Do older patients with acute or subacute subdural hematoma benefit from surgery?

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.

Traumatic brain injury - the effects of patient age on treatment intensity and mortality

“…The reduced use of ICP-monitoring with increasing age has been reported before (10,42), and a low rate of surgical evacuation of traumatic intracranial mass lesions in TBI patients ≥ 65 years is in line with previous reports (10,43). Bus et al suggested that the tendency to restrict surgical treatment in the elderly is because of presumed poor prognosis and may have acted as a self-ful lling prophecy (43). Whitmore and colleagues wrote in 2012: "When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients.…”

“…Invasive ICP-monitoring of patients with TBI, according to the recommendations by the Brain Trauma Foundation, has been proven bene cial (42). The reduced use of ICP-monitoring with increasing age has been reported before (10,42), and a low rate of surgical evacuation of traumatic intracranial mass lesions in TBI patients ≥ 65 years is in line with previous reports (10,43). Bus et al suggested that the tendency to restrict surgical treatment in the elderly is because of presumed poor prognosis and may have acted as a self-ful lling prophecy (43).…”

Traumatic brain injury—the effects of patient age on treatment intensity and mortality

“…The reduced use of ICP-monitoring with increasing age has been reported before [10,42], and a low rate of surgical evacuation of traumatic intracranial mass lesions in TBI patients ≥ 65 years is in line with previous reports [10,43]. Bus et al suggested that the tendency to restrict surgical treatment in the elderly is because of presumed poor prognosis and may have acted as a self-fulfilling prophecy [43]. Whitmore and colleagues wrote in 2012: "When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients.…”

“…Invasive ICP-monitoring of patients with TBI, according to the recommendations by the Brain Trauma Foundation, has been proven beneficial [42]. The reduced use of ICP-monitoring with increasing age has been reported before [10,42], and a low rate of surgical evacuation of traumatic intracranial mass lesions in TBI patients ≥ 65 years is in line with previous reports [10,43]. Bus et al suggested that the tendency to restrict surgical treatment in the elderly is because of presumed poor prognosis and may have acted as a self-fulfilling prophecy [43].…”

Comparative effectiveness of surgery in traumatic acute subdural and intracerebral haematoma: study protocol for a prospective observational study within CENTER-TBI and Net-QuRe

“…Furthermore, certain subgroups may not benefit from surgery because the damage by the primary injury is simply too devastating 9. On the other hand, surgery may not always be necessary and a substantial proportion of patients managed conservatively have satisfactory outcomes 10–14. In addition, timing of surgery plays a role, specifically for a t-ICH.…”