- Email: [email protected]
Craniotomy for Acute Subdural Hematoma in the Elderly: Not as Bad as You Thought
Perspectives Commentary on: Age and Salvageability: Analysis of Outcome of Patients Older than 65 Years Undergoing Craniotomy for Acute Traumatic Subdural Hematoma by Taussky et al. pp. 306-311.
Alex B. Valadka, M.D. Chief Executive Officer Seton Brain and Spine Institute
Craniotomy for Acute Subdural Hematoma in the Elderly: Not as Bad as You Thought Alex B. Valadka1 and Julie M. Sprunt 2
I
ncreasing age is associated with worse outcome from virtually all illnesses. Traumatic brain injury (TBI) is no exception. Numerous investigations report the disproportionate influence that a few key variables have on outcome after TBI, of which age is among the most significant (4, 6, 9-11, 20, 23). Other important factors include initial Glasgow Coma Scale score (either total score or only the motor component), pupillary response, and computed tomography (CT) scan characteristics (3, 8, 12, 15, 18, 19). Except for age, these outcome determinants all represent different ways of characterizing the severity of injury, or more precisely, the impact of the traumatic pathophysiology on neurological examination and imaging findings. Of note, these indicators of injury severity may wax or wane during the first few hours after injury. Neurological status can improve or worsen, just as imaging results can move in a favorable or unfavorable direction, hence the importance of noting the exact time that the patient is being examined and of performing careful serial examinations. Furthermore, our specialty is on the brink of adding serum markers to our list of tools for diagnosing and serially tracking the severity of brain injury, just as the diagnosis of myocardial infarction is facilitated by measuring levels of heart-specific proteins and enzymes (14). Because these assessment tools all provide a window into the severity of injury, it is reasonable to expect that they would convey roughly comparable information and also trend in the same direction. A poor Glasgow motor score, a fixed and dilated pupil, and a CT scan demonstrating significant midline shift or effaced basilar cisterns are all indicators of a very severe injury. Of course, less severe abnormalities in some or all of these areas suggest that the brain injury may not be as severe. Age is different. Unlike motor examination, pupillary abnormalities, CT findings, or perhaps serum levels of prognostic biomarkers, patient age does not fluctuate in the immediate postinjury period. Instead, age is an important nonneurological variable that is ever-present in the background. It often seems to magnify the impact of primary and secondary insults, including such common
Key words 䡲 Acute subdural hematoma 䡲 Craniotomy 䡲 Elderly 䡲 Old age 䡲 Trauma
Abbreviations and Acronyms ASDH: Acute subdural hematoma CT: Computed tomography TBI: Traumatic brain injury
and well-recognized secondary insults as hypoxia and hypotension, which are associated with worse outcome after TBI. A major difference, of course, is that these secondary insults are most worrisome in the early postinjury period, and they can often be prevented or at least mitigated, unlike advanced age. Perhaps a more appropriate way to view the physiologic impact of advanced age is to consider its effects on a patient’s baseline health status. Several grading scales attempt to quantify the impact of overall systemic health on outcome of acute diseases such as TBI. Such scales are often based on chronic problems such as heart disease, pulmonary disease, chronic renal insufficiency, etc. Many elderly patients suffer from baseline impairment of function of major organ systems. However, advanced age may have adverse effects on outcome that are distinct from what might be expected by concomitant decreased function of important organ systems. A common explanation is the frequently cited concept of decreased physiologic reserve that is associated with aging (21). Parenthetically, several reports describe better outcomes after TBI in patients who were taking beta-blockers or statins prior to injury (7, 17). Such patients tend to be elderly. It might be tempting to assume that one of the unintended benefits of aging is a greater likelihood of being a regular user of such apparently neuroprotective medications in the event of a TBI. It is doubtful, however, that such prophylactic pharmacological therapy can overcome the adverse effects of the underlying health problems that necessitated such medications in the first place, especially when these problems are superimposed upon advanced age (17). Some investigators have reported a specific age cutoff above which outcome is said to worsen precipitously. Most of us have heard statements such as, “Outcome from TBI is much worse above age 30 [or 40, or 50, etc.].” Although several published reports lend support to this view, common sense suggests that age should have a more-or-less linear relationship to outcome after TBI: the older the
