Elderly Patients with Severe Traumatic Brain Injury Could Benefit from Surgical Treatment

Original Article

Elderly Patients with Severe Traumatic Brain Injury Could Benefit from Surgical Treatment Xueyan Wan, Shengwen Liu, Sheng Wang, Suojun Zhang, Hongkuan Yang, Yibo Ou, Min Zhao, Lubuulwa James, Kai Shu, Jincao Chen, Ting Lei

OBJECTIVE: In elderly patients with severe traumatic brain injury, the use of aggressive versus conservative management remains controversial. The aim of this study was to assess the outcome of surgical alternatives for treatment of severe traumatic intracranial hematoma in patients ‡65 years old and identify factors that may contribute to the outcome.

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METHODS: This retrospective study included 112 patients with traumatic intracranial hematoma. Logistic regression analysis was used to identify independent predictors of unfavorable outcome. The Glasgow Outcome Scale was used to evaluate the outcome.

CONCLUSIONS: This study showed that Glasgow Coma Scale score (£5) was a major determinant of outcome in elderly patients with severe traumatic brain injury. However, surgical treatment reduced mortality and improved outcome in the elderly patients in this study.

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RESULTS: Surgery was performed in 70 (62.5%) patients ‡65 years old. A favorable outcome occurred in 33 (47.1%) surgical patients, and 23 (32.9%) surgical patients died. Patients who underwent surgery were less likely to have an unfavorable outcome (52.9% vs. 95.2%) and less likely to die (32.9% vs. 88.1%) at 6 months postinjury compared with patients treated conservatively. Multivariate logistic regression analysis revealed that lower Glasgow Coma Scale score (£5) was a significant factor associated with unfavorable outcome (odds ratio [OR] [ 18.7, 95% confidence interval [CI] [ 5.2e95.5, P < 0.001) and mortality (OR [ 10.7, 95% CI [ 4.4e28.5, P < 0.001). However, neurosurgical intervention was a significant factor to negatively predict unfavorable outcome (OR [ 0.03, 95% CI [ 0.01e0.1, P < 0.001) and mortality (OR [ 0.04, 95% CI [ 0.01e0.1, P < 0.001).

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INTRODUCTION

T

he elderly population is growing rapidly worldwide, and according to a 2010 national census in China, 118.8 million people were
65 years old, accounting for 8.87% of the population of the country, and this number has been rising steadily. In China, it is estimated that elderly patients with traumatic brain injury (TBI) account for approximately 8% of all patients with TBI.1 TBI, especially traumatic intracranial hematoma (TIH) in elderly patients, poses a great challenge for clinicians and can have a substantial impact on the lives of the patients. Mortality in elderly patients with TBI has been reported to be 24%e78%.2,3 It has been well documented that elderly patients with TBI have higher mortality and, compared with their younger counterparts, are less likely to function or live independently after TBI.4-9 Several factors were found to contribute to the poorer outcome in elderly patients, including lower Glasgow Coma Scale (GCS) scores,4,10 preexisting systemic diseases,11,12 systemic complications,12 closed basal cisterns and midline shift,13 and limited intensive care.14 However, whether treatment strategies are linked to TBI outcomes so far remains unclear. Given the worse outcome and

Key words Elderly - Prognosis - Surgery - Therapeutic approach - Traumatic brain injury

Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

Abbreviations and Acronyms CI: Confidence interval CT: Computed tomography GCS: Glasgow Coma Scale OR: Odds ratio TBI: Traumatic brain injury TIH: Traumatic intracranial hematoma

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WORLD NEUROSURGERY 89: 147-152, MAY 2016

To whom correspondence should be addressed: Sheng Wang, Ph.D., M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2016) 89:147-152. http://dx.doi.org/10.1016/j.wneu.2016.01.084

