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

Figures & data

Table 1. Characteristics of 84 patients aged ≥65 years undergoing craniotomy for (s)aSDH according to outcome.

	Unfavourable outcome	Favourable outcome	p-Value
	(GOS 1–3), n = 63	(GOS 4–5), n = 21
Age, years, mean ± SD (range)	75 ± 6 years (65–88)	73 ± 5 years (65–84)
65–69 years, n (%)	9 (14)	5 (24)
70–79 years, n (%)	37 (59)	13 (62)
≥80 years, n (%)	17 (27)	3 (14)
Gender, n	Male 43, female 20	Male 11, female 10
(s)aSDH at dominant side, n (%)	33 (52)	13 (62)
(s)aSDH thickness, mm, mean ± SD (range)	19 ± 7 mm (4–46)^a	17 ± 7 mm (8–34)
Midline shift, mm, mean ± SD (range)	13 ± 6 mm (3–28)^b	11 ± 6 mm (2–23)^c
Age of SDH, n (%)
aSDH	48 (76)	15 (71)
saSDH	5 (8)	1 (5)
Spontaneous	10 (16)	5 (24)
Anticoagulation, n (%)
None	19 (30)	6 (29)
Acenocoumarol/phenprocoumon	26 (41)	11 (52)
Thrombocyte aggregation inhibitor	12 (19)	4 (19)
Unknown	6 (10)
Neurological examination on admission
Intubated, n (%)	8 (13)	2 (10)
GCS non-intubated patients, mean ± SD (range)	9.4 ± 3.5 (3–15)^c	10.4 ± 3.5 (5–15)
- GCS 3–8, n (%)	29 (53)	6 (32)	.08
- GCS 9–15, n (%)	25 (45)	13 (68)
- GCS unknown, n (%)	1 (2)
Pupillary light reflexes
Normal, n (%)	37 (59)	16 (76)
Unilaterally absent, n (%)	8 (13)	3 (14)
Bilaterally absent, n (%)	14 (22)		.03
- Bilaterally dilated, n	3
- At least one normal-sized pupil, n	11
Unknown, n (%)	4 (6)	2 (10)
Time elapsed (hr) from admission to surgery
Presentation at level I trauma center
GCS >8, hrs, median (IQR)	3 (1.1–7.2), n = 11	2.3 (1.2–12.5), n = 7
GCS ≤8 or intubated, hrs, median (IQR)	0.9 (0.5–1.4), n = 24	0.8 (0.4–2.5), n = 6
GCS unknown, hrs	3, n = 1
Presentation at referring hospital
GCS >8, hrs, median (IQR)	4.5 (3.2–12.1), n = 13	16 (5.4–32.3), n = 6
GCS ≤8 or intubated, hrs, median (IQR)	2.7 (2.1–3.2), n = 12	1.7 (1.1–1.7), n = 2
Unknown delay	n = 2
Neurological examination prior to surgery
Intubated, n (%)	25 (40)	6 (29)
GCS non-intubated patients, mean ± SD (range)	8.7 ± 2.8 (5–14)^c	9.5 ± 3.1 (4–14)
- GCS 3–8, n (%)	21 (55)	6 (40)	.22
- GCS 9–14, n (%)	16 (42)	9 (60)
- GCS unknown, n (%)	1 (3)
Pupillary light reflexes
Normal, n (%)	28 (44)	14 (67)
Unilaterally absent, n (%)	12 (19)	5 (24)
Bilaterally absent, n (%)	18 (29)		.009
- Bilaterally dilated, n	6
- At least one normal-sized pupil, n	12
Unknown, n (%)	5 (8)	2 (10)
Postoperative CT
residual SDH/subdural air, mm, mean ± SD (range)	9 ± 8 (0–30)^d	6 ± 6 (0–17)^b
residual midline shift, mm, mean ± SD (range)	6 ± 5 (0–22)^d	4 ± 4 (0–13)^b

^a2 missing.

^b3 missing.

^c1 missing.

^d6 missing.

CT: computer tomography; hrs: hours; GCS: Glasgow Coma Scale score; GOS: Glasgow Outcome Scale score; IQR: interquartile range; n: number of patients; (s)aSDH = (sub)acute subdural hematoma; SD: standard deviation.

Table 2. Types of surgery in 84 patients aged ≥65 years undergoing craniotomy for (s)aSDH.

	Unfavourable outcome	Favourable outcome
	(GOS 1–3), n = 63	(GOS 4–5), n = 21
Initial surgery
Craniotomy, n (%)	55 (87)	19 (90)
+ ICP	7	4
+ EVD	1
+ hinge craniotomy	3	1
bilateral	2	1
- initial craniotomy at the wrong side	1
Decompressive craniectomy, n (%)	8 (13)	2 (10)
+ ICP	2	1
+ EVD	1
bilateral	1
Additional surgeries, n (%)	12 (19)	6 (29)
Craniotomy for recurrent (ipsilateral) aSDH	5	2
Craniotomy for ipsilateral EDH	4	2
Ipsilateral craniectomy	2
EVD	1
Ventricular-peritoneal shunt	1	1
Removal of infected bone flap	1
Cranioplasty	1	2

(s)aSDH: (sub)acute subdural hematoma; EDH: epidural hematoma; EVD: external ventricular drain; GOS: Glasgow Outcome Scale score; ICP: intracranial pressure monitoring catheter.

Table 3. Causes of death in 54 patients aged ≥65 years undergoing craniotomy for (s)aSDH.

