Impact of Antithrombotic Medications and Reversal Strategies on the Surgical Management and Outcomes of Traumatic Acute Subdural Hematoma.

OBJECTIVE: Careful hematologic management is required in surgical patients with traumatic acute subdural hematoma (aSDH) taking antithrombotic medications. We sought to compare outcomes between patients with aSDH taking antithrombotic medications at admission who received antithrombotic reversal with patients with aSDH not taking antithrombotics. METHODS: Retrospective review identified patients with traumatic aSDH requiring surgical evacuation. The cohort was divided based on antithrombotic use and whether pharmacologic reversal agents or platelet transfusions were administered. A 3-way comparison of outcomes was performed between patients taking anticoagulants who received pharmacologic reversal, patients taking antiplatelets who received platelet transfusion, and patients not taking antithrombotics. Multivariable regressions, adjusted for injury severity, further investigated associations with outcomes. RESULTS: Of 138 patients who met inclusion criteria, 13.0% (n = 18) reported taking anticoagulants, 16.7% (n = 23) reported taking antiplatelets, and 3.6% (n = 5) reported taking both. Patients taking antiplatelets who received platelet transfusion had longer intraoperative times (P = 0.040) and higher rates of palliative care consultations (P = 0.046) compared with patients taking anticoagulants who received pharmacologic reversal and patients not taking antithrombotics. Across groups, no significant differences were found in frequency of in-hospital intracranial hemorrhage and venous thromboembolism, length of hospital stay, rate of inpatient mortality, or follow-up health status. In multivariable analysis, intraoperative time remained longest for the antiplatelets with platelet transfusion group. Other outcomes were not associated with patient group. CONCLUSIONS: Among surgical patients with traumatic aSDH, those taking antiplatelet medications who receive platelet transfusions experience longer intraoperative procedure times and higher rates of palliative care consultation. Comparable outcomes were observed between patients receiving antithrombotic reversal and patients not taking antithrombotics.

Craniotomy versus craniectomy for traumatic acute subdural hematoma-coarsened exact matched analysis of outcomes.

BACKGROUND AND OBJECTIVES: Acute subdural hematoma (aSDH) after traumatic brain injury frequently requires emergent craniotomy (CO) or decompressive craniectomy (DC). We sought to determine the variables associated with either surgical approach and to compare outcomes between matched patients. METHODS: A multi-center retrospective review was used to identify traumatic aSDH patients who underwent CO or DC. Patient variables independently associated with surgical approach were used for coarsened exact matching.Multivariate logistic regression and multivariate Cox proportional-hazards regression wereconducted on matched patients to determine independent predictors of mortality. RESULTS: Seventy-six patients underwent CO and sixty-two underwent DC for aSDH evacuation. DC patients were21.4 years younger (P < 0.001), more likely to be male (80.6 % vs 60.5 %,P = 0.011), and present with GCS ≤ 8 (64.5 % vs 36.8 %,P = 0.001). Age (P < 0.001), epidural hematoma (P = 0.01), skull fracture (P = 0.001), and cisternal effacement (P = 0.02) were independently associated with surgical approach. After coarsened exact matching, DC (P = 0.008), older age (P = 0.007), male sex (P = 0.04), and intraventricular hemorrhage (P = 0.02), were independently associated with inpatient mortality. Multivariate Cox proportional-hazards regression demonstrated that DC was independently associated with mortality at 90-days (P = 0.001) and 1-year post-operation (P = 0.003). CONCLUSION: aSDH patients who receive surgical evacuation via DC as opposed to CO are younger, more likely to be male, and have worse clinical exam. After controlling for patient differences via coarsened exact matching, DC is independently associated with mortality.

Endoscope-Assisted Keyhole Surgery for Traumatic Subacute Subdural Hematoma Evacuation in Emergencies.