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higher mortality in elderly patients with TBI, many researchers recommended a conservative approach for the treatment of severe head injury of elderly patients.4,15 Some authors16 argued that the poor outcome did not justify conservative treatment, and, on the contrary, less aggressive alternatives might be related to poor outcome.14,17 Moreover, a previous study8 reported that some neurosurgeons were reluctant to transfer elderly patients to neurosurgical facilities and attributed the poor outcome of the patients to the conservative management. Nonetheless, other researchers demonstrated that aggressive treatment could yield better outcomes.18,19 The use of aggressive versus conservative treatments in elderly patients with TBI remains controversial, and the neurosurgical approaches currently used for elderly patients should be critically evaluated. This study assessed the outcome of surgical treatments for severe TIH in patients
65 years old and attempted to identify the factors that may contribute to the outcome.

members. If the patients’ family members did not consent to surgical treatment for financial reasons even though the operation was needed, we did not perform the operation, and medical treatment was administered. Medical treatment was given to 42 patients, and 70 patients underwent surgery. For surgical cases, a craniotomy was performed to remove intracranial hematoma. After hematoma removal, the surgeon decided whether the bone flap would be implanted on the basis of the intraoperative presence or absence of brain edema. After surgery, the patient was admitted to the neurosurgical intensive care unit. When the patient regained consciousness or the patient’s condition was stable, he or she was transferred to the wards. All patients were clinically and radiologically evaluated 6 months after injury at an outpatient follow-up visit or were interviewed by telephone. Outcome and mortality were also assessed 6 months after injury. In all patients, outcome was assessed on a 5-point scale (Glasgow Outcome Scale) and was categorized into 2 groups: unfavorable (Glasgow Outcome Scale score 1e3) and favorable (Glasgow Outcome Scale score 4e5).

MATERIALS AND METHODS Patients We conducted a retrospective study in 328 consecutive patients with TBI
65 years old who were admitted to the Department of Neurosurgery of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, between January 2008 and December 2014. Because this study focused on the impact of surgical alternatives on the outcome of TIH in elderly patients, our inclusion criteria included the following: 1) patients with acute supratentorial TIH and lowest unsedated GCS score <9 during the hospital stay and 2) class mass lesion evacuated or class nonmass lesion evacuated according to Marshall’s classification system.20 Patients with multiple trauma and unstable vital signs at admission were excluded. The criteria were satisfied by 112 patients, and this cohort was included in the study. Demographic data (sex and age), mechanism of injury, and GCS score and pupil reactivity were recorded when the patients arrived at the emergency department. Patient Management Axial computed tomography (CT) scans of the head were performed routinely at admission and thereafter. All patients received a repeat CT scan within 12 hours after admission. Another CT scan was performed if the patient’s condition deteriorated or intracranial pressure was increased. The hematoma was located on CT scan, and the extent of midline shift and the status of the basic cistern were determined. The volume of the hematoma was calculated according to Petersen’s equation21: A  B  C  0.5, where “A” and “B” represent the largest perpendicular diameters through the hyperdense area on CT scan, and “C” represents the thickness of the lesion. The images were subsequently classified in accordance with Marshall’s classification system.20 After admission, some patients with cerebral herniation were sent directly to the operating room for removal of intracranial hematoma, and the other patients were taken to wards for resuscitation and reevaluation. The treatment choices (i.e., neurosurgical intervention or medical treatment) were based on a well-established guideline22 and on the consent of patients’ family