From the 1Seton Brain and Spine Institute, Austin; and 2Department of Surgery, University of Texas Southwestern at Austin, Austin, Texas, USA To whom correspondence should be addressed: Alex B. Valadka, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2012) 78, 3/4:231-232. DOI: 10.1016/j.wneu.2011.12.067
WORLD NEUROSURGERY 78 [3/4]: 231-232, SEPTEMBER/OCTOBER 2012
www.WORLDNEUROSURGERY.org
231
PERSPECTIVES
patient, the worse the outcome, with no clear break point beyond which age has a dramatically worsening effect. This is the type of relationship seen by Maas et al. in one of the largest investigations of the interaction between age and outcome after TBI (13). Because outcomes worsen as age increases, some authorities have adopted a nihilistic attitude toward aggressive therapy of TBI in the elderly population. Their experience with performing emergency craniotomies in this population is so negative that they strongly discourage aggressive care beyond a certain age threshold, such as 65 years (2). This philosophy sounds reasonable to many clinicians who have repeatedly had the same poor outcomes in the elderly TBI population. However, other experts point out that good outcomes can and do occur in some of these patients, suggesting that dogmatic proscriptions against aggressive intervention are overly broad (1, 5, 22). Elderly patients in good general health and with relatively less severe injuries may enjoy surprisingly good outcomes from TBI. Taussky et al. add new data to this controversy. They retrospectively reviewed a series of 37 consecutive patients older than 65 years of age who underwent craniotomy for acute subdural hematoma (ASDH). The median age was 73 years. Half of these patients had pupillary abnormalities, more than 80% had significant comorbidities, and over 40% were treated with anticoagulants or platelet aggregation inhibitors.
Approximately one third of these patients died. The overall poor outcome rate on the dichotomized Glasgow Outcome Scale was 60%. Conversely, favorable outcomes occurred in 40% of patients. At first glance, the favorable outcome rate may seem low. However, when patient age, comorbidity, and use of antiplatelet and anticoagulant medications are considered, the favorable outcome rate is impressive (4, 6, 10, 16, 23). This study has important weaknesses. It is an uncontrolled series, without any comparison group. How were these patients selected? How many ASDH patients in this age group did not undergo craniotomy because their neurological status was good enough to justify nonoperative management? How many elderly patients were treated for other types of brain injury during this time period, and what were their outcomes? Another potential confounder is the fact that almost half the patients had a Glasgow Coma Scale score above 8, suggesting that the severity of neurological injury may have been less severe than in other reported series. These types of weaknesses are unavoidable in retrospective analyses. A prospective investigation would likely address some of these limitations by providing more robust data. Yet despite its imperfections, this report clearly documents that at least some elderly patients—perhaps many more than one might think— go on to good recovery after craniotomy for ASDH.
10. Koç RK, Akdemir H, Oktem IS, Meral M, Menkü A: Acute subdural hematoma: outcome and outcome prediction. Neurosurg Rev 20:239-244, 1997.
associated with improved survival and functional outcomes in older head-injured individuals. J Trauma 71:815-819, 2011.
1. Cagetti B, Cossu M, Pau A, Rivano C, Viale G: The outcome from acute subdural and epidural intracranial haematomas in very elderly patients. Br J Neurosurg 6:227-231, 1992.
11. Munro PT, Smith RD, Parke TR: Effect of patients’ age on management of acute intracranial haematoma: prospective national study. BMJ 325(7371):1001, 2002.
2. De Bonis P, Pompucci A, Mangiola A, Paternoster G, Festa R, Nucci CG, Maviglia R, Antonelli M, Anile C: Decompressive craniectomy for elderly patients with traumatic brain injury: it’s probably not worth the while. J Neurotrauma 28:2043-2048, 2011.
