Prognosis of Acute Subdural Hematoma in the Elderly: A Systematic Review

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.

Factors Associated with Poor Outcomes in Patients with Mild or Moderate Acute Subdural Hematomas

“…A systematic review into the prognosis of ASDH in the elderly demonstrated that the mechanism of injury was not a predictor of mortality. 18) Although another study found that injuries caused by traffic accidents were associated with poor outcomes, as this study was performed 37 years ago, 19) its findings may no longer be accurate.…”

Predictive factors of 30‑day mortality in patients with traumatic subdural hematoma

“…Prognosis of ASDH, particularly in the elderly, was evaluated in a systematic review that included seven eligible studies. The researchers investigated the predictive factors and modified index and they found that an initial GCS of 3-8 was the most important predictive factor for a negative outcome (18). In a retrospective study focusing on the criteria for surgery in elderly patients with ASDH, a GCS of 3-8 was a significant indicator for high mortality (P<0.001) (19).…”

Fifteen Cases of Endoscopic Treatment of Acute Subdural Hematoma with Small Craniotomy under Local Anesthesia: Endoscopic Hematoma Removal Reduces the Intraoperative Bleeding Amount and the Operative Time Compared with Craniotomy in Patients Aged 70 or Older

“…However, older age is generally accepted to be an important predictor of poor prognosis and mortality of SDH, which has a mortality rate ranging from 35% to 80%. [19][20][21][22] Furthermore, craniotomy under general anesthesia is often inappropriate in elderly patients due to their systemic comorbid burdens, such as cardiopulmonary failure, diabetes mellitus, and the use of antithrombotic drugs. Therefore, an endoscopic procedure under local anesthesia would be useful for patients with ASDH who cannot undergo craniotomy under general anesthesia.…”