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Statistical Analysis All statistical analyses were conducted with the open source statistical package R version 3.1.0.23 Differences between the 2 groups were assessed by c2 test or Fisher exact test for categorical variables, and Wilcoxon rank sum test was used for comparison of mean age, midline shift, and hematoma size. Variables with P value < 0.05, as determined by univariate analysis, were included for multivariate analysis. Multivariate logistic regression analysis was used to identify independent predictors of unfavorable outcome. P values <0.05 were considered statistically significant. RESULTS Clinical Features of Patients Acute supratentorial TIH was present in 112 patients, including 30 women and 82 men. Surgery was performed in 70 patients (10 patients underwent craniotomy for hematoma removal and 60 patients underwent decompressive craniectomy), and 42 patients were treated medically because patients’ family members did not give consent for surgery. The mean age of the 2 groups was 74.5 years  6.2 for the conservative treatment group and 73.0 years  4.2 for the surgical treatment group; the difference was not statistically significant (P ¼ 0.27). The differences in general features, including sex, injury mechanism, pupil reactivity, GCS score, comorbidity, traumatic subarachnoid hemorrhage, location of hematoma, status of basal cistern, midline shift, and hematoma size, between the surgical and conservative treatment groups were not significant (Table 1). Clinical Outcome of Patients Overall unfavorable outcome and death occurred in 77 (68.8%) patients and 60 (53.6%) patients, respectively. Favorable outcome and mortality of patients undergoing surgery occurred in 33 (47.1%) patients and 23 (32.9%) patients, respectively. Patients undergoing surgery were less likely to have an unfavorable outcome (52.9% vs. 95.2%) or to die (32.9% vs. 88.1%) at 6

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SURGICAL TREATMENT OF ELDERLY PATIENTS WITH SEVERE TBI

Table 1. Characteristics of Patients Characteristic

All Patients

Conservative Treatment

Operation

112

42 (37.5)

70 (62.5)

Number of patients Age, years

Table 2. Clinical Outcome of Patients with or without Operation

73.5  5.1

Sex, male

82

74.5  6.2

73.0  4.2

31 (37.8)

51 (62.2)

P Value

0.27

Clinical Outcome

All Patients

Conservative Treatment Operation P Value

Mortality

60 (53.6)

37 (88.1)

23 (32.9)

< 0.001

Unfavorable outcome

77 (68.8)

40 (95.2)

37 (52.9)

< 0.001

Favorable outcome

35 (31.2)

2 (4.8)

33 (47.1)

1 Data are presented as number (%).

Mechanism of injury Fall

65

25 (22.3)

40 (35.7)

Traffic accident

38

12 (10.7)

26 (23.2)

9

5 (4.5)

4 (3.6)

Normal

53

21 (18.8)

32 (28.6)

Abnormal

59

21 (18.8)

38 (33.8)

3e5

40

15 (13.4)

25 (22.3)

6e8

72

27 (24.1)

45 (40.2)

Comorbidity

51

22 (43.1)

29 (56.9)

0.35

tSAH

46

20 (43.5)

26 (56.5)

0.37

9

1 (0.9)

8 (7.1)

0.24

Other*

0.41

of cerebral infarction, and 13 patients died of uncontrollable brain swelling.

Pupil reactivity 0.81

GCS score 1

Location of hematomay Epidural Subdural

25

9 (8.0)

16 (14.3)

Intracerebral

78

32 (28.6)

46 (41.1)

6

3 (2.7)

3 (2.7)

39 (34.8)

67 (59.8)

Status of basal cistern Open Compressed or closed

106

0.67

Midline shift, mm

8.9  4.3

8.1  4.6

9.3  4.0

0.09

Volume of hematoma, mL

46.9  20.4

46.5  21.6

47.1  19.9

0.56

Data are presented as number (%) or mean  SD. GCS, Glasgow Coma Scale; tSAH, traumatic subarachnoid hemorrhage. *Including hit by falling things, fighting, and boxing. yThe position of the major proportion of hematoma.

months after injury compared with patients treated conservatively; these differences were statistically significant (P < 0.001 and P < 0.001) (Table 2). Postoperative Complications and the Cause of Death We evaluated the relationship between the postoperative complications and deaths. In the surgical treatment group, 23 patients died 2.3 days (range, 1e7 days) after surgical treatment. Complications related to surgery developed in 14 patients, including cerebral infarction (n ¼ 2) and postsurgery hematoma (n ¼ 12). Among those patients, 5 died of postoperative hemorrhage, 1 died

