Chronic subdural hematoma in patients aged 80 years and older: A two-centre study☆
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.
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Cited by (24)
Non-surgical patient characteristics best predict outcome after 6 months in patients surgically treated for chronic subdural haematoma
2023, Journal of Clinical NeuroscienceMortality and Outcome in Patients Older Than 80 Years of Age Undergoing Burr-Hole Drainage of Chronic Subdural Hematoma
2021, World NeurosurgeryCitation Excerpt :However, these studies all had heterogeneous inclusion criteria concerning the type of hematoma (e.g., acute, subacute, chronic, and acute-on-chronic hematomas), the type of surgery (BHD or craniotomy), and the patients' age, whereas none included solely geriatric patients. De Bonis et al.22 found a greater comorbidity index to be an independent risk factor for mortality and postoperative complications in patients older than the age of 80 years undergoing BHD for cSDH. Similarly, Pilitsis et al.21 showed that patients with 3 or more comorbidities had greater mortality rates in patients older than the age of 80 years.
Outcomes of Surgical Evacuation of Chronic Subdural Hematoma in the Aged: Institutional Experience and Systematic Review
2020, World NeurosurgeryCitation Excerpt :Of 25 nonagenerians in the study, 24 achieved improvement from preoperative MGS after 1 month. Another similar study32 measured the change in mRS score as a primary end point; patients were categorized as improved, worsened, or stable based on their preoperative and 6-month mRS score. This study also failed to show any significant difference in outcome between age groups.
Risk-assessment in chronic subdural hematoma evaluated in 148 patients - A score for predicting recurrence
2020, Clinical Neurology and NeurosurgeryCitation Excerpt :Nevertheless, this paper explores an exciting individualized risk-score assessment, which might harbor advantages for these patients. It merits mention that surgery for CSDH in very elderly patients can be performed under local anesthesia [31,32]. Hence, reducing co-morbidities and postoperative complications as pneumonia or cardiovascular adverse events.
Treatment Outcomes of Burr-Hole Surgery for Chronic Subdural Hematoma in the Elderly Living Beyond Life Expectancy: A Study Comparing Cure, Recurrence, and Complications in Patients Aged ≥80 Years versus ≤79 Years
2019, World NeurosurgeryCitation Excerpt :Rauhala et al.12 reported that among adults younger than 70 years, the incidence of CSDH remained stable, whereas the incidence clearly increased in the population >80 years of age, from 46.9 to 129.5/100,000/year. However, despite several previous reports on treatment results using a cutoff value of 80 years,13,14 evidence for this age group remains insufficient. Because this age group represents a population near the life expectancy in developed countries, their treatment outcomes merit consideration.
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This work has been presented at the 66th National Congress of the Italian Society of Neurosurgeons (Società Italiana di Neurochirurgia – SINch), held in Verona, 21–23 June 2017.