Following withdrawal of artificial respiration	18
absence of cerebral blood flow	1
status epilepticus	1
poor GCS
E1M1Vtube	7
E1M2Vtube	4
E1M3Vtube	3
E1M4Vtube	2
Following restriction of treatment (‘do not resuscitate’)	25
dementia	1
recurrent pneumonia with sepsis	6
status epilepticus	1
poor GCS
E1M1V1	3
E1M2V1	3
E1M3V1	2
E1M4V1	3
E1M5V1	4
E1M5V2	1
E2M5V2	1
Cardiac arrest	2
Congestive heart failure	2
Acute myeloid leukemia	1
Refusal of fluid/food intake	1
Unknown	5

(s)aSDH: (sub)acute subdural hematoma; E: eye response; GCS: Glasgow Coma Scale score; M: motor response; V: verbal response.

Table 4. Characteristics of 84 patients aged ≥65 years undergoing craniotomy according to age of SDH.

	aSDH, n = 63	saSDH, n = 6	Spontaneous SDH, n = 15
Age, years, mean ± SD (range)	75 ± 6 (65–88)	75 ± 6 (68–86)	73 ± 5 (65–83)
Neurological examination on admission
Intubated, n (%)	9 (14)	0 (0)	1 (7)
GCS non-intubated patients, mean ± SD (range)	10.0 ± 3.2 (3–15)^a	9.2 ± 4.5 (4–15)	8.6 ± 4.1 (3–15)
- GCS 3–8, n (%)	25 (46)	3 (50)	7 (50)
- GCS 9–15, n (%)	28 (52)	3 (50)	7 (50)
- GCS unknown, n (%)	1 (2)
Pupillary light reflexes
Normal, n (%)	42 (67)	3 (50)	8 (53)
Unilaterally absent, n (%)	8 (13)		3 (20)
Bilaterally absent, n (%)	9 (14)	2 (33)	3 (20)
- Bilaterally dilated, n	3
- At least one normal-sized pupil, n	6	2	3
Unknown, n (%)	4 (6)	1 (17)	1 (7)
Time elapsed (hr) from admission to surgery
Presentation at level I trauma center
GCS ≥9, hrs, median (IQR)	2.3 (1.1–7.1), n = 14	12.5, n = 1	2.3 (1.5–2.3), n = 3
GCS ≤8 or intubated, hrs, median (IQR)	0.8 (0.5–1.4), n = 24	0.7 (0.6–0.7), n = 3	1.2 (0.8–1.2), n = 3
GCS unknown, hrs	3, n = 1
Presentation at referring hospital
GCS ≥9, hrs, median (IQR)	5.8 (3.3–19.8), n = 13	5.2 (4.3–5.2), n = 2	8.4 (4.1–13), n = 4
GCS ≤8 or intubated, median (IQR)	2.7 (2.3–3.1), n = 9		2.2 (1.2–19.2), n = 5
Unknown delay	n = 2
Neurological examination prior to surgery
Intubated, n (%)	26 (41)	0 (0)	5 (33)
GCS non-intubated patients, mean ± SD (range)	9.0 ± 2.7 (4–14)^a	8.5 ± 4.0 (4–14)	8.8 ± 3.1 (5–14)
- GCS 3–8, n (%)	18 (49)	4 (66)	5 (50)
- GCS 9–14, n (%)	18 (49)	2 (33)	5 (50)
- GCS unknown, n (%)	1 (3)
Pupillary light reflexes
Normal, n (%)	32 (51)	3 (50)	7 (47)
Unilaterally absent, n (%)	14 (22)	1 (17)	2 (13)
Bilaterally, n (%)	12 (19)	2 (33)	4 (27)
- Bilaterally dilated, n	4		2
- At least one normal-sized pupil, n	8	2	2
Unknown, n (%)	5 (8)		2 (13)
Outcome
GOS 1	41 (65)	4 (67)	9 (60)
GOS 3	7 (11)	1 (17)	1 (7)
GOS 4	7 (11)		3 (20)
GOS 5	8 (13)	1 (17)	2 (13)

^a1 missing.

aSDH: acute subdural hematoma, hrs: hours, GCS: Glasgow Coma Scale score, GOS: Glasgow Outcome Scale score, IQR: interquartile range, n: number of patients, saSDH: subacute subdural hematoma, SD: standard deviation.

Table 5. Literature review of elderly patients undergoing craniotomy for aSDH.

Authors	Year	N	Age (years)	Follow up (months)	Favourable outcome (%)	Mortality (%)
Fell et al.^10	1975	13	≥60	NM	NM	69
Hernesniemi^2	1979	20	≥60	46 (mean)	10	80
Wilberger et al.^11	1991	28	>65	18	5	82
Jamjoom et al.^12	1992	66	≥65	NM	30	NM
Cagetti et al.^4	1992	26	>80	NM	NM	88
Kotwica and Brzeziński^5	1993	22	61–65	3	14	68
Phuenpathom et al.^13	1993	10	>60	6	20	80
Koç et al.^14	1997	15	>61	3	20	73
Hanif et al.^15	2009	26	>70	6	26	50
Petridis et al.^16	2009	119	>65	at discharge	21	54
Leitgeb et al.^17	2012	92	61–75	6	NM	42
		88	≥75	6	NM	63
Taussky et al.^6	2012	37	>65	6	41	35
Raj et al.^18	2016	44	≥75	12	NM	50
Benedetto et al.^19	2017	67	>70	6	13	67
McGinity et al.^20	2017	34	≥80	2 (mean)	18	53
Current series		84	≥65	12	25	64

aSDH: acute subdural hematoma; N: number of patients; NM: not mentioned.

Figure 1. Overall outcome (left) and outcome of subpopulations of the 63 patients suffering from aSDH when assorted for GCS and pupillary light reflexes at the moment of diagnosis (middle) or prior to surgery (right). GCS: Glasgow Coma Scale score, GOS: Glasgow Outcome Scale, N: number of patients.

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