WORLD NEUROSURGERY 89: 147-152, MAY 2016

Risk Factors for Unfavorable Outcome Univariate analyses and multivariate logistic regression analyses were conducted to identify the predicting factors for unfavorable outcome for elderly patients with TIH. Univariate analyses showed that GCS score 5 (P < 0.001), treatment method (P < 0.001), pupil abnormality (P ¼ 0.005), and midline shift
10 mm (P ¼ 0.04) were significantly associated with unfavorable outcome. Multivariate logistic analyses revealed that GCS score 5 was an independent predictor for unfavorable outcome (odds ratio [OR] ¼ 18.7, 95% confidence interval [CI] ¼ 5.2e95.5, P < 0.001), and pupil abnormality was marginally associated with unfavorable outcome (OR ¼ 3.0, 95% CI ¼ 1.1e8.3, P ¼ 0.08). In contrast, surgical treatment was a significant factor to negatively predict the unfavorable outcome (OR ¼ 0.03, 95% CI ¼ 0.01e0.1, P < 0.001) (Table 3). Risk Factors for Mortality Univariate analyses and multivariate logistic regression analyses were performed to find the predictors for death in elderly patients with TIH. Table 4 showed that GCS score 5 (P < 0.001) and treatment method (P < .001) were significantly associated with death of the patients. Multivariate logistic analyses indicated that GCS score 5 was an independent predictor for mortality (OR ¼ 10.7, 95% CI ¼ 4.4e28.5, P < 0.001); however, surgical treatment was a significant factor to negatively predict death (OR ¼ 0.04, 95% CI ¼ 0.01e0.1, P < 0.001). DISCUSSION TIH is an emergency medical condition that often warrants surgical intervention; if treatment is not provided promptly, an unfavorable outcome, including death, tends to result.24 Previous studies19,25 reported that patients with TIH would benefit from neurosurgical intervention. Nonetheless, some neurosurgeons are skeptical about the worth of surgery for the treatment of head injuries in elderly patients8 and prefer conservative treatment in these cases4,15 out of concern over worse outcomes and more deaths in elderly patients3-9,15,26,27 secondary to advanced age3-9 or concomitant diseases.28,29 Some researchers14 also observed that the treatment intensity was lower in older patients with TBI, and conservative treatment was associated with poor outcome in elderly patients.14,17 More recently, mounting evidence has shown that patients might benefit from more aggressive treatment.2,18,19

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Table 3. Association Between Clinical Factors and Unfavorable Outcome Among 112 Patients Univariate Analysis GOS £3

GOS >3

Male

58

24

Female

19

11

Clinical Factors

P Value

Multivariate Analysis

OR

95% CI

P Value

Sex

Univariate Analysis GOS 1

GOS >1

Male

48

34

Female

12

18

Operation

23

47

Nonsurgical

37

5

Clinical Factors

P Value

Multivariate Analysis

OR

95% CI

P Value

0.04 0.01e0.1

< 0.001

Sex 0.60

Treatment method

0.13

Treatment method

Operation

37

33

Nonsurgical

40

2

< 0.001

0.03 0.01e0.1

< 0.001

Pupil reactivity

< 0.001

Pupil reactivity

Normal

29

24

Abnormal

48

11

0.005

3.0

1.1e8.3

0.08

tSAH

Normal

23

30

Abnormal

37

22

Yes

21

25

No

39

27

Epidural þ subdural

18

16

Intracerebral

42

36

0.06

tSAH

Yes

28

18

No

49

17

Epidural þ subdural

23

11

Intracerebral

54

24

0.20

Location*

0.23

Location* 1

GCS score

1

GCS score

5

38

2

>5

39

33

< 0.001

18.7

5.2e95.5

< 0.001

Midline shift, mm 40

10

<10

37

25

0.04

0.82

0.2e2.7

0.79

Volume of hematoma, mL 57

29

30

20

6

0.35

Status of basal cistern

Compressed or closed

31

9

29

43


10

29

21

<10

31

31

< 0.001

10.7

4.4e28.5

< 0.001

0.51

Volume of hematoma, mL

>30

Open

5 >5 Midline shift, mm


10

>30

42

44

30

18

8

0.11

Status of basal cistern 5

1

72

34

0.66

Open

5

1

55

51

Yes

33

18

No

27

34

Yes

11

10

No

49

22

Compressed or closed

Comorbidities

0.21

Comorbidities

Yes

39

12

No

38

23

Yes

12

9

No

65

26

0.16

Complications

0.05

Complications 0.31

GOS, Glasgow Outcome Scale; OR, odds ratio; CI, confidence interval; tSAH, traumatic subarachnoid hemorrhage; GCS, Glasgow Coma Scale. *The position of the major proportion of hematoma.

