hemisphere rCSA along the dorso-ventral axis and, specifically, ipsilateral hemisphere rCSA at the high convexity level were predictors for DC. CT segmentation analysis exhibited a modest relationship with early death, which was limited to the basal supratentorial subregion, but could not predict long-term outcome.

CONCLUSION

rCSA is an objectifiable and reliable radiologic parameter available on admission CT that might provide valuable information to optimize surgical treatment.

Moderate and severe traumatic brain injury in general hospitals: a ten-year population-based retrospective cohort study in central Norway

BACKGROUND

Patients with moderate and severe traumatic brain injury (TBI) are admitted to general hospitals (GHs) without neurosurgical services, but few studies have addressed the management of these patients. This study aimed to describe these patients, the rate of and reasons for managing patients entirely at the GH, and differences between patients managed entirely at the GH (GH group) and patients transferred to the regional trauma centre (RTC group). We specifically examined the characteristics of elderly patients.

METHODS

Patients with moderate (Glasgow Coma Scale score 9-13) and severe (score ≤ 8) TBIs who were admitted to one of the seven GHs without neurosurgical services in central Norway between 01.10.2004 and 01.10.2014 were retrospectively identified. Demographic, injury-related and outcome data were collected from medical records. Head CT scans were reviewed.

RESULTS

Among 274 patients admitted to GHs, 137 (50%) were in the GH group. The transferral rate was 58% for severe TBI and 40% for moderate TBI. Compared to the RTC group, patients in the GH group were older (median age: 78 years vs. 54 years, p < 0.001), more often had a preinjury disability (50% vs. 39%, p = 0.037), and more often had moderate TBI (52% vs. 35%, p = 0.005). The six-month case fatality rate was low (8%) in the GH group when transferral was considered unnecessary due to a low risk of further deterioration and high (90%, median age: 87 years) when neurosurgical intervention was considered nonbeneficial. Only 16% of patients ≥ 80 years old were transferred to the RTC. For this age group, the in-hospital case fatality rate was 67% in the GH group and 36% in the RTC group and 84% and 73%, respectively, at 6 months.

CONCLUSIONS

Half of the patients were managed entirely at a GH, and these were mainly patients considered to have a low risk of further deterioration, patients with moderate TBI, and elderly patients. Less than two of ten patients ≥ 80 years old were transferred, and survival was poor regardless of the transferral status.

Does the Timing of the Surgery Have a Major Role in Influencing the Outcome in Elders with Acute Subdural Hematomas?

BACKGROUND

The incidence of traumatic acute subdural hematomas (ASDH) in the elderly is increasing. Despite surgical evacuation, these patients have poor survival and low rate of functional outcome, and surgical timing plays no clear role as a predictor. We investigated whether the timing of surgery had a major role in influencing the outcome in these patients.

METHODS

We retrospectively retrieved clinical and radiological data of all patients ≥70 years operated on for post-traumatic ASDH in a 3 year period in five Italian hospitals. Patients were divided into three surgical timing groups from hospital arrival: ultra-early (within 6 h); early (6-24 h); and delayed (after 24 h). Outcome was measured at discharge using two endpoints: survival (alive/dead) and functional outcome at the Glasgow Outcome Scale (GOS). Univariate and multivariate predictor models were constructed.

RESULTS

We included 136 patients. About 33% died as a result of the consequences of ASDH and among the survivors, only 24% were in good functional outcome at discharge. Surgical timing groups appeared different according to presenting the Glasgow Outcome Scale (GCS), which was on average lower in the ultra-early surgery group, and radiological findings, which appeared worse in the same group. Delayed surgery was more frequent in patients with subacute clinical deterioration. Surgical timing appeared to be neither associated with survival nor with functional outcome, also after stratification for preoperative GCS. Preoperative midline shift was the strongest outcome predictor.

CONCLUSIONS

An earlier surgery was offered to patients with worse clinical-radiological findings. Additionally, after stratification for GCS, it was not associated with better outcome. Among the radiological markers, preoperative midline shift was the strongest outcome predictor.