12. Murray GD, Butcher I, McHugh GS, Lu J, Mushkudiani NA, Maas AI, Marmarou A, Steyerberg EW: Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:329-337, 2007.
18. Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, Murray GD, Marmarou A, Roberts I, Habbema JD, Maas AI: Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 5:e165, 2008.
3. Dent DL, Croce MA, Menke PG, Young BH, Hinson MS, Kudsk KA, Minard G, Pritchard FE, Robertson JT, Fabian TC: Prognostic factors after acute subdural hematoma. J Trauma 39:36-42, 1995.
13. Mushkudiani NA, Engel DC, Steyerberg EW, Butcher I, Lu J, Marmarou A, Slieker F, McHugh GS, Murray GD, Maas AI: Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:259-269, 2007.
REFERENCES
4. Hanif S, Abodunde O, Ali Z, Pidgeon C: Age related outcome in acute subdural haematoma following traumatic head injury. Ir Med J 102:255-257, 2009. 5. Hernesniemi J: Outcome following head injuries in the aged. Acta Neurochir (Wien) 49:67-79, 1979. 6. Howard MA 3rd, Gross AS, Dacey RG Jr, Winn HR: Acute subdural hematomas: an age-dependent clinical entity. J Neurosurg 71:858-863, 1989. 7. Inaba K, Teixeira PG, David JS, Chan LS, Salim A, Brown C, Browder T, Beale E, Rhee P, Demetriades D: Beta-blockers in isolated blunt head injury. J Am Coll Surg 206:432-438, 2008. 8. Jamjoom A: Justification for evacuating acute subdural haematomas in patients above the age of 75 years. Injury 23:518-520, 1992. 9. Klun B, Fettich M: Factors influencing the outcome in acute subdural haematoma. A review of 330 cases. Acta Neurochir (Wien) 71:171-178, 1984.
232
www.SCIENCEDIRECT.com
14. Papa L, Lewis LM, Falk JL, Zhang Z, Silvestri S, Giordano P, Brophy GM, Demery JA, Dixit NK, Ferguson I, Liu MC, Mo J, Akinyi L, Schmid K, Mondello S, Robertson CS, Tortella FC, Hayes RL, Wang KK: Elevated levels of serum glial fibrillary acidic protein breakdown products in mild and moderate traumatic brain injury are associated with intracranial lesions and neurosurgical intervention. Ann Emerg Med 2011 Nov 8. [Epub ahead of print]. 15. Petridis AK, Dörner L, Doukas A, Eifrig S, Barth H, Mehdorn M: Acute subdural hematoma in the elderly; clinical and CT factors influencing the surgical treatment decision. Cen Eur Neurosurg 70:7378, 2009. 16. Rozzelle CJ, Wofford JL, Branch CL: Predictors of hospital mortality in older patients with subdural hematoma. J Am Geriatr Soc 43:240-244, 1995. 17. Schneider EB, Efron DT, Mackenzie EJ, Rivara FP, Nathens AB, Jurkovich GJ: Premorbid statin use is
19. Taussky P, Widmer HR, Takala J, Fandino J: Outcome after acute traumatic subdural and epidural haematoma in Switzerland: a single-centre experience. Swiss Med Wkly 138:281-285, 2008. 20. Tian HL, Chen SW, Xu T, Hu J, Rong BY, Wang G, Gao WW, Chen H: Risk factors related to hospital mortality in patients with isolated traumatic acute subdural haematoma: analysis of 308 patients undergone surgery. Chin Med J (Engl) 121:1080-1084, 2008. 21. Victorino GP, Chong TJ, Pal JD: Trauma in the elderly patient. Arch Surg 138:1093-1098, 2003. 22. Vyas NA, Chicoine MR: Extended survival after evacuation of subdural hematoma in a 102-year-old patient: case report and review of the literature. Surg Neurol 67:314-316, 2007. 23. Wilberger JE Jr, Harris M, Diamond DL: Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg 74:212-218, 1991. Citation: World Neurosurg. (2012) 78, 3/4:231-232. DOI: 10.1016/j.wneu.2011.12.067 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.12.067
Alex B. Valadka, M.D. Chief Executive Officer Seton Brain and Spine Institute
Craniotomy for Acute Subdural Hematoma in the Elderly: Not as Bad as You Thought Alex B. Valadka1 and Julie M. Sprunt 2
I