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Table 4. Association Between Clinical Factors and Mortality Among 112 Patients

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0.25

GOS, Glasgow Outcome Scale; OR, odds ratio; CI, confidence interval; tSAH, traumatic subarachnoid hemorrhage; GCS, Glasgow Coma Scale. *The position of the major proportion of hematoma.

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Taussky et al.19 reported that among 37 consecutive patients >65 years old undergoing craniotomy for acute subdural hematoma, a favorable outcome occurred in 40% of the subjects. A surprising finding was that 50% of patients had pupillary abnormalities; >80% had significant comorbidities, and >40% had been treated with anticoagulants or platelet aggregation inhibitors. Because of the small study size, the authors performed a descriptive statistics analysis only. Shimoda et al.,18 in a study involving 888 subjects, also demonstrated that the surgically treated patients had significantly more favorable outcome at 6 months (18% vs. 7%) and lower mortality (62% vs. 81%) than patients treated conservatively. In this study, we also demonstrated that surgical treatment could significantly improve outcome (47.1% vs. 4.8%) and reduce mortality (32.9% vs. 88.1%). Multivariate logistic analysis showed that surgical treatment was a significant factor to negatively predict unfavorable outcome and mortality, and the finding was consistent with the result reported by a recent study.18 Therefore, we conclude that passive conservative treatment may be associated with the poor outcome, especially in the patients requiring neurosurgical intervention. This study showed that the outcome of elderly patients with TBI was associated with the GCS score. Patients with GCS scores <6 were 18.7 times more likely to have an unfavorable outcome and 10.7 times more likely to die than patients with GCS scores of 6e8. GCS scores might be one of the most important considerations in the selection of treatment schemes for patients with TBI because numerous studies showed that lower GCS scores predicted poorer outcome and higher mortality.9,10,15,18,30,31 Shimoda et al.18 demonstrated that elderly patients with GCS scores of 6e15 could benefit from surgical management. Patel et al.2 suggested that patients with GCS scores of 6e8 were also suitable for more aggressive therapy. However, which treatment was suitable for patients with GCS scores of 3e5 remained controversial. De Bonis et al.15 found that none of 22 patients with postresuscitation GCS scores of 3e5 had a good outcome and concluded that elderly patients with GCS scores of 3e5 could not benefit from decompressive craniectomy, whereas Brazinova et al.13 took issue with this conclusion and demonstrated that 11% of patients with GCS scores of 3e4 and age >65 years had favorable outcome 12 months after trauma and pointed out that this group patients were not hopeless. It is widely accepted the patients with GCS scores >5 could benefit from surgery. Nonetheless, whether elderly patients with GCS scores of 3e5 should be given aggressive treatment warrants further studies.

Previous studies showed that complications, a major concern of most neurosurgeons, were a predictor of poor outcome.10,17 In this study, we analyzed the relationship between the causes of death and the postoperative complications and found that the main cause of death was uncontrollable brain swelling, rather than complications related to the operation. Moreover, our univariate analysis failed to reveal any association between causes of death and postoperative complications, which was similar to earlier findings.9,30 Tokutomi et al.9 demonstrated that only 8.3% of patients died of systemic complications. Huang et al.30 also demonstrated that most deaths resulted from uncontrollable brain swelling. These findings suggested that complications might not be the main cause that led to unfavorable outcome and that other factors might be involved, such as destructive progression of the secondary brain injury.9 This study has some limitations. First, this was a retrospective study, and all the operations were not performed by the same surgeon, which might affect the outcome of patients. Second, the study included only patients with GCS scores <9 and acute supratentorial TIH; the conclusions might not be extrapolated to all patients with head injury. Finally, the power of the study was limited by the relatively small number of subjects. Some factors, such as pupil abnormality and status of basal cisterns, failed to register statistical significance in the study, and the causes need further study in larger populations.