Gender Discrepancy in Patients with Traumatic Brain Injury: A Retrospective Study from a Level 1 Trauma Center

Objectives. The objective of this study is to explore the gender discrepancy in patients with traumatic brain injury (TBI). Methods. A retrospective analysis of Qatar Trauma Registry (QTR) was conducted among patients (age ≥14y) who were hospitalized with TBI. Data were collected and analyzed based on the gender and age. Results. Over 5 years (2014-2019), 9, 309 trauma patients (90% males and 10% females) were admitted to the trauma center. Of these, 1, 620 (17.4%) patients were hospitalized with TBI (94% males and 6% females). Motor vehicle crash was the main mechanism of injury (MOI) in females, and fall from height was predominant among males. Subdural hematoma (SDH) was the more frequent type of TBI in both genders, but it was more prevalent in male patients ≥55 years. Injury severity score, Glasgow coma scale, and head abbreviated injury score were comparable between males and females. The length of stay in the ICU and hospital and mortality were similar in both genders. However, mortality was higher among males ≥55 years when compared to 14-54 years within the same gender (21% vs. 12%, $p=0.002$ ). The crude and adjusted odds ratio did not show that gender is a significant predictor of mortality among TBI patients. Conclusions. Although the incidence and MOI of TBI show significant differences between male and female patients, the severity and outcomes are comparable.

A Validation Study for SHE Score for Acute Subdural Hematoma in the Elderly

OBJECTIVE

The aim of this study was the verification of the Subdural Hematoma in the Elderly (SHE) score proposed by Alford et al. as a mortality predictor in patients older than 65 years with nontraumatic/minor trauma acute subdural hematoma (aSDH). Additionally, we evaluated further predictors associated with poor outcome.

METHODS

Patients were scored according to age (1 point is given if patients were older than 80 years), GCS by admission (1 point for GCS 5-12, 2 points for GCS 3-4), and SDH volume (1 point for volume 50 mL). The sum of points determines the SHE score. Multivariate logistic regression analysis was performed to identify additional independent risk factors associated with 30-day mortality.

RESULTS

We evaluated 131 patients with aSDH who were treated at our institution between 2008 and 2020. We observed the same 30-day mortality rates published by Alford et al.: SHE 0: 4.3% vs. 3.2%, p = 1.0; SHE 1: 12.2% vs. 13.1%, p = 1.0; SHE 2: 36.6% vs. 32.7%, p = 0.8; SHE 3: 97.1% vs. 95.7%, p = 1.0 and SHE 4: 100% vs. 100%, p = 1.0. Additionally, 18 patients who developed status epilepticus (SE) had a mortality of 100 percent regardless of the SHE score. The distribution of SE among the groups was: 1 for SHE 1, 6 for SHE 2, 9 for SHE 3, and 2 for SHE 4. The logistic regression showed the surgical evacuation to be the only significant risk factor for developing the seizure. All patients who developed SE underwent surgery (p = 0.0065). Furthermore, SHE 3 and 4 showed no difference regarding the outcome between surgical and conservative treatment.

CONCLUSIONS

SHE score is a reliable mortality predictor for minor trauma acute subdural hematoma in elderly patients. In addition, we identified status epilepticus as a strong life-expectancy-limiting factor in patients undergoing surgical evacuation.

Machine learning model prediction of 6-month functional outcome in elderly patients with intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) has an increasing incidence and a worse outcome in elderly patients. The ability to predict the functional outcome in these patients can be helpful in supporting treatment decisions and establishing prognostic expectations. We evaluated the performance of a machine learning (ML) model to predict the 6-month functional status in elderly patients with ICH leveraging the predictive value of the clinical characteristics at hospital admission. Data were extracted by a retrospective multicentric database of patients ≥ 70 years of age consecutively admitted for the management of spontaneous ICH between January 1, 2014 and December 31, 2019. Relevant demographic, clinical, and radiological variables were selected by a feature selection algorithm (Boruta) and used to build a ML model. Outcome was determined according to the Glasgow Outcome Scale (GOS) at 6 months from ICH: dead (GOS 1), poor outcome (GOS 2–3: vegetative status/severe disability), and good outcome (GOS 4–5: moderate disability/good recovery). Ten features were selected by Boruta with the following relative importance order in the ML model: Glasgow Coma Scale, Charlson Comorbidity Index, ICH score, ICH volume, pupillary status, brainstem location, age, anticoagulant/antiplatelet agents, intraventricular hemorrhage, and cerebellar location. Random forest prediction model, evaluated on the hold-out test set, achieved an AUC of 0.96 (0.94–0.98), 0.89 (0.86–0.93), and 0.93 (0.90–0.95) for dead, poor, and good outcome classes, respectively, demonstrating high discriminative ability. A random forest classifier was successfully trained and internally validated to stratify elderly patients with spontaneous ICH into prognostic subclasses. The predictive value is enhanced by the ability of ML model to identify synergy among variables.