OBJECTIVE: This study aimed to investigate whether a simple endoscopic method was effective for the evacuation of traumatic subacute subdural hematomas. METHODS: A total of 51 patients with subacute subdural hematomas requiring surgery were enrolled in this study. An endoscopic hematoma evacuation was performed through a small bone window for 22 patients. Hematoma evacuation by open surgery was performed for 29 patients. The postoperative Glasgow Coma Scale scores improvement, surgery times, displacement of midline measurements, and intraoperative blood loss were recorded and analyzed for each patient. RESULTS: The average time from the initial incision to suture completion was 38.41 ± 6.97 minutes for the endoscopic surgery group and 74.66 ± 9.54 minutes for the open-surgery group (P < 0.01). The average total blood loss was 41.36 ± 10.82 ml for the endoscopic group and 250.00 ± 58.25 ml for the open-surgery group (P < 0.01). No postoperative bleeding occurred in either group. The midline displacement measurement showed significant improvement on the day after surgery, with 5.21 ± 1.98 mm in the study group versus 6.75 ± 1.37 mm in the control group (P < 0.01). At the 1-month follow-up appointment, the midline measurement was normal in both groups. Computed tomography scans revealed almost no residual hematomas, representing an average evacuation rate of 100% in both groups. The average Glasgow Coma Scale scores improvement on the day after surgery were 1.77 ± 1.93 in the endoscopic surgery group and 1.66 ± 0.77 in the open-surgery group (P = 0.766). CONCLUSION: Endoscopic subacute subdural hematoma removal through a small bone window achieved satisfactory hematoma removal using a minimally invasive method when compared with an open-surgery method.

Neurologic Outcomes for Octogenarians Undergoing Emergent Surgery for Traumatic Acute Subdural Hematoma.

BACKGROUND: Determining the appropriate surgical indications for obtunded octogenarians with traumatic acute subdural hematoma (aSDH) has been challenging. We sought to determine which easily available data would be useful adjuncts to assist in early and quick decision-making. METHODS: We performed a single-center, retrospective review of patients aged ≥80 years with confirmed traumatic aSDH who had undergone emergent surgery. The clinical measurements included the Karnofsky performance scale score, Charlson comorbidity index, Glasgow coma scale (GCS), and abbreviated injury score. The radiographic measurements included the Rotterdam computed tomography score, aSDH thickness, midline shift, and optic nerve sheath diameter (ONSD). The neurologic outcomes were defined using the extended Glasgow outcome scale-extended (GOS-E) at hospital discharge and 3-month follow-up. The Pearson correlation coefficient was used to compare the ONSD with all clinical, radiographic, and outcome variables. Multivariate logistic regression was used to assess the relationship between the discharge and 3-month GOS-E scores between all clinical and radiographic variables. RESULTS: A total of 17 patients met the inclusion criteria. The mean age was 82.5 ± 1.6 years (range, 80-85 years), and the mean GCS score was 11.2 ± 4.1 (range, 4-15). The mean discharge and 3-month GOS-E scores were 3.4 ± 2.6 (range, 1-8) and 2.3 ± 2.1 (range, 1-7), respectively. We found significant negative correlations between the ONSD and the GCS score (r = -0.62; P < 0.01) and the ONSD and discharge GOS-E score (r = -0.49; P = 0.05). Multivariate analysis revealed a significant association between the abbreviated injury score and the discharge GOS-E score (P = 0.05). CONCLUSIONS: Octogenarians sustaining aSDH and requiring emergent surgery have poor outcomes. More data are needed to determine whether the ONSD can be a useful adjunct tool to predict the efficacy of emergent surgery.

Subdural haematoma in the elderly: management and outcomes of a UK Major Trauma Centre.

BACKGROUND: An estimated 40% of all traumatic brain injury (TBI) occurs in ≥70-year-olds with a high prevalence of traumatic subdural haematoma (tSDH). It is anticipated that an expanding elderly population will lead to a proportional increase in the incidence of patients with tSDH presenting to UK trauma centres, but the long-term clinical outcomes and factors influencing functional outcomes in this patient group remain poorly understood. AIM: To examine the management and clinical outcomes for elderly (≥70 years) patients diagnosed with tSDH. METHODS: Patient data for this single-centre, retrospective cohort study were analysed from a Major Trauma Centre (MTC) electronic patient records between January 2013 and December 2019. RESULTS: Two hundred and eighty patients were included, 43% aged 70-79, 42% aged 80-89 and 15% >90. In total, 37% underwent a surgical intervention. The 6-month survival in the severe, moderate, and mild TBI groups was 14%, 43%, and 67%, respectively. The 6-month survival in the surgical group was 58%, vs. 60% in the conservatively managed group. Surgical intervention did not significantly impact Extended Glasgow Coma Score (GOS-E) at 6 months, regardless of injury severity. Advanced age (p = 0.04), mixed intracranial injuries (p < 0.0001), craniotomies (p = 0.03), and poor premorbid performance status (p = 0.02) were associated with worse survival and functional outcomes. CONCLUSIONS: Our study demonstrated that increasing age, increasing severity of TBI and poorer premorbid performance status were associated with significantly poorer 6-month survival and functional outcomes in elderly patients with tSDH. Burr hole evacuation was associated with better functional outcomes compared to craniotomy, but overall, there was no significant difference in the outcomes of the surgical and non-surgical groups. We identified strong risk factors for death and poor functional outcomes at 6-months which are important to consider when counselling patients and families about the long-term prognosis of elderly patients with tSDH and can help guide clinical decision-making.