REFERENCES 1. Wang ZC. Neurosurgery. Beijing: People’s Medical Publishing House; 1974. 2. Patel HC, Bouamra O, Woodford M, Yates DW, Lecky FE. Mortality associated with severe head injury in the elderly. Acta Neurochir (Wien). 2010; 152:1353-1357 [discussion: 1357]. 3. Susman M, DiRusso SM, Sullivan T, Risucci D, Nealon P, Cuff S, et al. Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury

CONCLUSIONS This study showed that the prognosis of elderly patients with TBI was poor. GCS score 5 was a major determinant of unfavorable outcome in elderly patients with TIH; however, surgical treatment might reduce the mortality and improve the outcome. Moreover, complications were not the main cause of the unfavorable outcome. Therefore, in these patients, indiscriminately rejecting a surgical approach might not be a wise choice; treatment decisions should be made on a case-by-case basis. ACKNOWLEDGMENTS This work was supported by the “Dawn” Program of Science and Technology for Young Scientists of Wuhan, China (Grant No. 201150431121), and National Clinical Key Specialty Construction Project. The authors thank Wenhua Liu (Clinical and Translational Medical Center) for statistical assistance.

severity. J Trauma. 2002;53:219-223 [discussion: 223-224]. 4. Gan BK, Lim JH, Ng IH. Outcome of moderate and severe traumatic brain injury amongst the elderly in Singapore. Ann Acad Med Singapore. 2004; 33:63-67. 5. Hukkelhoven CW, Steyerberg EW, Rampen AJ, Farace E, Habbema JD, Marshall LF, et al. Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. J Neurosurg. 2003;99:666-673.

WORLD NEUROSURGERY 89: 147-152, MAY 2016

6. Marquez de la Plata CD, Hart T, Hammond FM, Frol AB, Hudak A, Harper CR, et al. Impact of age on long-term recovery from traumatic brain injury. Arch Phys Med Rehabil. 2008;89:896-903. 7. Mosenthal AC, Lavery RF, Addis M, Kaul S, Ross S, Marburger R, et al. Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome. J Trauma. 2002;52: 907-911. 8. Munro PT, Smith RD, Parke TR. Effect of patients’ age on management of acute intracranial

www.WORLDNEUROSURGERY.org

151

ORIGINAL ARTICLE XUEYAN WAN ET AL.

SURGICAL TREATMENT OF ELDERLY PATIENTS WITH SEVERE TBI

haematoma: prospective national study. BMJ. 2002;325:1001.

traumatic brain injury: a meta-analysis. Brain Inj. 2013;27:31-40.

9. Tokutomi T, Miyagi T, Ogawa T, Ono J, Kawamata T, Sakamoto T, et al. Age-associated increases in poor outcomes after traumatic brain injury: a report from the Japan Neurotrauma Data Bank. J Neurotrauma. 2008;25:1407-1414.

18. Shimoda K, Maeda T, Tado M, Yoshino A, Katayama Y, Bullock MR. Outcome and surgical management for geriatric traumatic brain injury: analysis of 888 cases registered in the Japan Neurotrauma Data Bank. World Neurosurg. 2014;82: 1300-1306.

10. Labib N, Nouh T, Winocour S, Deckelbaum D, Banici L, Fata P, et al. Severely injured geriatric population: morbidity, mortality, and risk factors. J Trauma. 2011;71:1908-1914. 11. Grossman MD, Miller D, Scaff DW, Arcona S. When is an elder old? Effect of preexisting conditions on mortality in geriatric trauma. J Trauma. 2002;52:242-246. 12. Perdue PW, Watts DD, Kaufmann CR, Trask AL. Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death. J Trauma. 1998;45: 805-810.