Simultaneous presentation of subcortical hemorrhage, subdural hemorrhage, and cerebral infarct in a hemiplegic patient

A 90-year-old, non-hypertensive woman presented gait disturbance followed by falls. She had developed a lacunar infarction in the right frontal lobe 1 month previously that subsequently resulted in subtle motor weakness in the left lower extremity. At presentation, the patient showed motor weakness in the left upper and lower extremities with normal findings on blood test. Cranial computed tomography (CT) revealed a subcortical hemorrhage in the anterior part of the right frontal lobe that was accompanied by perilesional edema. In addition, two small subdural hematomas, apparently in the acute phase, were found. Magnetic resonance imaging performed immediately after the CT revealed hyperacute infarct in the right precentral gyrus adjacent to the previous infarct. It was hyperintense on the diffusion-weighted imaging but indistinct on the fluid-attenuated inversion recovery sequence. In addition, findings suggesting cerebral contusions were not observed. Based on these, we assumed that the patient's symptoms were mainly derived from the infarct and the subdural hemorrhages had developed in association with falls. However, it was unclear whether the infarct had developed before or after the formation of subcortical hemorrhage. Traumatic and non-traumatic intracranial hemorrhage and cerebral infarcts may present simultaneously. When intracranial hemorrhages appearing on CT do not adequately explain the patient's neurological findings, undetected cerebral ischemia should be assumed.

Acute subdural haematoma in the elderly: to operate or not to operate? A systematic review and meta-analysis of outcomes following surgery

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.

Superiority of craniotomy over supportive care for octogenarians and nonagenarians in operable acute traumatic subdural hematoma

OBJECTIVE

Neurosurgical evacuation in elderly trauma patients is controversial. We analyzed impact of craniotomy for acute subdural hematoma on survival in octogenarians and nonagenarians. Methods The study population included all patients aged ≥ 80 years who presented with acute traumatic SDHs 09/01/15 - 01/01/20, with radiography indicating operative eligibility (i.e. MLS >5 mm and/or overall thickness >10 mm). Of 1054 TBIs aged ≥ 80 years, 104 (9.87%) were surgically indicated. Of these, 35 received craniotomy and 69 received supportive measures due to family/patient wishes or surgeon's professional decision. We analyzed these data using a Poisson regression adjusted for influence of covariates.

RESULTS

Of 35 craniotomies, 21 (60.00%) were deceased at 2 years of follow-up, compared to 48 (69.57%) deceased of 69 non-surgical patients. No significant demographic differences existed between these groups, other than age (craniotomy patients were younger; median age 84 vs 86; p < 0.001). In outcomes, the craniotomy cohort survived longer and in higher proportions (p = 0.028; Gehan-Breslow-Wilcoxon). When adjusting for covariates, this effect became more pronounced: craniotomy patients died at 41.1% the rate of non-surgical ones. Of all the covariates, only initial GCS significantly impacted the protective effect of craniotomy. In a logarithmic relationship, each point on initial GCS was associated with less benefit from surgery. We also found that patients with GCS< 3 were overall less likely to benefit from surgery. Our conclusions are limited by the impact of patient/surgeon choice on whether or not to operate. It is possible healthier subjects elected for craniotomies. We have attempted to correct for this by including comorbidities as covariates in our regression analyses.

CONCLUSIONS

Our results indicate a surgical benefit for this elderly cohort, consistent with prior findings of benefit in the setting of severe traumatic aSDH. Patients with worse neurologic impairment, i.e. low GCS, had the greatest survival benefit from surgical intervention.

Traumatic acute subdural hematoma and coma: retrospective cohort of surgically treated patients

BACKGROUND

A subdural hematoma is defined as clot formation in the subdural space after vessel rupture or brain parenchyma damage. Several demographic and tomographic factors were associated to poor prognosis, although some debate according to their specific roles still remains.

METHODS

Retrospective cohort study of comatose patients admitted to a single-institution, tertiary hospital center, between the years 2013 and 2019 with traumatic acute subdural hematoma requiring surgical evacuation were studied. Demographic and tomographic data were obtained from medical records. Univariate and multivariate statistical analysis were performed, using a value of P < 0.05 for significance.

