Chronic subdural hematoma in patients aged 80 years and older: A two-centre study

https://doi.org/10.1016/j.clineuro.2018.05.002Get rights and content

Highlights

  • Patients over 80 with chronic subdural hematoma are more and more very frequent in daily practice.

  • Risk factors influencing outcome of surgery have been analysed in 151 surgically treated patients.

  • Higher CCI correlated with complications (OR = 3,18) and 6-month mortality (OR = 11,71).

  • Patients under antithrombotic drugs had a longer hospital stay (OR = 3,07).

  • CCI can represent a useful tool to predict outcome after surgery for CSDH in very elderly patients.

Abstract

Objective

Chronic subdural hematoma (CSDH) is a common condition in the elderly, and the ageing of population will increase the number of “superaged” patients presenting this pathology for the years to come. Few studies investigating the outcome of superaged patients surgically treated for CSDH are available, and study populations are generally small. The outcome of surgically treated patients and risk factors are not completely clear.

Aim of the work is to identify the risk factors which may influence the outcome of patients aged 80 years and older surgically treated for CSDH.

Patients and Methods

This is a retrospective two-centre study including 151 surgically treated patients. A univariate (Fisher exact test) and multivariate (logistic regression) analysis of possible risk factors influencing outcome was performed. Outcome was expressed as: 6-month clinical outcome, 6-month mortality, complications and length of hospital stay.

Results

Univariate analysis showed an association between Charlson Comorbidity Index (CCI) and 6-month clinical outcome (p = 0,048), complications (p = 0,034) and 6-month mortality (p = 0,007). Antithrombotic drugs were associated with longer hospital stay (p < 0,001). Logistic regression analysis showed an association between CCI and complications (p = 0,016, HR = 3,18) and 6-month mortality (p = 0,034, HR = 11,71), and between antithrombotic drugs and longer hospital stay (p = 0,002, HR = 3,07).

Conclusions

Age alone is not a predictor of bad outcome for patients aged 80 years and older surgically treated for CSDH. Charlson Comorbidity Index (CCI) may prove a valuable outcome predicting tool in these patients, and a longer hospital stay may be anticipated for patients under antithrombotic agents.

Introduction

Chronic subdural hematoma (CSDH) is a frequently encountered condition in neurosurgical practice that mainly affects the elderly: the incidence of this condition progressively increases with age [19,13,7]. With the ageing of society and the continuing growth of the older population, this condition is expected to have a further diffusion [8,1].

CSDH is often caused by head trauma, but up to 50% of patients show no history of direct trauma or they can't recall it: elderly subjects are more likely to develop chronic subdural hematoma even due to minor or indirect trauma [12,21,22], because of cerebral atrophy and increased venous fragility which are consequences of the ageing of the brain, stretching the bridging veins and making them vulnerable to injuries [23,5,16]. In many cases, especially in the elderly, CSDH can develop spontaneously [10] and enlarge due to recurrent hemorrage from the hematoma capsule [9,15,24,17,2].

Antiplatelet and anticoagulant agents represent well known risk factors for bleedings. In the last decades there has been a significant increasing use of antiplatelet and anticoagulation therapy among adult patients, especially in the elderly [4,6].

As a result, the number of “superaged” patients referring to hospitals for surgical treatment of CSDH is expected to increase, and this entails a growing need for specialised assistance and more elevated healthcare costs. Few data are available in the literature about the outcome of super-aged patients who undergo surgery for CSDH.

The objective of this study was to analyse patients aged 80 years and older surgically treated for CSDH, examining risk factors and outcome.

Section snippets

Patients

In this retrospective two-centre study, we included patients treated for chronic subdural haematoma at S.Anna University Hospital in Ferrara, Italy (Jul 2012 - Oct 2016) and at Neurotrauma Department at Catholic University School of Medicine in Rome, Italy (Jan 2010 - Oct 2016). Patients were identified using electronic databases. ICD9 codes used as search terms were: 432.1 for diagnosis and 01.24, 01.25, 01.31 for treatment.

Electronic medical records were therefore analysed and demographic and

Results

69 patients were included at S.Anna University Hospital in Ferrara, Italy and 82 patients at Neurotrauma Department at Catholic University School of Medicine in Rome, Italy. The mean age of the patients was 844 years. Table 1 shows patients’ comorbidities and scoring at Charlson Comorbidity Index

Clinical outcome was evaluated 6 months after surgical treatment, and patients were stratified into 3 cathegories: patients maintaining the same clinical condition as before the operation, patients

Discussion

Few Authors have studied the outcome of very elderly patients surgically treated for chronic subdural hematoma.

Most studies included a limited number of subjects. Moreover, the majority of the Authors included all patients presenting with CSDH independently of the treatment (surgical and non surgical).

In our study, we analysed the outcome of 151 patients aged 80 years and older all treated with surgery.

Conclusions

Advanced age considered alone does not lead to a poor outcome in patients aged 80 years and older surgically treated for CSDH. Charlson Comorbidity Index may be a useful outcome predicting tool in very old aged patients, since higher scores correlate with increased risk of complications and are associated with a worse clinical outcome and with a higher 6-month mortality.

Despite being a well-known risk factor for bleedings, the intake of anticoagulant/antiplatelet drugs seems to be ineffective

Funding

No funding was received for this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest, or non-financial interest, in the subject matter or materials discussed in this manuscript.

Ethical approval

For this type of study formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References (24)

  • M. Sambasivan

    An overview of chronic subdural hematoma: experience with 2300 cases

    Surg. Neurol.

    (1997)
  • S. Senger et al.

    New target-specific oral anticoagulants and intracranial bleeding: management and outcome in a single-center case series

    World Neurosurg.

    (2016)
  • V. Adhiyaman et al.

    Chronic subdural hematoma in the elderly

    Postgrad. Med. J.

    (2008)
  • H. Bacchli et al.

    Demographics and prevalent risk factors of chronic subdural hematoma: results of a large single-center cohort study

    Neurosurg. Rev.

    (2014)
  • V. Borger et al.

    Chronic subdural hematoma in elderly patients: a retrospective analysis of 322 patients between the ages of 65-94 years

    Acta Neurochir.

    (2012)
  • P. De Bonis et al.

    Antiplatelet/anticoagulant agents and chronic subdural hematoma in the elderly

    PloS One

    (2013)
  • R.G. Feldman et al.

    Cerebrovascular accident or subdural fluid collection?

    Arch. Intern. Med.

    (1963)
  • M.L. Flaherty et al.

    The increasing incidence of anticoagulant-associated intracerebral hemorrhage

    Neurology

    (2007)
  • R. Fogelholm et al.

    Epidemiology of chronic subdural hematoma

    Acta Neurochir.

    (1975)
  • I.A. Iliescu

    Current diagnosis and treatment of chronic subdural hematomas

    J. Med. Life

    (2015)
  • L. Kyeong-Seok

    History of chronic subdural hematoma

    Korean J. Neurotrauma

    (2015)
  • K.S. Lee

    Chronic subdural hematoma in the aged: trauma or degeneration?

    J. Korean Neurosurg. Soc.

    (2016)
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