ncreasing age is associated with worse outcome from virtually all illnesses. Traumatic brain injury (TBI) is no exception. Numerous investigations report the disproportionate influence that a few key variables have on outcome after TBI, of which age is among the most significant (4, 6, 9-11, 20, 23). Other important factors include initial Glasgow Coma Scale score (either total score or only the motor component), pupillary response, and computed tomography (CT) scan characteristics (3, 8, 12, 15, 18, 19). Except for age, these outcome determinants all represent different ways of characterizing the severity of injury, or more precisely, the impact of the traumatic pathophysiology on neurological examination and imaging findings. Of note, these indicators of injury severity may wax or wane during the first few hours after injury. Neurological status can improve or worsen, just as imaging results can move in a favorable or unfavorable direction, hence the importance of noting the exact time that the patient is being examined and of performing careful serial examinations. Furthermore, our specialty is on the brink of adding serum markers to our list of tools for diagnosing and serially tracking the severity of brain injury, just as the diagnosis of myocardial infarction is facilitated by measuring levels of heart-specific proteins and enzymes (14). Because these assessment tools all provide a window into the severity of injury, it is reasonable to expect that they would convey roughly comparable information and also trend in the same direction. A poor Glasgow motor score, a fixed and dilated pupil, and a CT scan demonstrating significant midline shift or effaced basilar cisterns are all indicators of a very severe injury. Of course, less severe abnormalities in some or all of these areas suggest that the brain injury may not be as severe. Age is different. Unlike motor examination, pupillary abnormalities, CT findings, or perhaps serum levels of prognostic biomarkers, patient age does not fluctuate in the immediate postinjury period. Instead, age is an important nonneurological variable that is ever-present in the background. It often seems to magnify the impact of primary and secondary insults, including such common
Key words 䡲 Acute subdural hematoma 䡲 Craniotomy 䡲 Elderly 䡲 Old age 䡲 Trauma
Abbreviations and Acronyms ASDH: Acute subdural hematoma CT: Computed tomography TBI: Traumatic brain injury
and well-recognized secondary insults as hypoxia and hypotension, which are associated with worse outcome after TBI. A major difference, of course, is that these secondary insults are most worrisome in the early postinjury period, and they can often be prevented or at least mitigated, unlike advanced age. Perhaps a more appropriate way to view the physiologic impact of advanced age is to consider its effects on a patient’s baseline health status. Several grading scales attempt to quantify the impact of overall systemic health on outcome of acute diseases such as TBI. Such scales are often based on chronic problems such as heart disease, pulmonary disease, chronic renal insufficiency, etc. Many elderly patients suffer from baseline impairment of function of major organ systems. However, advanced age may have adverse effects on outcome that are distinct from what might be expected by concomitant decreased function of important organ systems. A common explanation is the frequently cited concept of decreased physiologic reserve that is associated with aging (21). Parenthetically, several reports describe better outcomes after TBI in patients who were taking beta-blockers or statins prior to injury (7, 17). Such patients tend to be elderly. It might be tempting to assume that one of the unintended benefits of aging is a greater likelihood of being a regular user of such apparently neuroprotective medications in the event of a TBI. It is doubtful, however, that such prophylactic pharmacological therapy can overcome the adverse effects of the underlying health problems that necessitated such medications in the first place, especially when these problems are superimposed upon advanced age (17). Some investigators have reported a specific age cutoff above which outcome is said to worsen precipitously. Most of us have heard statements such as, “Outcome from TBI is much worse above age 30 [or 40, or 50, etc.].” Although several published reports lend support to this view, common sense suggests that age should have a more-or-less linear relationship to outcome after TBI: the older the
