Has the Timing of the Surgery a Major Role in Influencing Outcome in Elderly Patients with Acute Subdural Hematomas?

Abstract

Background: The incidence of traumatic acute subdural hematomas (ASDH) in elderly is increasing. Despite surgical evacuation, these patients have poor survival and low rate of functional outcome, and surgical timing plays a no clear role as predictor. We investigated if the timing of surgery has a major role in influencing outcome in these patients.Methods: We retrospectively retrieved clinical and radiological data of all patients ≥70 years operated on for post-traumatic ASDH in a 3 years period in 5 Italian Hospitals. Patients were divided in 3 surgical timing groups from hospital arrival: ultra-early (within 6h); early (6-24h); delayed (after 24h). Outcome was measured at discharge using two endpoints: survival (alive/dead) and functional outcome at Glasgow Outcome Scale (GOS). Univariate and multivariate predictor models were constructed.Results: We included 136 patients. About 33% died for consequences of ASDH and among the survivors only 24% were in good functional outcome at discharge. Surgical timing groups appeared different according to presenting GCS, which was on average lower in ultra-early surgery group, and radiological findings, which appeared worse in the same group. Delayed surgery was more frequent in patients with subacute clinical deterioration. Surgical timing appeared associated neither with survival nor with functional outcome also after stratification for preoperative GCS. Preoperative midline shift was the strongest outcome predictor. Conclusions: An earlier surgery was offered to patients with worse clinical-radiological findings. Also after stratification for GCS it was not associated with better outcome. Among the radiological markers, preoperative midline shift was the strongest outcome predictor.

A Comparative Effectiveness Study in Health Care Management of Neurosurgery Patients by Bangkok International Hospital Case Manager Nurse

“…Especially in patients with delayed surgery and aged ≥70 years with subacute clinical degeneration. 27 Therefore, CM nurses may not directly assist in the reduction of the LoS in neurosurgery patients with more comorbidities and complications. However, CM should watch out for unnecessary delays in starting treatment and nursing care, and delays in surgery.…”

“…Factors affecting higher hospital expense and growing cost pressures, include population ageing with chronic diseases, patients with high-risk factors, new technologies, patient and family expectations. 34 Furthermore, hospital expenses can occur from clinical risks, such as a prolonged discharge process, 24 delays in intervention, 27 complications after surgery and hospital readmission. [32][33][34] These factors can increase hospital risk costs and lead to bad debt expense.…”