Effect of Pre-Management Antithrombotic Agent Use on Outcome after Traumatic Acute Subdural Hematoma in the Elderly: A Systematic Review.

Traumatic acute subdural hematomas (ASDH) are common in elderly patients (age ≥65 years) and are associated with a poorer prognosis compared with younger populations. Antithrombotic agent (ATA) use is also common in the elderly; however, the influence that pre-morbid ATA has on outcome in ASDH is poorly understood. We hypothesized that pre-morbid ATA use significantly worsens outcomes in elderly patients presenting with traumatic ASDH. English language medical literature was searched for articles relating to ATA use in the elderly with ASDH. Data were collated and appraised where possible. Analyses of study bias were performed. Twelve articles encompassing 2038 patients were included; controls were poorly described in the included studies. Pre-morbid ATA use was seen in 1042 (51.1%) patients and 18 different ATA combination therapies were identified, with coumarins being the most common single agent used. The newer direct oral anticoagulants were evaluated in only two studies. ATA use was associated with a lower presenting Glasgow Coma Scale (GCS) score but not hematoma volume on computed tomography (CT) or post-operative hematoma re-accumulation. No studies connected ATA use with patient outcomes without the presence of confounders and bias. Reversal strategies, bridging therapy, recommencement of ATA, and comparison groups were poorly described; accordingly, our hypothesis was rejected. ATA reversal methods, identification of surgical candidates, optimal surgery methods, and when or whether ATA should be recommenced following ASDH resolution remain topics of debate. This study defines our current understanding on this topic, revealing clear deficiencies in the literature with recommendations for future research.

Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute?

The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.

High Long-Term Mortality Rate in Elderly Patients with Mild Traumatic Brain Injury and Subdural Hematoma due to Ground-Level Fall: Neurosurgery's Hip Fracture?

BACKGROUND: Moderate-to-severe traumatic brain injury (TBI) is a major source of morbidity and mortality in elderly patients. Little is known about long-term mortality in elderly patients following mild, nonfatal TBI and how the injury mechanism predicts survival. This study aimed to compare long-term mortality in elderly patients with mild TBI and traumatic subdural hematoma (tSDH) due to ground-level fall (GLF) versus those with TBI and tSDH due to another cause (i.e., non-ground-level fall [nGLF]). METHODS: This retrospective study comprised 288 patients ≥60 years old from a single Level I trauma center with tSDH and Glasgow Coma Scale scores 13-15. RESULTS: Median follow-up after initial TBI presentation was 2.9 years for the GLF group and 2.4 years for the nGLF group. During follow-up, 98 patients died, and median survival for all elderly patients with mild TBI and tSDH was 4.6 years. The GLF group had a higher mortality rate than the nGLF group, with 93 patients in GLF group dying during follow-up compared with 5 in nGLF group (P < 0.0001). The annual death rate for patients in the GLF group was 12.5% per year. For patients 60-69 years old, 39% in GLF group died compared with 4% in nGLF group during follow-up (P = 0.0002). Likewise, for patients 70-79 years old, 29% in GLF group died compared with 7% in nGLF group (P = 0.021). Finally, 56% of patients >80 years old in GLF group compared with 18% in nGLF group (P = 0.11). CONCLUSIONS: Elderly patients with mild TBI and tSDH due to GLF have significantly higher long-term mortality than patients with injuries due to nGLF.

Intraoperative Ultrasonography for Surgery of Cranial Traumatic Acute Subdural Hematoma: Technical Note.