From the 1Seton Brain and Spine Institute, Austin; and 2Department of Surgery, University of Texas Southwestern at Austin, Austin, Texas, USA To whom correspondence should be addressed: Alex B. Valadka, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2012) 78, 3/4:231-232. DOI: 10.1016/j.wneu.2011.12.067
WORLD NEUROSURGERY 78 [3/4]: 231-232, SEPTEMBER/OCTOBER 2012
www.WORLDNEUROSURGERY.org
231
PERSPECTIVES
patient, the worse the outcome, with no clear break point beyond which age has a dramatically worsening effect. This is the type of relationship seen by Maas et al. in one of the largest investigations of the interaction between age and outcome after TBI (13). Because outcomes worsen as age increases, some authorities have adopted a nihilistic attitude toward aggressive therapy of TBI in the elderly population. Their experience with performing emergency craniotomies in this population is so negative that they strongly discourage aggressive care beyond a certain age threshold, such as 65 years (2). This philosophy sounds reasonable to many clinicians who have repeatedly had the same poor outcomes in the elderly TBI population. However, other experts point out that good outcomes can and do occur in some of these patients, suggesting that dogmatic proscriptions against aggressive intervention are overly broad (1, 5, 22). Elderly patients in good general health and with relatively less severe injuries may enjoy surprisingly good outcomes from TBI. Taussky et al. add new data to this controversy. They retrospectively reviewed a series of 37 consecutive patients older than 65 years of age who underwent craniotomy for acute subdural hematoma (ASDH). The median age was 73 years. Half of these patients had pupillary abnormalities, more than 80% had significant comorbidities, and over 40% were treated with anticoagulants or platelet aggregation inhibitors.
Approximately one third of these patients died. The overall poor outcome rate on the dichotomized Glasgow Outcome Scale was 60%. Conversely, favorable outcomes occurred in 40% of patients. At first glance, the favorable outcome rate may seem low. However, when patient age, comorbidity, and use of antiplatelet and anticoagulant medications are considered, the favorable outcome rate is impressive (4, 6, 10, 16, 23). This study has important weaknesses. It is an uncontrolled series, without any comparison group. How were these patients selected? How many ASDH patients in this age group did not undergo craniotomy because their neurological status was good enough to justify nonoperative management? How many elderly patients were treated for other types of brain injury during this time period, and what were their outcomes? Another potential confounder is the fact that almost half the patients had a Glasgow Coma Scale score above 8, suggesting that the severity of neurological injury may have been less severe than in other reported series. These types of weaknesses are unavoidable in retrospective analyses. A prospective investigation would likely address some of these limitations by providing more robust data. Yet despite its imperfections, this report clearly documents that at least some elderly patients—perhaps many more than one might think— go on to good recovery after craniotomy for ASDH.
10. Koç RK, Akdemir H, Oktem IS, Meral M, Menkü A: Acute subdural hematoma: outcome and outcome prediction. Neurosurg Rev 20:239-244, 1997.
associated with improved survival and functional outcomes in older head-injured individuals. J Trauma 71:815-819, 2011.
1. Cagetti B, Cossu M, Pau A, Rivano C, Viale G: The outcome from acute subdural and epidural intracranial haematomas in very elderly patients. Br J Neurosurg 6:227-231, 1992.
11. Munro PT, Smith RD, Parke TR: Effect of patients’ age on management of acute intracranial haematoma: prospective national study. BMJ 325(7371):1001, 2002.
2. De Bonis P, Pompucci A, Mangiola A, Paternoster G, Festa R, Nucci CG, Maviglia R, Antonelli M, Anile C: Decompressive craniectomy for elderly patients with traumatic brain injury: it’s probably not worth the while. J Neurotrauma 28:2043-2048, 2011.
12. Murray GD, Butcher I, McHugh GS, Lu J, Mushkudiani NA, Maas AI, Marmarou A, Steyerberg EW: Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:329-337, 2007.
18. Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, Murray GD, Marmarou A, Roberts I, Habbema JD, Maas AI: Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 5:e165, 2008.
3. Dent DL, Croce MA, Menke PG, Young BH, Hinson MS, Kudsk KA, Minard G, Pritchard FE, Robertson JT, Fabian TC: Prognostic factors after acute subdural hematoma. J Trauma 39:36-42, 1995.
13. Mushkudiani NA, Engel DC, Steyerberg EW, Butcher I, Lu J, Marmarou A, Slieker F, McHugh GS, Murray GD, Maas AI: Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:259-269, 2007.
REFERENCES
4. Hanif S, Abodunde O, Ali Z, Pidgeon C: Age related outcome in acute subdural haematoma following traumatic head injury. Ir Med J 102:255-257, 2009. 5. Hernesniemi J: Outcome following head injuries in the aged. Acta Neurochir (Wien) 49:67-79, 1979. 6. Howard MA 3rd, Gross AS, Dacey RG Jr, Winn HR: Acute subdural hematomas: an age-dependent clinical entity. J Neurosurg 71:858-863, 1989. 7. Inaba K, Teixeira PG, David JS, Chan LS, Salim A, Brown C, Browder T, Beale E, Rhee P, Demetriades D: Beta-blockers in isolated blunt head injury. J Am Coll Surg 206:432-438, 2008. 8. Jamjoom A: Justification for evacuating acute subdural haematomas in patients above the age of 75 years. Injury 23:518-520, 1992. 9. Klun B, Fettich M: Factors influencing the outcome in acute subdural haematoma. A review of 330 cases. Acta Neurochir (Wien) 71:171-178, 1984.
232
www.SCIENCEDIRECT.com
14. Papa L, Lewis LM, Falk JL, Zhang Z, Silvestri S, Giordano P, Brophy GM, Demery JA, Dixit NK, Ferguson I, Liu MC, Mo J, Akinyi L, Schmid K, Mondello S, Robertson CS, Tortella FC, Hayes RL, Wang KK: Elevated levels of serum glial fibrillary acidic protein breakdown products in mild and moderate traumatic brain injury are associated with intracranial lesions and neurosurgical intervention. Ann Emerg Med 2011 Nov 8. [Epub ahead of print]. 15. Petridis AK, Dörner L, Doukas A, Eifrig S, Barth H, Mehdorn M: Acute subdural hematoma in the elderly; clinical and CT factors influencing the surgical treatment decision. Cen Eur Neurosurg 70:7378, 2009. 16. Rozzelle CJ, Wofford JL, Branch CL: Predictors of hospital mortality in older patients with subdural hematoma. J Am Geriatr Soc 43:240-244, 1995. 17. Schneider EB, Efron DT, Mackenzie EJ, Rivara FP, Nathens AB, Jurkovich GJ: Premorbid statin use is
19. Taussky P, Widmer HR, Takala J, Fandino J: Outcome after acute traumatic subdural and epidural haematoma in Switzerland: a single-centre experience. Swiss Med Wkly 138:281-285, 2008. 20. Tian HL, Chen SW, Xu T, Hu J, Rong BY, Wang G, Gao WW, Chen H: Risk factors related to hospital mortality in patients with isolated traumatic acute subdural haematoma: analysis of 308 patients undergone surgery. Chin Med J (Engl) 121:1080-1084, 2008. 21. Victorino GP, Chong TJ, Pal JD: Trauma in the elderly patient. Arch Surg 138:1093-1098, 2003. 22. Vyas NA, Chicoine MR: Extended survival after evacuation of subdural hematoma in a 102-year-old patient: case report and review of the literature. Surg Neurol 67:314-316, 2007. 23. Wilberger JE Jr, Harris M, Diamond DL: Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg 74:212-218, 1991. Citation: World Neurosurg. (2012) 78, 3/4:231-232. DOI: 10.1016/j.wneu.2011.12.067 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2012 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.12.067