RESULTS

Seventy-seven patients were selected using the criteria and a total of 37 (48%) head CT exams were evaluated. The overall mortality was 57.1% and achieved 100% at ≥75-years-old subgroup. Univariate analysis only found young age as a good prognosis factor (P = 0.002). Gender (P = 0.784), abnormal pupillary response (P = 0.643), midline shift (P = 0.874), clot thickness (P = 0.206), compressed basal cisterns (P = 0.643), hematoma side (P = 0.879), and subarachnoid hemorrhage (P = 0.510) showed no association. Multivariate analysis showed no statistically significant association between covariates.

CONCLUSION

Traumatic acute subdural hematoma is a life-threatening condition. Younger age was the only positive prognostic factor identified. More research is necessary to establish age as a rule-out criterion to surgical indication.

Endoscope-assisted techniques for evacuation of acute subdural haematoma in the elderly: The lesser of two evils? A scoping review of the literature

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.

Influence of nutritional status on the clinical outcome of patients with chronic subdural hematoma: a prospective multicenter clinical study

BACKGROUND

Elderly patients present a higher risk of developing chronic subdural hematomas (CSDHs) together with increased risk of malnutrition. The nutritional status may affect outcomes, response to treatments, and prognosis. Influence on other kinds of diseases was investigated showing an increased risk of mortality, morbidity, and adverse outcomes. However, no studies are available on its possible role for the outcome of patients with CSDH. This study aims to evaluate a possible relationship between the nutritional status and the clinical outcome of patients who underwent CSDH surgery.

METHODS

This is a multicenter prospective study enrolling all patients treated for CSDH. Demographic and clinical data were collected. For nutritional status evaluation, we used the Mini Nutritional Assessment (MNA). Chi-square test was used for comparing clinical variables of patients and logistic regression analysis was used for defining the impact of the aforementioned variables on the clinical outcome.

RESULTS

We enrolled 178 patients. Modified Rankin scale (mRS) was 0-2 pre-operatively in 23.6% of patients and post-operatively in 61.2% of patients. Total assessment MNA score was >23.5 in 47.8% of patients. Ninety-three patients (52.2%) presented a normal nutritional status, 63 (35.4%) were at risk of malnutrition and 22 (12.4%) were malnourished. The mean follow-up was 2.6 months. Malnourished patients were at higher risk of a worse outcome (OR 81; CI = 9-750).

CONCLUSION

This study suggests that nutritional status represents a strong predictor of outcome. Our results, albeit preliminary, demonstrated malnutrition is correlated to the risk of worse clinical outcome for patients undergoing surgery for chronic subdural hematoma. Further investigations with wider casuistry and multiple nutritional scores are required to validate our data.

Risk Factors for Progression of Conservatively Managed Acute Traumatic Subdural Hematoma: A Systematic Review and Meta-Analysis

BACKGROUND

Conservatively managed posttraumatic acute subdural hematoma (SDH) can present with progression of the size of the hematoma with increased mass effect, necessitating delayed surgery. The factors contributing to this progression remain largely unknown.

METHODS

A comprehensive search of the PubMed, Embase, and Scopus databases was performed to retrieve case control studies, retrospective cohort studies, and prospective studies with retrospective evaluation of risk factors until August 2, 2020. The different risk factors that were evaluated in the studies were compiled and the results were analyzed to arrive at a conclusion.

RESULTS

A total of 7 studies were included in the systematic review and 6 were included in the analysis, with an aggregate of 679 patients. The following factors were found to have a relation with progression of acute SDH: age (odds ratio, 7.12; 95% confidence interval [CI], 2.52-11.72), use of antiplatelet drugs (odds ratio, 1.89; 95% CI, 1.18-2.77), use of anticoagulants (odds ratio, 3.09; 95% CI, 1.21-7.88), thickness of SDH (odds ratio, 4.13; 95% CI, 3.29-4.97), midline shift (odds ratio, 1.86; 95% CI, 0.69-3.03), hypertension (odds ratio, 2.22; 95% CI, 1.25-3.96) and ischemic heart disease (odds ratio, 3.32; 95% CI, 1.63-6.76).

CONCLUSIONS

The results of this analysis showed that patients with the risk factors outlined are at higher risk of developing symptomatic chronic SDH after conservatively managed traumatic acute SDH compared with those without them. It is therefore necessary to provide more intensive follow-up for these patients to avoid an adverse outcome.