BACKGROUND: Intraoperative ultrasonography (IOUS) in traumatic brain injury is a fast, easy, and low-cost technique that has been poorly investigated so far even though it could potentially answer many of the intraoperative needs of the surgeon. The aim of this study was to investigate the role of IOUS in patients undergoing surgery for traumatic acute subdural hematoma (aSDH), focusing on its influence on intraoperative surgical strategy, particularly regarding the management of intracerebral contusions (ICCs) associated with aSDH. METHODS: Data of patients who consecutively underwent surgical evacuation of traumatic aSDH with IOUS assistance at our institution from May 2017 to December 2020 were retrospectively analyzed. Patients were dichotomized into an ICC group (ICCs associated with aSDH on preoperative computed tomography scan) and no ICC group (no ICCs associated with aSDH on preoperative computed tomography scan). RESULTS: The study included 41 patients. Before aSDH evacuation, IOUS findings were similar to preoperative computed tomography data. After aSDH evacuation, IOUS detected a new-onset ICC in 13% of patients in the no ICC group and a volume increase of the known ICCs in 22% of patients in the ICC group. Therefore, IOUS made it possible to evacuate these new-onset or expanding hematomas in the same operation, changing our surgical strategy and avoiding a delayed reintervention. CONCLUSIONS: Our study suggests that IOUS in patients undergoing surgery for traumatic aSDH can promptly identify possible evolution of a primary head injury, leading to early and effective treatment.

The Impact of Preinjury Antiplatelet and Anticoagulant Use on Elderly Patients with Moderate or Severe Traumatic Brain Injury Following Traumatic Acute Subdural Hematoma.

BACKGROUND: Although it is often assumed that preinjury anticoagulant (AC) or antiplatelet (AP) use is associated with poorer outcomes among those with acute subdural hematoma (aSDH), previous studies have had varied results. This study examines the impact of preinjury AC and AP therapy on aSDH thickness, 30-day mortality, and extended Glasgow Outcome Scale at 6 months in elderly patients (aged ≥65). METHODS: A level 1 trauma center registry was interrogated to identify consecutive elderly patients who presented with moderate or severe traumatic brain injury (TBI) and associated traumatic aSDH between the first of January 2013 and the first of January 2018. Relevant demographic, clinical, and radiological data were retrieved from institutional medical records. The 3 primary outcome measures were aSDH thickness on initial computed tomography scan, 30-day mortality, and unfavorable outcome at 6 months (extended Glasgow Outcome Scale). RESULTS: One hundred thirty-two elderly patients were admitted with moderate or severe TBI and traumatic aSDH. The mean (±SD) age was 78.39 (±7.87) years, and a majority of patients (59.8%, n = 79) were male. There was a statistically significant difference in mean aSDH thickness, but there were no significant differences in 30-day mortality (P = 0.732) and unfavorable outcome between the AP, AC, combined AP and AC, and no antithrombotic exposure groups (P = 0.342). CONCLUSIONS: Further studies with larger sample sizes are necessary to confirm these observations, but our findings do not support the preconceived notion in clinical practice that antithrombotic use is associated with poor outcomes in elderly patients with moderate or severe TBI.

Impact of Thrombocytopenia on Preoperative Hematoma Expansion for Acute Traumatic Subdural Hematoma.

BACKGROUND: Acute subdural hematoma is a neurosurgical emergency. Thrombocytopenia poses a management challenge for these patients. We aimed to determine the impact of thrombocytopenia on preoperative hemorrhage expansion and postoperative outcomes. METHODS: This retrospective study evaluated patients presenting at our institution with acute subdural hematoma between 2009 and 2019. Patients who underwent surgery, had thrombocytopenia (platelets <150,000/µL), and had multiple preoperative computed tomography scans were included. Case control 1:1 matching was performed to generate a matched cohort with no thrombocytopenia. Univariate analyses were conducted to determine changes in subdural thickness and midline shift, postoperative Glasgow Coma Scale score, mortality, length of stay, and readmission rates. RESULTS: We identified 19 patients with both thrombocytopenia and multiple preoperative computed tomography scans. Median platelet count was 112,000/µL (Q1 69,000, Q3 127,000). Comparing the thrombocytopenia cohort with the control group, there was a statistically significant difference in change in subdural thickness (median 5 mm [Q1 2, Q3 7.4] vs. 0 mm [Q1 0, Q3 1.5]; P = 0.001) and change in midline shift (median 3 mm [Q1 0, Q3 9.5] vs. median 0.5 mm [Q1 0, Q3 1.5]; P = 0.018). The thrombocytopenia cohort had higher in-hospital mortality (10 [52.6%] vs. 2 [10.5%]; P = 0.003). No significant differences were found in postoperative Glasgow Coma Scale score, length of stay, number of readmissions, and number of reoperations. CONCLUSIONS: Thrombocytopenia is significantly associated with expansion of hematoma preoperatively in patients with acute subdural hematoma. While the benefit of early platelet correction cannot be determined from this study, patients who present with thrombocytopenia will benefit from close monitoring, a low threshold to obtain repeat imaging, and anticipating early surgical evacuation after platelet optimization.