19. Taussky P, Hidalgo ET, Landolt H, Fandino J. Age and salvageability: analysis of outcome of patients older than 65 years undergoing craniotomy for acute traumatic subdural hematoma. World Neurosurg. 2012;78:306-311. 20. Marshall LF, Marshall SB, Klauber MR, Van Berkum Clark M, Eisenberg H, Jane JA, et al. The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma. 1992;9(Suppl 1):S287-S292. 21. Petersen OF, Espersen JO. Extradural hematomas: measurement of size by volume summation on CT scanning. Neuroradiology. 1984;26:363-367.

13. Brazinova A, Mauritz W, Leitgeb J, Wilbacher I, Majdan M, Janciak I, et al. Outcomes of patients with severe traumatic brain injury who have Glasgow Coma Scale scores of 3 or 4 and are over 65 years old. J Neurotrauma. 2010;27:1549-1555.

22. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al. Guidelines for the surgical management of traumatic brain injury. Neurosurgery. 2006;58(3suppl):S1-S60.

14. Thompson HJ, Rivara FP, Jurkovich GJ, Wang J, Nathens AB, MacKenzie EJ. Evaluation of the effect of intensity of care on mortality after traumatic brain injury. Crit Care Med. 2008;36:282-390.

23. R Core Team. R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. Available at: http:// www.R-project.org/. Accessed August 10, 2014.

15. De Bonis P, Pompucci A, Mangiola A, Paternoster G, Festa R, Nucci CG, et al. Decompressive craniectomy for elderly patients with traumatic brain injury: it’s probably not worth the while. J Neurotrauma. 2008;28:2043-2048.

24. Stieg PE, Kase CS. Intracranial hemorrhage: diagnosis and emergency management. Neurol Clin. 1998;16:373-390.

of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. J Trauma. 2002;56:1042-1048. 27. Richmond R, Aldaghlas TA, Burke C, Rizzo AG, Griffen M, Pullarkat R. Age: is it all in the head? Factors influencing mortality in elderly patients with head injuries. J Trauma. 2011;71:E8-E11. 28. Colantonio A, Escobar MD, Chipman M, McLellan B, Austin PC, Mirabella G, et al. Predictors of postacute mortality following traumatic brain injury in a seriously injured population. J Trauma. 2008;64:876-882. 29. Lecours A, Sirois MJ, Ouellet MC, Boivin K, Simard JF. Long-term functional outcome of older adults after a traumatic brain injury. J Head Trauma Rehabil. 2012;27:379-390. 30. Huang YH, Lee TC, Lee TH, Liao CC, Sheehan J, Kwan AL. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg. 2013;118:1329-1335. 31. Utomo WK, Gabbe BJ, Simpson PM, Cameron PA. Predictors of in-hospital mortality and 6-month functional outcomes in older adults after moderate to severe traumatic brain injury. Injury. 2009;40: 973-977.

Conflict of interest statement: There is no conflict of interest.

16. McIntyre A, Mehta S, Janzen S, Aubut J, Teasell RW. A meta-analysis of functional outcome among older adults with traumatic brain injury. Neurorehabilitation. 2013;32:409-414.

25. Chibbaro S, Di Rocco F, Mirone G, Fricia M, Makiese O, Di Emidio P, et al. Decompressive craniectomy and early cranioplasty for the management of severe head injury: a prospective multicenter study on 147 patients. World Neurosurg. 2011;75:558-562.

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17. McIntyre A, Mehta S, Aubut J, Dijkers M, Teasell RW. Mortality among older adults after a

26. Mosenthal AC, Livingston DH, Lavery RF, Knudson MM, Lee S, Morabito D, et al. The effect

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Received 17 October 2015; accepted 29 January 2016 Citation: World Neurosurg. (2016) 89:147-152. http://dx.doi.org/10.1016/j.wneu.2016.01.084 Journal homepage: www.WORLDNEUROSURGERY.org

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