Concomitant spontaneous spinal and posterior fossa subdural hematoma in an 11-year-old child with aplastic anemia: a case report and review of literature.

PURPOSE: The current article describes an 11-year-old male who has aplastic anemia with an extremely rare condition, that is, concomitant posterior fossa SDH and spinal SDH. METHODS: This is a case report and review of literature. CASE PRESENTATION: This case presents an 11-year-old male known to have aplastic anemia complained of neck and back pain, headache, and persistent vomiting for 3 days. He had no history of head or spine trauma at all. His parents are relatives "positive consanguinity," and his sister suffers from aplastic anemia. Clinical examination revealed severe pallor at the time of presentation, with no neurologic or locomotor deficit and positive Kernig's sign. CONCLUSION: Patients with aplastic anemia or any bleeding disorder conditions should be investigated thoroughly if symptoms denoted a CNS pathology. Concomitant cranial and spinal SDH rarely occurs, and more studies are advocated to be structured to investigate the specific pathophysiology and etiologies of this condition.

Impact of Frailty on Morbidity and Mortality in Adult Patients Undergoing Surgical Evacuation of Acute Traumatic Subdural Hematoma.

OBJECTIVE: To determine whether baseline frailty is an independent predictor of extended hospital length of stay (LOS), nonroutine discharge, and in-hospital mortality after evacuation of an acute traumatic subdural hematoma (SDH). METHODS: A retrospective cohort study was performed. All adult patients who underwent surgery for an acute traumatic SDH were identified using the National Trauma Database from the year 2017. Patients were categorized into 3 cohorts based on the criteria of the 5-item modified frailty index (mFI-5): mFI = 0, mFI = 1, or mFI = 2+. A multivariate logistic regression analysis was used to identify independent predictors of extended LOS, nonroutine discharge, and in-hospital mortality. RESULTS: Of the 2620 patients identified, 41.7% were classified as mFI = 0, 32.7% as mFI = 1, and 25.6% as mFI = 2+. Rates of extended LOS and in-hospital mortality did differ significantly between the cohorts, with the mFI = 0 cohort most often experiencing a prolonged LOS (mFI = 0: 29.41% vs. mFI = 1: 19.45% vs. mFI = 2+: 19.73%, P < 0.001) and in-hospital mortality (mFI = 0: 24.66% vs. mFI = 1: 18.11% vs. mFI = 2+: 21.58%, P = 0.002). On multivariate regression analysis, when compared with mFI = 0, mFI = 2+ (odds ratio 1.4, P = 0.03) predicted extended LOS and nonroutine discharge (odds ratio 1.61, P = 0.001). CONCLUSIONS: Our study demonstrates that baseline frailty may be an independent predictor of extended LOS and nonroutine discharge, but not in-hospital mortality, in patients undergoing evacuation for an acute traumatic SDH. Further investigations are warranted as they may guide treatment plans and reduce health care expenditures for frail patients with SDH.

Procedimiento anestésico - quirúrgico en un lactante con higrohematoma subdural / Anesthetic - surgical procedure in an infant with subdural hygrohematoma

Se describe el caso clínico de un lactante de 47 días de nacido, quien fue atendido en el Cuerpo de Guardia de Pediatría del Hospital Provincial General Docente Antonio Luaces Iraola de Ciego de Ávila, por presentar aumento de la circunferencia cefálica, irritabilidad y agitación. Los exámenes realizados mostraron signos de hipertensión endocraneana descompensada, secundaria a colección del espacio subdural izquierdo. Se eliminó el higroma subdural y la recuperación fue favorable en las primeras 36 horas; luego comenzó a convulsionar y apareció nuevamente el deterioro neurológico, por lo cual se decidió reintervenir. Se realizó inducción anestésica con tiopental sódico fentanilo y rocuronio. El paciente evolucionó sin complicaciones.

The case report of a 47 days infant is described. He was assisted in the children emergency room of Antonio Luaces Iraola Teaching General Provincial Hospital in Ciego de Ávila, due to an increase of the cephalic circumference, irritability and agitation. The exams showed signs of upset endocranial hypertension, secondary to collection of the left subdural space. The subdural hygroma was eliminated and the recovery was favorable in the first 36 hours; then a covulsion began and the neurological deterioration appeared again, reason why it was decided to operate once more. Anesthetic induction was carried out with fentanyl sodium thiopental and rocuronium. The patient had a favorable clinical course without complications.

Surgical management of acute subdural hematoma: a comparison between decompressive craniectomy and craniotomy on patients treated from 2010 to the present in a single center.

BACKGROUND: Acute subdural hematoma represents an important cause of disability and mortality. Its surgical treatment takes advantage of two surgical procedures: craniotomy and decompressive craniectomy, nevertheless the effectiveness of one procedure rather than the other is still debated. This study was conducted to identify which of the surgical procedures could provide better neurological outcome after traumatic acute subdural hematoma; as a secondary endpoint, the study tries to settle preoperative prognostic factors useful to identify the most appropriate surgical technique for every specific patient and kind of trauma. METHODS: A retrospective analysis was performed on patients who underwent craniotomy or decompressive craniectomy between January 2010 and July 2017 at the Department of Neurosurgery of Umberto I Hospital in Rome. Ninety-four patients were selected and reviewing clinical records, preoperative and postoperative's data were collected (e.g., GCS, mechanism of trauma, CT findings, mortality rate, neurological outcome at discharge, mRS at 12 months). Data were analyzed using χ2 test and the F test. The multivariate analysis was performed using a stepwise logistic regression. The analysis was carried out using SPSS software and a P value ≤0.05 was considered significant. RESULTS: In 94 patients, 46.8% underwent decompressive craniectomy and 53.2% underwent craniotomy. The mortality rate was (53.2%); it was shown to be related to a GCS<8 (P=0.033) and to age >60 years old (P=0.0001). Decompressive craniectomy was performed most frequently for high energy trauma (P=0.006); the mean GCS at admission was 7.91 for decompressive craniectomy and 9.64 for craniotomy (P=0.05). Patients who underwent decompressive craniectomy and survived surgery showed a better neurological outcome compared to those who underwent craniotomy (P=0.009). The evaluation of mRS after 12 months did not show a statistically significant difference between the two groups. CONCLUSIONS: In case of high energy trauma and GCS≤8 different neurosurgeons decided to perform most frequently decompressive craniectomy rather than craniotomy. Furthermore, even if not related to survival rate, decompressive craniectomy showed a better neurological outcome especially in patients with GCS≤8 at admission. In conclusion, even if prospective studies are required, these results depict the current attitude about the choice between craniotomy and decompressive craniectomy.

Craniotomy size for traumatic acute subdural hematomas in elderly patients-same procedure for every age?

Surgical treatment of acute subdural hematoma (aSDH) is still matter of debate, especially in the elderly. A retrospective study to compare two different surgical approaches, namely standard (SC, craniotomy size > 8 cm) and limited craniotomy (LC, craniotomy size < 8 cm), was conducted in elderly patients with traumatic aSDH to identify the role of craniotomy size in terms of clinical and radiological outcome. Sixty-four patients aged 75 or older with aSDH as sole lesion were retrospectively analyzed. Data were collected pre- and postoperatively including clinical and radiological criteria. The primary outcome parameter was 30-day mortality. Secondary outcome parameters were radiological. The mean age was 79.2 (± 3.1) years with no difference between groups and almost equal distribution of craniotomy size. Mortality rate was significantly higher in the SC group in comparison to the LC group (68.4% vs. 31.6%; p = 0.045). The preoperative HD (p = 0.08) and the MLS (p = 0.09) were significantly higher in the SC group, whereas postoperative radiological evaluation showed no significant difference in HD or MLS. A limited craniotomy is sufficient for adequate evacuation of an aSDH in the elderly achieving the same radiological and clinical outcome.

Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit.

BACKGROUND AND OBJECTIVE: Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207). METHODS: Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge. RESULTS: Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes. CONCLUSIONS: Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.